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Based on observation and interview, the facility failed to maintain one exit access in accordance with NFPA 101 (2012 edition) 19.2.10.1, 7.10.8.3.1. This deficient practice could affect and undetermined number of inpatients and staff in 1 of 6 smoke compartments in the facility.

Findings Include:

On 01/16/19 at 2:30 pm, observation revealed an exit sign above the double doors that opened into a construction area. There were no "NO EXIT" signs on the doors. The doors adjacent to Stair 2 were located at the east end of exit access Corridor 110. Due to an exit sign above the doors, and a lack of NO EXIT signs on the doors, the double doors were likely to be mistaken for an exit or exit access doors, and could direct occupants into the construction area the beyond doors, which is deemed unsafe. The deficient practice was confirmed by a concurrent interview with Staff I and Staff G at the time of survey.

Based on observation and interview, the facility failed to maintain the fire-resistance rating of one of six vertical openings due to non-latching stairwell door in accordance with NFPA 101 (2012 edition) 19.3.1.1, 8.6.5, 8.3.3.1. This deficient practice could affect 13 of 67 inpatients and undetermined number of staff and visitors in 1 of 10 smoke compartments in the facility.

Findings include:

On 01/14/19 at 1:25 pm, observation revealed that the fire-rated west double doors of Stairwell G did not latch. The deficient practice was confirmed by a concurrent interview with Staff I and Staff CC at the time of survey.

Based on observation and interview, the facility failed to maintain the fire-resistance rating of one of three vertical openings due to a non-latching stairwell door in accordance with NFPA 101 (2012 edition) 19.3.1.1, 8.6.5, 8.3.3.1. This deficient practice could affect 22 of 68 inpatients and undetermined number of staff and visitors in 1 of 6 smoke compartments in the facility.

Findings include:

On 01/16/19 at 3:30 pm, observation revealed that the 1 1/2-hour fire-rated door of south stairwell of Unit 5 on the 2nd Floor did not latch. The deficient practice was confirmed by a concurrent interview with Staff I and Staff G at the time of survey.

Based on observation and interview, the facility did not maintain the fire and smoke resistive separation of one hazardous areas in accordance with NFPA 101 (2012 edition) 19.3.2.1, 8.4.3.5. The deficient practice could affect an undetermined number of staff in the Kitchen in 1 of 10 smoke compartments in the facility.

Findings include:

On 01/14/19 at 11:20 am, observation revealed that the door to the Dry Food Storage Room, which is a hazardous area, was propped open with a rubber wedge that prevented it from self-closing to provide required separation from other spaces in the event of fire. The deficient practice was confirmed by a concurrent interview with Staff I and Staff CC at the time of survey.

Based on observation and interview, the facility failed to properly install smoke detectors in three locations in accordance with NFPA 101 (2012 edition) 19.3.4.5, 9.6.1.3 and NFPA 72 (2010) 17.7.1.8. This deficient practice could affect 24 of 50 inpatients, and undetermined number of staff and visitors in 2 of 4 smoke compartments in the facility.

Findings Include

1. On 01/17/19 at 11:25 am, observation revealed that one ceiling mounted spot-type smoke detector was within 15 inches from the adjacent HVAC supply air diffuser in the ceiling in the Child/Adolescent Day Room. There was no evidence available at the time of survey that the air velocity at detector was less than or equal to 300 fpm.

2. On 01/17/19 at 11:29 am, observation revealed that one ceiling mounted spot-type smoke detector was within 16 inches from the adjacent HVAC supply air diffuser in the Corridor adjacent to Patient Room 1142 in the Child/Adolescent Unit. There was no evidence available at the time of survey that the air velocity at detector was less than or equal to 300 fpm.

3. On 01/17/19 at 12:00 pm, observation revealed that one ceiling mounted spot-type smoke detector was less than 18 inches from the adjacent HVAC supply air diffuser in the administration suite. There was no evidence available at the time of survey that the air velocity at detector was less than or equal to 300 fpm.

The above deficient practice was confirmed by a concurrent interview with Staff I, Staff EE, Staff FF at the time of survey.

Based on observation and interview, the facility failed to properly install smoke detectors in two locations in accordance with NFPA 101 (2012 edition) 19.3.4.5, 9.6.1.3 and NFPA 72 (2010) 17.7.1.8. This deficient practice could affect 35 of 68 inpatients, and undetermined number of staff and visitors in 2 of 6 smoke compartments in the facility.
Findings include:

1. On 01/16/19 at 1:55 pm, observation revealed that one ceiling mounted spot-type smoke detector was within 15 inches from the adjacent HVAC supply air diffuser in the ceiling. There was no evidence available at the time of survey that the air velocity at the detector was less than or equal to 300 fpm. The detector was located in the Day Room of Unit 1.

2. On 01/16/19 at 2:40 pm, observation revealed that one ceiling mounted spot-type smoke detector was within 16 inches from the adjacent HVAC supply air diffuser in the ceiling. There was no evidence available at the time of survey that the air velocity at detector was less than or equal to 300 fpm. The detector was located in the passage adjacent to medical director's office in the administration suite.

The deficient practice was confirmed by a concurrent interview with Staff I and Staff G at the time of survey.

