HospitalInspections.org

Based on observations during the survey walk of the facility on the afternoon of 3/26/2014, with the Facilities Director, immediate care room ' s door was equipped with roller latching hardware. Provide positive latching hardware on corridor doors.

Based on observations during the survey walk of the facility on the morning of 3/26/2014, with the Facilities Director, the facility lacked an exit sign marking the exit path to an egress corridor from dietary department ' s dining room and at control doors near reading room.
If the solution requires adding an EXIT light, provide power from the Life Safety Branch of the EES to meet the requirements of NFPA 99

Based on observations during the survey walk of the facility on the morning of 3/26/2014, with the Facilities Director, the facility failed to assure the doors in smoke barriers had the required smoke control amenities. At opposite swing cross-corridor smoke doors, astragals were missing. Install them to provide a smoke tight seal at the meeting edges of the doors when closed

Based on observations during the survey walk of the facility on the afternoon of 3/26/2014, with the Facilities Director, the facility failed to assure the integrity of the one hour enclosure. Hazardous rooms must be separated from the rest of the facility by rated 1-hour fire walls that go up to the deck and a 45 minute door with closer and positive latch. At outpatient department ' s soiled utility door was missing a closure and the nursing department ' s soiled utility had no latch at the door 117.

Based on observations during the survey walk of the facility on the morning of 3/26/2014, with the Facilities Director, the facility failed to maintain a clear and unobstructed egress path. Large storage cart on wheels impeded egress path at OB corridor. This is a required exit.

Based on observations during the survey walk of the facility on the morning of 3/26/2014, with the Facilities Director, the facility failed to maintain proper clearance from the fire sprinkler head. Boxes sat less than 18 " underneath sprinkler head in the respiratory therapy closet.

Based on observations during the survey walk of the facility on the morning of 3/26/2014, with the Administrator and Facilities Director, the facility failed to maintain the lab ' s fire extinguisher since it sat on the floor.
Fire extinguishers with a gross weight of 40 pounds or less must be 1) installed so that the top of the extinguisher is not more than 5 feet above the floor and 2) be conspicuously located where they will be immediately available and easily accessible in the event of fire and 3) not be obstructed or obscured from view and 4) be securely installed on the hanger or bracket supplied or placed in cabinets or wall recesses with the hanger or bracket securely anchored to the mounting surface

Based on observations during the survey walk of the facility on the morning of 3/26/2014, with the Facilities Director, the facility failed to assure that the essential electrical system was in full compliance. In radiology department, circuit 5 and 7 labeled " lab " were supplied with power from life safety panel. It did not appear that these circuits were part of life safety.
The life safety branch of the emergency system shall supply power for the following lighting, receptacles and equipment: 1. Illumination of means of egress as required in NFPA 101, Life Safety Code; 2. Exit signs and exit direction signs required in NFPA 101, Life safety Code; 3. Alarm and alerting systems including the following: a. Fire Alarms, b. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, "Gas and Vacuum Systems;" 4. (Hospital or ASC) communication systems, where used for issuing instruction during emergency conditions;
5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location; 6. Elevator ... 7. Automatically opened doors used for building egress. No functions other than those listed above in items 1 through 7 shall be connected to the life safety branch.



Based on observations during the survey walk of the facility on the morning of 3/26/2014, with the Facilities Director, the facility failed to ensure that the Type I essential electrical service (EES) is in accordance with NFPA 99. Panel boards did not have a permanent label reading in English what the panel powers. Ensure all panel boards powered by generator are labeled "LIFE SAFETY", "CRITICAL" or "EQUIPMENT", as applicable to identify which branch they serve. This occurred in radiology department.




Based on observations during the survey walk of the facility on the morning of 3/26/2014, with the Facilities Director, the facility failed to maintain the type I EES system. Electrical panel boards were unlocked at first floor radiology department. This area had patients or public access.

Based on observations during the survey walk of the facility on the afternoon of 3/26/2014, with the Facilities Director, immediate care room ' s door was equipped with roller latching hardware. Provide positive latching hardware on corridor doors.

Based on observations during the survey walk of the facility on the morning of 3/26/2014, with the Facilities Director, the facility lacked an exit sign marking the exit path to an egress corridor from dietary department ' s dining room and at control doors near reading room.
If the solution requires adding an EXIT light, provide power from the Life Safety Branch of the EES to meet the requirements of NFPA 99

Based on observations during the survey walk of the facility on the morning of 3/26/2014, with the Facilities Director, the facility failed to assure the doors in smoke barriers had the required smoke control amenities. At opposite swing cross-corridor smoke doors, astragals were missing. Install them to provide a smoke tight seal at the meeting edges of the doors when closed

Based on observations during the survey walk of the facility on the afternoon of 3/26/2014, with the Facilities Director, the facility failed to assure the integrity of the one hour enclosure. Hazardous rooms must be separated from the rest of the facility by rated 1-hour fire walls that go up to the deck and a 45 minute door with closer and positive latch. At outpatient department ' s soiled utility door was missing a closure and the nursing department ' s soiled utility had no latch at the door 117.

Based on observations during the survey walk of the facility on the morning of 3/26/2014, with the Facilities Director, the facility failed to maintain a clear and unobstructed egress path. Large storage cart on wheels impeded egress path at OB corridor. This is a required exit.

Based on observations during the survey walk of the facility on the morning of 3/26/2014, with the Facilities Director, the facility failed to maintain proper clearance from the fire sprinkler head. Boxes sat less than 18 " underneath sprinkler head in the respiratory therapy closet.

Based on observations during the survey walk of the facility on the morning of 3/26/2014, with the Administrator and Facilities Director, the facility failed to maintain the lab ' s fire extinguisher since it sat on the floor.
Fire extinguishers with a gross weight of 40 pounds or less must be 1) installed so that the top of the extinguisher is not more than 5 feet above the floor and 2) be conspicuously located where they will be immediately available and easily accessible in the event of fire and 3) not be obstructed or obscured from view and 4) be securely installed on the hanger or bracket supplied or placed in cabinets or wall recesses with the hanger or bracket securely anchored to the mounting surface

Based on observations during the survey walk of the facility on the morning of 3/26/2014, with the Facilities Director, the facility failed to assure that the essential electrical system was in full compliance. In radiology department, circuit 5 and 7 labeled " lab " were supplied with power from life safety panel. It did not appear that these circuits were part of life safety.
The life safety branch of the emergency system shall supply power for the following lighting, receptacles and equipment: 1. Illumination of means of egress as required in NFPA 101, Life Safety Code; 2. Exit signs and exit direction signs required in NFPA 101, Life safety Code; 3. Alarm and alerting systems including the following: a. Fire Alarms, b. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, "Gas and Vacuum Systems;" 4. (Hospital or ASC) communication systems, where used for issuing instruction during emergency conditions;
5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location; 6. Elevator ... 7. Automatically opened doors used for building egress. No functions other than those listed above in items 1 through 7 shall be connected to the life safety branch.



Based on observations during the survey walk of the facility on the morning of 3/26/2014, with the Facilities Director, the facility failed to ensure that the Type I essential electrical service (EES) is in accordance with NFPA 99. Panel boards did not have a permanent label reading in English what the panel powers. Ensure all panel boards powered by generator are labeled "LIFE SAFETY", "CRITICAL" or "EQUIPMENT", as applicable to identify which branch they serve. This occurred in radiology department.




Based on observations during the survey walk of the facility on the morning of 3/26/2014, with the Facilities Director, the facility failed to maintain the type I EES system. Electrical panel boards were unlocked at first floor radiology department. This area had patients or public access.