HospitalInspections.org

Based on observation, testing, and interview, the provider failed to:
*Install delayed egress signage for the south exit into the shared egress corridor with the hospital.
*Maintain a clear and unobstructed path to the exit discharge door.
*Install visible 'No Smoking' signs for the oxygen manifold system.
*Maintain illuminated exit signs.
*Maintain a storage room over 100 square feet with combustible storage with a self-closing, positive latching door in a smoketight room.
Findings include:

1. Building SRMC
a. Observation at 9:45 a.m. on 11/01/16 revealed the south exit from the clinic discharged into a shared egress corridor with the hospital. The clinic exit door was equipped with a magnetic lock. A push button was mounted on the left side of the door, adjacent to the door handle and positive latching hardware. Testing of the push button while simultaneously turning the handle and pushing on the door revealed the magnet would function as a delayed egress lock. There was no signage stating how to egress using the delayed egress function to exit the building. The dual operation (pushing the button and turning the lever style door handle while pushing on the door) did not conform to delayed egress requirements (such as a panic bar).

b. Interview with the plant operations manager at the time of the observation confirmed that finding.

2. Building QCRMC
a. Observation beginning at 12:45 p.m. on 11/01/16 revealed:
*The exit sign at the urgent care nurse station was not lit.
*The exit sign at the northwest corridor was not lit.
*The exit sign by Exam 2 room was not lit.

b. Observation beginning at 1:05 p.m. on 11/01/16 revealed a basement storage room over 100 square feet in area with combustible storage that had the following conditions:
*The corridor door was not equipped with positive latching hardware.
*The corridor door was not equipped with a door closer.
*The rooms walls had numerous unsealed openings and penetrations in the interior wall. The wall was not finished on one side. Gypsum board provided only a partial wall cover, exposing wood studs.

c. Observation at 1:10 p.m. on 11/01/16 revealed control wiring was fastened to the overhead fire protection system sprinkler piping with plastic zip ties.

d. Interview with the plant operations manager at the time of the observations confirmed those findings.

3. Building SRSC
a. Observation at 2:15 p.m. on 11/01/16 revealed there was not a sign indicating No Smoking for the liquid oxygen manifold storage closet on the corridor side of the room. A sign was situated within the closet but was not visible with the doors shut.

b. Interview with the plant operations manager at the time of the observation confirmed that finding.

4. Building RR
a. Observation at 3:25 p.m. on 11/01/16 revealed the east double-door exit was obstructed by a chair and a cart that were set within four feet of the front of the doors.

b. Interview with the plant operations manager at the time of the observation confirmed that finding.

Based on observation and interview, the provider failed to maintain the fire-resistive characteristics of the two hour fire-resistive wall between building 01 (1963 main building) and building 02 (1999 addition) in one randomly observed location (emergency department corridor roll-up window). Findings include:

1. Observation at 8:20 a.m. on 11/01/16 revealed the ninety-minute, fire-rated, roll-up window in the two-hour fire-rated wall at the south side of the emergency department was propped up (open) with a piece of white one-half inch PVC tubing. The tubing would prevent the roll-up window from closing when the fire alarm was activated.

Interview with the plant operations manager at the time of the observation revealed he was unaware the ninety-minute, fire-rated, roll-up window was being propped open.

The blocking of the 90 minute roll up window had the capability to affect 100% of the occupants in that smoke compartment.

Based on observation and interview, the provider failed to maintain proper separation of one randomly observed hazardous area (elevator mechancial room) in the lower level. Findings include:

1. Observation at 4:45 p.m. on 11/01/16 revealed the 3/4 hour fire-rated door to the elevator mechanical room would not close and latch with the operation of the door closer. The door's leading edge was rubbing on the door frame. The top door hinge was loose.

Interview with the plant operations manager at the time of the observation confirmed that finding.

The deficiency had the potential to affect 100% of the occupants of the smoke compartment.

Based on observation and interview, the provider failed to maintain conforming exit stairs for one randomly observed location (southeast basement stairway). Items were stored in the stair enclosure. An exit enclosure shall not be used for any purpose that has the potential to interfere with its use as an exit and, if so designated, as an area of refuge. There shall be no enclosed, usable space within an exit enclosure, including under stairs, nor shall any open space within the enclosure be used for any purpose that has the potential to interfere with egress. Findings include:

1. Observation at 11:25 a.m. on 11/01/16 revealed construction materials, carts, wet/dry vacuum cleaner, wiring, and a plastic trash container were stored in the stair enclosure at the basement level of the southeast stair enclosure.

Interview with the plant operations manager at the time of the observation confirmed those findings. He stated he was unaware those items could not be kept in the stair enclosure.

