HospitalInspections.org

Based on observation and interview, the facility did not provide and maintain wall construction to protect the corridor from non-corridor spaces or with smoke detection in spaces that are open to the corridor. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.6.1.

FINDINGS INCLUDE:

On 8/29/2016 at 10:00 am, observation and interview revealed on the 1st floor in the welcome desk, main entrance, that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that are open to the corridor. The space did not have a smoke detector and, as an alternative, was not fully observable from a 24 hour occupied location.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff T (Facility Director).

Based on observation and interview, the facility did not provide and maintain wall construction to protect the corridor from non-corridor spaces with smoke detection in spaces that are open to the corridor, and no patient treatment in spaces that are open to the corridor. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.6.1 and 18.3.6.2.1, Exception 1.

FINDINGS INCLUDE:

1. On 08/25/2016 at 10:23 am, observation revealed on the 1st floor in the kitchen, that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that are open to the corridor. The space did not have a smoke detector and, as an alternative, was not fully observable from a 24 hour occupied location.

2. On 08/25/2016 at 10:00 am, observation revealed on the 1st floor in the area open to corridor, that the area was not separated from the exit egress corridor by wall construction and was used for the treatment of patients. Patients 25 and 26 were receiving treatment from Staff BB, Activity Director.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff T (Facility Director).

Based on observation and interview, the facility did not provide corridor separation doors with compliant corridor doors, double doors with an astragal seal, positive latching Dutch doors, doors with positive-latching hardware, and corridor doors that would close when pushed or pulled. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.6.3.1.; 18.2.3.5-exception 4; 18.3.6.3.6.; 18.3.6.3.2.; and 18.3.6.3.3,

FINDINGS INCLUDE:

1. On 08/24/2016 at 2:15 pm, observation and interview revealed on the 2nd Floor floor in the administration suite, that the corridor was not compliant. The 'WON' door could not be closed from the outside or inside of the room without a special key for the key switch located in the corridor.

2. On 8/29/2016 at 10:20 am, observation and interview revealed on the 1st floor, in the entrance from the corridor into Emergency Department and the similar entrance into Urgent Care, that the room had double corridor doors with a gap at their meeting edges that were not sealed with an astragal to resist the passage of smoke.

3. On 08/25/2016 at 12:45 pm, observation and interview revealed on the 2nd Floor in the Pharmacy, that the door to the corridor was split in the middle to form a "Dutch door". The 'upper' door would not positively self-latch to the 'bottom' door or the frame.

4. On 8/29/2016 at 12:24 pm, observation and interview revealed on the 1st floor in the infusion entrance, that the corridor door would not positively self-latch when pushed to a closed position.

5. On 08/24/2016 at 10:48 am, observation and interview revealed on the lower level floor in the Maintenance Shop, that a pair of corridor doors did not close and latch automatically. The doors were installed with automatic closers and had an astragal to control smoke transmission, but the combination of devices prevented the doors from fully and automatically closing and latching.

6. On 8/25/2016 at 2:56 pm, observation and interview revealed on the lower level floor in the 'Edge', that a pair of corridor doors did not close and latch automatically. The doors were installed with automatic closers and had an astragal to control smoke transmission, but the combination of devices prevented the doors from fully and automatically closing and latching.

7. On 8/29/2016 at 12:16 pm, observation and interview revealed on the 1st floor in the lab, that the door to the corridor was held open with a electric hold open. The door would not release with a push or pull.

8. On 8/29/2016 at 12:50 pm, observation and interview revealed on the 1st floor in the old specialty clinic, that the door to the corridor was held open with a electric hold open. The door would not release with a push or pull.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff T (Facility Director).

Based on observation and interview, the facility did not ensure the path of egress was clearly identified by appropriate exit signs when the egress path is not readily apparent. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.10.1.4.

FINDINGS INCLUDE:

1. On 08/24/2016 at 1:05 pm, observation and interview revealed on the lower level floor near the cafeteria, that the path of egress was not readily apparent at the across corridor doors when the doors were closed. Exit signs were missing on both sides of the smoke barrier across corridor doors by the cafeteria.

2. On 8/29/2016 at 1:25 pm, observation and interview revealed on the penthouse floor in the penthouse, that the path of egress was not readily apparent and an exit sign was not provided. In the penthouse, the path to the second exit to the west is not apparent.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff T (Facility Director).

Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls with sealed wall penetrations. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.7.3.

FINDINGS INCLUDE:

On 08/25/2016 at 11:05 am, observation revealed on the 1st floor in the corridor by patient room 7A & 7B, above the across corridor doors, that penetrations were not sealed according to an approved method. The deficiency included 2 insulated pipe did not have fire caulk around the pipes.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff T (Facility Director).

