HospitalInspections.org

Based on observation, testing, and staff interviews it was determined the facility failed to maintain doors in corridors capable of resisting fire for at least 20 minutes and having no impediment to closing the doors. NFPA 101 19.3.6.3
The findings were:
During a tour of the facility with Staff M on 03/16-17/15 from 11:20 a.m. to 4:30 p.m. it was observed by testing doors protecting corridor openings that they did create a smoke resistance barrier at their edges. NFPA 101 18.3.6.3
· Patient Rooms
624, 636, 637, 503, 515, 520, Corridor Doors 5th Floor (This is a typical issue through facility)

Door that did not latch NFPA 101 18.3.6.3.2
627, 634, T1078, T1049 (This is a typical issue through facility)

· Corridor smoke doors damaged or modified no longer carry their UL Listing
Stair C, 3rd and 4th floors corridor doors. (This is a typical issue through facility)
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 properly maintain rated walls for Soiled Utility Rooms.
The findings were:
During a tour of the facility with Staff M on 03/16-17/15 from 11:20 a.m. to 4:30 p.m. it was observed that the walls creating the Soiled Utility Rooms do not create the required enclosure.
· Soiled Utility Rooms in the facility that fall under Chapter 18 do not create a one hour fire-rated barrier. NFPA 101
During a tour of the facility with Staff M on 03/16-17/15 from 11:20 a.m. to 4:30 p.m. it was observed that fire rated walls are not properly maintained.
· Unprotected penetrations
· Improperly protected penetrations room K 029 - mixing of fire protection caulks (Typical throughout facility)
· Fire rated door with non-rated hinge
· Rated walls not sealed to floor above (Typical throughout facility)
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 properly maintain rated walls that create the emergency egress stairwell enclosure.
The findings were:
During a tour of the facility with Staff M on 03/16-17/15 from 11:20 a.m. to 4:30 p.m. the below identified violations were noted regarding rated wall construction.
· Unprotected penetrations by fire sprinkler piping NFPA 101 8.2.5.2
· Openings between structural members and walls NFPA 101 8.2.5.2 NFPA 101 8.2.5.2
· Use of non-rated expansion foam to seal holes in wall. Penthouse
These finding were confirmed by Staff M at the time of discovery.

Based on observation and staff interviews it was determined the facility failed to properly maintain egress doors in the facility. NFPA 101 18.2.1, 7.2.1.7
The findings were:
During a tour of the facility with Staff M on 03/16-17/15 from 11:20 a.m. to 4:30 p.m. that the exit doors from Burn Unit 2 do not have the required panic hardware.
These finding were confirmed by Staff M at the time of discovery.

Based on observation, review of facility records, and staff interviews it was determined the facility failed to maintain emergency lighting of at least one and one half hours duration. NFPA 101 7.9.3
The findings were:
During a review of facility records with Staff M on 03/16/15 at approximately 8:15 a.m. it was observed that the emergency light testing was not properly documented to determine the duration of testing conducted each month. 30 second each month and 90 minutes annually. NFPA 101 7.9.3
During the tour of the facility with Staff M on 03/16-17/15 from 11:20 a.m. to 4:30 p.m. the below violation with emergency lighting was identified.
· No emergency lighting is installed from the exits of the facility to the public way. NFPA 101 7.8.1.1
These findings were confirmed by Staff M at the time of discovery.

Based on observation and staff interview it was determined the facility failed to provide exit and directional signs with continuous illumination. NFPA 101 7.10.9.2 and 7.9.3

The findings were:

During a tour of the facility with Staff M on 03/16/15 03/16-17/15 from 11:20 a.m. to 4:30 p.m. the below violations were noted regarding Exit and Exit directional signs.

· Exit light at the rear door of the Board Room was not illuminated. NFPA 101 7.10.9.2 and 7.9.3
· Exit lights damaged - Corridor OR4, Corridor T1201

During a tour of the facility with Staff M on 03/17-18/15 from 1:00 p.m. to 2:30 p.m. it was identified that the 2 exit lights in the back hall did not illuminate when tested at 3624 Dewey Gray Circle, Women 's Diagnostic Center.

This finding was confirmed by Staff M at the time of discovery.

