HospitalInspections.org

Based on observation and staff interview, the facility failed to mark exits by approved, readily visible signs in all cases where the exit or way to reach the exit was not readily apparent to the occupants. This condition would not allow occupants to efficiently evacuate the facility during a fire or other emergency.

Findings are:
Observations during the facility tour on 1/20/15, at 1:24 pm revealed two exit signs failed to be visible in the corridor when the double doors by the Laundry were closed.
In an interview conducted at the time of observations (1/20/15, at 1:24 pm), Maintenance A acknowledged an exit sign was not installed on the double doors by the Laundry.

Based on observation, record review and staff interview, the facility failed to provide smoke barriers that would resist the passage of smoke, and floor plans to verify the exact locations of the smoke barriers. This condition had the potential to allow smoke to migrate between smoke compartments.

Findings are:
Observation above ceiling during the facility tour on 1/20/15, from 2:55 pm to 3:33 pm revealed:
1. The 2nd Floor West Wing Smoke barrier failed to have penetrations sealed on both sides of the wall throughout the barrier. Drywall failed to be installed on the smoke barrier above the patient room bathrooms to the roof deck.
2. Holes around conduits in the smoke barrier above the OB Smoke Doors failed to be sealed.
Record review on 1/20/15, from 2:55 pm to 3:33 pm revealed the facility failed to provide floor plans that identified all smoke and fire barriers throughout the facility. The condition of all the barriers could not be accurately verified without the floor plans.
In an interview conducted at the time of observation, (1/20/15, from 2:55 pm to 3:33 pm), Maintenance A confirmed the findings.

Based on observation and staff interview, the facility failed to separate hazardous areas from use areas. This condition had the potential to allow smoke and fire to migrate into other areas of the facility.

Findings are:
Observations during the facility tour on 1/20/15, from 11:42 am to 2:08 pm revealed:
1. The Electrical Room A135 Door failed to self-close because the closure had been unhooked.
2. Holes around conduits inside the Electrical Room A135 failed to be sealed inside the room.
3. A self-closure failed to be installed on the 1927 Basement Storage Door.
4. A self-closure failed to be installed on the Respiratory Supply Room Door.
5. Self-closures failed to be installed on both 2nd Floor North storage room doors.
In an interview conducted at the time of observations (1/20/15, from 11:42 am to 2:08 pm), Maintenance A acknowledged the findings.

Based on observation and staff interview, the facility failed to maintain a set of doors in a horizontal exit to resist the passage of smoke and fire. This condition would allow smoke and fire to migrate to other areas of the facility.

Findings are:
Observation during the facility tour on 1/20/15, at 12:00 pm revealed a gap between the meeting edges of the fire doors by the MRI failed to be sealed to resist the passage of smoke.
In an interview conducted at the time of observation, (1/20/15, at 12:00 pm), Maintenance A confirmed the gap.

NFPA 80, 1999, 2-3.1.7
The clearance between the edge of the door on the pull side and the frame, and the meeting edges of doors swinging in pairs on the pull side shall be 1/8 in. ± 1/16 in. (3.18 mm ± 1.59 mm) for steel doors and shall not exceed 1/8 in. (3.18 mm) for wood doors.

Based on observation and staff interview, the facility failed to maintain corridors free of obstructions. This condition would slow the evacuation of patients during an emergency.

Findings are:
Observation during the facility tour on 1/20/15, at 2:22 pm revealed carts on wheels, beds, wheel chairs and other storage items failed to be removed from exit corridors throughout the 2nd Floor after not being used for 30 minutes.
In an interview conducted at the time of observation, (1/20/15, at 2:22 pm), Maintenance A acknowledged the findings.

Based on record review and staff interview, the facility failed to maintain operating room humidity levels at a minimum of 35% during procedures. This condition increased the potential of a fire during procedures.

Findings are:
Record review on 1/20/15, at 2:49 pm during the facility tour revealed that the humidity levels failed to be maintained at a minimum of 35% during procedures for the last year.
In an interview conducted at the time of record review, (1/20/15, at 2:49 pm), Maintenance A confirmed the findings.

