HospitalInspections.org

Based on observation and staff interview, it was determined that the facility failed to ensure that areas within the health care occupancy meet the stricter requirements of hotel and dormitory occupancy based on the use of the space.

Findings include:

Reference #1: NFPA 101:28.3.4.5, "Smoke Detection. An approved single-station smoke alarm shall be installed in accordance with 9.6.2.10 in every guest room and every living area and sleeping room within a guest suite."

Reference #2: NFPA 101:28.2.4.6.5, "Carbon monoxide alarms or carbon monoxide detectors shall be provided in accordance with the manufacturer's published instructions in the locations specified as follows... (2) Centrally located within occupiable spaces served by the first supply air register from a permanently installed, fuel burning HVAC system."

1. On 10/9/19 at 1:15 PM, in the presence of Staff #32, Staff #33, and Staff #34, the Third Floor East Wing was converted into sixteen (16) on-call rooms, which changes the occupancy classification from Health Care to Hotel and Dormitories. These sixteen rooms each consisting of two (2) or more beds provided sleeping accommodations for more than sixteen (16) persons, and are primarily used by transients for lodging while working within the health care occupancy.

a. Upon interview on 10/9/19 at 1:20 PM, Staff #32 confirmed the following:

(i) All sixteen (16) sleeping rooms on the Third Floor East Wing lacked smoke detection (Refer to Reference #1).

(ii) The Third Floor East Wing lacks carbon monoxide detectors or alarms (Refer to Reference #2).

Based on observation, it was determined that the facility failed to ensure that patient sleeping rooms are equipped with a window or a door to the outside.

Findings include:

1. On 10/9/18 at 11:10 AM, in the presence of Staff #32, Staff #33, and Staff #35, the following Intensive Care Unit in-patient Rooms lacked either a window or a door to the outside:

a. Room #5001

b. Room #5006

c. Room #5007

d. Room #5012

e. Room #5031

Based on observation, it was determined that the facility failed to ensure portable space heating devices are not utilized in health care occupancies.

Findings include:

1. On 10/9/19 at 10:50 AM, in the presence of Staff #33, Staff #34, and Staff #35, a portable space heater was being utilized by staff in Patient Care Room #583 E.