HospitalInspections.org

Based on observation during tour and staff verification it was determined this facility failed to ensure the common walls of nonconforming buildings were constructed with at least a two hour fire resistance rating. This had the potential to affect all those utilizing this area of the facility. The facility had a capacity of 346 beds with a census of 235 patients at the time of the survey.
Findings included:
1. On 08/02/11 between 2:35 P.M. and 5:00 P.M. tour of the third floor was completed with Staff MMM and NNN. Observation of the third floor corridor, above the ceiling tiles at the fire door, between facility building #1 and facility building #6 revealed penetrations. One penetration was surrounding a pipe. The other open area was estimated to be approximately 14 feet long, 1 to 2 feet wide and open to the floor decking above. Staff present on tour verified that facility building #1 was construction type I(332) and facility building #6 was construction type II(000).
Review of facility schematics revealed the wall was to be a two hour fire rated wall between the two buildings. Staff present on tour verified the two fire rated wall was not complete.

2. Tour of the second floor common wall area located between the physician's offices (building # 6) and the surgical area (building # 9) was completed the morning of 08/05/11 with staff members MMM and NNN. This common wall was designated as a smoke barrier according to the schematics.
Observation above the ceiling tile revealed an approximate three inch penetration from which this surveyor and both staff members were able to determine the wall was constructed with two layers of 5/8 inch drywall making it a one hour fire rated construction. Included in this observation was the wall below the ceiling which was also determined to be constructed with a one hour fire rated construction. The door in this assembly was determined to be 3/4 hour fire resistance rated. The entire common wall area of the second floor between building # 6 and building # 9 was not constructed with the required two hour fire resistance rating and this area was estimated to be approximately ten feet wide by twelve feet high.

3. Tour of facility building #1 basement took place on 08/03/11, with staff member NNN. During tour of the two hour fire rated common wall separating the physician's offices from the main building near the cardiac center, observation was made of one penetration above the double doors with blue wires passing through. Additionally, one leaf of the double doors failed to close and latch shut.

This finding was verified by staff member MMM during tour on 08/04/11.

Based on observation during tour and staff verification it was determined this facility failed to ensure the doors protecting corridors openings were constructed to resist the passage of smoke for at least twenty minutes. This had the potential to affect all those utilizing this area of the facility. The hospital had a capacity of 346 certified beds with a census of 235 patients at the time of the survey.

Findings included:

Tour of the basement of building # 1 took place on 08/03/11 with staff NNN and first floor on 08/04/11 with staff members MMM and NNN. During tour of the corridors, observation was made of two corridor doors which failed to close properly in order to resist the passage of smoke in the following locations:
Basement:
*At the northwest corner of the dish room of the dietary department from the corridor side, observation was made of the corridor dish room door which failed to shut properly leaving a small gap between the door and the door frame.
First floor:
* Within the corridor between the emergency department and laboratory and at the southeast corner of the emergency department, observation was made of the smoke barrier doors failing to close properly when disengaged from the holding devices.

These findings were verified by the staff present during tour on 08/03/11 and 08/04/11.

Based on observation during tour and staff interview it was determined this facility failed to ensure directional and exit signs were located in areas to ensure proper way of travel to an exit discharge. This had the potential to affect all those utilizing this area of the facility. The facility had a capacity of 346 beds with a census of 235 patients at the time of the survey.
Findings include:
Tour of the basement of building # 1 took place on 08/03/11 with staff NNN. During tour of the 9,375 square foot medical records/IT department observation was made of two exit directional signs, one at the northeast end of the room and the other at the southeast end. Both signs directed flow to an exit access located on the east side, center of the room. Observation was made of three doors located in the east side center of this room, none of which had an exit sign designating it as the exit access. This surveyor was not able to determine which door was the exit access and was not able to locate a fire escape plan within this department to verify the designated exit route.
The exit access door was revealed to this surveyor by staff NNN. Observation was made by this surveyor and staff NNN that no directional sign was mounted in order to direct any persons to the exit access door, nor was there an exit sign located above the exit access door.
Additionally, observation was made of stairs located outside of this exit door which were assessable only once one was outside of this room.

Based on observation during tour and staff verification it was determined this facility failed to ensure the smoke barriers were constructed with at least a one hour fire resistance rating. This had the potential to affect all those utilizing that area of the facility.

Findings included:

1. On 08/01/11 between 1:40 P.M. and 3:20 P.M. tour of the offsite facility was completed with Staff MMM and NNN. During the tour observation was made of the smoke barriers which included the spaces above ceiling tiles. The following locations were noted to have penetrations located in the smoke barrier above the ceiling tile:
*Located above the fire doors leading to the emergency department from the business occupancy, an area approximately 10 inches in diameter was not sealed. The area at the floor decking above was also not sealed.
* An area was not sealed in the smoke barrier wall at the floor decking at the back wall of the men's bathroom.

Staff present on the tour verified the observation and findings with regards to penetrations in the smoke barrier wall.

Based on observation during tour and staff verification it was determined this facility failed to ensure the smoke barriers were constructed with at least a one half hour fire resistance rating. This had the potential to affect all those utilizing this area of the facility. The hospital had a capacity of 346 certified beds with a census of 235 patients at the time of the survey.

Findings included:

1. On 08/02/11 between 2:35 P.M. and 5:00 P.M. tour of the third floor was completed with Staff MMM and NNN. During tour of the smoke barriers, observation was made of several penetrations located in the smoke barrier above the ceiling tile in the following locations:
* Located in the vascular/lab corridor, penetrations were noted surrounding a heat pump loop and data cable wires.
* Located above B311, a penetration was noted approximately 1 inch by 2 inches. Also visible was an unsealed area surrounding conduit.
* Located above B314 a penetration was noted approximately 1/2 inch by 1 inch and 3 unsealed areas surrounding conduit.

