HospitalInspections.org

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Based on document review and staff interview the facility failed to review and updated the Emergency Preparedness Plan (EPP) as required.

The findings were:

Review of the EPP on 04/06/2022 starting at 3:30 PM revealed that it had been last reviewed and updated in January of 2020. The EPP must be reviewed and updated at least every two (2) years.

Interview with the facilities manager at the time of the observation acknowledged the deficiency, and indicated that they were aware of the requirement.

Interview with the CEO at the time of exit acknowledged the deficiency.
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Based on observation and staff interview, the facility failed to properly maintain means of egress width in accordance with the 2012 NFPA 101, Life Safety Code. Failure to properly maintain means of egress width could result in injury or death in the event of an emergency requiring evacuation. The deficiency affected one (1) of three (3) smoke compartments.

The findings were:

Observation on 04/06/2022 at 11:36 AM revealed couches and chairs located in the corridor directly outside of the Gift Shop near the main entrance. The furniture was located on one side of the corridor, which was 8' in width, and was not securely attached to the floor or wall. The furniture reduced the clear width of the corridor to approximately 5'. Where corridors are 8' in width, fixed furniture that is securely attached to the floor or wall and does not reduce the clear unobstructed corridor width to less than 6' may be permitted.

Interview with the facilities manager at the time of the observation acknowledged the deficiency, and indicated that they were unaware of the requirement.

Interview with the Director of Nursing at the time of exit acknowledged the deficiency.

Ref: 2012 NFPA 101 19.2.3.4(5)
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Based on observation and staff interview, the facility failed to protect hazardous areas in accordance with the 2012 NFPA 101, Life Safety Code. Failure to protect hazardous areas could result in injury or death in the event of a fire. The deficiencies affected four (4) of multiple hazardous storage rooms.

The findings were:

1) Observation on 04/06/2022 at 12:02 PM and 12:05 PM revealed storage rooms greater than 50 s.f. and containing combustible materials that were not equipped with self-closing or automatic-closing doors. Observation of the gift shop storage room and janitor storage room, respectively, revealed large amounts of combustible storage and no operational door closer. Hazardous storage rooms greater than 50 s.f. shall be equipped with doors that are self-closing or automatic-closing.

Interview with the facilities manager at the time of the observation acknowledged the deficiency, and indicated that they were aware of the requirement.

Interview with the CEO at the time of exit acknowledged the deficiency.

Ref: 2012 NFPA 101 19.3.2.1.3, 19.3.2.1.5(7)

2) Observation on 04/06/2022 at 12:22 PM revealed a storage room greater than 50 s.f. and containing combustible materials that had an air transfer opening that was not properly protected. Observation of the basement storage room revealed an air transfer opening between it and the adjacent conference room that was not protected with a smoke damper. Hazardous areas shall be separated by other spaces from smoke partitions. Air transfer openings in smoke partitions shall be provided with approved smoke dampers.

Interview with the facilities manager at the time of the observation acknowledged the deficiency, and indicated that they were unaware of the requirement.

Interview with the CEO at the time of exit acknowledged the deficiency.

Ref: 2012 NFPA 101 19.3.2.1.2, 8.4.6.2

3) Observation on 04/06/2022 at 12:22 PM revealed a storage room greater than 50 s.f. and containing combustible materials that had doors with automatic closers. Observation of the basement materials storage room revealed double doors with automatic closers that had kick-down door stops attached that were being utilized to hold the doors open. A door required to normally be kept closed shall not be secured in the opening position except by means of a magnetic hold-open device that is released by loss of power and fire alarm activation.

Interview with the facilities manager at the time of the observation acknowledged the deficiency, and indicated that they were aware of the requirement.

Interview with the CEO at the time of exit acknowledged the deficiency.

Ref: 2012 NFPA 101 19.3.2.1.2, 8.4.3.5, 7.2.1.8
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Based on document review and staff interview, the facility failed to properly test and maintain the fire alarm system in accordance with the 2010 NFPA 72, National Fire Alarm and Signal Code. Failure to properly test and maintain the fire alarm system could result in injury or death in the event of a fire. The deficiencies affected one (1) of one (1) fire alarm system.

The findings were:

1) Document review on 04/06/2022 starting at 1:35 PM revealed that the annual testing of the fire alarm system did not include all required testing. Review of the documentation revealed that the annunciator panels had not been tested in the last 12 (twelve) months. Annunciator panels associated with the fire alarm system shall be tested every twelve months.

Interview with the facilities manager at the time of the observation acknowledged the deficiency, and indicated that they were aware of the requirement.

Interview with the CEO at the time of exit acknowledged the deficiency.

Ref: 2010 NFPA 72 Table 14.4.5(1)

2) Document review on 04/06/2022 starting at at 1:35 PM revealed that the annual testing of the fire alarm system did not include all required testing. Review of the documentation revealed that the smoke detector sensitivity test had not been conducted in the last 24 (twenty-four) months. The smoke detector sensitivity test shall be conducted every twenty-four months.

Interview with the facilities manager at the time of the observation acknowledged the deficiency, and indicated that they were aware of the requirement.

Interview with the CEO at the time of exit acknowledged the deficiency.

Ref: 2010 NFPA 72 Table 14.4.5(15)(i)
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Based on document review and staff interview, the facility failed to properly maintain elevators in accordance with the 2012 NFPA 101, Life Safety Code. Failure to properly maintain elevators could result in injury or death in the event of an emergency. The deficiency affected one (1) of one (1) elevator.

The findings were:

Document review on 04/06/2022 starting at 1:35 PM revealed that monthly testing of the elevator's fire fighter's emergency operation was not being conducted. Elevators equipped with fire fighter's emergency operations shall have the system operated monthly.

Interview with the facilities manager at the time of the observation acknowledged the deficiency, and indicated that they were not aware of the requirement.

Interview with the CEO at the time of exit acknowledged the deficiency.

Ref: 2012 NFPA 101 19.5.3, 9.4.6.2
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Based on observation and staff interview, the facility failed to utilize power strips in accordance with the 2012 NFPA 99, Health Care Facilities Code. Failure to properly utilize power strips could result in injury or death. The deficiency affected one (1) of one (1) procedure room.

The findings were:

Observation on 04/06/2022 at 11:17 AM revealed a power strip located in the procedure room in the OR suite. Observation of the power strip revealed that it was positioned on the ground and not part of an equipment assembly. Power strips are permitted in patient care areas when part of a movable equipment assembly and when permanently attached to that assembly.

Interview with the facilities manager at the time of the observation acknowledged the deficiency, and indicated that they were unaware of the requirement.

Interview with the CEO at the time of exit acknowledged the deficiency.

Ref: 2012 NFPA 99 10.2.3.6; CMS S&C: 14-46-LSC