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Based on observation and interview the facility failed to provide exit signage as required by NFPA 101 7.10. The facility failed to provide signage to mark the way to reach the exit in the Office of Environmental Health. The facility failed to provide NO EXIT signage for two doors that could be mistaken for exits. Failure to provide proper exit signage may lead to panic and result in delayed exit or inability to exit the building during a fire or other emergency event.

Findings include;

Hospital (building 1)
On 3/24/21 from 8:30 AM through 3:30 PM, Facilities Maintenance Director (Staff 79) and Staff 35 accompanied on a life safety observational tour of the hospital building.

The area occupied by Office of Environmental Health (OEH) (1B6-19) included a large open space filled with a maze of cubicles. The walls of the cubicles were high so that an average height person could not see over the top pf the cubicles. When standing on the south side and amongst the cubicles, no exit signs were visible and the direction of egress was not apparent. Exits located in the northeast and northwest corners were marked with exit signs over the doors, however due to the height of the cubicles, the exit signs were not visible from most of the cubicle space.

Staff 79 and Staff 35 confirmed the findings. Staff 35 said additional signage was required to ensure exit signage could be seen from all areas in OEH

The corridor on the second floor Multi-Service Unit (MSU) (Pediatric ward) between patient rooms 17 and 18 had a bank of large windows with a glassed door. The door obviously opened to the outdoors. The door opened onto a second-floor balcony patio with no way to exit from the balcony patio to reach the public way. The door did not have signage to indicate it was not an exit. During the tour, Staff 79 noted the door across from 2A504 also needed a NO EXIT sign.

Staff 79 confirmed the findings. Staff 79 later stated staff reported the doors had NO EXIT signage at one time but it was apparently removed..

NFPA 101 2012 Edition18.2.10.1 Means of egress shall have signs in accordance with Section 7.10 unless otherwise permitted. 7.10.8.3.1 Any door, passage, or stairway that is neither an exit nor way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads as follows: NO EXIT.

Sanders Clinic (building 2)
Staff 79, Staff 35, and Staff 15 accompanied on a LSC observational tour of the hospital's Sanders Clinic on 3/25/21 from 10:00 AM to 12:30 PM. Office doors in the mental health services area opened onto a short corridor with closed doors at both ends. The corrdior had no signage to indicate the direction of travel to exit the building. Staff 79 and Staff 35 confirmed the findings and stated an exit sign should be displayed on door 209..

Based on observation and interview the hospital failed to ensure alcohol-based hand rub (ABHR) dispensers were maintained and tested to ensure operation of the dispenser complied with NFPA 101 requirements. Failure to maintainthe dispensers increased the risk of fire due to uncontrolled relaease of flammable alcohol liquid and vapor placing patients, staff, and visitors at risk for injury due to fire.

Findings include;

On 3/22/21 at 10:30 AM the ABHR dispenser located by room 19 was observed and tested for operation. The ABHR dispenser automatically delivered alcohol gel solution when hand was placed a few inches below the dispenser. Alcohol gel was delivered in a forceful stream off to the left. The alcohol struck the side of the temporary anteroom structure that extended into the corridor. The alcohol solution ran down the wall and puddled on the floor. The alcohol solution did not flow into the hand and was not collected in the drip pan installed below the dispenser. Testing repeated two more times yielded the same results.

On 3/24/21 from 8:30 AM through 3:30 PM, Facilities Maintenance Director (Staff 79) and Staff 35 accompanied on a life safety observational tour of the hospital building. ABHR dispensers were observed mounted on the corridor walls throughout the hospital and outside of every patient room. Staff 19 reported the hospital installed additional ABHR dispensers in response to the COVID pandemic.

The ABHR dispenser near room 19 was tested, the alcohol solution ran down the wall and puddled on the floor no alcohol solution was delivered to the hand or to the collection pan. Staff 19 examined the dispenser and stated the alcohol solution "gummed up the spout" causing the alcohol solution to squirt out away from the hand. Testing of 3 randomly selected ABHR dispensers on the MSU found the stream of alcohol solution was misdirected, 2 had no drip trays, and multiple ABHR dispensers had dirty and nearly full drip trays.

Staff 19 and Staff 35 reported they were aware of LSC requirements for installation of ABHR dispensers but were not aware of requirements for the operation of the dispenser or required testing each time a new refill was installed.

Staff 79 reported Environmental Services Department (EVS) filled and maintained the ABHR dispensers. Staff 79 phoned the EVS supervisor who stated the hospital did not have a system in place to ensure inspection or testing of the ABHR dispensers when new refills were installed.