2. On 08/03/11 between 10:00 A.M. and 4:00 P.M. tour of the second floor was completed with Staff MMM. During tour of the smoke barriers, observation was made of several penetrations located in the smoke barrier above the ceiling tile in the following locations:
* Located at the surgical waiting area, near the elevators, penetrations were observed surrounding a protected beam.
* Located at the surgical waiting area, near the heart vascular institute, two penetrations were observed. one area was approximately 4 inches square and the other approximately 2 inches square.
* Located in the same area was an unsealed opening surrounding an area where at least six data cable lines penetrated the wall.
*Located near stairwell C a open area was noted surrounding a conduit and a hole approximately 3 inches square.
* Located at the CCU smoke doors, near the cath lab entrance, a penetrations was noted surrounding conduit and an area was not sealed surrounding an I-beam.

3. Tour of the basement of building # 1 took place on 08/03/11 with staff NNN and first floor on 08/04/11 with staff members MMM and NNN. During tour of the smoke barriers, observation was made of several penetrations located in the smoke barrier above the ceiling tile in the following locations:
First floor:
* Above the west double doors of the smoke barrier bordering the infusion therapy room of the oncology department, observation was made of one, two inch open ended conduit.
* The smoke barrier bordering the south side of the pastoral care room and near the stairs, observation was made of two one inch unsealed penetrations.
Additionally, observation was made of a four inch penetration and two unsealed insulated lines above a dryer near the same area.
* Above the double doors between the PBX room and the breast center, observation was made of four unsealed penetrations. Additionally, at the southeast corner of the breast center, observation was made of two-two inch unsealed penetrations in the smoke barrier.
* Above the double doors by the stairwell between the PBX and EMS room, observation was made of two unsealed areas where data lines penetrated through the drywall. Additionally, above the smoke barrier doors at the west end of the east-west corridor, adjacent to the previous doors, observation was made of one, three inch unsealed silver conduit.
* Within the emergency department at the west end smoke barrier doors, observation was made of two unsealed conduits with wires passing through.
* Within the emergency department at the east end smoke barrier doors, observation was made of two unsealed insulated lines passing through two sleeves and one unsealed three inch sleeve with wires passing through.
* Within the corridor between the emergency department and laboratory and at the southeast corner of the emergency department, observation was made above the smoke barrier doors of a large penetration around the duct.
* Within the same corridor by room #170, observation was made of one, one inch unsealed conduit.

Basement:
*Above the smoke barrier doors located between pathology and nuclear medicine, observation was made of an approximate four by eight foot section of missing drywall.
*Within the "pop storage" room adjacent to the physical therapy offices, observation was made of a penetration around an electrical chase.
*Within the dish room of the dietary department at the east wall near the wall mounted fan, one unsealed conduit was observed. Also, on the north wall near the portable fire extinguisher another unsealed conduit was observed. Additionally, from the corridor on the north side of the dish room and near the corridor door bordering the locker room, observation was made of one unsealed conduit and one unsealed black wire passing through the smoke barrier.
* Above the smoke barrier door within the volunteers TV service area, observation was made of two unsealed orange flex lines.
*Above the smoke barrier corridor door by community room number eight, observation was made of an approximate four foot by two and a half foot area of missing drywall.
*Within the corridor wall bordering the south side of the community health room, observation was made of three open end conduits with flesh colored wires passing through.

These findings were verified by staff MMM and NNN during tour on 08/03/11 and 08/04/11.

Based on facility tour and staff interview and verification the facility failed to ensure that door openings in smoke barriers had at least a 20-minute fire protection rating. The hospital had a capacity of 346 certified beds with a census of 235 patients at the time of the survey.

Findings included:

On 08/02 and 08/03/11 tour of the second and third floors of the facility was completed with Staff MMM and NNN. During tour of the second and third floors, observation was made of the corridor smoke doors. Testing of the corridor smoke doors revealed that gaps greater than 1/8 inch were present at the door edges when the smoke doors were in the closed position.

The affected smoke barrier doors were observed near the third floor psychiatric unit for geriatric patients and on the second floor near the coronary care unit.

Staff present on tour verified the gaps at the door edges were greater than 1/8 inch and would permit the passage of smoke.

Based on facility tour, review of facility documentation and staff interview and verification, the facility failed to ensure that hazardous areas were protected in accordance with 8.4. The areas were to be enclosed with a one hour fire-rated barrier, with a 3/4 hour fire-rated door, without windows (in accordance with 8.4). This had the potential to affect all those utilizing that area of the facility.

Findings included:

On 08/01/11 between 1:40 P.M. and 3:20 P.M. tour of the offsite facility was completed with Staff MMM and NNN. During the tour observation was made of soiled utility areas and areas designated to store biohazard materials until picked up for disposal. The following observations were noted of the areas considered to be hazardous storage.

* Review of facility schematics revealed the soiled utility room located in the emergency department did not have walls that provided a one hour fire rated barrier. Observation of the walls above the ceiling tiles verified the information on the schematic. The door to the soiled room was noted to have a 20 minutes fire resistance rating.

* Observation of an area identified to be used for biohazard storage until picked up for disposal, revealed areas were not sealed in the fire rated walls at the floor decking. Areas surrounding 4 pipes observed above the door to the biohazard room were not sealed.

*A room identified as a soiled linen hold area was noted by review of schematics drawing have been increased in size. When the room was increased in size , two walls were not provided with a one hour fire resistance rating. The door to the room did not have a 3/4 hour fire resistance rating.

