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Based on observation and staff interview, the facility failed maintain the means of egress in accordance with the minimum requirements as established in NFPA 101, Life Safety Code (LSC) 2000. The findings were:

Observation on 08/04/15 at 8:05 AM of the hospital's Blood Draw Lab, located in the Medical Arts Building revealed that the lab's means of egress included a single exit from the lab to the Medical Arts Building corridor which is open to an unenclosed vertical opening connecting two stories of the building. At the time of the observation the Facility Maintenance Manager acknowledged the corridor from the blood draw lab was not separated from the vertical opening and that it was a required means of egress.

Ref:
2000 NFPA 101, Sections 38.3.1.1 and 8.2.5.8 (3,4)

Based on observation and staff interview, the facility failed to ensure hazardous areas were protected from the corridor with self-closing doors in 3 of 4 floors. The findings were:

1. Observations on 08/04/15 at 8:10 AM revealed the door to the penthouse elevator room was not provided with a self-closing device, and two unsealed penetrations from pipes from the stairwell into the elevator room. At the time of the observations the Facility Maintenance Manager acknowledged the door was not provided with a self-closing device, and the penetrations from the pipes from the stairwell.

2. Observation on 08/04/15 at 9:10 AM revealed the east radiation hall door was provided with a self-closing device, but when activated would not fully close and latch the door into it's frame. At the time of the observation the Facility Maintenance Manager acknowledged the door would not fully close and latch into it's frame.

3. Observation on 08/04/15 at 10:02 AM revealed the pediatric storage room door was provided with a self-closing device, but when activated would not fully close and latch the door into it's frame. At the time of the observation the Facility Maintenance Manager acknowledged the door would not fully close and latch into it's frame.

4. Observation on 08/04/15 at 11:20 AM revealed the corridor door to the basement mechanical room with the york air handling unit was provided with a self-closing device, but when activated would not fully close and latch the door into it's frame. At the time of the observation the Facility Maintenance Manager acknowledged the door would not fully close and latch into it's frame.

5. Observation on 08/04/15 at 2:05 PM revealed an 2" penetration on the back wall in the mechanical room located in the administration area. At the time of the observation the Facility Maintenance Manager acknowledged the penetration.

6. Observation on 08/04/15 at 3:30 PM revealed the maintenance paint shop door was provided with a self-closing device, but when activated would not fully close and latch the door into it's frame. At the time of the observation the Facility Maintenance Manager acknowledged the door would not fully close and latch into it's frame.



Ref:
2000 NFPA 101, Section 19.3.2.1

Based on observation and staff interview, the facility failed to arrange protected stairwells in a way to avoid the potential to interfere with egress. The findings were:

Observation of the south medical surgical stairwell on 08/04/15 at 2:30 PM revealed a trash can, chair, and a box of ice melt being stored under the stairwell in the basement. At the time of the observation the Facility Maintenance Staff acknowledged the items being stored inside the stairwell.

Ref:
2000 NFPA 101, Sections 19.2.2.3, 7.2.2.1, 7.1.3.2.3, and 7.2.2.5.3

Based on observation and staff interview, the facility failed to arrange exit access so that exits are readily accessible at all times on 1 of 4 floors. The findings were:

Observation on 08/04/15 at 10:15 AM revealed the north medical surgical physician dictation room door was double locked. A second dead bolt lock was located approximately 42" above the floor. At the time of the observation the Facility Maintenance Manager acknowledged the second lock on the door.

Ref:
2000 NFPA 101, Sections 19.2.2.2.1 and 7.2.1.5.4

Based on observation, staff interview, and record review, the facility failed to ensure automatic sprinkler systems are continuously maintained per the requirements of NFPA 25. The finding were:

Observation on 08/05/15 from 8:30 AM to 8:45 AM of the Wyoming Rehab Building revealed both upstairs furnace rooms were protected by an automatic sprinkler system connected to the domestic water supply. Documentation was not present for review of annual testing and maintenance of the system. Interview with the Facility Maintenance Manager at the time of the observation revealed they were not aware that the two furnace room were sprinkled.

