HospitalInspections.org

Based on observation and staff interview it was determined the Giro Psych Seculsion patient room door had multiple locking devices.

This could place one patient at risk in the event of a fire in the facility.

The finding includes:

During a tour of the facility with Staff M on 05/08/2018 between 08:30am and 12:00pm observation revealed the Giro Psych Seclution patient room door had 3 sliding hasp locks and a dead bolt lock on the egress door from the room.

This finding was confirmed by Staff M at the time of discovery.

2012 NFPA 101, Chapter 19, Section 19.2.2.2.2(1)

Based on observation and staff interview it was determined the facility failed to provide a fire sprinkler system that meets all the requirements set forth in NFPA 13.

This finding could place all 21 patients at risk in the event of a fire in the facility.

The findings were:

During a tour of the facility with Staff M on 05/08/2018 between 08:30am and 12:00pm observation revealed the clean linen closet across the corridor from room #119 was not provided with fire sprinkler coverage.

It was also observed the fire sprinkler system was not provided with an outside water control valve.

These findings were confirmed by staff M at the time of discovery.

2012 NFPA 101, 19.3.5.1, 9.7.1.1, 2010 NFPA 13, 8.1.1, CMS S&C 13-55-LSC

2012 NFPA 101 Chapter 19, 19.3.5.1;Chapter 9, 9.9.7.1(1); 2010 NFPA 13 Chapter 6, 6.7.1.3.2

Based on observation and staff interview it was determined the facility failed to provide smoke barriers with at least a 1/2 hour fire resistance rating.

This could place all 21 patients at risk in the event of a fire in the facility.

The findings were:

During a tour of the facility with Staff M on 05/08/2018 between 08:30am and 12:00pm observation revealed all three smoke barrier walls were sealed to the deck with sheetrock mud and covered in small areas by fire caulk.

It was further observed an unsealed sprinkler pipe penetration in the wall located in the lab and an unsealed low voltage penetration above the smoke barrier door next to room 129.

These findings were confirmed by Staff M at the time of discovery.

2012 NFPA 101 Chapter 19, 19.3.7.1, 19.3.7.3: Chapter 8, 8.5.7.1, 8.5.7.2, 8.5.7.3, 8.5.7.4, 8.5.7.5; Chapter 4, 4.6.12.1

2012 NFPA 101 , Chapter 19, Sections 19.3.7.1, 19.3.7.3, Chapter 8 Sections 8.3.5, 8.5.2.1, 8.5.2.2, 8.5.7.4, 8.5.6.1, 8.5.6.2, 8.5.6.3, Chapter 4, Section 4.6.12.1

Based on observation and staff interview it was determined the facility failed to meet all the required provisions set forth in the facility smoking policy.

This could place any patient or staff at risk of burns using the designated smoking areas.

The findings were:

During a tour of the facility with Staff M on 05/08/2018 between 08:30am and 12:00pm observation revealed the designated smoking areas did not contain noncombustible ashtrays or a metal container with a self closing cover device into which cigarette butts and ashes may be disposed of.

These findings were confirmed by Staff M at the time of discovery.

2012 NFPA 101 19.7.4 (5)

2012 NFPA 101 19.7.4 (6)

Based on observation and staff interview it was determined the facility generator did not meet all the requirements set forth in NFPA 99.

This could place all 21 patients at risk in the event of a power failure.

The findings were:

During a tour of the facility with Staff M on 05/08/2018 between 08:30am and 12:00pm observation revealed the facility generator did not have remote annunciator that is storage battery powered located outside of the generating room in a location readily observed by the staff.

This finding was confirmed by Staff M at the time of discovery.

2012 NFPA 99 Chapter 6, Section 6.4.1.1.17