Staff present on tour observed and verified the findings.

Based on observation during tour and staff verification it was determined this facility failed to ensure hazardous areas were constructed with at least a one hour fire rated construction regarding doors in storerooms and soiled utilities. This had the potential to affect all those utilizing these areas of the facility. The facility had a capacity of 346 beds with a census of 235 patients at the time of the survey.
Findings include:
Tour of the first floor of building # 1 took place on 08/04/11 with staff members MMM and NNN. During tour of the oncology department and within their medical records storeroom, observation was made of the one hour fire rated door failing to shut and latch properly.
During tour of the northeast section of the outpatient center and within the soiled utility room, observation was made of a large mobile trash container stored within this room. The door of this soiled utility room lacked a fire resistance rating.
During tour of the east section of the radiology center and within the soiled utility room located across from the medical gas room, observation was made of a large mobile trash container stored within this room. The door of this soiled utility room lacked a fire resistance rating.
These findings were observed and acknowledged by staff members MMM and NNN during tour on 08/04/11.

Based on observation during tour and staff verification it was determined this facility failed to ensure the stairwell exit discharge door closed and latched properly in order to preserve the two hour fire resistance rating of this exit component. This had the potential to affect all those utilizing this area of the facility. The hospital had a capacity of 346 certified beds with a census of 235 patients at the time of the survey.

Findings included:

Tour of the basement of building number # 1 took place on 08/03/11 with staff member NNN. During tour of stairwell J, observation was made of the exit discharge door leading directly outside, failing to close and latch when tested. This left at least a two inch gap between the door leaf and the door frame.
This finding was verified by staff member MMM during tour on 08/03/11.

Based on facility observation and staff interview and verification, the facility failed to ensure that patient room doors were arranged so that patients could open the door from inside without using a key. Ten of ten patients residing on the secured psychiatric unit were affected. The psychiatric unit capacity was eleven patient rooms.

Findings included

On 08/02/11 between 2:35 P.M. and 5:00 P.M. tour of the third floor was completed with Staff MMM and NNN. Observation of the third floor revealed the presence of the secured psychiatric unit for geriatric patients. Observation of the unit revealed that patient sleeping rooms had deadbolt type locks present on the doors in addition to the door handle. Interview of unit staff revealed that patient room doors could be locked from the outside using a key. Once the doors were locked, doors could not be opened from inside the room by use of the door handle. The bathroom doors, inside the patient rooms, were equipped with the same deadbolt type locks as well as roller latches.

Staff on the unit stated that no patients were locked in the rooms but the purpose of the locks was to secure the rooms so that patients would not go into unoccupied, clean rooms or could not go into rooms to hide. Patient room doors were observed to be open during tour of the unit.

Based on facility tour and staff interview and verification, the facility failed to ensure that exit discharges were provided with emergency lighting. Potentially any patient, visitor or staff utilizing the exit could be affected. The hospital had a capacity of 346 certified beds with a census of 235 patients at the time of the survey.

Findings included:

On 08/02/11 between 2:00 P.M. and 2:30 P.M. tour of the fourth floor was initiated with Staff MMM and NNN. Observation of two exit stairwells to the point of exit discharge revealed the exits lacked adequate emergency lighting.

Stairwell L was noted to have no emergency lighting present at the exit discharge and Stairwell F had one light fixture at the exit discharge. A second means of lighting was a remote parking lot light.

Staff MMM present on tour verified the emergency lighting was not present for stairwell L and limited for stairwell F.

Based on facility documentation review and staff interview and verification, the facility failed to ensure that fire drills were held at unexpected times under varying conditions, at least quarterly on each shift. The facility had a census of 14 patients at the time of survey.

Finding included:

On 08/02/11 between 11:00 A.M. and 12:00 P.M. review of facility documentation was completed with Staff MMM and TTT. Review of fire drills for 2010 and to date in 2011 was competed. Staff TTT presented the information. Review of the fire drills for the offsite location revealed that no fire drill was completed for the second second shift in the second quarter of 2011. Staff TTT verified there was no documented evidence the fire drill had been completed.

Based on facility documentation review and staff interview and verification, the facility failed to ensure that fire drills were held at unexpected times under varying conditions, at least quarterly on each shift. The facility had a census of 14 patients at the time of survey.

Finding included:

On 08/02/11 between 11:45 A.M. and 12:00 P.M. review of facility documentation was completed with Staff MMM and TTT. Review fire drills for 2010 and to date in 2011 was competed. Staff TTT presented the information. Review of the fire drills for the offsite location revealed that no fire drill was completed for the second shift in the third quarter of 2010 and the third shift for the first quarter of 2011. Staff TTT verified there was no documented evidence the fire drills had been completed.

Based on observation during tour and staff verification, it was determined this facility failed to ensure all trash containers exceeding 32 gallon capacity, while not attended, are stored within a room with at least a one hour fire rated construction. This had the potential to affect all those utilizing this area of the facility. The facility had a capacity of 346 beds with a census of 235 patients at the time of the survey.
Findings include:
Tour of the first floor of building # 1 took place on 08/04/11 with staff members MMM and NNN. During tour of the laboratory department and near the southwest exit, observation was made of a large mobile trash container located just inside the exit access. This mobile trash bin contained layers of cardboard boxes and this surveyor asked the department manager if this container is kept here all day and removed when full and then replaced with an empty container. The department manager stated "yes" . This finding was acknowledged by staff MMM during tour.

Based on facility observation and staff interview and verification the facility failed to ensure that medical gas storage and administration areas were protected in accordance with NFPA 99, Standards for Health Care Facilities.

