HospitalInspections.org

Based on observation, interviews and document reviews, CHI Health Schuyler failed to meet the life safety code regulations and placed all patients, staff and visitors at risk resulting in the Condition of Participation for Physical Environment not being met. The hospital has 25 certified beds.

Findings include:

1. Based on observation or interview, the facility failed to maintain fire doors in the two-hour fire barrier that separated two occupancies, the hospital and the clinic. This deficient practice had the potential to affect patients, staff and visitors. See the findings at K011 of the Life Safety Code survey that was conducted on 11/10/2015.

2. Based on observation and interview, the facility failed to use materials in accordance with the interior finish requirements for walls in healthcare occupancies and failed to provide documentation for the flame spread rating of the wood on walls in the data room. This deficient practice had the potential to affect patients, staff and visitors. See the findings at K015 of the Life Safety Code survey that was conducted on 11/10/2015.

3. Based on observation and interview, the facility failed to assure that 1 of 3 Countryside Dining corridor doors would latch within the doorframe. This deficient practice would prevent containment of fire and smoke within the exiting corridor which could affect all patients in 1 of 6 smoke compartments based on the occupancy load of Countryside Dining and the adjacent Courtyard Dining Room of the facility. See the findings at K018 of the Life Safety Code survey that was conducted on 11/10/2015.

4. Based on observation and interview, the facility failed to provide 'No Exit' signs on the exterior door leading to the patio on the second floor. This deficient practice had the potential to allow the door to the patio to be mistaken as exit access from the building. See the findings at K022 of the Life Safety Code survey that was conducted on 11/10/2015.

5. Based on observation and interview, the facility failed to ensure that smoke separation doors were capable of resisting the passage of smoke as the doors would allow smoke and gasses to spread. This had the potential to affect all patients, staff and visitors. See the findings at K027 of the Life Safety Code survey that was conducted on 11/10/2015.

6. Based on observation and interview, the facility failed to maintain the doors to hazardous areas so they would latch within the door frame, allowed metal kick down on hazardous areas doors and failed to install self-closing devices on rooms used as storage. These deficient practices would allow fire and smoke to migrate out of the hazard areas into the exiting corridors which would delay egress. See the findings at K029 of the Life Safety Code survey that was conducted on 11/10/2015.

7. Based on observation and interview, the facility failed to provide a sidewalk to a public way from the north exit door from the facility. This deficient practice would delay egress during an emergency. See the findings at K038 of the Life Safety Code survey that was conducted on 11/10/2015.

8. Based on observation and interview, the facility failed to provide two-bulb illumination outside of an exit. This deficient practice would have the potential to leave occupants in darkness during an emergency. See the findings at K045 of the Life Safety Code survey that was conducted on 11/10/2015.

9. Based on observation and interview, the facility failed to provide exit signs for the required second exit throughout the facility. This deficient practice would delay or cause confusion during an emergency as occupants would not be aware of the exits or they would reenter the building. See the findings at K047 of the Life Safety Code survey that was conducted on 11/10./2015.

10. Based on observation and interview, the facility failed to provide fire alarm notification devices in the interior courtyard and a sleeping room. The lack of fire alarm notification devices could cause a fire emergency to go undetected in those areas of the facility because of the inability to hear and see an alarm device. See the findings at K051 of the Life Safety Code survey conducted on 11-10-2015.

11. Based on documentation review and interview, the facility failed to provide documentation for current testing and inspection of the facility fire alarm system. This deficient practice increased the potential that the fire alarm would fail to detect smoke. See the findings at K052 of the Life Safety Code survey conducted on 11-10-2015.

12. Based on observation and interview, the facility failed to provide sprinkler coverage in 2 of 2 folding door storage locations and at the exterior dock. This deficient practice would allow fire and smoke to spread. See the findings at K056 of the Life Safety Code survey conducted on 11-10-2015.

13. Based on observation and interview, the facility failed to provide an unobstructed path to the K type fire extinguisher in the kitchen. The deficient practice would delay the attempt to extinguish a fire. See the findings at K064 of the Life Safety Code survey conducted on 11-10-2015.

14. Based on observation and interview, the facility failed to provide documentation that the curtain in Conference Room B was flame resistant. This had the potential to affect all patients, visitors and staff at the facility. See the findings at K074 of the Life Safety Code survey conducted on 11-10-2015.

15. Based on observation, interview and documentation review, the facility failed to maintain signage on the bulk oxygen and failed to provide documentation of inspection. This practice would have the potential to affect all patients, visitors and staff at the facility. See the findings at K076 of the Life Safety Code survey that was conducted on 11-10-2015.

16. Based on observation, interview and document review, the facility failed to maintain the emergency generator in accordance with the National Fire Protection Association (NFPA) 110. This deficient condition increased the potential that the generator would fail to run during loss of power. See the findings at K144 of the Life Safety Code survey that was conducted on 11-10-2015.

17. Based on interview and observation, the facility failed to provide a remote audible annunciator panel which was functional and failed to verify low fuel on the exterior fuel tank. This deficient practice would affect all smoke compartments of the building and all occupants as it would delay the response to maintain the generator in the event of failure. See the findings at K146 of the Life Safety Code survey that was conducted on 11-10-2015.

18. Based on observation, interview and documentation review, the facility failed to assure that power strips, extention cords and electrical adaptors were not used in the facility, failed to keep electrical panels free of obstructions, and failed to test and document retention for electrical outlets. These deficient practices increased the potential for electrical fire. See the findings at K147 of the Life Safety Code survey that was conducted on 11-10-2015.

19. Based on record review and interview, the facility failed to assure that a policy was in place regarding the procedures to be taken in the event that the sprinkler system was out of service for more than 4 hours in a 24-hour period. The lack of procedures could affect the actions taken by staff in the event of an emergency. See the findings at K154 of the Life Safety Code survey that was conducted on 11-10-2015.

20. Based on record review and interview, the facility failed to assure that a policy is in place regarding the procedures to be taken in the event that the fire alarm system is out of service for more than 4 hours in a 24-hour period. The lack of procedures could affect the actions taken by staff in the event of an emergency. See the findings at K155 of the Life Safety Code survey that was conducted on 11-10-2015.