HospitalInspections.org

Based on observations, the facility failed to keep the means of egress open to full and instant use in accordance with NFPA 101, 2012 Edition, Sections 7.1.10.1 and 19.2.3.4(5).

Findings include:

1. During an observation on 5/3/23 at 10:55 a.m., the corridor area of Main Street and the short corridor going toward imaging was inspected. There were many sitting chairs side by side in the corridor. These chairs were in the 6 ft-8 ft path of egress and were not bolted to the wall or the floor.

2. During an observation on 5/3/23 at 11:27 a.m., room 110, an isolation room, was inspected. The room had an ante room which was being used to store linen containers, garbage cans, and two IV poles. There was so many in the room that the door to the resident room would not open all the way.

Based on observation, the facility failed to ensure doors in the path of egress did not require the use of a key, a tool, or special knowledge or effort for operation from the egress side in accordance with NFPA 101-2012, Section 7.2.1.5.3 and 7.2.1.6.2.

Findings include:

1. During an observation on 5/3/23 at 11:50 a.m., the OR area was inspected. Since the last survey of the facility, magnetic locks had been installed on cross-corridor doors going into the OR. The locks lacked any kind of delayed egress or access-controlled egress mechanisms to unlock the doors. There were illuminated exit signs leading occupants through these doors, one outside the OR suite, and a second one at the locked doors.

Based on observation, the facility failed to ensure a second exit sign was located to guide occupants to a second exit where egress was not obvious in accordance with NFPA 101, 2012 edition, section 7.10.1.9, and failed to maintain visibility of exit signs in accordance with NFPA 101-2012, Section 7.10.1.8.

Findings Include:

1. During an observation on 5/3/23 at 10:59 a.m., the exiting strategy in the Main Street corridor was inspected. There was no visible exit sign on the south end of the corridor which could guide occupants toward the main entrance from several areas along the corridor where occupants may need a second visible exit.

Based on observation, the facility failed to ensure hazardous rooms had doors which were able to close, and latch under the power of a self-closing device, in accordance with NFPA 101, 2012 Edition, Sections 19.3.2.1 and 19.3.2.1.3.

Findings include:

1. During an observation on 5/3/23 at 11:07 a.m., the imaging storage room was inspected. The room is over 50 square feet. The self-closer on the door was unable to close and latch the door under the power of the self-closer. Upon further inspection the top hinge on one side was found to be loosened from the door.

2. During an observation on 5/3/23 at 11:16 a.m., the decontamination room was inspected. It was being used as an ambulance storage room. It lacked the required self-closing device on the door to the room as required for storage areas.

Based on observation the facility failed to maintain the sprinkler system by installing sprinkler heads too close to walls in accordance with NFPA 13 Standard for Automatic Sprinkler Systems, 2010 Edition, Section 8.5.5.2.2

Findings Include:

1. During an observation on 5/3/23 at 11:42 a.m., the janitor's closet on medical way was inspected. There was a straight pendant sprinkler head within 3" of the wall. The minimum distance a sprinkler head can be from the wall without being a directional head is 4".

Based on observation, the facility failed to:

a) ensure sprinkler systems maintained satisfactory performance with respect to activation time in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.1.1(3).

b) ensure sprinkler pipes were free of external loads in accordance with NFPA 25, Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 5.2.2.2.

Findings include:

1. During an observation on 5/3/23 at 11:11 a.m., the electrical utility closet in imaging was inspected. There were large holes in the ceiling tiles where they had been cut around large electrical conduits as they left the room through the ceiling, creating an unprotected opening.

2. During an observation on 5/3/23 at 11:38 a.m., the IT room was inspected. There were Cat 5 and RG 6 wires zip-tied to the sprinkler pipes in the room. There was also a very large cluster of IT wires resting on the sprinkler pipe, as it appeared a hanger was removed from the wall which would have held them off the sprinkler pipe.

Based on observation, the facility failed to inspect portable fire extinguishers in accordance with NFPA 10 Standard for Portable Fire Extinguishers, 2010 Edition, Section 7.2.1.2.

Findings include:

1. During an observation on 5/3/23 at 11:51 a.m., the portable extinguisher in sterile supply was inspected. It had not been initialed as having been inspected since the month of December 2022.

Based on observation, the facility failed to store oxygen cylinders in accordance with NFPA 99, 2012 Edition, Sections 11.3.2, 11.3.2.1, 11.3.2.3, 11.3.4.2 and 11.6.2.3.

Findings include:

1. During an observation on 5/3/23 at 11:36 a.m., the electrical utility room was inspected. There were two K sized tanks being stored in the room. This amounts to 562 square feet of oxygen. This amount of oxygen needs to be stored in a designated oxygen storage room that is lockable, free of combustibles within 5 feet of the tanks, and labeled with proper signage.