The deficiency had the potential to affect 100% of the occupants using the stair enclosure as an exit.

Based on observation and interview, the provider failed to install exterior exit discharge lighting at one randomly observed exit (the east exit, adjacent to the MRI room). Findings include:

1. Observation at 9:55 a.m. on 11/01/16 revealed the east exit discharge past the MRI room did not have exterior lighting. The egress corridor was shared with the adjacent clinic.

Interview with the plant operations manager at the time of the observation confirmed that finding. He stated it appeared the exit discharge location had never had exterior lighting installed.

The deficiency affected one of several requirements to provide illumination for the means of egress.

Based on observation, testing, and interview, the provider failed to maintain emergency lighting for one of one randomly observed location (generator room). The battery pack emergency light did not work. Findings include:

1. Observation at 8:45 a.m. on 11/01/16 revealed the generator room was equipped with a battery pack emergency light. Testing of the emergency light by depressing the test button did not cause the light to work. Unplugging the light from the electrical receptacle also did not cause the light to work.

Interview with the plant operations manager at the time of the observation confirmed that finding. He discovered the electrical receptacle did not have power.

The deficiency affected one of several requirements to provide emergency lighting for the building.

Based on observation and interview, the provider failed to install exit and directional signs with continuous illumination also served by the emergency lighting system for one randomly observed location (patient wing nurse station). Findings include:

1. Observation at 9:20 a.m. on 11/01/16 revealed the east-west corridor immediately north of the patient wing nurses station did not have visible exit signs. The path of egress wasn't indicated when looking toward the nurses station area from either end of the corridor.

The deficiency affected one of numerous requirements for the installation of egress directional signs.

Based on observation and interview, the provider failed to maintain proper separation of one randomly observed vertical opening (southwest stair enclosure) at the lower level. Findings include:

1. Observation at 4:15 p.m. on 11/01/16 revealed the door to the southwest stair enclosure would not latch and hold the door shut. The strike plate in the door frame had one of two screws stripped and could not be tightened to hold the strike plate in place.

Interview with the plant operations manager at the time of the observation confirmed that finding.

The deficiency had the potential to affect 100% of the occupants of the smoke compartment.

Based on observation and interview, the provider failed to maintain proper separation of one randomly observed hazardous area (medical records storage room). Findings include:

1. Observation at 10:40 a.m. on 11/01/16 revealed the medical records storage room (in housekeeping room across from radiology) had a one foot by six inch hole in the gypsum board ceiling.

Interview with the plant operations manager at the time of the observation confirmed that finding. He stated it appeared a leaking steam pipe appeared to have damaged the ceiling.

The deficiency had the potential to affect 100% of the smoke compartment occupants.

Based on observation and interview, the provider failed to maintain the automatic fire sprinkler system in a full operational condition at one randomly observed location (housekeeping supply closet). Findings include:

1. Observation at 11:00 a.m. on 11/01/16 revealed three plastic sharps containers were on the top of a wood shelving unit holding folded paper towels in the housekeeping supply closet. The sharps containers extended to the ceiling of the room and obstructed the sprinkler for that room.

Interview with the plant operations manager at the time of the observation confirmed that finding.

The deficiency had the potential to affect 100% of the occupants of the smoke compartment.

Based on observation and interview, the provider failed to maintain the smoke tight rating of corridor wall assemblies for one of one randomly observed location (clean supply room). Findings include:

1. Observation at 9:30 a.m. on 11/01/16 revealed the latch bolt for the clean supply room (adjacent room 105) corridor door was stuck inside the door. The stuck bolt did not provide positive latching for the door.

Interview with the plant operations manager at the time of the observation confirmed that finding.

This deficiency had the potential to affect all occupants within the smoke compartment.

Based on observation and interview, the provider failed to maintain conforming exit stairs for one randomly observed location (southwest basement stairwell). Items were stored in the stair enclosure. An exit enclosure shall not be used for any purpose that has the potential to interfere with its use as an exit and, if so designated, as an area of refuge. There shall be no enclosed, usable space within an exit enclosure, including under stairs, nor shall any open space within the enclosure be used for any purpose that has the potential to interfere with egress. Findings include:

1. Observation at 11:15 a.m. on 11/01/16 revealed a pallet jack, combustible cardboard boxes, tables, and door leaves were stored in the stair enclosure at the basement level of the southwest stair enclosure.

Interview with the plant operations manager at the time of the observation confirmed those findings. He stated he was unaware those items could not be kept in the stair enclosure.

The deficiency had the potential to affect 100% of the occupants using the stair enclosure as an exit.