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A. A Patient room door in an exit access corridor was observed to be equipped with a thumb-turn dead-bolt retractor, this requires more than one releasing operation to exit
the room which does not comply with 7.2.1.5.4. Location observed:

1. Room # 302 designated as a Patient room


B. Doors in exit access corridors were observed that do not latch upon closing to comply with 19.3.6.3.2. Locations observed:

1. Pair of entry doors to ICU
2. Entry door to CT
3. Entry door to MRI




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A. Based on random observations during the survey walk through, not all areas designated as hazardous areas are separated from adjacent spaces or exit access corridors to comply with 19.3.2.1. Findings include:

1. Hazardous areas not covered by a sprinkler system were observed at which doors are not self-closing as required by 19.3.2.1 and 8.2.3.2.3.1(2). Location observed:
Pharmacy

2. Hazardous areas not covered by a sprinkler system were observed which contain holes within the fire rated enclosure and do not comply with 19.3.2.1. for a fire resistant and smoke resistant construction. Locations observed:

a. Utility room across from Room # 312 contains holes in several walls located above the entry door and adjacent to penetrating ductwork.

b. "Oxygen storage" room located adjacent to "Domestic Boiler' room contains several holes in the concrete block walls which are not sealed against the passage of smoke and fire.




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A. Based on random observation during the survey walk through it was noted that a continuous protected path to the outside is not provided in order to comply with 7.2.2.5. The finding includes:

1. Designated exit Stair located within the Surgery suite across from the Anesthesia Storage room, contains a medgas line within the stair. This does not comply with 7.1.3.2.1 (e) for a continuous protected one hour fire rated enclosure.




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A. Based on random observation during the survey walk through, it was noted that not all designated or required horizontal exits or fire barriers are constructed or maintained as fire resistant assemblies. Location observed Cross corridor doors between 1963 and 1955 building:

1. Cross corridor doors at required 2 hour fire rated building separations do not maintain a continuous fire separation between buildings due to the following:
a. Doors do not latch upon closing
b. Doors lack an astragal and coordinator
c. One of the pair of doors does not close and remains in the open position.




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A. Based on direct observation, the facility failed to:

1. Restrain medical gas cylinders within the medical gas store room. (NFPA, 1999, 4-3.5.2.1 (b) 27)

2. Isolate the nitrous oxide manifold enclosure for that use only. The enclosure is being used for the storage of items other than those associated with the medical gas manifold.




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A. By direct observation the surveyor finds:

1. PVC drainage pipe storage less than 50 feet from the liquid oxygen supply facility. (NFPA 50, 1996, 2-2)

2. Wood frame storage building less than 50 feet from the liquid oxygen supply facility. (NFPA 50, 1996, 2-2)



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A. Based on direct observation the facility failed to provide:

1. A remote manual emergency stop station for the "Hospital" emergency generator.
(NFPA 110, 1999, 3-5.5.6)

2. A remote alarm annunciator for the "Hospital" emergency generator at a constantly attended work station. NFPA 99, 1999, 3-4.1.1.15 (b)

3. Acceptance testing and certification per NFPA 110, 1999, 5-13 was not available for the "Hospital" emergency generator. Staff interview indicated the engine was recently replaced thus requiring acceptance testing to be performed.

4. Battery-powered emergency lighting at two of two emergency generators. (NFPA 110, 1999, 5-3.1)





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A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.


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A. By direct observation the surveyor finds the facility failed to provide barrier protection from live electrical connections:

1. Electrical distribution panels located within the second floor electrical closet were missing interior cover plates exposing users to live electrical connections.



20224

B. A critical patient care area contained duplex recepticals with a green dot indicating a hospital grade outlet without the destinctive coloring to identify them as being supplied by emergency power to comply with NFPA 70 The National Electric Code 1999 517-19 and labeling with panel and circuit number to comply with NEC 1999 517-33(c). Location observed: Emergency Department Room # 411.