Based on record review and staff interview, the facility failed to maintain the emergency generator in accordance with the National Fire Protection Association (NFPA), 110. This condition increased the potential that the generator would fail to run during loss of power.

Findings are:
Record review on 1/20/15, at 10:53 am of emergency generator maintenance revealed:
1. The time from loss of normal power to when emergency generator power was established failed to be documented during monthly load tests.
2. The monthly test for April, 2014 failed to be documented.
In an interview conducted at the time of record review, (1/20/15, at 10:53 am), Maintenance A confirmed that the generator documentation failed to be completed.

Actual NFPA Standard:
NFPA 110, 1999, 6-4.1*
Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
Exception: If the generator set is used for standby power or for peak load shaving, such use shall be recorded and shall be permitted to be substituted for scheduled operations and testing of the generator set, provided the appropriate data are recorded.
6-4.2*
Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
The date and time of day for required testing shall be decided by the owner, based on facility operations.

Based on observation and staff interview, the facility failed to use electrical equipment in accordance with the National Fire Protection Association (NFPA), 70. This condition had the potential to cause an electrical fire.

Findings are:
Observation during the facility tour on 1/20/15, from 11:14 am to 1:56 pm revealed:
1. Exposed wiring in a light ballast at the base of the 1927 Basement Storage Room Steps failed to be installed in a junction box.
2. A junction box cover failed to be installed on the open junction box by the diesel tank in the 1927 Basement Storage Room.
3. Three feet of clearance in front of the electrical panel in the Laundry failed to be maintained, due to a cart stored in front of the panel.
4. Heat producing crock pots were plugged into power strips and failed to be plugged directly into wall outlets in the Business Kitchenette.
5. A junction box cover failed to be installed on the open junction box between the boilers in the Boiler Room.
6. A junction box cover failed to be installed on the open junction box above the boilers in the Boiler Room.
7. An exposed outlet failed to have a cover installed over the outlet box between the boilers in the Boiler Room.
In an interview conducted at the time of observation (on 1/20/15, from 11:14 am to 1:56 pm), Maintenance A acknowledged the findings.

Based on observation and staff interview, the facility failed to mark exits by approved, readily visible signs in all cases where the exit or way to reach the exit was not readily apparent to the occupants. This condition would not allow occupants to efficiently evacuate the facility during a fire or other emergency.

Findings are:
Observations during the facility tour on 1/20/15, at 1:24 pm revealed two exit signs failed to be visible in the corridor when the double doors by the Laundry were closed.
In an interview conducted at the time of observations (1/20/15, at 1:24 pm), Maintenance A acknowledged an exit sign was not installed on the double doors by the Laundry.

Based on observation, record review and staff interview, the facility failed to provide smoke barriers that would resist the passage of smoke, and floor plans to verify the exact locations of the smoke barriers. This condition had the potential to allow smoke to migrate between smoke compartments.

Findings are:
Observation above ceiling during the facility tour on 1/20/15, from 2:55 pm to 3:33 pm revealed:
1. The 2nd Floor West Wing Smoke barrier failed to have penetrations sealed on both sides of the wall throughout the barrier. Drywall failed to be installed on the smoke barrier above the patient room bathrooms to the roof deck.
2. Holes around conduits in the smoke barrier above the OB Smoke Doors failed to be sealed.
Record review on 1/20/15, from 2:55 pm to 3:33 pm revealed the facility failed to provide floor plans that identified all smoke and fire barriers throughout the facility. The condition of all the barriers could not be accurately verified without the floor plans.
In an interview conducted at the time of observation, (1/20/15, from 2:55 pm to 3:33 pm), Maintenance A confirmed the findings.

Based on observation and staff interview, the facility failed to separate hazardous areas from use areas. This condition had the potential to allow smoke and fire to migrate into other areas of the facility.

Findings are:
Observations during the facility tour on 1/20/15, from 11:42 am to 2:08 pm revealed:
1. The Electrical Room A135 Door failed to self-close because the closure had been unhooked.
2. Holes around conduits inside the Electrical Room A135 failed to be sealed inside the room.
3. A self-closure failed to be installed on the 1927 Basement Storage Door.
4. A self-closure failed to be installed on the Respiratory Supply Room Door.
5. Self-closures failed to be installed on both 2nd Floor North storage room doors.
In an interview conducted at the time of observations (1/20/15, from 11:42 am to 2:08 pm), Maintenance A acknowledged the findings.

