HospitalInspections.org

Based on observations during tour, review of floor plans, and staff interview, the facility failed to provide smoke barriers that formed at least two smoke compartments constructed to provide at least a one hour fire resistance rating. This had the potential to affect all patients, staff and visitors utilizing the facility. The patient census was 13 at the time of the survey.

Findings include:

Tour of the facility's main building took place on 01/26/10 to 01/27/10 with the manager of plant engineering (staff #C).
Penetrations were observed in the one hour rated smoke barrier above the ceiling tile in the following locations:

* A two inch open end conduit was observed above the smoke barrier doors located near the main fire panel.
* One and a half inch unsealed conduit above the pharmacy door.
* In the corridor on the northeast corner of the wellness center above the double doors, observation was made of a half inch unsealed conduit.
* In the corridor on the north side of the morgue above the double doors, observation was made of eight large unsealed conduits and one four inch open end conduit passing through the smoke barrier.
* Two four inch open end conduits were observed above the ceiling tile to the west of the entrance door to the morgue.
* One and a half inch open end conduit above the ceiling tile in the smoke barrier bordering the east side of the morgue across from the soiled linen room.
* One half inch open end conduit observed in smoke barrier separating the storage room and the administrator service office outside the kitchen area.

These findings were verified by staff C during tour on 01/26/10 at approximately 3:45 PM.

Based on observations made during tour and staff interview, it was determined that the facility failed to ensure that one door in the smoke barrier was self-closing or automatic closing and all swinging doors in the smoke barriers were fitted with an astragal. This could affect all individuals utilizing the services of this smoke compartment. The facility census was 13 at the time of the survey.

Findings include:

Tour of the facility's main building took place on 01/26/10 to 01/27/10 with the manager of plant engineering (staff #C). Observation was made of doors within the smoke barrier as:

* The door to the consultation room was observed as part of the smoke barrier, but was not equipped with an automatic closing device or self-closer.
* Double doors between the consultation room and the rest rooms was observed to have a gap greater than one eighth inch between the doors when the doors were in the closed position. These doors also lacked an astragal.
* Double doors north of the consultation room was observed to have a gap greater than one eighth inch between the doors when the doors were in the closed position. These doors also lacked an astragal.

These findings were verified by staff C during tour on 01/26/10 at approximately 2:35 PM.

Based on observations during tour, review of floor plans, and staff interview, the facility failed to provide at least a one hour fire rated construction for hazardous areas in accordance with NFPA 8.4. This had the potential to affect all patients, staff and visitors utilizing these areas. The current census was 13 patients.

Findings include:

Tour of the facility's main building took place on 01/26/10 to 01/27/10 with the manager of plant engineering (staff #C).
Penetrations were observed in the hazardous areas of the one hour fire rated construction above the ceiling tile in the following locations:

* Within the emergency department soiled utility room observation was made of 13 penetrations and unsealed conduits.
* Within the surgery department's biohazard room, one open end conduit was observed.
* Within the gift shop storage room two unsealed conduits, two open end conduits and an approximate ten inch long by one half inch wide opening with a conduit passing through were observed.
Additionally, the door which was equipped with a self closer failed to latch shut.

These findings were verified by staff C during tour on 01/26/10 at approximately 3:15 PM.

Based on facility observation and staff interview and verification the facility failed to ensure that exit egress accesses were arranged so that exits were accessible at all times to allow all occupants safe access to a public way according to NFPA 7.1 and 7.1.1. The facility had a census of 13 patients at the time of the survey.

Findings included:

Tour of the facility's main building took place on 01/26/10 to 01/27/10 with the manager of plant engineering (staff #C).
Observation was made of the exit discharge located on the southeast corner of the facility near the administrative entrance. Exit discharge was made onto a five foot by five foot cement stoop. Surrounding the cement stoop was a grassy area. Approximately 70 feet of grass separated the cement stoop to the nearest public way.
During the night of 01/27/10 approximately half an inch of snow fell. Observation was made of the entrance/exits of the building and they were noted to have been cleared of the snow and salt had been scattered on the walkways.
Observation was also made of the particular exit discharge noted above. The snow had not been removed from the cement stoop nor had salt been placed on it.

Verification of the discharge site was made by staff C on 01/27/10 at approximately 11:40 AM. Staff C stated no one including the fire Marshall has ever mentioned anything about the exit discharge not being in compliance.

Based on observation during tour and staff verification it was determined this facility failed to ensure all exit accesses were equipped with exit and directional signs with continuous illumination. This has the potential to affect all patients, staff and visitors utilizing this area. The facility census was 13 at the time of the survey.

Findings include:

Tour of the facility's main building took place on 01/26/10 to 01/27/10 with the manager of plant engineering (staff #C).
During tour of the physical therapy outpatient rehabilitation area, observation was made of no exit signage within this department which includes the therapy pool area. There are two exits from this department, one is located in the pool area and the other is in the exercise area.

