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Tag No.: K0020
Based on observations made during tour and staff interview, it was determined that the facility failed to ensure that vertical openings between floors were enclosed with construction having a fire resistance rating of at least one hour around the north entrance atrium and around one exterior stairway. This could affect all individuals in the affected smoke compartments.
Adena Regional Medical Center has a capacity of 261 beds with a census of 160 patients at the time of the survey.
Findings include:
Tour was conducted with staff AA, staff BB, and staff CC on 11/1/11 from 11:45 AM until 4:00 PM. When the one-hour barrier around the second floor level of the atrium at the north entrance was observed, unsealed penetrations of the barrier were observed above the ceiling tiles as follows:
Above the 2NO6A doors, two three-inch sleeves that contained IT wires were not sealed inside the sleeves.
Above the 2NO8A doors, two sleeves that contained conduit were not sealed inside the sleeves. In addition, one three-inch sleeve containing IT wires and one conduit containing wire were not sealed inside.
Above the 2NO 4 doors, four three-inch sleeves that contained IT wires were not sealed inside the sleeves.
The exit stairway near room 2NE-28 was observed to have two openings into the exterior stairway around conduit.
These findings were confirmed by staff AA during the tour.
Tag No.: K0025
Based on observations made during tour and staff interview, it was determined that the facility failed to ensure that smoke barriers were constructed to provide at least a one half hour fire resistance rating. This could affect all individuals in the affected areas of the facility.
Adena Regional Medical Center has a capacity of 261 beds with a census of 160 patients at the time of the survey.
Findings include:
Tour was conducted with staff AA, staff BB, and staff CC on 11/1/11 from 11:45 AM until 4:00 PM, on 11/2/11 from 10:10 AM until 4:00 PM, and on 11/3/11 from 10:10 AM until 12:30 PM. Smoke barriers were observed, above the ceiling tiles, to have unsealed penetrations or to have been sealed with unapproved materials as follows:
There was a one and one-half inch by one and one-half inch opening around IT wires in the smoke barrier by waiting room 3C38.
There was an irregular six inch by one and one-half inch opening around a sleeve in the smoke wall above the doors at the nurses station in the 20's and 30's hallway, near 21/31.
In the smoke wall in the nourishment room across from the above nurses station, there was a one and one-half to two foot section of drywall above a duct that was not seamed and finished.
In the smoke wall near rooms 41 and 51, there was a light-colored spray foam material around two flex conduits and wires.
Above doors 3A70S, near 3A-62, there were five areas observed filled with the light-colored spray foam.
Above smoke doors 2A70N, near room 2A-62, there was an opening around IT cable and light-colored foam was observed around a sleeve.
There were five areas noted to have light-colored foam sealant above the smoke doors near 2A-42. The foam was observed on both sides of the barrier. In addition, there was a sleeve that contained green data cable that had not been sealed.
In the barrier in biohazard room 2A40S there was spray foam filling a one-inch open area below a duct.
Above smoke doors 2A30S there was spray foam in three places and an unfilled opening around pipes at the far right side of the doors.
Spray foam was observed in three places above the double doors to ICU and in several places above doors 2A17S.
An unsealed opening was observed on the east wall of the respiratory hallway on the back side of cath lab 1.
Spray foam was observed filling one opening above 2B17A doors.
Above the smoke doors to the emergency room, there were three unsealed penetrations around green and yellow cable.
In the emergency room triage PA room, across from security, the drywall was not sealed and finished up to the decking of the floor above, and for approximately two feet where the drywall met the decking.
Above the smoke doors near CT room 1, insulation was observed filling a gap below a duct and there was insulation at the far right side of the duct. In addition, one of the two smoke doors did not close completely when released.
There were two areas of piping not sealed in mechanical room 2D57 off the main lobby.
There was spray foam observed in several places above smoke doors 1C81, and it was open above a piece of set-in drywall near the decking on the left side when observed from the facilities operations biomedical services side of the wall.
Above the door to the inpatient psychiatric unit, spray foam was observed in several places and it was open at the far right side below the decking.
