HospitalInspections.org

Based on record review and interview, the provider failed to conduct a large-scale exercise for emergency preparedness in 2023 or 2024. Findings include:

1. Record review on 3/5/25 at 9:15 a.m. revealed no documentation that indicated a large-scale exercise was conducted to test the provider's emergency plan in 2023 or 2024. Records indicated a large-scale exercise
had last been performed in 2019.

Interview with the environmental services director and maintenance supervisor on 3/5/25 at 11:30 a.m. confirmed that finding.

Based on observation and interview, the provider failed to provide egress doors as required at three randomly observed EXIT door locations (the corridor at Inpatient Care to OB). Findings include:

1. Observation beginning on 3/4/25 at 2:00 p.m. revealed the corridor between Inpatient Care to OB had three sets of cross-corridor doors. All three sets of doors were equipped with magnet locks and were identified with EXIT signs. The doors also had an extra sign approximately three inches tall and eight inches wide affixed to the doors stating "NOT AN EXIT". EXIT doors may not be labeled as non-EXITs. It was not determined at the time of the survey how each magnetically locked door functioned (card-swipe, delayed-egress, or access-controlled).

Interview at the time of the observation with the maintenance supervisor confirmed that condition.

Failure to provide egress doors as required increases the risk of death or injury due to fire.

The deficiency affected 100% of the smoke compartment occupants.

Based on observation and interview, the provider failed to maintain the required exit corridor width at one location (therapy wing exit). Findings include:

1. Observation on 3/4/25 at 9:50 a.m. revealed the therapy wing on the ground floor was eight feet wide and had approximately six chairs in the corridor along the wall on one side. The chairs were not affixed in place. The chairs could be easily moved to obstruct the path of egress to the exterior EXIT.

Interview with the maintenance supervisor at the time of the observation confirmed that finding. He stated he was unaware the chairs needed to be affixed in place.

The deficiency has the potential to affect egress exit ability for all occupants of that smoke compartment.

Based on observation, testing, and interview, the provider failed to maintain corridors without dead-ends greater than 30 feet in length for one randomly observed corridor (ER Entrance south side). Findings include:

1. Observation on 3/4/25 at 2:20 p.m. revealed the corridor to the ER entrance on the south side from two sets of cross-corridor doors was over 100 feet in length and did not have a second path of egress. The two sets of cross-corridor doors (each for different corridors) were key-card access only and were not marked as Exits. Interview with the maintenance supervisor at the time of the observation confirmed that condition.

The deficiency had the potential to affect 100% of the smoke compartment occupants.

Based on observation and interview, the provider failed to maintain one randomly observed hazardous area (kitchen pantry storage room) as required. Findings include:

1. Observation on 3/4/25 at 11:45 a.m. revealed the kitchen pantry storage room was over 100 square feet in area and contained combustible items (canned goods, cardboard boxes, plastic-wrapped items). The egress corridor door was not equipped with a closer.

Interview with the maintenance supervisor at the time of the observation confirmed that finding. He stated it appeared the door had been equipped with a closer at one time but it had been removed (holes remained in the door).

The deficiency affected one of numerous requirements for hazardous storage rooms and had the potential to affect 100% of the occupants of the smoke compartment.

Based on observation and interview, the provider failed to maintain combustion (fresh) air in one randomly observed area (laundry). Findings include:

1. Observation of the four commercial Speed Queen natural gas-fired dryers in the laundry room on 3/4/25 at 10:15 a.m. revealed the following:
*There were several staff working in the laundry room which had ventilation into the room from overhead ductwork.
*Each dryer had an individual metal exhaust duct to the exterior of the building.
*There was not any dedicated combustion (fresh) air ductwork provided for the operation of the four natural gas-fired commercial clothes dryers. Each dryer had a rating of 165,000 BTU/hr input.
*The gas-fired dryers were taking combustion air from the occupied room itself as a result.

Interview with the environmental services director on 3/5/25 at 11:00 a.m. confirmed that finding. He stated the dryers had never been equipped with separate combustion air.

The deficiency affected one of several requirements for fuel-fired devices.