This was acknowledged by staff C on 01/28/10 at 1:30 PM when staff C stated it was not on the blue prints but the architect stated there is no reason why there should not be any.

Based on observation during tour and staff interview it was determined this facility failed to ensure the automatic sprinkler system was installed in order to provide a reliable and adequate water supply to cover all areas in the event of a fire. The facility census was 13 at the time of the survey.

Findings include:

Tour of the facility's main building took place on 01/26/10 to 01/27/10 with the manager of plant engineering (staff #C).
*Observation was made within a the administrative area of a storage closet which contained shelving and was constructed in a manner which would inhibit the spray pattern of the sprinkler head upon discharge. The left vertical support for the horizontal shelves was located within two inches of the sprinkler head.
* Observation was made of a sprinkler head in the clean linen room within the medical surgical department which had a thick coating of dust.
* Observation was made of at least six sprinkler heads in the kitchen prep and dining room areas which had a thick coating of dust.

These findings were verified by staff C during tour on 01/27/10 at approximately 9:45 AM. These findings may not include all sprinkler heads within the facility which may contain a coating of dust and/or debris.

Based on observations made during tour and staff interview, it was determined that the facility failed to ensure that the means of egress through one of two exits out of the physician's office area was maintained free of all obstructions. This had the potential to affect all patients, staff and visitors utilizing this area.

Findings include:

Tour of the facility's main building took place on 01/26/10 to 01/27/10 with the manager of plant engineering (staff #C).
Within the southwest physician's office area in the exit corridor by the exit access, near exam room number 9, observation was made of 8-10 cardboard boxes varying in size, a large plastic trash can (approximately 55 gallons) filled with items and a coat rack attached to the corridor wall containing several winter coats. The boxes and plastic trash can were stored under and beside the coat rack. These items narrowed the exit corridor width by approximately two feet.
Additionally, these items were blocking the portable fire extinguisher.

Interview with the physician's office manager (staff K) at approximately 11:50 AM on 01/27/10 reveals these supplies are usually kept in this area.

Based on staff interview and relative humidity documentation review, it was determined this facility failed to maintain the relative humidity levels equal to or greater than 35% in three operating rooms and one C-section room. This had the potential to affect all those utilizing this area.

Findings include:

Review of the relative humidity documentation took place in the afternoon of 01/27/10. Review was made of the humidity levels for the three operating rooms and C-section room for the entire year of 2009. For the months of January through April only 17 days of relative humidity were documented to be above or equal to the required 35% relative humidity within the three operating rooms. For the months of October through December, 34 days were documented to be above or equal to the required 35% relative humidity within the three operating rooms.
Review of the relative humidity readings for the C-section room during the months of January through May reveals 15 days recorded as having met the required 35% or greater humidity level reading. For the months of October through December, 3 days were recorded as having met the required 35% or greater humidity level reading.

This was verified by staff C on 01/27/10 at 3:00 PM when he/she stated the relative humidity readings are read and recorded from the H-VAC systems return air from the operating rooms and C-section room. One central location for the three operating rooms and another central location for the C-section room.

Based on observation and staff interview, the facility failed to ensure that smoke detectors in spaces served by air-handling systems were not located where airflow patterns could prevent the operation of the detectors. The requirement located in National Fire Protection Association (NFPA) 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1. This had the potential to affect all patient's, staff and visitors utilizing the facility. The patient census was 13 at the time of the survey.

Findings include:

Tour of the facility's main building took place on 01/26/10 to 01/27/10 with the manager of plant engineering (staff #C). Observation was made of multiple smoke detectors located where airflow patterns may affect their proper function. These were located in the following locations:

* Two within the medical records office in the administrative area.
* One in the medical surgical department nurse's station.
* Two in obstetrics department, one by the nurse's station and the other in the corridor near the nurse's station.
* Three within the southwest physician's office area near the reception and waiting area, within exam room numbers 1, 2 and 3. One within the physician's office lab.
* One in the corridor on the west end of the welcome center.
* Four within the lab and lab offices.
* Four within the radiology department.
* Seven within the northwest physician's office area.
* Two in the emergency room area, one in the reception area and the other in the soiled utility room.
* Within two rooms of the corridor on the west side of H-Vac 3. One in the restroom and the other in the storage room.
* Seven in the surgery department corridors and two rooms boarding the west side of operating room # 3.
* One in the corridor near the birthing care services.
* One within the corridor west of the morgue and one within the morgue.
* One in the corridor by the Heller room.

These may not reflect a comprehensive list of all smoke detectors located where airflow patterns may affect the normal operation of the unit.

This finding was verified by staff C as each detector was identified during tour of the main building on 01/26/10 to 01/27/10.