The above findings were confirmed by the accompanying staff during the tour. Staff AA also confirmed that the spray foam that was observed could not be proven to be an acceptable fire stop material.
Tag No.: K0025
Based on observations made during tour and staff interview, it was determined that the facility failed to ensure that smoke barriers were maintained to provide at least a one-hour fire resistance rating in all areas of the facility. This could affect all individuals in the affected smoke compartments.
Adena Regional Medical Center has a capacity of 261 beds with a census of 160 patients at the time of the survey.
Findings include:
Tour was conducted with staff AA, staff BB, and staff CC on 11/1/11 from 11:45 AM until 4:00 PM. Unsealed penetrations of the smoke barriers were observed above the ceiling tiles above the double doors leading to 2NE, where there was a sleeve containing cables, and above the ceiling tiles above double doors 2EO3A, where there was a large sleeve containing green IT wires. These findings were confirmed by staff AA during the tour.
Tag No.: K0029
Based on observations made during tour and staff interview, it was determined that the facility failed to ensure that the biohazard room in the emergency department had a door that latched securely into the door frame. This could affect all individuals in the affected smoke compartment.
Adena Regional Medical Center has a capacity of 261 beds with a census of 160 patients at the time of the survey.
Findings include:
Tour was conducted with staff AA, staff BB, and staff CC on 11/2/11 from 10:10 AM until 4:00 PM. During tour of the emergency department, it was observed that the door to the biohazard room did not latch. This was confirmed by staff AA during the tour.
Tag No.: K0029
Based on observations made during tour and staff interview, it was determined that the facility failed to ensure that two hazardous areas were enclosed with a one hour fire-rated barrier. This could affect all individuals in the affected smoke compartments.
Adena Regional Medical Center has a capacity of 261 beds with a census of 160 patients at the time of the survey.
Findings include:
Tour was conducted with staff AA, staff BB, and staff CC on 11/1/11 from 11:45 AM until 4:00 PM. It was observed that above the ceiling tiles in biohazard room 2E152 there was an unsealed conduit containing green IT wires. This unsealed conduit was observed on both sides of the barrier. In addition, above the door to soiled utility room 3E152, there was a three by one inch opening around IT wires in conduit. These findings were confirmed by staff AA during the tour.
Tag No.: K0046
Based on documentation review of emergency battery operated lights and staff verification it was determined this facility failed to ensure all battery operated emergency lights were tested annually and documented. This had the potential to affect all those utilizing this facility. The facility census was 163 for the of 11/03/11.
Findings include:
Documentation review of emergency battery operated lights took place on 11/04/11 with staff members AA and BB on 11/04/11. Verification was made of the 30 second monthly testing of the emergency lights but no documentation was available in order to verify the 90 minute annual test.
Staff AA stated at 10:40 AM on 11/04/11 that he/she was sure the tests were performed but acknowledged there was no documentation to verify this.
Tag No.: K0046
Based on documentation review of emergency battery operated lights and staff verification it was determined this facility failed to ensure all battery operated emergency lights were tested annually and documented. This had the potential to affect all those utilizing this facility. The facility census was 187 for the of 11/03/11.
Findings include:
Documentation review of emergency battery operated lights took place on 11/04/11 with staff members AA and BB on 11/04/11. Verification was made of the 30 second monthly testing of the emergency lights but no documentation was available in order to verify the 90 minute annual test.
Staff AA stated at 10:40 AM on 11/04/11 that he/she was sure the tests were performed but acknowledged there was no documentation to verify this.
Tag No.: K0062
Based on facility tour and staff verification it was determined this facility failed to ensure the sprinkler system and all its components were maintained in reliable operating condition at all times according to the National Fire Protection Association 25, Chapter 9-7.1. This had the potential to affect all those utilizing this facility. The facility census was 187 for 11/03/11.
Findings include:
Facility tour took place on 11/03/11 with staff members BB and DD. During tour of the outside of the building specifically at the southeast corner section, observation was made of a fire department connection mounted on the side of the building which was obstructed by bushes that were approximately three to four feet high. Staff BB commented that they will have them removed next week.