Based on observation and staff interview, the facility failed to maintain a set of doors in a horizontal exit to resist the passage of smoke and fire. This condition would allow smoke and fire to migrate to other areas of the facility.

Findings are:
Observation during the facility tour on 1/20/15, at 12:00 pm revealed a gap between the meeting edges of the fire doors by the MRI failed to be sealed to resist the passage of smoke.
In an interview conducted at the time of observation, (1/20/15, at 12:00 pm), Maintenance A confirmed the gap.

NFPA 80, 1999, 2-3.1.7
The clearance between the edge of the door on the pull side and the frame, and the meeting edges of doors swinging in pairs on the pull side shall be 1/8 in. ± 1/16 in. (3.18 mm ± 1.59 mm) for steel doors and shall not exceed 1/8 in. (3.18 mm) for wood doors.

Based on observation and staff interview, the facility failed to maintain corridors free of obstructions. This condition would slow the evacuation of patients during an emergency.

Findings are:
Observation during the facility tour on 1/20/15, at 2:22 pm revealed carts on wheels, beds, wheel chairs and other storage items failed to be removed from exit corridors throughout the 2nd Floor after not being used for 30 minutes.
In an interview conducted at the time of observation, (1/20/15, at 2:22 pm), Maintenance A acknowledged the findings.

Based on record review and staff interview, the facility failed to maintain operating room humidity levels at a minimum of 35% during procedures. This condition increased the potential of a fire during procedures.

Findings are:
Record review on 1/20/15, at 2:49 pm during the facility tour revealed that the humidity levels failed to be maintained at a minimum of 35% during procedures for the last year.
In an interview conducted at the time of record review, (1/20/15, at 2:49 pm), Maintenance A confirmed the findings.

Based on record review and staff interview, the facility failed to maintain the emergency generator in accordance with the National Fire Protection Association (NFPA), 110. This condition increased the potential that the generator would fail to run during loss of power.

Findings are:
Record review on 1/20/15, at 10:53 am of emergency generator maintenance revealed:
1. The time from loss of normal power to when emergency generator power was established failed to be documented during monthly load tests.
2. The monthly test for April, 2014 failed to be documented.
In an interview conducted at the time of record review, (1/20/15, at 10:53 am), Maintenance A confirmed that the generator documentation failed to be completed.

Actual NFPA Standard:
NFPA 110, 1999, 6-4.1*
Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
Exception: If the generator set is used for standby power or for peak load shaving, such use shall be recorded and shall be permitted to be substituted for scheduled operations and testing of the generator set, provided the appropriate data are recorded.
6-4.2*
Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
The date and time of day for required testing shall be decided by the owner, based on facility operations.

Based on observation and staff interview, the facility failed to use electrical equipment in accordance with the National Fire Protection Association (NFPA), 70. This condition had the potential to cause an electrical fire.

Findings are:
Observation during the facility tour on 1/20/15, from 11:14 am to 1:56 pm revealed:
1. Exposed wiring in a light ballast at the base of the 1927 Basement Storage Room Steps failed to be installed in a junction box.
2. A junction box cover failed to be installed on the open junction box by the diesel tank in the 1927 Basement Storage Room.
3. Three feet of clearance in front of the electrical panel in the Laundry failed to be maintained, due to a cart stored in front of the panel.
4. Heat producing crock pots were plugged into power strips and failed to be plugged directly into wall outlets in the Business Kitchenette.
5. A junction box cover failed to be installed on the open junction box between the boilers in the Boiler Room.
6. A junction box cover failed to be installed on the open junction box above the boilers in the Boiler Room.
7. An exposed outlet failed to have a cover installed over the outlet box between the boilers in the Boiler Room.
In an interview conducted at the time of observation (on 1/20/15, from 11:14 am to 1:56 pm), Maintenance A acknowledged the findings.