Based on observations during tour, review of floor plans, and staff interview, the facility failed to provide smoke barriers that formed at least two smoke compartments constructed to provide at least a one hour fire resistance rating. This had the potential to affect all patients, staff and visitors utilizing the facility. The patient census was 13 at the time of the survey.

Findings include:

Tour of the facility's main building took place on 01/26/10 to 01/27/10 with the manager of plant engineering (staff #C).
Penetrations were observed in the one hour rated smoke barrier above the ceiling tile in the following locations:

* A two inch open end conduit was observed above the smoke barrier doors located near the main fire panel.
* One and a half inch unsealed conduit above the pharmacy door.
* In the corridor on the northeast corner of the wellness center above the double doors, observation was made of a half inch unsealed conduit.
* In the corridor on the north side of the morgue above the double doors, observation was made of eight large unsealed conduits and one four inch open end conduit passing through the smoke barrier.
* Two four inch open end conduits were observed above the ceiling tile to the west of the entrance door to the morgue.
* One and a half inch open end conduit above the ceiling tile in the smoke barrier bordering the east side of the morgue across from the soiled linen room.
* One half inch open end conduit observed in smoke barrier separating the storage room and the administrator service office outside the kitchen area.

These findings were verified by staff C during tour on 01/26/10 at approximately 3:45 PM.

Based on observations made during tour and staff interview, it was determined that the facility failed to ensure that one door in the smoke barrier was self-closing or automatic closing and all swinging doors in the smoke barriers were fitted with an astragal. This could affect all individuals utilizing the services of this smoke compartment. The facility census was 13 at the time of the survey.

Findings include:

Tour of the facility's main building took place on 01/26/10 to 01/27/10 with the manager of plant engineering (staff #C). Observation was made of doors within the smoke barrier as:

* The door to the consultation room was observed as part of the smoke barrier, but was not equipped with an automatic closing device or self-closer.
* Double doors between the consultation room and the rest rooms was observed to have a gap greater than one eighth inch between the doors when the doors were in the closed position. These doors also lacked an astragal.
* Double doors north of the consultation room was observed to have a gap greater than one eighth inch between the doors when the doors were in the closed position. These doors also lacked an astragal.

These findings were verified by staff C during tour on 01/26/10 at approximately 2:35 PM.

Based on observations during tour, review of floor plans, and staff interview, the facility failed to provide at least a one hour fire rated construction for hazardous areas in accordance with NFPA 8.4. This had the potential to affect all patients, staff and visitors utilizing these areas. The current census was 13 patients.

Findings include:

Tour of the facility's main building took place on 01/26/10 to 01/27/10 with the manager of plant engineering (staff #C).
Penetrations were observed in the hazardous areas of the one hour fire rated construction above the ceiling tile in the following locations:

* Within the emergency department soiled utility room observation was made of 13 penetrations and unsealed conduits.
* Within the surgery department's biohazard room, one open end conduit was observed.
* Within the gift shop storage room two unsealed conduits, two open end conduits and an approximate ten inch long by one half inch wide opening with a conduit passing through were observed.
Additionally, the door which was equipped with a self closer failed to latch shut.

These findings were verified by staff C during tour on 01/26/10 at approximately 3:15 PM.

Based on facility observation and staff interview and verification the facility failed to ensure that exit egress accesses were arranged so that exits were accessible at all times to allow all occupants safe access to a public way according to NFPA 7.1 and 7.1.1. The facility had a census of 13 patients at the time of the survey.

Findings included:

Tour of the facility's main building took place on 01/26/10 to 01/27/10 with the manager of plant engineering (staff #C).
Observation was made of the exit discharge located on the southeast corner of the facility near the administrative entrance. Exit discharge was made onto a five foot by five foot cement stoop. Surrounding the cement stoop was a grassy area. Approximately 70 feet of grass separated the cement stoop to the nearest public way.
During the night of 01/27/10 approximately half an inch of snow fell. Observation was made of the entrance/exits of the building and they were noted to have been cleared of the snow and salt had been scattered on the walkways.
Observation was also made of the particular exit discharge noted above. The snow had not been removed from the cement stoop nor had salt been placed on it.

Verification of the discharge site was made by staff C on 01/27/10 at approximately 11:40 AM. Staff C stated no one including the fire Marshall has ever mentioned anything about the exit discharge not being in compliance.

Based on observation during tour and staff verification it was determined this facility failed to ensure all exit accesses were equipped with exit and directional signs with continuous illumination. This has the potential to affect all patients, staff and visitors utilizing this area. The facility census was 13 at the time of the survey.

Findings include:

Tour of the facility's main building took place on 01/26/10 to 01/27/10 with the manager of plant engineering (staff #C).
During tour of the physical therapy outpatient rehabilitation area, observation was made of no exit signage within this department which includes the therapy pool area. There are two exits from this department, one is located in the pool area and the other is in the exercise area.

