HospitalInspections.org

Based on observation, the facility failed to keep the means of egress open to full and instant use in accordance with NFPA 101, 2012 Edition, Sections 7.1.10.1 and 19.2.3.4(5).

Findings include:

1. During an observation on 4/1/24 at 2:20 p.m., the LTC corridor near the clinic exit was inspected. There were two chairs in the corridor which were not fastened to the floor or the wall. Furniture groups are allowed in the corridor as long as they are secured to the floor or wall so they do not move and impede egress during a fire or emergency.

Based on observation, the facility failed to ensure all exit passageways were marked in accordance with NFPA 101 2012 Edition, Section 7.7.3.2.

Findings include:

1. During an observation on 4/1/24 at 2:08 p.m., the OR suite was inspected. The suite was found to be lacking any exit signage. There were many doors in the suite, and exit during panic and/or fire would not be obvious.

Based on observation, the facility failed to ensure alcohol-based hand rub (ABHR) dispensers were not mounted over ignition sources in accordance with NFPA 101, 2012 Edition, Section 19.3.2.6 (8).

Findings include:

1. During an observation on 4/1/24 at 1:44 p.m., patient room 105-1 was inspected. There was an ABHR dispenser mounted over the light switch immediately inside the door of the room.

2. During an observation on 4/1/24 at 1:47 p.m., patient room 109 was inspected. There was an ABHR dispenser mounted over the light switch immediately inside the door of the room.

3. During an observation on 4/1/24 at 1:49 p.m., patient room 115 was inspected. There was an ABHR dispenser mounted over the light switch immediately inside the door of the room.

Based on observation, the facility failed to maintain sprinkler heads free of foreign materials per NFPA 25 Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 5.2.1.1.1, and failed to ensure sprinkler systems maintained satisfactory performance with respect to activation time in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.1.1(3).

Findings include:

1. During an observation on 4/1/24 at 1:15 p.m., the laundry was inspected. The sprinkler head above the dryers was found to be choked with debris and there was paint and spackle on a sprinkler head in the soiled side of the laundry.

2. During an observation on 4/1/24 at 1:20 p.m., the dish room adjacent to the kitchen was inspected. The sprinkler head in the dish room was found to be corroded and the bulb had turned white. You could not see the color of the fluid in the bulb.

3. During an observation on 4/1/24 at 1:40 p.m., the custodial closet in the helicopter hall was inspected. The sprinkler head in the closet was missing the escutcheon ring.

4. During an observation on 4/1/24 at 1:53 p.m., the ER vestibule was inspected. The sprinkler head in the area was missing the escutcheon ring.

Based on observation, the facility failed to maintain the electrical system in accordance with NFPA 70 National Electric Code, 2011 Edition, Article 110-12(B).

Findings include:

1. During an observation on 4/1/24 at 1:51 p.m., the pantry in the acute care area of the hospital was inspected. A high voltage junction box was found to be missing the cover plate.