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A. A Patient room door in an exit access corridor was observed to be equipped with a thumb-turn dead-bolt retractor, this requires more than one releasing operation to exit
the room which does not comply with 7.2.1.5.4. Location observed:

1. Room # 302 designated as a Patient room


B. Doors in exit access corridors were observed that do not latch upon closing to comply with 19.3.6.3.2. Locations observed:

1. Pair of entry doors to ICU
2. Entry door to CT
3. Entry door to MRI




.

A. Based on random observations during the survey walk through, not all areas designated as hazardous areas are separated from adjacent spaces or exit access corridors to comply with 19.3.2.1. Findings include:

1. Hazardous areas not covered by a sprinkler system were observed at which doors are not self-closing as required by 19.3.2.1 and 8.2.3.2.3.1(2). Location observed:
Pharmacy

2. Hazardous areas not covered by a sprinkler system were observed which contain holes within the fire rated enclosure and do not comply with 19.3.2.1. for a fire resistant and smoke resistant construction. Locations observed:

a. Utility room across from Room # 312 contains holes in several walls located above the entry door and adjacent to penetrating ductwork.

b. "Oxygen storage" room located adjacent to "Domestic Boiler' room contains several holes in the concrete block walls which are not sealed against the passage of smoke and fire.




.

A. Based on random observation during the survey walk through it was noted that a continuous protected path to the outside is not provided in order to comply with 7.2.2.5. The finding includes:

1. Designated exit Stair located within the Surgery suite across from the Anesthesia Storage room, contains a medgas line within the stair. This does not comply with 7.1.3.2.1 (e) for a continuous protected one hour fire rated enclosure.




.

A. Based on random observation during the survey walk through, it was noted that not all designated or required horizontal exits or fire barriers are constructed or maintained as fire resistant assemblies. Location observed Cross corridor doors between 1963 and 1955 building:

1. Cross corridor doors at required 2 hour fire rated building separations do not maintain a continuous fire separation between buildings due to the following:
a. Doors do not latch upon closing
b. Doors lack an astragal and coordinator
c. One of the pair of doors does not close and remains in the open position.




.

A. Based on direct observation, the facility failed to:

1. Restrain medical gas cylinders within the medical gas store room. (NFPA, 1999, 4-3.5.2.1 (b) 27)

2. Isolate the nitrous oxide manifold enclosure for that use only. The enclosure is being used for the storage of items other than those associated with the medical gas manifold.




.

A. By direct observation the surveyor finds:

1. PVC drainage pipe storage less than 50 feet from the liquid oxygen supply facility. (NFPA 50, 1996, 2-2)

2. Wood frame storage building less than 50 feet from the liquid oxygen supply facility. (NFPA 50, 1996, 2-2)



.

A. Based on direct observation the facility failed to provide:

1. A remote manual emergency stop station for the "Hospital" emergency generator.
(NFPA 110, 1999, 3-5.5.6)

2. A remote alarm annunciator for the "Hospital" emergency generator at a constantly attended work station. NFPA 99, 1999, 3-4.1.1.15 (b)

3. Acceptance testing and certification per NFPA 110, 1999, 5-13 was not available for the "Hospital" emergency generator. Staff interview indicated the engine was recently replaced thus requiring acceptance testing to be performed.

4. Battery-powered emergency lighting at two of two emergency generators. (NFPA 110, 1999, 5-3.1)





.

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.


.

A. By direct observation the surveyor finds the facility failed to provide barrier protection from live electrical connections:

1. Electrical distribution panels located within the second floor electrical closet were missing interior cover plates exposing users to live electrical connections.



20224

B. A critical patient care area contained duplex recepticals with a green dot indicating a hospital grade outlet without the destinctive coloring to identify them as being supplied by emergency power to comply with NFPA 70 The National Electric Code 1999 517-19 and labeling with panel and circuit number to comply with NEC 1999 517-33(c). Location observed: Emergency Department Room # 411.



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