This was acknowledged by staff C on 01/28/10 at 1:30 PM when staff C stated it was not on the blue prints but the architect stated there is no reason why there should not be any.

Based on observation during tour and staff interview it was determined this facility failed to ensure the automatic sprinkler system was installed in order to provide a reliable and adequate water supply to cover all areas in the event of a fire. The facility census was 13 at the time of the survey.

Findings include:

Tour of the facility's main building took place on 01/26/10 to 01/27/10 with the manager of plant engineering (staff #C).
*Observation was made within a the administrative area of a storage closet which contained shelving and was constructed in a manner which would inhibit the spray pattern of the sprinkler head upon discharge. The left vertical support for the horizontal shelves was located within two inches of the sprinkler head.
* Observation was made of a sprinkler head in the clean linen room within the medical surgical department which had a thick coating of dust.
* Observation was made of at least six sprinkler heads in the kitchen prep and dining room areas which had a thick coating of dust.

These findings were verified by staff C during tour on 01/27/10 at approximately 9:45 AM. These findings may not include all sprinkler heads within the facility which may contain a coating of dust and/or debris.

Based on observations made during tour and staff interview, it was determined that the facility failed to ensure that the means of egress through one of two exits out of the physician's office area was maintained free of all obstructions. This had the potential to affect all patients, staff and visitors utilizing this area.

Findings include:

Tour of the facility's main building took place on 01/26/10 to 01/27/10 with the manager of plant engineering (staff #C).
Within the southwest physician's office area in the exit corridor by the exit access, near exam room number 9, observation was made of 8-10 cardboard boxes varying in size, a large plastic trash can (approximately 55 gallons) filled with items and a coat rack attached to the corridor wall containing several winter coats. The boxes and plastic trash can were stored under and beside the coat rack. These items narrowed the exit corridor width by approximately two feet.
Additionally, these items were blocking the portable fire extinguisher.

Interview with the physician's office manager (staff K) at approximately 11:50 AM on 01/27/10 reveals these supplies are usually kept in this area.

Based on staff interview and relative humidity documentation review, it was determined this facility failed to maintain the relative humidity levels equal to or greater than 35% in three operating rooms and one C-section room. This had the potential to affect all those utilizing this area.

Findings include:

Review of the relative humidity documentation took place in the afternoon of 01/27/10. Review was made of the humidity levels for the three operating rooms and C-section room for the entire year of 2009. For the months of January through April only 17 days of relative humidity were documented to be above or equal to the required 35% relative humidity within the three operating rooms. For the months of October through December, 34 days were documented to be above or equal to the required 35% relative humidity within the three operating rooms.
Review of the relative humidity readings for the C-section room during the months of January through May reveals 15 days recorded as having met the required 35% or greater humidity level reading. For the months of October through December, 3 days were recorded as having met the required 35% or greater humidity level reading.

This was verified by staff C on 01/27/10 at 3:00 PM when he/she stated the relative humidity readings are read and recorded from the H-VAC systems return air from the operating rooms and C-section room. One central location for the three operating rooms and another central location for the C-section room.

Based on observation and staff interview, the facility failed to ensure that smoke detectors in spaces served by air-handling systems were not located where airflow patterns could prevent the operation of the detectors. The requirement located in National Fire Protection Association (NFPA) 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1. This had the potential to affect all patient's, staff and visitors utilizing the facility. The patient census was 13 at the time of the survey.

Findings include:

Tour of the facility's main building took place on 01/26/10 to 01/27/10 with the manager of plant engineering (staff #C). Observation was made of multiple smoke detectors located where airflow patterns may affect their proper function. These were located in the following locations:

* Two within the medical records office in the administrative area.
* One in the medical surgical department nurse's station.
* Two in obstetrics department, one by the nurse's station and the other in the corridor near the nurse's station.
* Three within the southwest physician's office area near the reception and waiting area, within exam room numbers 1, 2 and 3. One within the physician's office lab.
* One in the corridor on the west end of the welcome center.
* Four within the lab and lab offices.
* Four within the radiology department.
* Seven within the northwest physician's office area.
* Two in the emergency room area, one in the reception area and the other in the soiled utility room.
* Within two rooms of the corridor on the west side of H-Vac 3. One in the restroom and the other in the storage room.
* Seven in the surgery department corridors and two rooms boarding the west side of operating room # 3.
* One in the corridor near the birthing care services.
* One within the corridor west of the morgue and one within the morgue.
* One in the corridor by the Heller room.

These may not reflect a comprehensive list of all smoke detectors located where airflow patterns may affect the normal operation of the unit.

This finding was verified by staff C as each detector was identified during tour of the main building on 01/26/10 to 01/27/10.