Building 2: Sanders Clinic
Staff 79 and Staff 35 accompanied on a LSC tour of the hospital's Sanders Clinic on 3/25/21 from 10:00 AM to 12:30 PM. The ABHR dispenser by the electrical room dispensed alcohol gel solution onto the floor as staff walked by. Staff 79 examined the ABHR and said it was too sensitive requiring adjustment or replacement and should have a drip plate. An ABHR dispenser near the optometry clinic dispensed a weak stream with an insufficient amount of alcohol solution for hand sanitization.

Based on observation and interview the hospital failed to ensure a manual alarm box was provided in the required path of egress at the therapy exit in the Wellness Center. This failure may result in delayed notification of fire to patients, visitors, and staff with increased potential for injury or death from fire.

Findings include;

The Facilities Maintenance Director (Staff 79) and Staff 35 accompanied on a LSC observational tour of the Wellness Center on 3/26/21 from 8:30 AM to 10:30 AM. Observation of the therapy department exit revealed no manual fire alarm pull station (alarm box) in the path of egress near the required exit.

Staff 79 confirmed the observation and stated a pull station was required near the exit.

Based on interview and record review the facility did not establish procedures to ensure evacuation of affected areas of the hospital or implementation of an approved fire watch in the event the fire alarm system was out of service for more than four hours. This failure may lead to delayed identification of fire and placed patients, staff, and visitors at risk for injury from fire.

Findings include;

The hospital administration was asked to provide the hospital policy and procedures to be implemented in the event the fire alarm system was out of service for more than 4 hours in a 24-hour period. The facility provided a document; PolicyStat ID: 3918374 effective date 03/2011 and titled Contingency Plan-Failure of Fire Alarm System.

The procedures A.4. directed if the fire alarm system is out of service for more than 4 hours in a 24-hour period, an approved fire watch will be established until the system has been returned to service. The policy did not define what was specifically required for a fire watch, what must be observed, frequency of observations, who initiated fire watch, or who conducted fire watch (must have no other duties). Specific fire watch policy and procedures were requested of administration; the Facilities Maintenance Director (Staff 79)confirmed no additional policy or procedure for fire watch..

Definition per NFPA 3.3.104 Fire Watch. The assignment of a person or persons to an area for the express purpose of notifying the fire department, the building occupants, or both of an emergency; preventing a fire from occurring; extinguishing small fires; or protecting the public from fire or life safety dangers.

Based on observation and interview the hospital failed to inspect and maintain the automatic sprinkler system in building 2 (the Sanders Clinic) in accordance with NFPA 25. Failure to inspect and maintain the sprinkler system may result in delayed activation or failure of the sprinkler system in the event of a fire potentially exposing all patients, staff, and visitors to injury from exposure to fire.

Findings include:
Facilities Maintenance Director (Staff 79), Staff 35, and Staff 15 accompanied on a LSC tour of the hospital's Sanders Clinic on 3/25/21 from 10:00 AM to 12:30 PM. The sprinkler system was visually inspected. Sprinkler heads were observed without *escutcheons plates and/ or retracted up above the ceiling panels creating a penetration (gap) around the sprinkler heads. Sprinkler heads were retracted up into the space above the ceiling panels preventing full development of sprinkler spray pattern in the following locations.

Storage room 195; no escutcheon and sprinkler head partially retracted above ceiling
Janitor closet 199; sprinkler head retracted above ceiling and
ceiling penetration (gap) more than one inch wide around a 3 inch pipe.
Exam room #5; no escutcheon
Room 120: no escutcheon
Janitor room 128: no escutcheon and sprinkler head retracted above ceiling.
Fitness gym: five inch diameter penetration in the ceiling. Staff 19 stated a speaker was moved
leaving a whole in the ceiling panel.

Staff 79 said the hospital and clinic maintenance staff conducted visual inspections of sprinkler gauges and valves but did not inspect the sprinkler heads throughout the buildings.

*Escutcheon plates, also known as trim plates, seal the gap between the fire sprinkler head and the ceiling. If the gap between the ceiling and the sprinkler is not filled, both heat and smoke from a fire would escape past the sprinkler head into the space above the ceiling. Since a fire sprinkler head is activated by heat rising to a certain temperature, its activation would be delayed if the escutcheon plates were not in place. If smoke alarms are present, their activation may be delayed, since smoke will be able to escape through the gap left by a missing escutcheon plate.

Based on interview and record review the facility did not establish procedures to ensure evacuation of affected areas of the hospital or implementation of an approved fire watch in the event the fire sprinkler system was out of service for more than ten hours. This failure may lead to rapid fire growth placing patients, staff, and visitors at risk for injury from fire.

The hospital administration was asked to provide the hospital policy and procedures to be implemented in the event the fire sprinkler system was out of service for more than 10 hours in a 24-hour period. The facility provided a document; titled Contingency Plan- Failure of the Sprinkler System, revised June 2009
The procedures A.4. directed if the sprinkler system is out of service for more than 4 hours in a 24-hour period, an approved fire watch will be established until the sprinkler system has been returned to service. The policy did not define what was specifically required for a fire watch, what must be observed, frequency of observations, who initiated fire watch, or who conducted fire watch.