Based on observation, review of facility records, and staff interviews it was determined the facility failed to provide all required information in their Fire Evacuation Plan. NFPA 101 18.7.2.2

The findings were:
During a review of facility records on 03/16/15 at approximately 8:45 a.m. it was determined the facility Fire Plan does not fully address the 8 elements identified in NFPA 101, Chapter 18 2000 Edition.
· Transmission of alarm to fire department
· Extinguishment of fire
· Evacuation of Smoke Compartment
· Evacuation of immediate area
· Preparation of floor and building for evacuation
· Staff responsibilities
These findings were confirmed by Staff M at the time of discovery.

Based on observation, review of facility records, and staff interviews it was determined the facility failed to ensure that quarterly fire drills are conducted on all shifts. I the event of an emergency this would place all residents at risk.
The findings were:
During a review of facility records on 03/16/15 at approximately 9:10 a.m. it was determined the below identified violations occurred involving fire drills or their reporting. NFPA 101 18.7.1.2
Fire Drill not conducted quarterly NFPA 101 18.7.1.2
· No fire drills were conducted for the 3rd shift during the 1st and 2nd quarters
Fire/relocation drills were not conducted at varying times throughout the shift as required by NFPA 101 Chapter 4, : " 4.7.5* Simulated Conditions. Drills shall be held at expected and unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency." and Annex A which states,
"A.4.7.5 Fire is always unexpected. If the drill is always held in the same way at the same time, it loses much of its value. When, for some reason during an actual fire, it is not possible to follow the usual routine of the emergency egress and relocation drill to which occupants have become accustomed, confusion and panic might ensue. Drills should be carefully planned to simulate actual fire conditions. Not only should drills be held at varying times, but different means of exit or relocation areas should be used, based on an assumption that fire or smoke might prevent the use of normal egress and relocation avenues.

1. First shift drills were conducted between 9:00 and 11:30 a.m.
2. Third shift drills for 3rd and 4th quarters were conducted between 6:10 and 6:30 a.m.
During a review of offsite facility records on 03/18/15 at approximately 8:10 a.m. it was determined that the office site facilities located at two different locations are not conducting quarterly fire drills.
Fire drill records do not provide all needed information to evaluate the drills as outlined in NFPA 101 18.7.1.2 and 18.7.2.1
These findings were confirmed by Staff M at the time of discovery.

Based on observation, review of facility records, and staff interviews it was determined the facility failed to properly maintain the fire alarm system. NFPA 101 9.6.1.3
The findings were:
During a review of facility records on 03/16/15 at approximately 9:30 a.m. it was determined that no sensitivity testing has been conducted on facility smoke detectors in over 5 years.
These findings were confirmed by Staff M at the time of discovery.

Based on observation, facility tour, and staff interviews it was determined the facility failed to properly maintain the fire sprinkler system. NFPA 101 9.7.2.1,
The findings were:
During a tour of the facility with Staff M on 03/16-17/15 from 11:20 a.m. to 4:30 p.m. the below identified violations were identified with the Fire Sprinkler System.
· 2 OS&Y valves above ceiling on the First Floor near the Pharmacy are not supervised as required.
· All outside valves are not supervised
These findings were confirmed by Staff M at the time of discovery.

Based on observation, facility tour, and staff interviews it was determined the facility failed to properly maintain the fire sprinkler system. NFPA 25 5.3.2, 5.2.1.1.2
The findings were:
During a tour of the facility with Staff M on 03/16/15 03/16-17/15 from 11:20 a.m. to 4:30 p.m. the below identified violations were identified with the Fire Sprinkler System. (The below violations are typical)
· Fire sprinkler heads loaded with dust, grease in the Kitchen, Penthouse, and the Pyxis on the 5th Floor
· Endoscopy Section A due to an added wall there is a gap in fire sprinkler coverage. NFPA 13
· Fire sprinkler supports are not properly spaced
· Fire sprinkler piping supports improperly attached to other piping
· Low voltage wires attached to fire sprinkler piping
These finding were confirmed by Staff M at the time of discovery.

Based on observation, facility tour, and staff interviews it was determined the facility failed to properly maintain egress corridors.
The findings were:
During a tour of the facility with Staff M on 03/16/15 03/16-17/15 from 11:20 a.m. to 4:30 p.m. the below identified violations were identified. (The below violations are typical) NFPA 101 18.2.1, 7.1.10
· Fifth floor - Patient bed and extra mattresses stored in corridor
· Elevator lobbies used for storage - damaged beds, cleaning equipment
These finding were confirmed by Staff M at the time of discovery.