Findings include:

On 08/01/11 between 1:40 P.M. and 3:20 P.M. tour of the offsite facility was completed with Staff MMM and NNN. During the tour observation was made of the medical gas storage area. Observation of the medical gas storage area revealed the presence of 21 full H size tanks of oxygen and 7 empty H size tanks of oxygen. The light switch to the room was observed to be inside the storage room and was placed at less than 5 feet from the floor.

Staff present on tour verified the medical gas room was full and that a recent shipment of oxygen had been delivered. Staff present verified the light switch was less than 5 feet from the floor of the room.

Based on facility tour and staff interview and verification, the facility failed to ensure that medical gas storage and administration areas were protected in accordance with NFPA 99, Standards for Health Care Facilities. Two of two operating rooms located on the maternity unit were affected. Potentially, patients, visitors and staff in the operating room area could be affected. The hospital had a capacity of 346 certified beds with a census of 235 patients at the time of the survey.

Findings included:

On 08/02/11 between 2:35 P.M. and 5:00 P.M. tour of the third floor was completed with Staff MMM and NNN. Observation of the third floor revealed the presence of two operating rooms located on the maternity unit. Tour of the operating rooms and the surgical area revealed a small room noted to store medical gases. Four H-sized cylinders of nitrous oxide were secured in the small room. In addition, the small room contained stored items in boxes and containers as well as some equipment used on the unit. A light switch inside the room was placed less than 5 feet from the floor of the room. The door to the room had no identified fire rating.

Observation of the facility schematic indicated the room walls did not provide for adequate fire rating for at least two walls of the small room. Staff present on tour verified the observation and findings.

Based on facility observation, review of facility documentation and staff interview and verification, the facility failed to ensure that emergency illumination was provided in accordance with section 7.9 with regards to documentation of monthly and yearly testing. The facility was an offsite location which provided outpatient therapy services, MRI testing and a community fitness facility.

Findings included:

On 08/02/11 between 8:50 A.M. and 9:40 A.M. tour of the facility and review of facility documentation was completed with Staff MMM, NNN, and OOO. Observation of the facility revealed there was no emergency generator for provision of lighting in the event of a power outage. Battery powered emergency lighting was observed throughout the facility. Review of facility information revealed there was no documented evidence that battery powered emergency lighting was tested monthly or yearly.

Interview of Staff OOO revealed that battery back-up lighting was tested but there was no documentation of the testing.

Based on observation during tour and staff interview it was determined this facility failed to ensure directional and exit signs are located in areas to ensure proper way of travel to an exit discharge according to the National Fire Protection Association (NFPA) 7.10.1.4 Access to exits is marked by approved, readily visible signs in all cases where the exit or way to reach exit is not readily apparent to the occupants.
Potentially, any patient, visitor or staff utilizing this exit could be affected. The hospital had a capacity of 346 certified beds with a census of 235 patients at the time of the survey.

Findings include:

Tour of the endoscopy center took placed on 08/04/11 with staff members MMM and NNN. Within the northwest section of this 4,595 square foot complex, observation was made of a fire plan mounted on the wall near a door which lead directly to the outside of the building. The fire plan indicated this door was a designated exit and observation was made of a fire pull station mounted on the wall just inside of this door.
No directional sign was observed mounted in this room providing direction to this door nor was there an exit sign displayed above this designated exit door.
This finding was acknowledged by staff MMM during tour on 08/04/11. Staff MMM stated he/she did not think this particular door should have been marked as a designated exit on the fire plan.



Based on facility tour and staff interview and verification, the facility failed to ensure that all exit discharges were provided with emergency lighting according to the National Fire Protection Association (NFPA) 19.2.8 and 7.8 Illumination of means of egress, including exit discharge, is arranged so that failure of any single lighting fixture (bulb) will not leave the area in darkness.
Potentially any patient, visitor or staff utilizing the exit could be affected. The hospital had a capacity of 346 certified beds with a census of 235 patients at the time of the survey.

Findings included:

Tour of the endoscopy center took placed on 08/04/11 with staff members MMM and NNN. Within the northwest section of this 4,595 square foot complex, observation was made of a fire plan mounted on the wall near a door which lead directly to the outside of the building. The fire plan indicated this door was a designated exit and observation was made of a fire pull station mounted on the wall just inside of this door.
Observation was made of this exit discharge lacking any emergency lighting at the exterior of the door.

This finding was acknowledged by staff MMM during tour on 08/04/11. Staff MMM stated he/she did not think this particular door should have been marked as a designated exit on the fire plan.



Based on observation during tour and staff interview it was determined this facility failed to ensure all exit accesses were readily available in regards to a safe walkway from the exit discharge to a paved common way according to the National Fire Protection Association (NFPA) 19.2.1 and 7.7.1.
Potentially, any patient, visitor or staff utilizing this exit could be affected. The hospital had a capacity of 346 certified beds with a census of 235 patients at the time of the survey.

Findings include:

Tour of the endoscopy center took placed on 08/04/11 with staff members MMM and NNN. Within the northwest section of this 4,595 square foot complex, observation was made of a fire plan mounted on the wall near a door which lead directly to the outside of the building. The fire plan indicated this door was a designated exit and observation was made of a fire pull station mounted on the wall just inside of this door.
Upon discharge from this door observation was made of a six foot by five and a half foot cement stoop. Surrounding the cement stoop was a grassy area which extended approximately 45 feet before ending at a paved common way.

This finding was acknowledged by staff MMM during tour on 08/04/11. Staff MMM stated he/she did not think this particular door should have been marked as a designated exit on the fire plan.

