HospitalInspections.org

Based on observation, testing, and staff interview, the facility's practice failed to ensure emergency lighting is operational in the event of an emergency. This deficient practice has the potential to affect staff working within the Emergency Department mechanical room. The licensed capacity of the facility is 250 patients. The findings are:

On November 4, 2010, during a tour of the facility with the Director of Support Services, the Life Safety Code Surveyor observed the following:


1. At 10:45 am, the emergency light fixture located at the Emergency Department mechanical room failed to work when tested.
a. The Director of Support Services stated that he would replace the bulbs and would check all emergency light fixtures for any other bulbs that may be burned out.
b. On 11/04/10 at 3:00 pm, the Director of Support Services, Engineering Manager and the Safety and Security Manager acknowledged the finding at the exit conference.

NFPA 101, 2000 Edition
7.10.1.2 Exits:
Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.
7.10.1.4 Exit Access: Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants.
7.10.2 Directional Signs: A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent.

Exit and directional signs are displayed in accordance with section 7.10 with continuous illumination also served by the emergency lighting system. 19.2.10.1

7.10.5 Illumination of Signs.
7.10.5.1* General.
Every sign required by 7.10.1.2 or 7.10.1.4, other than where operations or processes require low lighting levels, shall be suitably illuminated by a reliable light source. Externally and internally illuminated signs shall be legible in both the normal and emergency lighting mode.




Based on observation, the facility's practice failed to ensure exit signs are installed and are arranged readily visible to provide clear direction of travel to the nearest exit. This deficient practice has the potential to affect staff working within the Emergency Department mechanical room. The licensed capacity of the facility is 250 patients. The findings are:

On November 4, 2010, during a tour of the facility with the Director of Support Services, the Life Safety Code Surveyor observed the following:


1. At 10:40 am, there was no exit sign visible within the Emergency Department mechanical room.
a. On 11/04/10 at 3:00 pm, the Director of Support Services, Engineering Manager and the Safety and Security Manager acknowledged the above finding at the exit conference.

Based on observation, testing, and staff interview, the facility failed to assure the components of the fire alarm system are installed and maintained in accordance with NFPA 70 (National Electric Code), and NFPA 72 (National Fire Alarm Code), and that all fire doors equipped with magnetic hold open hardware will release, close and latch with activation of the fire alarm system. This deficient practice has the potential to affect all staff working on the 3rd and 4th floors. The licensed capacity of the facility is 250 patients. The findings are:

On November 3, 2010, during a tour of the facility with the Director of Support Services, the Life Safety Code Surveyor observed the following:


1. On 11/03/10 at 10:30 am, during an interview with the Director of Support Services, it was explained that the fire doors located at the staff elevators were equipped with magnetic hold open devices and were designed to allow release, closing and latching when the fire alarm system is activated.

2. On 11/03/10 at 1:30 pm, the fire doors at the 4th floor staff elevators failed to close and latch when manually tested.
a. The north elevator fire door would not close when manually tested. The door frame was bent and prevented the fire door from closing properly.
b. On 11/04/10 at 3:00 pm, the Director of Support Services, Engineering Manager and the Safety and Security Manager acknowledged the above finding at the exit conference.


3. On 11/03/10 at 2:40 pm, the fire doors at the 3rd floor staff elevators failed to close and latch when manually tested.
a. When manually tested, the south elevator fire door was binding in its frame, and was preventing it from closing properly.
b. On 11/04/10 at 3:00 pm, the Director of Support Services, Engineering Manager and the Safety and Security Manager acknowledged the above finding at the exit conference.

Based on observation, testing, and staff interview, the facility's practice failed to ensure emergency lighting is operational in the event of an emergency. This deficient practice has the potential to affect staff working within the Emergency Department mechanical room. The licensed capacity of the facility is 250 patients. The findings are:

On November 4, 2010, during a tour of the facility with the Director of Support Services, the Life Safety Code Surveyor observed the following:


1. At 10:45 am, the emergency light fixture located at the Emergency Department mechanical room failed to work when tested.
a. The Director of Support Services stated that he would replace the bulbs and would check all emergency light fixtures for any other bulbs that may be burned out.
b. On 11/04/10 at 3:00 pm, the Director of Support Services, Engineering Manager and the Safety and Security Manager acknowledged the finding at the exit conference.

NFPA 101, 2000 Edition
7.10.1.2 Exits:
Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.
7.10.1.4 Exit Access: Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants.
7.10.2 Directional Signs: A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent.

Exit and directional signs are displayed in accordance with section 7.10 with continuous illumination also served by the emergency lighting system. 19.2.10.1

7.10.5 Illumination of Signs.
7.10.5.1* General.
Every sign required by 7.10.1.2 or 7.10.1.4, other than where operations or processes require low lighting levels, shall be suitably illuminated by a reliable light source. Externally and internally illuminated signs shall be legible in both the normal and emergency lighting mode.




Based on observation, the facility's practice failed to ensure exit signs are installed and are arranged readily visible to provide clear direction of travel to the nearest exit. This deficient practice has the potential to affect staff working within the Emergency Department mechanical room. The licensed capacity of the facility is 250 patients. The findings are:

On November 4, 2010, during a tour of the facility with the Director of Support Services, the Life Safety Code Surveyor observed the following:


1. At 10:40 am, there was no exit sign visible within the Emergency Department mechanical room.
a. On 11/04/10 at 3:00 pm, the Director of Support Services, Engineering Manager and the Safety and Security Manager acknowledged the above finding at the exit conference.

Based on observation, testing, and staff interview, the facility failed to assure the components of the fire alarm system are installed and maintained in accordance with NFPA 70 (National Electric Code), and NFPA 72 (National Fire Alarm Code), and that all fire doors equipped with magnetic hold open hardware will release, close and latch with activation of the fire alarm system. This deficient practice has the potential to affect all staff working on the 3rd and 4th floors. The licensed capacity of the facility is 250 patients. The findings are:

On November 3, 2010, during a tour of the facility with the Director of Support Services, the Life Safety Code Surveyor observed the following:


1. On 11/03/10 at 10:30 am, during an interview with the Director of Support Services, it was explained that the fire doors located at the staff elevators were equipped with magnetic hold open devices and were designed to allow release, closing and latching when the fire alarm system is activated.

2. On 11/03/10 at 1:30 pm, the fire doors at the 4th floor staff elevators failed to close and latch when manually tested.
a. The north elevator fire door would not close when manually tested. The door frame was bent and prevented the fire door from closing properly.
b. On 11/04/10 at 3:00 pm, the Director of Support Services, Engineering Manager and the Safety and Security Manager acknowledged the above finding at the exit conference.


3. On 11/03/10 at 2:40 pm, the fire doors at the 3rd floor staff elevators failed to close and latch when manually tested.
a. When manually tested, the south elevator fire door was binding in its frame, and was preventing it from closing properly.
b. On 11/04/10 at 3:00 pm, the Director of Support Services, Engineering Manager and the Safety and Security Manager acknowledged the above finding at the exit conference.