Based on observation, facility tour, and staff interviews it was determined the facility failed to properly secure oxygen cylinders. NFPA 99
The findings were:
During a tour of the facility with Staff M on 03/16/15 03/16-17/15 from 11:20 a.m. to 4:30 p.m. the below violations were identified regarding the storage of Oxygen Cylinders.
· 12 oxygen cylinders were not secured to prevent physical damage to the cylinders. NFPA 99 11.10.2.8
· Oxygen stored next to residential cloth dryer on treatment floors
These finding were confirmed by Staff M at the time of discovery.

Based on observation and staff interview it was determined the facility failed to properly identify the locations of stored oxygen.
The findings were:

During a tour of the facility with Staff M on 03/16/15 03/16-17/15 from 11:20 a.m. to 4:30 p.m. it was observed that the outside cylinder storage area and the outside oxygen tank area do not have the required signage.
CAUTION, OXIDIZING GAS (ES) STORED WITHIN, NO SMOKING
These findings were confirmed by Staff M at the time of discovery.

Based on observation, review of facility records, and staff interviews it was determined the facility failed to properly document testing NFPA 110 and NFPA 99.
The findings were:
During a review of the facility with Staff M on 03/16/15 at approximately 10:00 a.m. it was observed that the monthly load run paper work did not contain proof of duration of run and no readings were provided. Based on the information provided I was unable to determine how long the generators were ran monthly under load.
These findings were confirmed by Staff M at the time of discovery.

Based on observation and staff interview it was determined the facility failed to maintain the electrical wiring in accordance with NFPA 70 (These violations are typical throughout facility)

The findings were:

During a tour of the facility with Staff M on 03/16/15 03/16-17/15 from 11:20 a.m. to 4:30 p.m. the below violations were identified. NFPA 70 300.11, 604.6 (3) (These violations are typical throughout facility)

· Flexible power cords above ceiling - Board Room, Floor Nurse 's Stations
· Low voltage wiring not properly secured
· Electrical plug strips that fail to comply with manufacturer 's specification and code room T1077. (These violations are typical throughout facility)
· No cover on receptacle in room T1049, 203A
· Electrical system damaged in room T2076

These findings were confirmed by Staff M at the time of discovery.

Based on observation and staff interview it was determined the facility failed properly install Alcohol Based Hand Rub dispensers (ABHR). This could place all residents at risk in the event of a fire in the facility.

The findings were:

During a tour of the facility with Staff M on 03/16-17/15 from 11:20 a.m. to 4:30 p.m. it was observed that ABHR dispensers were installed directly above light switches in several locations throughout the facility. S&C Letter 07-01

These finding were confirmed by Staff M at the time of discovery.

Based on observation, testing, and staff interviews it was determined the facility failed to maintain doors in corridors capable of resisting fire for at least 20 minutes and having no impediment to closing the doors. NFPA 101 19.3.6.3
The findings were:
During a tour of the facility with Staff M on 03/16-17/15 from 11:20 a.m. to 4:30 p.m. it was observed by testing doors protecting corridor openings that they did create a smoke resistance barrier at their edges. NFPA 101 18.3.6.3
· Patient Rooms
624, 636, 637, 503, 515, 520, Corridor Doors 5th Floor (This is a typical issue through facility)

Door that did not latch NFPA 101 18.3.6.3.2
627, 634, T1078, T1049 (This is a typical issue through facility)

· Corridor smoke doors damaged or modified no longer carry their UL Listing
Stair C, 3rd and 4th floors corridor doors. (This is a typical issue through facility)
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 properly maintain rated walls for Soiled Utility Rooms.
The findings were:
During a tour of the facility with Staff M on 03/16-17/15 from 11:20 a.m. to 4:30 p.m. it was observed that the walls creating the Soiled Utility Rooms do not create the required enclosure.
· Soiled Utility Rooms in the facility that fall under Chapter 18 do not create a one hour fire-rated barrier. NFPA 101
During a tour of the facility with Staff M on 03/16-17/15 from 11:20 a.m. to 4:30 p.m. it was observed that fire rated walls are not properly maintained.
· Unprotected penetrations
· Improperly protected penetrations room K 029 - mixing of fire protection caulks (Typical throughout facility)
· Fire rated door with non-rated hinge
· Rated walls not sealed to floor above (Typical throughout facility)
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 properly maintain rated walls that create the emergency egress stairwell enclosure.
The findings were:
During a tour of the facility with Staff M on 03/16-17/15 from 11:20 a.m. to 4:30 p.m. the below identified violations were noted regarding rated wall construction.
· Unprotected penetrations by fire sprinkler piping NFPA 101 8.2.5.2
· Openings between structural members and walls NFPA 101 8.2.5.2 NFPA 101 8.2.5.2
· Use of non-rated expansion foam to seal holes in wall. Penthouse
These finding were confirmed by Staff M at the time of discovery.

