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272 HOSPITAL ROAD

CHILLICOTHE, OH 45601

PHYSICAL ENVIRONMENT

Tag No.: A0700

RECITE

Based on observations made during facility tour and staff interview the Condition of Participation of Physical Environment was not met related to fire in regard to smoke barrier penetrations, exit discharge lights, smoke detector locations, and dirty sprinkler heads. This has the potential to affect all patients. The census at the time of the survey was 142 patients.
Please refer to A709 and A710.


29731

LIFE SAFETY FROM FIRE

Tag No.: A0709

RECITE

Based on observations and staff interviews, the facility failed to meet the provisions of the Life Safety Code from fire requirements were met, related to smoke barrier penetrations, exit discharge lights, smoke detector locations, and dirty sprinkler heads. This has the potential to affect all patients. The census at the time of the survey was 142 patients.

Findings include:

A tour was conducted on 07/23/12 with Staff B (Director Facility Operations), Staff C (Facility Operations Coordinator), and Staff F (Interim Safety Officer) between 1:40 PM and 3:55 PM. Observations and interviews with these staff during tour revealed the facility failed to maintain the hospital environment related to penetrations in a smoke barrier, exit discharge lights, smoke detector locations at least 36 inches from air handler outlets, and to ensure sprinkler heads remained free from dust and dirt.

Refer to A710.




29731

LIFE SAFETY FROM FIRE

Tag No.: A0710

RECITE:
Based on observations and staff interviews, the facility failed to to meet the applicable provisions of the Life Safety Code, NFPA 101, 2000 edition of the Life Safety Code. This related to smoke barrier penetrations, exit discharge lights, smoke detector locations, and dirty sprinkler heads. This has the potential to affect all patients. The census at the time of the survey was 142 patients.

Findings include:

A tour was conducted on 07/23/12 with Staff B (Director Facility Operations), Staff C (Facility Operations Coordinator), and Staff F (Interim Safety Officer) between 1:40 PM and 3:55 PM. The following areas were observed and verified with Staff B and F during tour:

One of four smoke barriers was observed with a penetration. Refer to K25.

An exit from the Emergency Department lacked the required discharge lights. Refer to K45.

Smoke detectors were not located at least 36 inches from air handler outlets. Refer to K52.

The facility was observed with dirty sprinkler heads. Refer to K62.







29731