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Based on observation, the hospital failed to maintain exit access in accordance with section 7.1, 19.2.1 for delayed egress exit door locks. Failure to ensure exits are assessable at all times to allow patients to exit the building increase the risk for panic and injury to the patients in the case of an emergency.

Finding:

During a tour of the Birth Center on 5/10/2011 at 2:30 PM the surveyor found that the magnetic lock device on the exit door across from patient room #2308 did not sound an alarm and release the door lock when tested. The sign on the exit door instructed the patients to push on the door, the alarm will sound and the door will open in 30 seconds. A second testing of the magnetic door lock was done by hospital maintenance and security at which time the exit door remained locked after pushing steady pressure on the door for two minutes. The magnetic door lock never released during the two tests until after hospital security released the magnetic lock with a key and opened the exit door. The inoperable magnetic lock on the exit door was placed on an immediate repair order by hospital maintenance.



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Based on observation, the hospital failed to locate smoke detectors at least 3 feet from an air supply diffuser as required by the NFPA 72, 2-3.5.1. Failure to properly locate smoke detectors risks failure of smoke detectors in the event of a fire, and subsequent injury to patients, staff and visitors.

Findings:

During a tour of the hospital on 5/12/11, smoke detectors were found approximately 18 inches from air supply diffusers in the corridor outside Nuclear Medicine, in the corridor in the Respiratory Care Department, and in the EKG break room.

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Based on observation, the hospital failed to maintain the automatic sprinkler system in reliable operating condition [NFPA 25]. Failure to maintain the automatic sprinkler system in reliable operating condition risks failure of the system to operate and extinguish a fire.

Findings:

During a tour of the 4th floor patient unit on 5/11/11, a sprinkler head was observed covered in patient room 425. On this same tour, a painted sprinkler head was observed in patient room 425 toilet room.



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Based on observation, the hospital failed to provide electrical wiring and equipment in accordance with NFPA 70 9.1.2 by allowing a multi-tap strips to be connected in series. This practice commonly known as piggybacked multi-tap strips, places all building occupants at risk of electrical fires.

Findings:

During a tour of the 3rd Floor Respiratory Renal Unit on 5/10/11, piggybacked multi-tap strips were found at the nurses station.

CORRECTED DURING SURVEY



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Based on observation, the hospital failed to maintain exit access in accordance with section 7.1, 19.2.1 for delayed egress exit door locks. Failure to ensure exits are assessable at all times to allow patients to exit the building increase the risk for panic and injury to the patients in the case of an emergency.

Finding:

During a tour of the Birth Center on 5/10/2011 at 2:30 PM the surveyor found that the magnetic lock device on the exit door across from patient room #2308 did not sound an alarm and release the door lock when tested. The sign on the exit door instructed the patients to push on the door, the alarm will sound and the door will open in 30 seconds. A second testing of the magnetic door lock was done by hospital maintenance and security at which time the exit door remained locked after pushing steady pressure on the door for two minutes. The magnetic door lock never released during the two tests until after hospital security released the magnetic lock with a key and opened the exit door. The inoperable magnetic lock on the exit door was placed on an immediate repair order by hospital maintenance.



.

Based on observation, the hospital failed to locate smoke detectors at least 3 feet from an air supply diffuser as required by the NFPA 72, 2-3.5.1. Failure to properly locate smoke detectors risks failure of smoke detectors in the event of a fire, and subsequent injury to patients, staff and visitors.

Findings:

During a tour of the hospital on 5/12/11, smoke detectors were found approximately 18 inches from air supply diffusers in the corridor outside Nuclear Medicine, in the corridor in the Respiratory Care Department, and in the EKG break room.

.

Based on observation, the hospital failed to maintain the automatic sprinkler system in reliable operating condition [NFPA 25]. Failure to maintain the automatic sprinkler system in reliable operating condition risks failure of the system to operate and extinguish a fire.

Findings:

During a tour of the 4th floor patient unit on 5/11/11, a sprinkler head was observed covered in patient room 425. On this same tour, a painted sprinkler head was observed in patient room 425 toilet room.



.

Based on observation, the hospital failed to provide electrical wiring and equipment in accordance with NFPA 70 9.1.2 by allowing a multi-tap strips to be connected in series. This practice commonly known as piggybacked multi-tap strips, places all building occupants at risk of electrical fires.

Findings:

During a tour of the 3rd Floor Respiratory Renal Unit on 5/10/11, piggybacked multi-tap strips were found at the nurses station.

CORRECTED DURING SURVEY



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