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Tag No.: K0018
Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not having all doors protecting corridor openings provided with a means suitable for keeping the door closed or by not having all doors protecting corridor openings closing tightly in their frames.
The findings include:
During the survey on June 14, 2013 with the Director of Facilities, Maintenance Director, and other staff, it was observed between 8:30 am and 12:30 pm that:
1.) the corridor door to patient room #353 was impeded by a chair - when the chair was removed, the door drifted rapidly;
2.) the doors to exam rooms in the triage ER, #43, #45, and #46, failed to latch;
3.) some sliding glass doors in the main ER were difficult to close due to the stationary panel being misaligned - these doors need to be checked and regularly maintained to be ready to close without impediment;
4.) four exam room doors in a new ER section had a small panel that was only secured when the large panel was closed - this involves two steps to close the doors in the event of an emergency which is a poor design.
This could allow smoke to pass between the corridor and the rooms and could effect the patients of the listed rooms and up to 20% of the other patients in each section.
Tag No.: K0027
Based on observation of the physical environment, it was determined that the facility staff failed to provide base level protection by not ensuring that corridor smoke barrier doors function properly.
The findings include:
During the initial survey on June 14, 2013 with the Director of Facilities, Maintenance Director, and other staff, it was observed between 8:30 am and 12:30 pm that:
1.) one set of smoke barrier doors in the corridor on the 4th floor BHU failed to close properly;
2.) a 2nd set of smoke barrier doors on the 4th floor BHU had a large gap (greater than 1/2") between them when closed;
3.) one set of smoke barrier doors on the 2nd floor, 2C wing, had a large (greater than 1/2") gap between them when closed even with an existing astragal.
Smoke barrier doors, walls, and partitions are designed to insulate means of egress from other areas of a building and to resist the passage of smoke in the event of an emergency and failure to do so could impact up to 25% of the patients and staff.
Tag No.: K0050
Based on a review of records, it was determined that the facility staff failed to provide a safe and hazard free environment by failing to properly document regularly scheduled fire drills.
The findings include:
During the survey on June 14, 2013 with the Director of Facilities, Maintenance Director, and other staff, it was observed between 8:30 am and 12:30 pm that fire drill logs did not contain signatures of participants in all fire drills held on floors and in units of the hospital.
Failure to hold required fire drills at unexpected times and under varying conditions for all staff has the potential to create a hazardous environment for patients as the staff would not be familiar with the procedures to follow in the event of a fire or other emergency. This could effect 100% of the residents and staff. Documentation of staff training in fire drills and evacuations is essential for Life Safety.
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Tag No.: K0062
Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not maintaining the sprinkler system in a reliable operating condition.
The findings include:
During the survey on June 14, 2013 with the Director of Facilities, Maintenance Director, and other staff, it was observed between 8:30 am and 12:30 pm that:
1.) tamper and flow switch covers were not secured in many locations, including, but not limited to, stairwells 5-B, 2-A, 3-D, main riser, etc.;
2.) an escutcheon ring was missing on a sprinkler head in the ER vestibule;
3.) two test valves in a stairwell were easily accessible by the public - these need to be secured to prevent tampering;
4.) the most recent 5-year obstruction test was performed on 5/16/08 - it is due again;
5.) the spare sprinkler boxes in the boiler room need to be wall mounted and have representative samples of all sprinkler heads on hand as well as a sprinkler wrench.
These items could lead to improper operation of the sprinkler system in the event of an emergency and could effect up to 50% of the facility's residents.
Tag No.: K0147
Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by having locations where there were non-compliant electrical applications.
The findings include:
During the survey on June 14, 2013 with the Director of Facilities, Maintenance Director, and other staff, it was observed between 8:30 am and 12:30 pm that:
1.) an electrical outlet by the sink in nourishment room #382 had no ground fault circuit interrupter (GFCI) protection;
2.) a vending machine in the lobby of the ER was connected to a heavy duty extension cord;
3.) the central distribution center had a refrigerator and microwave connected to an inexpensive power strip and an extension cord - these were removed during the survey;
4.) an extension cord was wire-tied to conduit and railing in the trash compacter room - this was removed during the survey.
These items could cause overheating or electrical short circuits resulting in fire. NFPA 70, National Electrical Code states that: 1.) extension cords shall not be used as a substitute for permanent wiring. 11.1.5; 2.) extension cords and flexible cords shall not be affixed to structures, extend through walls, ceilings or floors, or be subject to environmental or physical damage. 11.1.5.3.5. 3.) multi-plug adapters, such as multi-plug extension cords, cube adapters, strip plugs, and other devices, shall be listed and used in accordance with their listing.