Specific fire watch policy and procedures were requested of administration. Facilities Maintenance Director (Staff 79) confirmed the hospital had no additional policy or procedure for fire watch.

Definition per NFPA 3.3.104 Fire Watch. The assignment of a person or persons to an area for the express purpose of notifying the fire department, the building occupants, or both of an emergency; preventing a fire from occurring; extinguishing small fires; or protecting the public from fire or life safety dangers

Based on observation, interview, and record review the hospital failed to inspect and maintain the portable fire extinguishers (3 of 3) on the Adolescent Care Unit (ACU) and in the Wellness Center. The Failure to inspected fire extinguishers may lead to delay in staff fire fighting efforts placing the 7 patients and staff on the ACU and patients, staff, and visitors in the Wellness Center therapy department at increased risk for injury from fire.

Findings include;

1. On 3/24/21 from 8:30 AM through 3:30 PM, The Facilities Maintenance Director (Staff 79) and Staff 35 accompanied on a life safety observational tour of the hospital. Staff 79 said the hospital conducted monthly fire extinguisher inspections which were current through March 2021. Staff 79 said the hospital documented the inspections for each individual fire extinguisher on the attached tag.

On 3/24/21 at 1:05 PM observation of the portable fire extinguishers on the ACU revealed each had a securely attached tag that documented an annual inspection in December 2020. The tags had spaces to document monthly inspections. Fire extinguishers at ACU locations; 1A118, 1A317, and 1A411 had no monthly inspections documented on the attached tags.

Staff 79 confirmed the ACU fire extinguishers were not inspected for the months of January, February, or March 2021.


2. Staff 79 and Staff 35 accompanied on a LSC observational tour of the Wellness Center on 3/26/21 from 8:30 AM to 10:30 AM. Observation of the rotunda revealed a fire extinguisher blocked from view and inaccessible due to furniture placed in front of the fire extinguisher.

Staff 79 and Staff 35 confirmed the observation and requested staff move the furniture.

NFPA 10
9.6.2.7 Each manual fire alarm box on a system shall be accessible, unobstructed, and visible.


6.1.3 Placement. 6.1.3.1 Fire extinguishers shall be conspicuously located where they are readily accessible and immediately available in the event of fire.. 6.1.3.3 Visual Obstructions 6.1.3.3.1 Fire extinguishers shall be installed in locations where they are visible except as permitted by 6.1.3.3.2.

Based on observation and interviews, the hospital failed to ensure oxygen cylinders with an aggregate volume of greater than 300 cubic feet, were stored in accordance with NFPA 99 Chapter 11. Improperly stored and protected oxygen cylinders increased the risk of physical trauma due to damaged regulators, injury from rapid fire growth in an oxygen enriched environment, and entrapment due to fire spread to egress corridor.

Findings include:

On 3/22/21 at 2:00 PM, three H-size oxygen cylinders with double regulators (provide oxygen to two patients at once) attached to each cylinder were observed in a second-floor room on the Multi-Service Unit (MSU). Each H-cylinder stood on the floor in a collar-type base. The room, labeled discharge, had a sliding glass door that opened directly onto the main egress corridor. The discharge room was unoccupied with no staff in the area and the door was wide open. When inspected, the oxygen cylinders rocked slightly side-to-side when the regulators were handled.

Observation on 3/22/21 at 2:45 PM found the discharge room was still open and unoccupied. The three H-cylinders remained. Charge Nurse (Staff 78) passed by then returned to assist surveyor. Staff 78 said two of the oxygen tanks were getting low and she planned to call for replacements. Staff 78 confirmed the room was the discharge lounge where discharged patients waited for rides home. Staff 78 said oxygen was administered to patients while they waited for a ride home, and added the room was rarely used.

On 3/23/21 at 2:45 PM when asked about the oxygen cylinders in the discharge lounge, Facilities Maintenance Director (Staff 79) and Staff 35 denied knowledge of the H-cylinders and accompanied to observe. Staff 79 confirmed the oxygen cylinders were H size and the aggregate volume of oxygen was 750 cubic feet (250 cubic feet per H cylinder). Staff 19 said the oxygen cylinders were not secure in the stands, the room was not rated for oxygen storage, and the egress corridor could be impacted in the event of fire. Staff 79 and Staff 35 said oxygen concentrators or E-size oxygen cylinders should be used in this area and should be secured when not in use. Staff 79 called for staff to remove the H- cylinders immediately.

On 3/24/21 during observations from 10:00 AM to 11:30 AM the oxygen H-cylinders remained in the discharge lounge as described above. Staff 79 said he would again direct staff to remove the oxygen cylinders.