Based on observation and staff interviews it was determined the facility failed to properly maintain egress doors in the facility. NFPA 101 18.2.1, 7.2.1.7
The findings were:
During a tour of the facility with Staff M on 03/16-17/15 from 11:20 a.m. to 4:30 p.m. that the exit doors from Burn Unit 2 do not have the required panic hardware.
These finding were confirmed by Staff M at the time of discovery.

Based on observation, review of facility records, and staff interviews it was determined the facility failed to maintain emergency lighting of at least one and one half hours duration. NFPA 101 7.9.3
The findings were:
During a review of facility records with Staff M on 03/16/15 at approximately 8:15 a.m. it was observed that the emergency light testing was not properly documented to determine the duration of testing conducted each month. 30 second each month and 90 minutes annually. NFPA 101 7.9.3
During the tour of the facility with Staff M on 03/16-17/15 from 11:20 a.m. to 4:30 p.m. the below violation with emergency lighting was identified.
· No emergency lighting is installed from the exits of the facility to the public way. NFPA 101 7.8.1.1
These findings were confirmed by Staff M at the time of discovery.

Based on observation and staff interview it was determined the facility failed to provide exit and directional signs with continuous illumination. NFPA 101 7.10.9.2 and 7.9.3

The findings were:

During a tour of the facility with Staff M on 03/16/15 03/16-17/15 from 11:20 a.m. to 4:30 p.m. the below violations were noted regarding Exit and Exit directional signs.

· Exit light at the rear door of the Board Room was not illuminated. NFPA 101 7.10.9.2 and 7.9.3
· Exit lights damaged - Corridor OR4, Corridor T1201

During a tour of the facility with Staff M on 03/17-18/15 from 1:00 p.m. to 2:30 p.m. it was identified that the 2 exit lights in the back hall did not illuminate when tested at 3624 Dewey Gray Circle, Women 's Diagnostic Center.

This finding was confirmed by Staff M at the time of discovery.

Based on observation, review of facility records, and staff interviews it was determined the facility failed to provide all required information in their Fire Evacuation Plan. NFPA 101 18.7.2.2

The findings were:
During a review of facility records on 03/16/15 at approximately 8:45 a.m. it was determined the facility Fire Plan does not fully address the 8 elements identified in NFPA 101, Chapter 18 2000 Edition.
· Transmission of alarm to fire department
· Extinguishment of fire
· Evacuation of Smoke Compartment
· Evacuation of immediate area
· Preparation of floor and building for evacuation
· Staff responsibilities
These findings were confirmed by Staff M at the time of discovery.

Based on observation, review of facility records, and staff interviews it was determined the facility failed to ensure that quarterly fire drills are conducted on all shifts. I the event of an emergency this would place all residents at risk.
The findings were:
During a review of facility records on 03/16/15 at approximately 9:10 a.m. it was determined the below identified violations occurred involving fire drills or their reporting. NFPA 101 18.7.1.2
Fire Drill not conducted quarterly NFPA 101 18.7.1.2
· No fire drills were conducted for the 3rd shift during the 1st and 2nd quarters
Fire/relocation drills were not conducted at varying times throughout the shift as required by NFPA 101 Chapter 4, : " 4.7.5* Simulated Conditions. Drills shall be held at expected and unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency." and Annex A which states,
"A.4.7.5 Fire is always unexpected. If the drill is always held in the same way at the same time, it loses much of its value. When, for some reason during an actual fire, it is not possible to follow the usual routine of the emergency egress and relocation drill to which occupants have become accustomed, confusion and panic might ensue. Drills should be carefully planned to simulate actual fire conditions. Not only should drills be held at varying times, but different means of exit or relocation areas should be used, based on an assumption that fire or smoke might prevent the use of normal egress and relocation avenues.

1. First shift drills were conducted between 9:00 and 11:30 a.m.
2. Third shift drills for 3rd and 4th quarters were conducted between 6:10 and 6:30 a.m.
During a review of offsite facility records on 03/18/15 at approximately 8:10 a.m. it was determined that the office site facilities located at two different locations are not conducting quarterly fire drills.
Fire drill records do not provide all needed information to evaluate the drills as outlined in NFPA 101 18.7.1.2 and 18.7.2.1
These findings were confirmed by Staff M at the time of discovery.

