HospitalInspections.org

Based on a review of the facility's Emergency Preparedness (EP) Plan, it was determined the facility failed to put in place policies and procedures to address their roles under a waiver declared by the Secretary.

Findings include:

1. Review of the EP Plan on March 20, 2019, at 8:30 a.m., revealed the facility failed to address their role under a waiver declared by the secretary in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials.

Interview with the Director of Plant Operations on March 20, 2019, at 8:30 a.m., confirmed the facility failed to address their roles under a waiver declared by the Secretary.

Based on observation and interview, it was determined the facility failed to maintain the two hour fire resitive rating of the common wall with non-compliant buildings in one instance, on one of two floors.

Findings include:

1. Observation on March 20, 2019, at 1:05 p.m., revealed a penetration in the two hour fire rated wall that separates Wing 2 on the second floor from the noncompliant building.

Interview with the Director of Plant Operations on March 20, 2019, at 2:15 p.m., confirmed the occupancy separation deficiency.

Based on observation and interview, it was determined the facility failed to provide the required number of exits in two instances, on two of three floors.

Findings include:

1. Observation on March 20, 2019, revealed the following exiting issues:

a) 10:30 a.m.., the second means of egress on the first floor of Wing 1, is through a non-compliant building;
b) 12:55 p.m., the second means of egress on the second floor of Wing 2 ASU, is through a non-compliant building.

Interview with the Director of Plant Operations on March 20, 2019, at 2:15 p.m., confirmed the 1st and 2nd floors lacked two approved exits.

Based on observation and interview, it was determined the facility failed to properly install exit signage in two instance, in two of more than 30 exit signs inspected.

Findings include:

1. Observation on March 20, 2019, revealed the following:

a) 10:08 a.m., the maintenance corridor exit sign in the basement did not display an arrow showing the direction of travel to the exit door;
b) 10:10 a.m., the maintenance garage exit sign displayed an arrow directing occupants to travel away from the exit door.

Interview with the Director of Plant Operations on March 20, 2019, at 2:15 p.m., confirmed the exit signage was not displayed correctly.

Based on observation and interview, it was determined the facility failed to maintain hazardous areas in one instance, in two of 11 smoke compartments.

Findings include:

1. Observation on March 20, 2019, revealed the following:

a) 10:15 a.m., the door to the basement Hazardous Waste Room would not positively latch when tested;
b) 10:30 a.m., the door to the Records Storage Room 1205 in the Wing 1 Sleep Lab lacked a self-closing device.

Interview with the Director of Plant Operations on March 20, 2019, at 2:15 p.m., confirmed the hazardous enclosure deficiencies.

Based on observation and interview, it was determined the facility failed to maintain smoke barrier walls in one instance, affecting two of 11 smoke compartments.

Findings include:

1. Observation on March 20, 2019, at 10:41 a.m., the smoke barrier wall was incomplete above the ceiling near the pharmacy storage room on the first floor.

Interview with the Director of Plant Operations on March 20, 2019, at 2:15 p.m., confirmed the smoke barrier deficiency.

Based on observation and interview, it was determined the facility failed to maintain electrical wiring in two instances, in two of eleven smoke compartments. Installation shall be in accordance with NFPA 70, National Electric Code. 19.5.1.1, NFPA 101.

Findings include:

1. Observation on March 20, 2019, revealed the following:

a) 10:50 a.m., there was unterminated electrical wiring in the old physical therapy room, in Wing 1 on the first floor;
b) 1:35 p.m., there was an uncovered electrical junction box in the third floor Boiler Room.

Interview with the Director of Plant Operations on March 20, 2019, at 2:15 p.m., confirmed the electrical wiring deficiencies

Based on observation and interview, it was determined the facility failed to install a remote emergency stop switch for the emergency generator for two of two generators, affecting the entire facility.

Findings include:

1. Observation on March 20, 2019, at 11:30 a.m., revealed there was no emergency generator remote manual stop station located outside of the generator enclosure.

Interview with the Director of Plant Operations on March 20, 2019, at 2:15 p.m., confirmed
there was not a remote manual stop switch located outside of the generator enclosures.

Based on observation and interview, it was determined the facility failed to maintain electrical wiring systems and equipment in one instance, in one of 11 smoke compartments.

Findings include:

1. Observation on March 20, 2019, at 10:30 a.m., revealed a four receptacle outlet plugged into another outlet for power under the desk in the sleep lab nurse station.

Interview with the Director of Plant Operations on March 20, 2019, at 2:15 p.m., confirmed the misuse of electrical wiring.