HospitalInspections.org

Based on random observation during the survey walk-through and staff interview, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1. These deficiencies could affect any patients, staff, or visitors in the Mother/Baby Unit by preventing their egress from the building under emergency conditions.

Findings include:

A. At 2:19 PM on August 21, 2012, the provider's Plant Operations Manager stated that the magnetic locking devices installed on the doors listed below are activated by the infant security (HUGS) system and do not release upon activation of the building fire alarm system as required by 19.2.2.2.4. and 7.2.1.6.1. Doors at which this condition was identified include (all Second Floor):
1. The door to Exit Stair 1.

2. The door to Exit Stair 2.

3. The pair of cross-corridor doors at the east end of the Mother/Baby Unit (east of Exit Stair 2).

UPDATE 3/6/13: The doors were tested with a bracelet and a pull station by the stair door. The doors are on a delay egress system and did release when tested. However, the doors do not have signs stating "Push until alarm sounds, Door can be opened in 15 seconds", as required by NFPA 101, 7.2.1.6.1(d). The surveyor was unable to locate any documentation that indicated approval from the Department that the signs did not have to be posted in these locations.

Based on random observation during the survey walk-through, not all portions of the building fire alarm system are installed in accordance with 19.3.4. This deficiency could affect any patients, staff, or visitors on the Third Floor because the unsynchronized strobe lights could trigger seizures.

Findings include:

A. Cleared 3/6/13

UPDATE 3/6/13: During a test of the building infant security (HUGS) system on the 2nd floor, more than two unsynchronized visual notification (strobe) devices were observed. This is prohibited by NFPA 72 1999 4-4.4.2.2.

Based on random observation during the survey walk-through and staff interview, not all portions of the building electrical system are installed in accordance with NFPA 70 1999. These deficiencies could affect any inpatients being treated in the Patient Sleeping Rooms because electrical power to support medical equipment may not be available under power outage conditions, and could affect any patients, staff, or visitors on the Fourth Floor because necessary power sources may be inadvertently disconnected.

Findings include:

A. At 12:36 PM on August 21, 2012, Fourth Floor Patient Sleeping Room 423 was observed to lack at least 1 circuit supplied by the building emergency electrical system as required by NFPA 70 1999 517-18(a). During an interview held at that time and location, the provider's Plant Operations Manager stated that the condition exists at all Patient Sleeping Rooms in the building except those (approximately 15) Patient Sleeping Rooms which had been recently remodeled under an ongoing construction project.

B. Corrected 3/6/13


UPDATE 3/6/13: The receptacles connected to the building emergency electrical system have been installed. However, the emergency receptacles were not identified or labeled with the panelboard and circuit number suppling the device as required by NFPA 70, article 517.18.