Based on observation and interview, the facility failed to provide occupant notification in three spaces in accordance with NFPA 101 (2012 edition) 19.3.4.3.1, 9.6.3, NFPA 72 (2010) 18.5.4.4.5. This deficient practice could affect 13 of 67 inpatients, and undetermined number of staff and visitors in 2 of 10 smoke compartments in the facility.

Findings include:

1. On 01/14/19 at 1:35 pm, observation revealed that there was no audible/visual fire alarm device installed to provide notification to occupants in the Doctor's Corridor in the Lower Level. The deficient practice was confirmed by a concurrent interview with Staff I and Staff CC at the time of survey.
2. On 01/14/19 at 1:38 pm, observation revealed that there was no visual fire alarm device installed to provide occupant notification in the Social Worker's Office G261 in the Lower Level. The deficient practice was confirmed by a concurrent interview with Staff I and Staff CC at the time of survey.
3. On 01/14/19 between 2:15 pm and 2:39 pm, observation revealed that there was no visual fire alarm device installed to provide occupant notification within 15 ft. of the end of corridor adjacent to Stair J, and visual or visual/audible alarm in Group Room in the Eating Disorder Inpatient Program unit on the 2nd Floor. The deficient practice was confirmed by a concurrent interview with Staff I, Staff CC, and Staff DD at the time of survey.

Based on observation and interview, the facility failed to provide smoke detection in one space open to the corridor in accordance with NFPA 101 (2012 edition) 19.3.6.1. This deficient practice could affect undetermined number of outpatients, staff and visitors in 1 of 10 smoke compartments in the facility.

Findings Include:

On 01/14/19 at 11:25 am, observation revealed that there was no smoke detector coverage provided in the Café area open to the corridor on the lower level. The deficient practice was confirmed by a concurrent interview with Staff I and Staff CC at the time of survey.

Based on observation and interview, the facility failed to maintain one smoke barrier in accordance with NFPA 101 (2012 edition) 19.3.7.8, 8.5.4.1. The deficient practice could affect 16 of 68 inpatients, and an undetermined number of staff in 1 of 6 smoke compartments in the facility.

Findings include:

On 01/16/19 at 1:35 pm, observation revealed that a set of smoke doors to Unit 4 had a gap of 1/4 inch at the meeting edge that would not prevent smoke transfer from one smoke compartment into the other in the event of fire. The gap was more than the minimum clearance required for the operation of smoke doors. The deficient practice was confirmed by a concurrent interview with Staff I and Staff G at the time of survey.

Based on observation and interview, the facility failed to install one dehumidifier unit in accordance with NFPA 101 (2012 edition) 19.5.2.1, 9.2, NFPA 90A (2012) 4.3.1. This deficient practice had a potential to affect all 22 inpatients and undetermined number of staff in 1 of 6 smoke compartments in the facility.

Findings include:

On 01/16/19 at 3:20 pm, observation revealed that one portable, self-contained dehumidifier unit was placed on top of the pharmacy work counter with a flexible plastic round duct of approximately 6 inches in diameter running from the unit to the ceiling space above and through one ceiling panel above the unit. The flexible duct was not made of iron, steel, aluminum, copper or other materials permitted by NFPA 90A standards.

When interviewed on 1/22/19 at 2:40 pm, Staff R stated that the unit was used to control humidity in the pharmacy and that the plastic flexible duct carried warm air from the dehumidifier unit and terminated into the 3 to 4 ft deep ceiling plenum space above. The ceiling plenum area formed by building walls extended to roof deck above was approximately 20 ft. by 20 ft. as shown by Staff R on the life safety code plan. Surveyor determined that the ductwork was not terminated properly to the exterior of building and an untreated (unfiltered) air was recirculated from ceiling space back into the pharmacy room as a make-up air without a ductwork, and that the room was under negative pressure and not air balanced i.e. equal amount of supply air and return/exhaust air, or under positive pressure.

The deficient practice was confirmed by a concurrent interview with Staff I and Staff G at the time of survey.

Based on observation and staff interview, the facility failed to ensure safety to patients by having a remote emergency manual stop for emergency generator in accordance with NFPA 110 5.6.5.6. This deficient practice affected the entire facility.

Findings Include

On 01/16/19 at 2:50 pm, observation revealed that there was no remote manual emergency stop station for one 800 kW emergency generator located outside. This deficient practice was acknowledged by Staff I and Staff G by a concurrent interview at the time of discovery.

Based on staff interview, the facility failed to ensure safety to patients by having a remote emergency manual stop for the emergency generator in accordance with NFPA 110 5.6.5.6. This deficient practice affected 50 of 50 inpatients in the facility.

Findings Include:

When interviewed on 01/17/19 at 1:20 pm, Staff EE stated that there was no remote emergency stop button installed on the premises for the emergency generator. This deficient practice was confirmed by Staff I, Staff EE and Staff FF at the time of exit conference on 01/17/19 at 1:45 pm.

Based on observation and staff interview, the facility failed to ensure safety to patients due to a lack of clear working space in front of one electrical panel in accordance with NFPA 70 110.34. This deficient practice had a potential to affect 13 of 67 patients in the facility.

Findings Include

On 01/14/19 at 2:42 pm, observation revealed that there was no working space provided due to a Clean Linen cart stored in front of the electrical panel in the Clean Utility Room in the Eating Disorder Inpatient Program unit on the 2nd Floor. This deficient practice was confirmed by a concurrent interview with Staff I, Staff CC and Staff DD at the time of survey.