Ref:
2000 NFPA 101, Sections 38.3.2.1, 8.4.1.1, and 9.7.5
1998 NFPA 25, Table 2-1

Based on observation and staff interview, the facility failed to maintain means of egress free of all obstructions or impediments to full instant use. The findings were:

1. Observation on 08/04/15 at 10:20 AM revealed the first floor north west medical surgical stairwell leading to the exterior of the building was blocked by a table and chairs on the patio, resulting in the door being unable to be opened to full use. At the time of the observation the Facility Maintenance Manager acknowledged the table and chairs blocking the exit door.

2. Observation on 08/04/15 at 2:00 PM revealed the east cafeteria foyer area exit was blocked by a table and chairs. At time of the observation the Facility Maintenance Manager acknowledged the table and chairs blocking the exit door.

Ref:
2000 NFPA 101, Sections 19.2.1 and 7.1.10.1

Based on observation and staff interview, the facility failed to maintain means of egress free of all obstructions or impediments to full instant use. The findings were:

Observation on 08/04/15 at 2:45 PM of the north east corner exit discharge to the public way revealed a gravel path approximately two feet wide that was not nominally level. The path switched back and forth down the hill for approximately 30ft. The path exceed 1 in 20 inches in slope.

Ref:
2000 NFPA 101, Sections 38.2.1.1, 7.1.6.3, and 7.1.6.4

Based on observation and staff interview, the facility failed to ensure that racks are provided to protect medical gas cylinders from accidental damage or dislocation in accordance with NFPA 99. The findings were:

Observation on 08/04/15 at 10:45 AM of the pulmonary function laboratory revealed two unsecured medical gas cylinders sitting upright on the floor. At the time of the observation the Facility Maintenance Staff acknowledged the two unsecured cylinders.

Ref:
2000 NFPA 101, Section 19.3.2.4
1999 NFPA 99, Section 8-3.1.11.1

Based on observation and staff interview, the facility failed maintain the means of egress in accordance with the minimum requirements as established in NFPA 101, Life Safety Code (LSC) 2000. The findings were:

Observation on 08/04/15 at 8:05 AM of the hospital's Blood Draw Lab, located in the Medical Arts Building revealed that the lab's means of egress included a single exit from the lab to the Medical Arts Building corridor which is open to an unenclosed vertical opening connecting two stories of the building. At the time of the observation the Facility Maintenance Manager acknowledged the corridor from the blood draw lab was not separated from the vertical opening and that it was a required means of egress.

Ref:
2000 NFPA 101, Sections 38.3.1.1 and 8.2.5.8 (3,4)

Based on observation and staff interview, the facility failed to ensure hazardous areas were protected from the corridor with self-closing doors in 3 of 4 floors. The findings were:

1. Observations on 08/04/15 at 8:10 AM revealed the door to the penthouse elevator room was not provided with a self-closing device, and two unsealed penetrations from pipes from the stairwell into the elevator room. At the time of the observations the Facility Maintenance Manager acknowledged the door was not provided with a self-closing device, and the penetrations from the pipes from the stairwell.

2. Observation on 08/04/15 at 9:10 AM revealed the east radiation hall door was provided with a self-closing device, but when activated would not fully close and latch the door into it's frame. At the time of the observation the Facility Maintenance Manager acknowledged the door would not fully close and latch into it's frame.

3. Observation on 08/04/15 at 10:02 AM revealed the pediatric storage room door was provided with a self-closing device, but when activated would not fully close and latch the door into it's frame. At the time of the observation the Facility Maintenance Manager acknowledged the door would not fully close and latch into it's frame.

4. Observation on 08/04/15 at 11:20 AM revealed the corridor door to the basement mechanical room with the york air handling unit was provided with a self-closing device, but when activated would not fully close and latch the door into it's frame. At the time of the observation the Facility Maintenance Manager acknowledged the door would not fully close and latch into it's frame.

