HospitalInspections.org

Based on observation, review of facility records, and staff interviews it was determined the facility failed to ensure that emergency lighting is provided as required.
This could place patients and staff at risk in the event of of a power outage or loss of electrical circuit.
The findings include:
During a tour of the facility with Staff M on 06/12/19 between 7:30 am and 5:00 pm observation revealed that emergency lighting units failed to operate when tested throughout the building.
Reference: 2012 NFPA 101 CHAPTER 7 SECTION 7.9.1.2
During a tour of the facility with Staff M on 06/12/19 between 7:30 am and 5:00 pm observation revealed that additional emergency lighting is needed in corridors to provide the required level of lighting for the means of egress.
These findings were confirmed by Staff M at the time of discovery.
Reference: 2012 NFPA 101 CHAPTER 7 SECTION 7.9.1.2

Based on observation, review of facility records, and staff interviews it was determined the facility failed to ensure that Exit signage is continuasly illuminated.
This could place patients and staff at risk in the event of an emergency event.
The findings include:
During a tour of the facility with Staff M on 06/12/19 between 7:30 am and 5:00 pm observation revealed that Exit signage throughout the building failed to be illuminated on back up power.
These findings were confirmed by Staff M at the time of discovery.
Reference: NFPA 101 2012 CHAPTER 7,SECTION 7.8.2.1

Based on observation, review of facility records, and staff interviews it was determined the facility failed to ensure that all vertical openings were protected as required.
This could place patients and staff at risk in the event of a fire or smoke event.
The findings include:
During a tour of the facility with Staff M on 06/12/19 between 7:30 am and 5:00 pm observation revealed that the stairwell door on 3rd floor would not close and latch properly..
These findings were confirmed by Staff M at the time of discovery.
Reference: 2012 NFPA 101 CHAPTER 8 SECTION 8.5.4.3

Based on observation, review of facility records, and staff interviews it was determined the facility failed to ensure that Hazardous areas were seperated as required.
This could place patients and staff at risk in the event of a fire.
The findings include:
1. During a tour of the facility with Staff M on 06/11/19 between 7:30 am and 5:00 pm observation revealed that a door closeing device had been removed from the rated doors for the boiler room and the main switch gear room.
These findings were confirmed by Staff M at the time of discovery.
Reference: 2012 NFPA 101 CHAPTER 39 SECTION 39.3.2.2(1)

Based on observation, review of facility records, and staff interviews it was determined the facility failed to ensure that Fire Alarm System is installed with requirements of NFPA 72.
This could place patients and staff at risk in the event of a fire or smoke event.
The findings include:
1. During a tour of the facility with Staff M on 06/12/19 between 7:30 am and 5:00 pm observation revealed that there was not a smoke detector provided over the fire alarm control panel as required.
Reference: 291 NFPA 101 CHAPTER 9 SECTION 9.6.2.8.1
2. The cross corridor does not have visual notification devices visable.
Reference: 2012 NFPA 101 SECTION 9.6.1.5 2010 NFPA 72 SECTIONS 18.5.4.4.1, 18-5.4.3, 18.5.4.4
These findings were confirmed by Staff M at the time of discovery.

Based on observation and staff interviews it was determined the facility failed to ensure sprinkler coverage met the requirements of NFPA 13.
This could place patients and staff at risk in the event of a fire.
The findings include:
During a tour of the facility with Staff M on 06/12/19 between 7:30 am and 5:00 pm observation revealed that sprinkler heads were not provided under duct work that is over four feet wide, in the IT Room on 5th Floor.
These findings were confirmed by Staff M at the time of discovery.
Reference: 2012 NFPA 101 Section 19.3.5.1; Chapter 9 Section 9.7.1.1(1); 2010 NFPA 13 Section 8.5.5.3.1

Based on observation, review of facility records, and staff interviews it was determined the facility failed to ensure that the sprinkler system was maintained as required.
This could place patients and staff at risk in the event of a fire.
The findings include:
During a tour of the facility with Staff M on 06/12/19 between 7:30 am and 5:00 pm observation revealed that sprinkler heads throughout the building were in need of adjustment.
These findings were confirmed by Staff M at the time of discovery.
Reference: 2012 NFPA 101 CHAPTER 9 SECTION 9.7.5, 2011 NFPA 25 CHAPTER 5 SECTION 5.2.3.1 AND 5.2.3.2

Based on observation, review of facility records, and staff interviews it was determined the facility failed to ensure that corridor doors latched properly.
This could place patients and staff at risk in the event of a fire.
The findings include:
1. During a tour of the facility with Staff M on 06/11/00 between 7:30 am and 5:00 pm observation revealed that Bio-hazard door on 6th floor would not latch properly.
2. During a tour of the facility with Staff M on 06/11/00 between 7:30 am and 5:00 pm observation revealed that door at 022775 on 8th floor needs to be repaired or replaced in order to close and latch properly.
These findings were confirmed by Staff M at the time of discovery.
Reference: 2012 NFPA 101 Chapter 19 sections 19.3.7.6, 19.3.7.8; Chapter 8 sections 8.5.4.3

Based on observation, review of facility records, and staff interviews it was determined the facility failed to ensure Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5.
This could place patients and staff at risk in the event of fire or smoke event.
The findings include:
1. During a tour of the facility with Staff M on 06/11/19 between 7:30 am and 5:00 pm observation revealed that a hole was noted around the sprinkler piping passing through the wall in Zone 7.
2. During a tour of the facility with Staff M on 06/11/19 between 7:30 am and 5:00 pm observation revealed that a hole was noted Enviromental Closet 8E025.
3. During a tour of the facility with Staff M on 06/11/19 between 7:30 am and 5:00 pm observation revealed that a hole was noted in Mechanical Room 8E001.
4.During a tour of the facility with Staff M on 06/11/19 between 7:30 am and 5:00 pm observation revealed that a hole was noted in Electrical room 4J010 fourth floor.





These findings were confirmed by Staff M at the time of discovery.
Reference 2012 NFPA 101 Chapter 19, Section 19.3.7.3, Chapter 8, Section 8.5.2.1, 8.5.2.2, 8.5.7.4, 8.5.6.1, 8.5.6.2