Based on observation during tour and staff verification it was determined this facility failed to ensure the common walls of nonconforming buildings were constructed with at least a two hour fire resistance rating. This had the potential to affect all those utilizing this area of the facility. The facility had a capacity of 346 beds with a census of 235 patients at the time of the survey.
Findings included:
1. On 08/02/11 between 2:35 P.M. and 5:00 P.M. tour of the third floor was completed with Staff MMM and NNN. Observation of the third floor corridor, above the ceiling tiles at the fire door, between facility building #1 and facility building #6 revealed penetrations. One penetration was surrounding a pipe. The other open area was estimated to be approximately 14 feet long, 1 to 2 feet wide and open to the floor decking above. Staff present on tour verified that facility building #1 was construction type I(332) and facility building #6 was construction type II(000).
Review of facility schematics revealed the wall was to be a two hour fire rated wall between the two buildings. Staff present on tour verified the two fire rated wall was not complete.

2. Tour of the second floor common wall area located between the physician's offices (building # 6) and the surgical area (building # 9) was completed the morning of 08/05/11 with staff members MMM and NNN. This common wall was designated as a smoke barrier according to the schematics.
Observation above the ceiling tile revealed an approximate three inch penetration from which this surveyor and both staff members were able to determine the wall was constructed with two layers of 5/8 inch drywall making it a one hour fire rated construction. Included in this observation was the wall below the ceiling which was also determined to be constructed with a one hour fire rated construction. The door in this assembly was determined to be 3/4 hour fire resistance rated. The entire common wall area of the second floor between building # 6 and building # 9 was not constructed with the required two hour fire resistance rating and this area was estimated to be approximately ten feet wide by twelve feet high.

3. Tour of facility building #1 basement took place on 08/03/11, with staff member NNN. During tour of the two hour fire rated common wall separating the physician's offices from the main building near the cardiac center, observation was made of one penetration above the double doors with blue wires passing through. Additionally, one leaf of the double doors failed to close and latch shut.

This finding was verified by staff member MMM during tour on 08/04/11.

Based on observation during tour and staff verification it was determined this facility failed to ensure the doors protecting corridors openings were constructed to resist the passage of smoke for at least twenty minutes. This had the potential to affect all those utilizing this area of the facility. The hospital had a capacity of 346 certified beds with a census of 235 patients at the time of the survey.

Findings included:

Tour of the basement of building # 1 took place on 08/03/11 with staff NNN and first floor on 08/04/11 with staff members MMM and NNN. During tour of the corridors, observation was made of two corridor doors which failed to close properly in order to resist the passage of smoke in the following locations:
Basement:
*At the northwest corner of the dish room of the dietary department from the corridor side, observation was made of the corridor dish room door which failed to shut properly leaving a small gap between the door and the door frame.
First floor:
* Within the corridor between the emergency department and laboratory and at the southeast corner of the emergency department, observation was made of the smoke barrier doors failing to close properly when disengaged from the holding devices.

These findings were verified by the staff present during tour on 08/03/11 and 08/04/11.

Based on observation during tour and staff interview it was determined this facility failed to ensure directional and exit signs were located in areas to ensure proper way of travel to an exit discharge. This had the potential to affect all those utilizing this area of the facility. The facility had a capacity of 346 beds with a census of 235 patients at the time of the survey.
Findings include:
Tour of the basement of building # 1 took place on 08/03/11 with staff NNN. During tour of the 9,375 square foot medical records/IT department observation was made of two exit directional signs, one at the northeast end of the room and the other at the southeast end. Both signs directed flow to an exit access located on the east side, center of the room. Observation was made of three doors located in the east side center of this room, none of which had an exit sign designating it as the exit access. This surveyor was not able to determine which door was the exit access and was not able to locate a fire escape plan within this department to verify the designated exit route.
The exit access door was revealed to this surveyor by staff NNN. Observation was made by this surveyor and staff NNN that no directional sign was mounted in order to direct any persons to the exit access door, nor was there an exit sign located above the exit access door.
Additionally, observation was made of stairs located outside of this exit door which were assessable only once one was outside of this room.

Based on observation during tour and staff verification it was determined this facility failed to ensure the smoke barriers were constructed with at least a one hour fire resistance rating. This had the potential to affect all those utilizing that area of the facility.

Findings included:

1. On 08/01/11 between 1:40 P.M. and 3:20 P.M. tour of the offsite facility was completed with Staff MMM and NNN. During the tour observation was made of the smoke barriers which included the spaces above ceiling tiles. The following locations were noted to have penetrations located in the smoke barrier above the ceiling tile:
*Located above the fire doors leading to the emergency department from the business occupancy, an area approximately 10 inches in diameter was not sealed. The area at the floor decking above was also not sealed.
* An area was not sealed in the smoke barrier wall at the floor decking at the back wall of the men's bathroom.

Staff present on the tour verified the observation and findings with regards to penetrations in the smoke barrier wall.

Based on observation during tour and staff verification it was determined this facility failed to ensure the smoke barriers were constructed with at least a one half hour fire resistance rating. This had the potential to affect all those utilizing this area of the facility. The hospital had a capacity of 346 certified beds with a census of 235 patients at the time of the survey.

Findings included:

1. On 08/02/11 between 2:35 P.M. and 5:00 P.M. tour of the third floor was completed with Staff MMM and NNN. During tour of the smoke barriers, observation was made of several penetrations located in the smoke barrier above the ceiling tile in the following locations:
* Located in the vascular/lab corridor, penetrations were noted surrounding a heat pump loop and data cable wires.
* Located above B311, a penetration was noted approximately 1 inch by 2 inches. Also visible was an unsealed area surrounding conduit.
* Located above B314 a penetration was noted approximately 1/2 inch by 1 inch and 3 unsealed areas surrounding conduit.

