HospitalInspections.org

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Based on observation, the facility failed to provide an emergency release switch for the full-time magnetic locks on the egress doors in the Emergency Department per the requirements of:

2012 NFPA 101, 19.2.2.2.5.2 (1), and 19.2.2.2.6

This deficiency affects 1 of 2 smoke compartments.

Findings include:

On 11/17/2021, during a tour of the facility from 7:45 am to 4:15 pm, the surveyor observed the egress doors in the Emergency Department with full time magnetic locks did not have an emergency release switch that automatically unlocked these doors in case of an emergency.

A member of the maintenance staff was present when this deficiency was identified.
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Based on observation, the facility failed to provide an emergency release switch for the full-time magnetic locks on the egress doors in the Geri-Psych Unit per the requirements of:

2012 NFPA 101, 19.2.2.2.5.1, and 19.2.2.2.6(1)

This deficiency affects 1 of 5 smoke compartments.

Findings include:

On 11/17/2021, during a tour of the facility from 7:45 am to 4:15 pm, the surveyor observed the egress doors in the Geri-Psych.Unit with full time magnetic locks did not have an emergency release switch that automatically unlocked these doors in case of an emergency.

A member of the maintenance staff was present when this deficiency was identified.
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Based on observation, the facility failed to provide continuous illumination of the means of egress per the requirements of:

2012 NFPA 101, 19.2.8, 7.8.1.2 and 7.8.1.4

This deficiency affects 2 of 10 smoke compartments.

Findings include:

On 11/17/2021, during a tour of the facility from 7:45 am to 4:15, the surveyor observed a single wall mounted fixture with a single bulb (no continuous illumination of the means of egress) at the following exits:

1. The 2nd floor exit to the roof
2. The 3rd floor exit to the roof

A member of the maintenance staff was present when this deficiency was identified.
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Based on observation, the facility failed to provide continuous illumination of the means of egress per the requirements of:

2012 NFPA 101, 19.2.8, 7.8.1.2 and 7.8.1.4

This deficiency affects 2 of 5 smoke compartments.

Findings include:

On 11/17/2021, during a tour of the facility from 7:45 am to 4:15, the surveyor observed the following exits:

1. A single wall mounted fixture with a single bulb (no continuous illumination of the means of egress) at the Psych Unit exit
2. The Cafeteria Classroom exit had no fixture at the exit

A member of the maintenance staff was present when this deficiency was identified.
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Based on observation, the facility failed to provide continuous or automatic emergency lighting in the corridor per the requirements of:.

2012 NFPA 101, 19.2.9.1, and 7.9.2.7

This deficiency affects 1 of 5 smoke compartments.

Findings include:

On 11/18/2021, during a tour of the facility from 8:00 am to 4:15 pm, the surveyor observed the corridor emergency lighting was on a swicth and was able to be turned off and not continuous in the Cafeteria corridor.

A member of the maintenance staff was present when this deficiency was identified.
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Based on observation, the facility failed to provide continuous or automatic emergency lighting in the corridors per the requirements of:.

2012 NFPA 101, 19.2.9.1, and 7.9.2.7

This deficiency affects 4 of 10 smoke compartments.

Findings include:

On 11/18/2021, during a tour of the facility from 8:00 am to 4:15 pm, the surveyor observed the following:
1. The corridor emergency lighting was on a swicth and was able to be turned off and not continuous in the following corridors:
a. The Dietary/Kitchen corridor
b. The Lab corridor


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2. The emergency light fixture (the only light fixture) in the the stairwell on the third floor was not illuminated at either of the two stairwells.

A member of the maintenance staff was present when this deficiency was identified.
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Based on observation, the facility failed to provide continuous illumination of the exit signage per the requirements of:

2012 NFPA 101, 19.2.10.1, and 7.10.5.2.1

This deficiency affects 1 of 5 smoke compartments.

Findings include:

On 11/16/2021, during a tour of the facility from 10:45 am to 2:45 pm, the surveyor observed the exit sign at the Wound Care Center's back door was not illuminated.

A member of the maintenance staff was present when the deficiency was identified.

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Based on observation, the facility failed to maintain the exit signage per the requirements of:

2012 NFPA 101, 39.2.10.1, 7.10.5.2.1, and 7.10.2.1

This deficiency affects 1 of 1 smoke compartment.

Findings include:

On 11/18/2021, during a tour of the facility from 8:00 am to 4:15 pm, the surveyor observed the following:
1. The following locations had exit/emergency signs that were not illuminated:
a. Over the egress door at the front entrance
b. Over the egress door at the rear exit leading to the common means of egress
c. Over both egress doors for the common means of egress to the outside

2. The exit sign over the egress door at the front entrance had chevron-type indicators directing egress to the left and the right

A member of the maintenance staff was present when the deficiency was identified.

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Based on observation, the facility failed to maintain an elevator shaft per the requirements of:

2012 NFPA 101, 19.3.1.1

This deficiency affects 1 of 10 smoke compartments.