5. Observation on 08/04/15 at 2:05 PM revealed an 2" penetration on the back wall in the mechanical room located in the administration area. At the time of the observation the Facility Maintenance Manager acknowledged the penetration.

6. Observation on 08/04/15 at 3:30 PM revealed the maintenance paint shop door was provided with a self-closing device, but when activated would not fully close and latch the door into it's frame. At the time of the observation the Facility Maintenance Manager acknowledged the door would not fully close and latch into it's frame.



Ref:
2000 NFPA 101, Section 19.3.2.1

Based on observation and staff interview, the facility failed to arrange protected stairwells in a way to avoid the potential to interfere with egress. The findings were:

Observation of the south medical surgical stairwell on 08/04/15 at 2:30 PM revealed a trash can, chair, and a box of ice melt being stored under the stairwell in the basement. At the time of the observation the Facility Maintenance Staff acknowledged the items being stored inside the stairwell.

Ref:
2000 NFPA 101, Sections 19.2.2.3, 7.2.2.1, 7.1.3.2.3, and 7.2.2.5.3

Based on observation and staff interview, the facility failed to arrange exit access so that exits are readily accessible at all times on 1 of 4 floors. The findings were:

Observation on 08/04/15 at 10:15 AM revealed the north medical surgical physician dictation room door was double locked. A second dead bolt lock was located approximately 42" above the floor. At the time of the observation the Facility Maintenance Manager acknowledged the second lock on the door.

Ref:
2000 NFPA 101, Sections 19.2.2.2.1 and 7.2.1.5.4

Based on observation, staff interview, and record review, the facility failed to ensure automatic sprinkler systems are continuously maintained per the requirements of NFPA 25. The finding were:

Observation on 08/05/15 from 8:30 AM to 8:45 AM of the Wyoming Rehab Building revealed both upstairs furnace rooms were protected by an automatic sprinkler system connected to the domestic water supply. Documentation was not present for review of annual testing and maintenance of the system. Interview with the Facility Maintenance Manager at the time of the observation revealed they were not aware that the two furnace room were sprinkled.

Ref:
2000 NFPA 101, Sections 38.3.2.1, 8.4.1.1, and 9.7.5
1998 NFPA 25, Table 2-1

Based on observation and staff interview, the facility failed to maintain means of egress free of all obstructions or impediments to full instant use. The findings were:

1. Observation on 08/04/15 at 10:20 AM revealed the first floor north west medical surgical stairwell leading to the exterior of the building was blocked by a table and chairs on the patio, resulting in the door being unable to be opened to full use. At the time of the observation the Facility Maintenance Manager acknowledged the table and chairs blocking the exit door.

2. Observation on 08/04/15 at 2:00 PM revealed the east cafeteria foyer area exit was blocked by a table and chairs. At time of the observation the Facility Maintenance Manager acknowledged the table and chairs blocking the exit door.

Ref:
2000 NFPA 101, Sections 19.2.1 and 7.1.10.1

Based on observation and staff interview, the facility failed to maintain means of egress free of all obstructions or impediments to full instant use. The findings were:

Observation on 08/04/15 at 2:45 PM of the north east corner exit discharge to the public way revealed a gravel path approximately two feet wide that was not nominally level. The path switched back and forth down the hill for approximately 30ft. The path exceed 1 in 20 inches in slope.

Ref:
2000 NFPA 101, Sections 38.2.1.1, 7.1.6.3, and 7.1.6.4

Based on observation and staff interview, the facility failed to ensure that racks are provided to protect medical gas cylinders from accidental damage or dislocation in accordance with NFPA 99. The findings were:

Observation on 08/04/15 at 10:45 AM of the pulmonary function laboratory revealed two unsecured medical gas cylinders sitting upright on the floor. At the time of the observation the Facility Maintenance Staff acknowledged the two unsecured cylinders.

Ref:
2000 NFPA 101, Section 19.3.2.4
1999 NFPA 99, Section 8-3.1.11.1