2. On 08/03/11 between 10:00 A.M. and 4:00 P.M. tour of the second floor was completed with Staff MMM. During tour of the smoke barriers, observation was made of several penetrations located in the smoke barrier above the ceiling tile in the following locations:
* Located at the surgical waiting area, near the elevators, penetrations were observed surrounding a protected beam.
* Located at the surgical waiting area, near the heart vascular institute, two penetrations were observed. one area was approximately 4 inches square and the other approximately 2 inches square.
* Located in the same area was an unsealed opening surrounding an area where at least six data cable lines penetrated the wall.
*Located near stairwell C a open area was noted surrounding a conduit and a hole approximately 3 inches square.
* Located at the CCU smoke doors, near the cath lab entrance, a penetrations was noted surrounding conduit and an area was not sealed surrounding an I-beam.

3. Tour of the basement of building # 1 took place on 08/03/11 with staff NNN and first floor on 08/04/11 with staff members MMM and NNN. During tour of the smoke barriers, observation was made of several penetrations located in the smoke barrier above the ceiling tile in the following locations:
First floor:
* Above the west double doors of the smoke barrier bordering the infusion therapy room of the oncology department, observation was made of one, two inch open ended conduit.
* The smoke barrier bordering the south side of the pastoral care room and near the stairs, observation was made of two one inch unsealed penetrations.
Additionally, observation was made of a four inch penetration and two unsealed insulated lines above a dryer near the same area.
* Above the double doors between the PBX room and the breast center, observation was made of four unsealed penetrations. Additionally, at the southeast corner of the breast center, observation was made of two-two inch unsealed penetrations in the smoke barrier.
* Above the double doors by the stairwell between the PBX and EMS room, observation was made of two unsealed areas where data lines penetrated through the drywall. Additionally, above the smoke barrier doors at the west end of the east-west corridor, adjacent to the previous doors, observation was made of one, three inch unsealed silver conduit.
* Within the emergency department at the west end smoke barrier doors, observation was made of two unsealed conduits with wires passing through.
* Within the emergency department at the east end smoke barrier doors, observation was made of two unsealed insulated lines passing through two sleeves and one unsealed three inch sleeve with wires passing through.
* Within the corridor between the emergency department and laboratory and at the southeast corner of the emergency department, observation was made above the smoke barrier doors of a large penetration around the duct.
* Within the same corridor by room #170, observation was made of one, one inch unsealed conduit.

Basement:
*Above the smoke barrier doors located between pathology and nuclear medicine, observation was made of an approximate four by eight foot section of missing drywall.
*Within the "pop storage" room adjacent to the physical therapy offices, observation was made of a penetration around an electrical chase.
*Within the dish room of the dietary department at the east wall near the wall mounted fan, one unsealed conduit was observed. Also, on the north wall near the portable fire extinguisher another unsealed conduit was observed. Additionally, from the corridor on the north side of the dish room and near the corridor door bordering the locker room, observation was made of one unsealed conduit and one unsealed black wire passing through the smoke barrier.
* Above the smoke barrier door within the volunteers TV service area, observation was made of two unsealed orange flex lines.
*Above the smoke barrier corridor door by community room number eight, observation was made of an approximate four foot by two and a half foot area of missing drywall.
*Within the corridor wall bordering the south side of the community health room, observation was made of three open end conduits with flesh colored wires passing through.

These findings were verified by staff MMM and NNN during tour on 08/03/11 and 08/04/11.

Based on facility tour and staff interview and verification the facility failed to ensure that door openings in smoke barriers had at least a 20-minute fire protection rating. The hospital had a capacity of 346 certified beds with a census of 235 patients at the time of the survey.

Findings included:

On 08/02 and 08/03/11 tour of the second and third floors of the facility was completed with Staff MMM and NNN. During tour of the second and third floors, observation was made of the corridor smoke doors. Testing of the corridor smoke doors revealed that gaps greater than 1/8 inch were present at the door edges when the smoke doors were in the closed position.

The affected smoke barrier doors were observed near the third floor psychiatric unit for geriatric patients and on the second floor near the coronary care unit.

Staff present on tour verified the gaps at the door edges were greater than 1/8 inch and would permit the passage of smoke.

Based on facility tour, review of facility documentation and staff interview and verification, the facility failed to ensure that hazardous areas were protected in accordance with 8.4. The areas were to be enclosed with a one hour fire-rated barrier, with a 3/4 hour fire-rated door, without windows (in accordance with 8.4). This had the potential to affect all those utilizing that area of the facility.

Findings included:

On 08/01/11 between 1:40 P.M. and 3:20 P.M. tour of the offsite facility was completed with Staff MMM and NNN. During the tour observation was made of soiled utility areas and areas designated to store biohazard materials until picked up for disposal. The following observations were noted of the areas considered to be hazardous storage.

* Review of facility schematics revealed the soiled utility room located in the emergency department did not have walls that provided a one hour fire rated barrier. Observation of the walls above the ceiling tiles verified the information on the schematic. The door to the soiled room was noted to have a 20 minutes fire resistance rating.

* Observation of an area identified to be used for biohazard storage until picked up for disposal, revealed areas were not sealed in the fire rated walls at the floor decking. Areas surrounding 4 pipes observed above the door to the biohazard room were not sealed.

*A room identified as a soiled linen hold area was noted by review of schematics drawing have been increased in size. When the room was increased in size , two walls were not provided with a one hour fire resistance rating. The door to the room did not have a 3/4 hour fire resistance rating.