Based on observation, review of facility records, and staff interviews it was determined the facility failed to properly maintain the fire alarm system. NFPA 101 9.6.1.3
The findings were:
During a review of facility records on 03/16/15 at approximately 9:30 a.m. it was determined that no sensitivity testing has been conducted on facility smoke detectors in over 5 years.
These findings were confirmed by Staff M at the time of discovery.

Based on observation, facility tour, and staff interviews it was determined the facility failed to properly maintain the fire sprinkler system. NFPA 101 9.7.2.1,
The findings were:
During a tour of the facility with Staff M on 03/16-17/15 from 11:20 a.m. to 4:30 p.m. the below identified violations were identified with the Fire Sprinkler System.
· 2 OS&Y valves above ceiling on the First Floor near the Pharmacy are not supervised as required.
· All outside valves are not supervised
These findings were confirmed by Staff M at the time of discovery.

Based on observation, facility tour, and staff interviews it was determined the facility failed to properly maintain the fire sprinkler system. NFPA 25 5.3.2, 5.2.1.1.2
The findings were:
During a tour of the facility with Staff M on 03/16/15 03/16-17/15 from 11:20 a.m. to 4:30 p.m. the below identified violations were identified with the Fire Sprinkler System. (The below violations are typical)
· Fire sprinkler heads loaded with dust, grease in the Kitchen, Penthouse, and the Pyxis on the 5th Floor
· Endoscopy Section A due to an added wall there is a gap in fire sprinkler coverage. NFPA 13
· Fire sprinkler supports are not properly spaced
· Fire sprinkler piping supports improperly attached to other piping
· Low voltage wires attached to fire sprinkler piping
These finding were confirmed by Staff M at the time of discovery.

Based on observation, facility tour, and staff interviews it was determined the facility failed to properly maintain egress corridors.
The findings were:
During a tour of the facility with Staff M on 03/16/15 03/16-17/15 from 11:20 a.m. to 4:30 p.m. the below identified violations were identified. (The below violations are typical) NFPA 101 18.2.1, 7.1.10
· Fifth floor - Patient bed and extra mattresses stored in corridor
· Elevator lobbies used for storage - damaged beds, cleaning equipment
These finding were confirmed by Staff M at the time of discovery.

Based on observation, facility tour, and staff interviews it was determined the facility failed to properly secure oxygen cylinders. NFPA 99
The findings were:
During a tour of the facility with Staff M on 03/16/15 03/16-17/15 from 11:20 a.m. to 4:30 p.m. the below violations were identified regarding the storage of Oxygen Cylinders.
· 12 oxygen cylinders were not secured to prevent physical damage to the cylinders. NFPA 99 11.10.2.8
· Oxygen stored next to residential cloth dryer on treatment floors
These finding were confirmed by Staff M at the time of discovery.

Based on observation and staff interview it was determined the facility failed to properly identify the locations of stored oxygen.
The findings were:

During a tour of the facility with Staff M on 03/16/15 03/16-17/15 from 11:20 a.m. to 4:30 p.m. it was observed that the outside cylinder storage area and the outside oxygen tank area do not have the required signage.
CAUTION, OXIDIZING GAS (ES) STORED WITHIN, NO SMOKING
These findings were confirmed by Staff M at the time of discovery.

Based on observation, review of facility records, and staff interviews it was determined the facility failed to properly document testing NFPA 110 and NFPA 99.
The findings were:
During a review of the facility with Staff M on 03/16/15 at approximately 10:00 a.m. it was observed that the monthly load run paper work did not contain proof of duration of run and no readings were provided. Based on the information provided I was unable to determine how long the generators were ran monthly under load.
These findings were confirmed by Staff M at the time of discovery.

Based on observation and staff interview it was determined the facility failed to maintain the electrical wiring in accordance with NFPA 70 (These violations are typical throughout facility)

The findings were:

During a tour of the facility with Staff M on 03/16/15 03/16-17/15 from 11:20 a.m. to 4:30 p.m. the below violations were identified. NFPA 70 300.11, 604.6 (3) (These violations are typical throughout facility)

· Flexible power cords above ceiling - Board Room, Floor Nurse 's Stations
· Low voltage wiring not properly secured
· Electrical plug strips that fail to comply with manufacturer 's specification and code room T1077. (These violations are typical throughout facility)
· No cover on receptacle in room T1049, 203A
· Electrical system damaged in room T2076

These findings were confirmed by Staff M at the time of discovery.