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Tag No.: K0011
Based on observation and interview, the facility failed to maintain a three hour rated barrier between the facility and the medical office building. This has the potential to affect all patients, staff, and visitors. The census was 11 patients.
Findings include:
On 01/15/14 from 9:06 A.M. to 11:34 A.M. a tour was conducted with Staff 1A, 1B, and 1C, of the first floor of the facility, including the three hour fire barrier separating the facility from the medical office building.
On 01/15/14 at 11:18 A.M. observation of the three hour barrier that is a part of the back wall of the men's bathroom revealed one inch conduits piercing the wall and having an annular space around them.
On 01/15/14 at 11:18 A.M., in an interview, Staff 1A and 1C confirmed the observation.
On 01/15/14 at 11:34 A.M. observation of the three hour barrier that is a part of the back wall of the physician's on call room revealed an open space about 12 inches wide and 6 inches tall.
On 01/15/14 at 11:34 A.M. in an interview, Staff 1A confirmed the observation saying that he/she thought there was a block missing.
Tag No.: K0018
Based on observation and interview, the facility failed to ensure each door protecting a corridor opening closed. This has the potential to affect all patients, staff, and visitors. The census was 11 patients.
Findings include:
On 01/15/14 from 9:06 A.M. to 11:34 A.M. a tour was conducted with Staff 1A, 1B, and 1C, of the first floor of the facility.
1. On 01/15/14 at 9:21 A.M. observation revealed double doors to a mechanical space in the northern most corridor. Observation revealed the doors did not close completely closed by self-closers.
On 01/15/14 at 9:21 A.M. Staff 1A confirmed the observation.
2. On 9:22 A.M. on 01/15/14 observation revealed a second set of double doors just north of the double doors in #1. Observation revealed the self-closing devices failed to completely close the doors.
On 01/15/14 at 9:22 A.M. Staff 1A confirmed the observation.
Tag No.: K0022
Based on observation and interview, the facility failed to ensure access to exits were marked by approved, readily visible signs in the or pre/post operative holding areas. This has the potential to affect all patients, staff, and visitors using the area. The facility's census was 11 patients.
Findings include:
On 01/14/14 at 3:37 P.M. a tour was conducted of the facility's pre and post op areas with Staff 1A. Observaton was made of the paths of egress from beds 2, 3, and 4. The observation did not reveal an exit sign observable in the immediate area leading to a path of egress.
On 01/14/14 at 3:37 P.M. in an interview Staff 1A confirmed the observation.
Tag No.: K0025
Based on observation and interview, the facility failed to ensure each barrier maintained its one half hour fire rating. This has the potential to affect all patients, staff, and visitors. The census was 11 patients.
Findings include:
On 01/15/14 from 9:06 A.M. to 11:34 A.M. a tour was conducted with Staff 1A, 1B, and 1C, of the first floor of the facility.
1. On 01/15/14 at 9:28 A.M. observation revealed an open junction box which exposed a one inch, unfilled conduit in a storage/equipment room that is surrounded by one hour rating on the north wing of the first floor.
On 01/15/14 at 9:28 A.M. in an interview Staff 1A confirmed the observation
2. On 01/15/14 at 9:46 A.M. observation revealed an open junction box which exposed a one inch unfilled conduit in a supply room near the storage/equipment room in #1.
On 01/15/14 at 9:46 A.M. in an interview Staff 1A confirmed the observation.
3. On 01/15/14 at 10:00 A.M. an observation in a room near the center stairwell revealed an exposed one inch unfilled conduit with a yellow wire coming from it.
On 01/15/14 at 10:00 A.M. in an interview Staff 1A confirmed the observation.
Tag No.: K0052
Based on interview and record review, the facility failed to ensure its fire alarm system complied with NFPA72. This has the potential to affect all patients, staff, and visitors. The census was 11 patients.
Findings include:
Review of the facility's November 2013 fire alarm inspection report revealed two initiating devices, B11 and A50, did not alarm. Documentation does not reveal when they were fixed.
On 01/15/14 at 11:00 A.M. in an interview Staff 1A stated he/she thought they were fixed in December, but upon review of his/her paperwork, he/she said they had not.
Tag No.: K0062
Based on observation and interview, the facility failed to ensure the sprinkler system maintained compliance with NFPA 13, specifically 5-5.5.2 obstructions to sprinkler discharge pattern development. This has the potential to affect all patients, staff, and visitors. The census was 11 patients.
Findings include:
On 01/14/14 at 2:04 P.M. observation was made of an information technology (IT) room with an IT cabinet inside. The IT cabinet was observed to be placed in the middle of the room and directly underneath a sprinkler. The distance from the top of the sprinkler to the top of the cabinet was observed to be 11 inches.
On 01/14/14 at 2:04 P.M. in an interview Staff 1A confirmed the observation.
Tag No.: K0067
Based on record review and interview, the facility failed to ensure compliance with section 9.2, and, therefore, NFPA 90A. The facility's census was 11 patients.
Findings include:
Review of the facility's November 2013 fire alarm inspection report revealed smoke dampers at A29 and A44 was tested and failed.
The report revealed "damper activation inoperative" for 18 of the facility's 50 damper locations. The report also stated for the 18 locations that they passed the test.
On 01/15/14 at 11:00 A.M. in an interview Staff 1A stated he/she did not know what "damper activation inoperative" meant (and still pass the test) and had nothing further to address testing of the dampers.
Tag No.: K0076
Based on interview and observation, the facility failed to ensure the medical gas system complied with NFPA 99. This has the potential to affect all patients, staff, and visitors. The census was 11 patients.
Findings include:
On 1/14/14 at 2:10 P.M. in an interview, Staff 1F was unable to locate the medical gas shutoff valves for the patient care unit. Staff 1F initially looked to the medical gas monitoring panel, and stated they could be shut off at the bed side.
On 01/14/14 at 3:35 P.M. in an interview, Staff 1D was unable to locate the medical gas shutoff valves for the preop/post op area.
On 01/14/14 at 3:35 P.M. in an interview Staff 1B also did not know where the medical gas shut off valves were for the preop/postop area.
On 01/14/14 at 3:37 P.M. in an interview, Staff 1B found the medical gas shut off valves, but determined they were labeled incorrectly. Signage at the valves indicated they were to 1, 2, 3, 4, and 5 isolation. Observation did not reveal a bed 1, but a bed 6. Staff 1B stated he/she thought bed 6 was bed 1 and somehow was changed.