Staff present on tour observed and verified the findings.

Based on observation during tour and staff verification it was determined this facility failed to ensure hazardous areas were constructed with at least a one hour fire rated construction regarding doors in storerooms and soiled utilities. This had the potential to affect all those utilizing these areas of the facility. The facility had a capacity of 346 beds with a census of 235 patients at the time of the survey.
Findings include:
Tour of the first floor of building # 1 took place on 08/04/11 with staff members MMM and NNN. During tour of the oncology department and within their medical records storeroom, observation was made of the one hour fire rated door failing to shut and latch properly.
During tour of the northeast section of the outpatient center and within the soiled utility room, observation was made of a large mobile trash container stored within this room. The door of this soiled utility room lacked a fire resistance rating.
During tour of the east section of the radiology center and within the soiled utility room located across from the medical gas room, observation was made of a large mobile trash container stored within this room. The door of this soiled utility room lacked a fire resistance rating.
These findings were observed and acknowledged by staff members MMM and NNN during tour on 08/04/11.

Based on observation during tour and staff verification it was determined this facility failed to ensure the stairwell exit discharge door closed and latched properly in order to preserve the two hour fire resistance rating of this exit component. This had the potential to affect all those utilizing this area of the facility. The hospital had a capacity of 346 certified beds with a census of 235 patients at the time of the survey.

Findings included:

Tour of the basement of building number # 1 took place on 08/03/11 with staff member NNN. During tour of stairwell J, observation was made of the exit discharge door leading directly outside, failing to close and latch when tested. This left at least a two inch gap between the door leaf and the door frame.
This finding was verified by staff member MMM during tour on 08/03/11.

Based on facility observation and staff interview and verification, the facility failed to ensure that patient room doors were arranged so that patients could open the door from inside without using a key. Ten of ten patients residing on the secured psychiatric unit were affected. The psychiatric unit capacity was eleven patient rooms.

Findings included

On 08/02/11 between 2:35 P.M. and 5:00 P.M. tour of the third floor was completed with Staff MMM and NNN. Observation of the third floor revealed the presence of the secured psychiatric unit for geriatric patients. Observation of the unit revealed that patient sleeping rooms had deadbolt type locks present on the doors in addition to the door handle. Interview of unit staff revealed that patient room doors could be locked from the outside using a key. Once the doors were locked, doors could not be opened from inside the room by use of the door handle. The bathroom doors, inside the patient rooms, were equipped with the same deadbolt type locks as well as roller latches.

Staff on the unit stated that no patients were locked in the rooms but the purpose of the locks was to secure the rooms so that patients would not go into unoccupied, clean rooms or could not go into rooms to hide. Patient room doors were observed to be open during tour of the unit.

Based on facility tour and staff interview and verification, the facility failed to ensure that exit discharges were provided with emergency lighting. Potentially any patient, visitor or staff utilizing the exit could be affected. The hospital had a capacity of 346 certified beds with a census of 235 patients at the time of the survey.

Findings included:

On 08/02/11 between 2:00 P.M. and 2:30 P.M. tour of the fourth floor was initiated with Staff MMM and NNN. Observation of two exit stairwells to the point of exit discharge revealed the exits lacked adequate emergency lighting.

Stairwell L was noted to have no emergency lighting present at the exit discharge and Stairwell F had one light fixture at the exit discharge. A second means of lighting was a remote parking lot light.

Staff MMM present on tour verified the emergency lighting was not present for stairwell L and limited for stairwell F.

Based on facility documentation review and staff interview and verification, the facility failed to ensure that fire drills were held at unexpected times under varying conditions, at least quarterly on each shift. The facility had a census of 14 patients at the time of survey.

Finding included:

On 08/02/11 between 11:00 A.M. and 12:00 P.M. review of facility documentation was completed with Staff MMM and TTT. Review of fire drills for 2010 and to date in 2011 was competed. Staff TTT presented the information. Review of the fire drills for the offsite location revealed that no fire drill was completed for the second second shift in the second quarter of 2011. Staff TTT verified there was no documented evidence the fire drill had been completed.

Based on facility documentation review and staff interview and verification, the facility failed to ensure that fire drills were held at unexpected times under varying conditions, at least quarterly on each shift. The facility had a census of 14 patients at the time of survey.

Finding included:

On 08/02/11 between 11:45 A.M. and 12:00 P.M. review of facility documentation was completed with Staff MMM and TTT. Review fire drills for 2010 and to date in 2011 was competed. Staff TTT presented the information. Review of the fire drills for the offsite location revealed that no fire drill was completed for the second shift in the third quarter of 2010 and the third shift for the first quarter of 2011. Staff TTT verified there was no documented evidence the fire drills had been completed.

Based on observation during tour and staff verification, it was determined this facility failed to ensure all trash containers exceeding 32 gallon capacity, while not attended, are stored within a room with at least a one hour fire rated construction. This had the potential to affect all those utilizing this area of the facility. The facility had a capacity of 346 beds with a census of 235 patients at the time of the survey.
Findings include:
Tour of the first floor of building # 1 took place on 08/04/11 with staff members MMM and NNN. During tour of the laboratory department and near the southwest exit, observation was made of a large mobile trash container located just inside the exit access. This mobile trash bin contained layers of cardboard boxes and this surveyor asked the department manager if this container is kept here all day and removed when full and then replaced with an empty container. The department manager stated "yes" . This finding was acknowledged by staff MMM during tour.

Based on facility observation and staff interview and verification the facility failed to ensure that medical gas storage and administration areas were protected in accordance with NFPA 99, Standards for Health Care Facilities.

