HospitalInspections.org

RE-CITE

Based on facility tour, review of facility documentation and staff interview, it was determined the facility failed to ensure any suite of rooms greater than 1,000 sq. ft. had at least two exit access doors remote from each other and the exit accesses did not exit through an intervening suite. This had the potential to affect all those utilizing this area of the facility. The facility census was 1,055, at the time of the post survey-revisit. .

Findings include:

Facility tour took place on 09/18/12 between 9:00 A.M. and 4:00 P.M. with staff members K, M and N present. During tour of the J building, fifth floor, a post anesthesia care unit (PACU Suite) which had a total of 5,250 sq. feet was observed. The unit was noted to have three exit accesses, two of which had egress access through intervening suites. The floor plan was reviewed and verified this finding.

Tour was conducted of the third floor of the Q building. The tour and schematic revealed the floor contained three suites: a non-sleeping procedure suite of 5478 square feet (1), a non-sleeping prep/recovery suite of 5914 square feet (2), and a waiting area of 705 square feet (3). By observation and review of the schematic, Suite #1 had one exit into corridor Q03 16, and the other into Suite #2. By observation and review of the schematic, Suite #2 had one exit into corridor Q03 14, another into Suite #1, and two others into Suite #3. By observation and review of the schematic, Suite #3 had one exit into lobby Q03 116, and another into Suite #2.

Interview of Staff J and K verified the finding noted during the survey ending 08/03/12. Staff verified the findings remained the same with regards to the suites and the facility planned to apply for a waiver. A copy of the request for waiver was provided for review.





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RE-CITED

Based on facility observation and staff interviews, the facility failed to ensure chute rooms were used exclusively for accessing the chute openings in accordance with the code at 8.4 and did not ensure chute rooms were separated from the service elevator with a one hour fire resistance rated barrier in accordance with the code at Section 18.5.4 and 9.5.1. This involved eight of eight floors in patient care areas. The facility had a total census of 1,055 at the time of the post survey re-visit.

During tour of the facility, on 09/18/12, between 9:00 A.M. and 4:00 P.M., with Staff K, M and N, a combination linen chute, trash chute, and service elevator room was observed on patient care floors one through eight. These rooms were located in the center of each floor between Units 1, 2, and 3. The room numbers for the sixth floor was J63-57, and for the seventh floor J73-57. The eighth floor room was directly above these two rooms. Observations of these rooms revealed the linen chute, trash chute, and service elevator were located in the same room, without a one hour fire rated separation between the chutes and the elevator.

Staff present on tour verified the chute rooms on floors one through eight were set up the same, with the service elevator in the same room as trash and linen chutes, and verified the lack of a one hour fire rated separation between the chutes and the elevator. Staff further verified the chute/elevator rooms had no construction changes since the life safety code survey completed on 08/03/12.

Interview on 09/17 and 09/18/12 with Staff J and K revealed the facility was in the process of obtaining building plans and permits in order to construct the barrier wall between the chutes and the elevators in each of the noted rooms.




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