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Based on observation and staff interview, it was determined the facility failed to ensure that doors in hazardous areas are held open by an automatic release device that complies with NFPA. Failure to ensure fire and smoke containment has the potential to harm patients and staff with the spread of fire and smoke.

NFPA 101 2012 Edition Section 9.2.2.2.7 "Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2, shall be arranged to initiate the closing action all such doors throughout the smoke compartment or throughout the entire facility."

Findings include:

Observation on tour of the facility on October 17, 2019, revealed a door wedge was used to keep EVS storage door (MCH 1-425) open and did not have an approved automatic release device. The storage room was greater than 100 ft2, and contained combustible material.

Key hospital staff acknowledged during the exit conference on October 18, 2019, that a door wedge was used to keep EVS storage door (MCH 1-425) open, and did not have an approved automatic release device. The storage room was greater than 100 ft2, and contained combustible material.

Based on observation and staff interview, it was determined the facility failed to ensure proper placement of emergency exit signage in all parts of the hospital. Failing to have proper emergency exit signage during an emergency has potential to delay egress, a delay has potential to harm staff and patients.

NFPA 101 2012 Edition Section 19.2.10 "Marking of Means of Egress." Section 19.2.10.1 "Means of egress shall have signs in accordance with Section 7.10, unless otherwise permitted by 19.2.10.2, 19.2.10.3, or 19.2.10.4." Section 19.2.10.2 "Where the path of egress travel is obvious, signs shall not be required in one-story buildings with an occupant load of fewer than 30 persons." Section 7.10.1.2.1 "Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign that is readily visible from any direction of exit access."

Findings include:

Observation on tour of the facility on October 17, 2019, revealed in Endosocpy northwest egress (CB 2-500-04), there was no emergency exit signage to lead to an exit access clearly visible, and in IR (1-640-B) the directional sign was directing egress in the wrong direction.

Key Hospital staff acknowledged during the exit conference on October 18, 2019, that in Endosocpy northwest egress (CB 2-500-04), there was no emergency exit signage to lead to an exit access clearly visible, and in IR (1-640-B) the directional sign was directing egress in the wrong direction.

Based on observation and staff interview, it was determined the facility failed to ensure that hazardous areas had doors be self-closing or automatic-closing. Failure to keep hazardous area doors closed during a fire could cause the spread of smoke or fire, which has the potential to harm patients and staff.

NFPA 101 2012 Edition Section 19.3.2.1 "Hazardous Areas. Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.7.1. Section 19.3.2.1.3 "The doors shall be self-closing or automatic-closing." Section 19.3.2.1.5 " Hazardous areas shall include, but shall not be restricted to, the following: (7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction."

Findings include:

Observation on tour of the facility on October 16, 2019, revealed in Dialysis a storage room door was not self-closing or automatic closing. The room was greater than 50 ft2, and had the storage of combustible material.

Key hospital staff acknowledged during the exit conference on October 18, 2019, that in Dialysis, a storage room door was not self-closing or automatic closing. The room was greater than 50 ft2, and had the storage of combustible material.

Based on observation and interview with staff, it was determined the facility failed to provide fire protection coverage for the home therapy oven. Failing to completely protect cooking equipment could result in fire, which could cause potential harm to the patients in time of a fire.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.6 "Cooking facilities shall be protected in accordance with 9.2.3." Section 9.2.3, "Commercial cooking equipment shall be in accordance with NFPA 96, Standard For Ventilation Control and Fire Protection of Commercial Cooking Operations." NFPA 96, Chapter 7, Section 10.1.2, "Cooking equipment that produces grease-laden vapors (such as but not limited to, deep fat fryers, ranges, griddles, and broilers, woks, tilting skillets, and braising pans) shall be protected by approved extinguishing equipment." 19.3.2.5.2 * "Where residential cooking equipment is used for food warming or limited cooking, the equipment shall not be required to be protected in accordance with 9.2.3, and the presence of the equipment shall not require the area to be protected as a hazardous area."

Findings Include:

Observation on tour of the facility on October 16, 2019, revealed the therapy oven located in the Therapy ADL Kitchen had grease on the hood. The therapy oven, a residential oven, and not a commercial oven with hood, was not protected by an approved extinguishing equipment.

Key Hospital staff acknowledged during the exit conference on October 18, 2019, that the therapy oven located in the Therapy ADL Kitchen had grease on the hood. The therapy oven is not a commercial oven with a hood, and was not protected by an approved extinguishing equipment.

Based on observation and staff interview, it was determined the facility failed to identify one electrical conduit box did not have an approved cover on it. Failure to cover open junction boxes has potential to cause harm to staff, and could cause a fire which may result in harm to both staff and patients.

NFPA 101 Life Safety Code, 2012 Edition, Chapter 19, Section 19.5.1.1 "Utilities shall comply with the provisions of Section 9.1." Section 9.1.2, "Electrical wiring and equipment installed shall be in accordance with NFPA 70 'National Electrical Code" NEC, 2011. NFPA 70, Article 314, Section 314.28 "Boxes and conduit bodies used as pull or junction boxes shall comply with 314.28(A) through (E). Subsection (C) Covers. "All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where used, metal covers shall comply with the grounding requirements of 250.110."

Findings include:

Observation on tour of the facility on October 17, 2019, revealed an open junction box in the room labeled MCH 2-509.

Key hospital staff acknowledged during the exit conference on October 18, 2019, that there was an open junction box in the room labeled MCH 2-509.