Findings include:

On 08/01/11 between 1:40 P.M. and 3:20 P.M. tour of the offsite facility was completed with Staff MMM and NNN. During the tour observation was made of the medical gas storage area. Observation of the medical gas storage area revealed the presence of 21 full H size tanks of oxygen and 7 empty H size tanks of oxygen. The light switch to the room was observed to be inside the storage room and was placed at less than 5 feet from the floor.

Staff present on tour verified the medical gas room was full and that a recent shipment of oxygen had been delivered. Staff present verified the light switch was less than 5 feet from the floor of the room.

Based on facility tour and staff interview and verification, the facility failed to ensure that medical gas storage and administration areas were protected in accordance with NFPA 99, Standards for Health Care Facilities. Two of two operating rooms located on the maternity unit were affected. Potentially, patients, visitors and staff in the operating room area could be affected. The hospital had a capacity of 346 certified beds with a census of 235 patients at the time of the survey.

Findings included:

On 08/02/11 between 2:35 P.M. and 5:00 P.M. tour of the third floor was completed with Staff MMM and NNN. Observation of the third floor revealed the presence of two operating rooms located on the maternity unit. Tour of the operating rooms and the surgical area revealed a small room noted to store medical gases. Four H-sized cylinders of nitrous oxide were secured in the small room. In addition, the small room contained stored items in boxes and containers as well as some equipment used on the unit. A light switch inside the room was placed less than 5 feet from the floor of the room. The door to the room had no identified fire rating.

Observation of the facility schematic indicated the room walls did not provide for adequate fire rating for at least two walls of the small room. Staff present on tour verified the observation and findings.

Based on facility observation, review of facility documentation and staff interview and verification, the facility failed to ensure that emergency illumination was provided in accordance with section 7.9 with regards to documentation of monthly and yearly testing. The facility was an offsite location which provided outpatient therapy services, MRI testing and a community fitness facility.

Findings included:

On 08/02/11 between 8:50 A.M. and 9:40 A.M. tour of the facility and review of facility documentation was completed with Staff MMM, NNN, and OOO. Observation of the facility revealed there was no emergency generator for provision of lighting in the event of a power outage. Battery powered emergency lighting was observed throughout the facility. Review of facility information revealed there was no documented evidence that battery powered emergency lighting was tested monthly or yearly.

Interview of Staff OOO revealed that battery back-up lighting was tested but there was no documentation of the testing.

Based on observation during tour and staff interview it was determined this facility failed to ensure directional and exit signs are located in areas to ensure proper way of travel to an exit discharge according to the National Fire Protection Association (NFPA) 7.10.1.4 Access to exits is marked by approved, readily visible signs in all cases where the exit or way to reach exit is not readily apparent to the occupants.
Potentially, any patient, visitor or staff utilizing this exit could be affected. The hospital had a capacity of 346 certified beds with a census of 235 patients at the time of the survey.

Findings include:

Tour of the endoscopy center took placed on 08/04/11 with staff members MMM and NNN. Within the northwest section of this 4,595 square foot complex, observation was made of a fire plan mounted on the wall near a door which lead directly to the outside of the building. The fire plan indicated this door was a designated exit and observation was made of a fire pull station mounted on the wall just inside of this door.
No directional sign was observed mounted in this room providing direction to this door nor was there an exit sign displayed above this designated exit door.
This finding was acknowledged by staff MMM during tour on 08/04/11. Staff MMM stated he/she did not think this particular door should have been marked as a designated exit on the fire plan.



Based on facility tour and staff interview and verification, the facility failed to ensure that all exit discharges were provided with emergency lighting according to the National Fire Protection Association (NFPA) 19.2.8 and 7.8 Illumination of means of egress, including exit discharge, is arranged so that failure of any single lighting fixture (bulb) will not leave the area in darkness.
Potentially any patient, visitor or staff utilizing the exit could be affected. The hospital had a capacity of 346 certified beds with a census of 235 patients at the time of the survey.

Findings included:

Tour of the endoscopy center took placed on 08/04/11 with staff members MMM and NNN. Within the northwest section of this 4,595 square foot complex, observation was made of a fire plan mounted on the wall near a door which lead directly to the outside of the building. The fire plan indicated this door was a designated exit and observation was made of a fire pull station mounted on the wall just inside of this door.
Observation was made of this exit discharge lacking any emergency lighting at the exterior of the door.

This finding was acknowledged by staff MMM during tour on 08/04/11. Staff MMM stated he/she did not think this particular door should have been marked as a designated exit on the fire plan.



Based on observation during tour and staff interview it was determined this facility failed to ensure all exit accesses were readily available in regards to a safe walkway from the exit discharge to a paved common way according to the National Fire Protection Association (NFPA) 19.2.1 and 7.7.1.
Potentially, any patient, visitor or staff utilizing this exit could be affected. The hospital had a capacity of 346 certified beds with a census of 235 patients at the time of the survey.

Findings include:

Tour of the endoscopy center took placed on 08/04/11 with staff members MMM and NNN. Within the northwest section of this 4,595 square foot complex, observation was made of a fire plan mounted on the wall near a door which lead directly to the outside of the building. The fire plan indicated this door was a designated exit and observation was made of a fire pull station mounted on the wall just inside of this door.
Upon discharge from this door observation was made of a six foot by five and a half foot cement stoop. Surrounding the cement stoop was a grassy area which extended approximately 45 feet before ending at a paved common way.

This finding was acknowledged by staff MMM during tour on 08/04/11. Staff MMM stated he/she did not think this particular door should have been marked as a designated exit on the fire plan.