HospitalInspections.org

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Based on observation and interview the facility failed to ensure two exit egresses was free from obstruction that did not allow for full and instant access for egress in accordance with NFPA 101: 19.2.1 and 7.1.10.1. This failed practice place occupants in 2 out of 4 smoke compartments at risk for delay in egress. Findings:

Observation of the Occupation Therapy Gym (A128) on 11/22/21 at 1:30 pm revealed an approximate 2 ft x 2 ft x 3 ft piece of physical therapy equipment stored directly in front of an exit egress door. Further observation revealed an illuminated exit sign located above the door.

Occupation Therapy Staff #1 stated the equipment is typically stored there at the time of discovery.

Observation of the Solid Room (B110) on 11/22/21 at 2:14 pm revealed the exit egress door was obstructed by surgical scope cleaning devices.

These findings were acknowledged by the Facilities Director at the time of their discovery.

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Based on observation and interview the facility filed to ensure a directional exit was installed at a T-shaped corridor crossing in accordance with NFPA 101: 7.10.1.2 as referenced by NFPA 101: 19.2.10.1. This failed practiced placed occupants in 1 out of 4 smoke compartments at risk for delay in egress. Findings:

Observation on 11/22/21 at 2:30 pm revealed the lack of exit signage with directional indication at the junction of Corridor B128 and Corridor B140 (outside of room B139).

This finding was acknowledged by the Facilities Director at the time of its discovery.

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Based on observation, record review and interview the facility failed to ensure the metal support construction was continuously protected with fire rated material in accordance with NFPA 101: 19.3. This failed practice placed all residents (based on a census of 2) at risk for exposure to a fire and/or smoke environment, as well as, loss of building integrity during a fire emergency. Findings:

Observation of the Mechanical Penthouse (P200) on 11/23/21 at 11:15 am revealed metal support structures covered in "monokoat" (fire proofing material used to cover metal construction). Further observation revealed multiple areas (15+) of weakened or loss of monokoat on the ceiling supports. Further observation revealed two angular steel supports (approximately 8" x 8" x 20') that did not contain any form of fire protection or monokoat protection.

Record review of the facility's Life Safety Code Drawings, dated 3/6/21, revealed the facility was a Type II (111) construction. This indicated the exterior walls, structure frame, and floor/ceiling/roof protection should have contained at least 1-hour fire rated protection.

These findings were confirmed by the Facilities Manager at the time of their discovery.

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Based on observation, record review, and interview the facility failed to ensure a hazardous area was protected by a self-closing door in accordance with NFPA 101: 19.3.2. This failed practice placed occupants in 1 out of 4 smoke compartments at risk for a fire and/or smoke environment. Findings:

Observation of Soiled Workroom (C115) on 11/22/21 at 1:47 pm revealed a rubber-like door stop with handle wedged under the door (in the open position) protecting the area. Further observation revealed no staff were in or around room C115 at the time of operation. As a result, the door with an installed self-closure was not able automatically close in the manner it was designed.

Record review of the facility's Life Safety Code Drawings, dated 3/6/21, revealed room C115 was identified as a hazardous area protected by a fire rated barrier. Further review revealed the area was 101.98 square feet.

This finding was acknowledged by the Facilities Director at the time of its discovery.

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Based on observation and interview the facility failed to ensure a battery-back up lighting unit was installed in areas where anesthesia is administered in accordance with NFPA 99: 6.3.2.2.11.1 as referenced by NFPA 101: 19.3.2.3. This failed practice placed occupants in 1 out of 1 operating room at risk for delay in task completion or evacuation in the operating room. Findings:

Observation of operating room #1 on 11/23/21 at 10:34 am revealed no battery-back up lighting units for task illumination was installed.

This finding was confirmed by the Facility Manager and Operating Room Manager at the time of discovery.

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Based on observation and interview the facility failed to ensure a sprinkler head has an escutcheon plate in accordance with NFPA 13: 6.2.7 as referenced by NFPA 101: 19.3.5.1 and 9.7.1.1. This failed practice placed occupants in 1 out of 4 smoke compartments at risk for exposure to a smoke and/or fire environment. Findings:

Observation of Physical Therapy Equipment Room (A181) on 11/22/21 at 3:14 pm revealed a sprinkler head installed without an escutcheon plate.

This finding was acknowledged by the Facilities Director at the time of its discovery.

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Based on observation and interview the facility failed to ensure sprinkler heads were free from foreign materials in accordance with NFPA 25: 5.2.1 as referenced by NFPA 101: 19.3.5.1 and 9.7.5. This failed practice placed occupants in 3 out of 4 smoke compartments at risk for a fire and/or smoke environment. Findings:

Random observations on 11/22/21 revealed sprinkler head(s) with dust-like debris covering the bulb and arms of the device located in rooms A121; B142; C103; C112; C145; C146; and C148.

Observation of the Dietary Office (A155) on 11/22/21 at 3:05 pm revealed a sprinkler head with tape around the deflector.

These findings were acknowledged by the Facilities Director at the time of their discovery.

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Based on observation and interview the facility failed to ensure electrical devices and wiring were maintained in a safe operational manner in accordance with NFPA 70 as referenced by NFPA 101: 19.5.1.1 and 9.1.2. This failed practice placed occupants in 2 out 4 smoke compartments at risk for exposure to electrical fire potential and electrocution. Findings:

Random observations on 11/22/21 revealed the following:

-Room C119 - outlet LC-40 was not installed as a GFCI (ground fault circuit interrupter) outlet that was located within 6 feet of a water source;

-Facility Lab - reagent refrigerator was supplied power via power strip device;

-Room B157 - refrigerator and microwave were supplied power via a power strip device;

-Business Office Break Room - microwave supplied power via a power strip device; and

-Mechanical Room - uncovered junction box with exposed live wires.

These findings were confirmed by the Facilities Manager at the time of their discovery.

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Based on observation and interview the facility failed to ensure medical gas cylinders were labeled in a manner that identified full versus empty tanks in accordance with NFPA 99: 11.6.5 as referenced by NFPA 101: 19.3.2.4. This failed practiced placed patients (based on a census of 2) at risk for delay in medical gas intervention and treatment. Findings:

Observation of a central medical gas receiving area on 11/22/21 at 3:08 pm revealed 12 - H-tanks of oxygen and 6 D-tanks of compressed air in the med-gas storage room without any form of identifiers that displayed the full versus empty status of tanks.

This finding was confirmed by the Facility Manager at the time of discovery.

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