Findings include:

On 11/16/2021, during a tour of the facility from 10:45 am to 2:15 pm, the surveyor observed (2) 4" x 4" unsealed openings in the sheetrock of the 1 hour rated ceiling in the west end elevator shaft on the third floor.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to install an Alcohol-Based Hand-Rub (ABHR) Dispenser and limit the storage of the solution per the requirements of:

2012 NFPA 101, 19.3.2.6 (8), and 19.3.2.6 (7)

This deficiency affects 1 of 5 smoke compartments.

Findings include:

On 11/18/2021, during a tour of the facility from 8:00 am to 4:15 pm, the surveyor observed:

1. An ABHR Dispenser mounted directly above a light switch (ignition source) in the Specialty Clinic Bathroom
2. 3800 fluid ounces (29 gallons) of ABHR solution stored in one smoke compartment, a storage room located across the corridor from the Maintenance Directors Office

A member of maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to ensure the fire alarm visible notification devices were synchronized per the requirements of:

2012 NFPA 101, 19.3.4.3.1, and 9.6.3.5
2010 NFPA 72, 18.5.4.4.7

This deficiency affects 1 of 5 smoke compartments.

Findings include:

On 11/17/2021, during a tour of the facility from 7:45 am to 4:15 pm, during the activation of the fire alarm system the surveyor observed five fire alarm notification devices in the field of view not flashing in synchronization in the Geri-Psych Unit corridor.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to maintain the automatic sprinkler system per the requirements of:

2012 NFPA 101, 19.3.5.1, and 9.7.1.1(1)
2010 NFPA 13, 8.5.6.1

This deficiency affects 1 of 10 smoke compartments.

Findings include:

On 11/16/2021, during a tour of the facility from 10:45 am to 2:15 pm, the surveyor observed boxes were stored within 12 inches of the sprinkler heads in the following rooms on the second floor:

1. The Pharmaceutical Supply Room
2. The Pharmacy Office

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to maintain the corridor doors per the requirements of:

2012 NFPA 101, 19.3.6.3.2 (2), and 19.3.6.4.1

This deficiency affects 1 of 5 smoke compartments.

Findings include:

On 11/17/2021, during a tour of the facility from 7:45 am to 4:15 pm, the surveyor observed two 18"x 18" transfer grilles in a set of double corridor doors (one in each door) for the washer and dryer closet in the Geri-Phych Unit, next to the Nurses' Station.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to maintain the Elevators Emergency Operation Fire Fighters Service/Recall per the requirements of:

2012 NFPA 101, 19.5.3, and 9.4.6.2
1996 ASME A17.3, 4.7.8, and 3.11

This deficiency affects 1 of 3 elevators.

Findings include:

On 11/18/2021, during a tour of the building from 8:00 am to 4:15 pm, the facility failed to provide documentation of monthly operation test on facility elevator equiped with "Fire Fighters' Emergency Operations" service.

A member of the maintenance staff was present when this deficiency was identified.

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Based on review of documentation, the facility failed to maintain the line isolation monitors (LIM) per the requirements of:

2012 NFPA 99, 6.3.2.6.3.6, 6.3.4.1.4, and 6.3.4.1.5

This deficiency affects 1 of 2 smoke compartments.

Findings include:

On 11/18/2021, during a tour of the facility from 8:00 am to 4:15 pm, the facility failed to provide documentation of testing the line isolation monitors in the OR's monthly.

A member of maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to maintain the electrical equipment per the requirements of:

2012 NFPA 99, 10.2.3.6, and 10.2.4
2011 NFPA 70, 400.8
S&C: 14-46-LCS

This deficiency affects 1 of 5 smoke compartments.

Findings include:

On 11/18/2021, during a tour of the facility from 8:00 am to 4:15 pm, the surveyor observed a power strip with one device plugged into it, plugged into another power strip with two devices plugged into it, plugged into a receptacle in the Cafeteria Classroom.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to maintain the electrical equipment per the requirements of:

2012 NFPA 99, 10.2.3.6, and 10.2.4
2011 NFPA 70, 400.8
S&C: 14-46-LCS

This deficiency affects 2 of 10 smoke compartments.

Findings include:

On 11/17/2021, during a tour of the facility from 7:45 am to 4:15 pm, the surveyor observed the following:

1. A microwave plugged in to a power strip then the power strip was plugged in to an extension cord that was plugged into a receptacle in the Cardio-Pulmonary Break Room.
2. Three electrical devices were plugged in to a power strip, plugged into another power strip with two devices plugged in to it, plugged in to another power strip with one device plugged in to it, plugged in to the receptacle in the 1st Floor Laboratory.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to identify the Class B hyperbaric chamber oxygen exhaust per the requirements of:

2012 NFPA 99, 14.2.9.2.5

This deficiency affects 1 of 5 smoke barriers.

Findings include:

On 11/17/2021, during a tour of the facility from 7:45 am to 4:15 am, the surveyor observed the sign prohibiting smoking or open flame for the point of exhaust was 6'-0" above grade and hidden by a canopy frame and canopy. The point of oxygen exhaust was actually 12'-0" above grade and was not identified.

A member of the maintenance staff was present when this deficiency was identified.