Based on observation and interview, the facility did not enclose hazardous rooms with closers on all rated doors, and doors with positive-latching hardware and the facility did not enclose hazardous rooms with rated doors. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1 and 18.3.6.3.4.; 18.3.2.1; 18.3.2.1; 8.2.3.2; 18.3.2.1 .

FINDINGS INCLUDE:

1. On 8/29/2016 at 12:10 pm, observation revealed on the 1st floor in the hazardous storage room in lab, that the door would not self-close because there was no closer on the door. The room size was between 50 and 100 square feet.

2. On 08/24/2016 at 1:40 pm, observation revealed on the 2nd Floor in the patient room 24, that the door in the hazard enclosure wall could not be verified of having at least a 45 minute rating. The room is used as hazardous combustible storage room.

3. On 08/24/2016 at 2:20 pm, observation revealed on the 2nd Floor in the medical records storage by the board room, that the door in the hazard enclosure wall could not be verified of having at least a 45 minute rating. The walls did not have a fire rating for one hour. .

4. On 8/29/2016 at 11:00 am, observation revealed on the 1st floor in the ambulance garage to ED , that the door would not positively self-latch when released because the latch was retracted. This is a fire rated door.

5. On 08/25/2016 at 12:50 pm, observation revealed on the 2nd Floor in the Pharmacy, a hazardous area, that the walls were not rated and the door could not be verified of having at least a 45 minute rating.

6. On 8/29/2016 at 12:40 pm, observation and interview revealed on the 1st floor in the storage room in the old spec clinic, that the door was magnetically held open and did not have a smoke detector.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff T (Facility Director).

Based on observation and interview, the facility did not provide egress paths at all times with no obstructions in the path of egress. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.5.1.1.

FINDINGS INCLUDE:

On 08/24/2016 at 10:35 am, observation and interview revealed on the 1st floor in the Utility access hallway, that the exit path was not readily accessible because a trash can was in front of the med gas storage room.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff T (Facility Director).

Based on observation and interview, the facility did not provide egress paths at all times with the required signage, multiple delayed-egress locks in the same egress path, no swinging door obstructions, and door hardware that operated with a single release motion. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.6.1 ; 18.2.2.2.2.4 (exception 2); 7.2.1.4.4; and this observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.4.4; 7.2.1.5.4; and 7.2.1.5.4.

FINDINGS INCLUDE:

1. On 08/24/2016 at 1:22 pm, observation and interview revealed on the 2nd Floor floor in the OBYGN Area, that a delayed egress lock (DEL) did not have the required signage on the door. The door are located from OBYGN to main lobby and in peds area.

2. On 08/24/2016 at 1:25 pm, observation and interview revealed on the 2nd Floor floor in the Peds area, that the path of egress required travel through more than two delayed egress locks (DEL) to exit the building

3. On 8/25/2016 at 2:22 pm, observation and interview revealed on the lower level floor in the ortho door to corridor, that one or more doors swung outward into the exit path and obstructed the path because when fully open the door 'stuck out' 2 feet into the corridor.

4. On 8/29/2016 at 10:30 am, observation and interview revealed on the 1st floor in the door from Radiologist and doors from staff bathroom to the corridor, that one or more doors swung outward into the exit path and obstructed the path because the door protruded more than 7 inches into the corridor when the door was fully open.

5. On 08/24/2016 at 3:15 pm, observation revealed on the 2nd floor in the C Section room, that the door release hardware required more than a single motion to release the door for exiting. The hardware included a dead bolt and a hand latch to open before the door would open.

6. On 08/24/2016 at 2:25 pm, observation revealed on the 2nd Floor floor in the door from administration area to connecting hallway, that the door release hardware required more than a single motion to release the door for exiting. The dead bolt lever was not large enough to grab and pull.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff T (Facility Director).

Based on observation and interview, the facility did not provide and maintain corridors and aisles that were at least the minimal clear width required by the code. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.2.3.3 where aisles used by others must be at least 44" wide.


FINDINGS INCLUDE:

On 08/24/2016 at 10:30 am, observation and interview revealed on the 1st floor in the Utility access hallway, that the clear and unobstructed width of the aisle is 36 inches.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff T (Facility Director).

Based on observation and interview, the facility did not adequately train staff on all the elements related to extinguishing a fire in the kitchen. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.7.1.3.


FINDINGS INCLUDE:

On 08/24/2016 at 12:08 pm, observation revealed on the lower level floor in the kitchen, that staff were not familiar with their responsibilities in the event of a fire. Staff AA, relief cook, did not know that an Ansell system should extinguish a fire on the grill, staff AA said that they would smother the fire on the stove, and they would use the ABC fire extinguisher instead of the K extinguisher. This situation was not compliant with NFPA 101 (2000 ed.), 18.7.1.3.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff T (Facility Director).

Based on record review, observation, and interview, the facility did not provide a fire alarm system that was installed according to NFPA 72 with manual pull stations at required locations, smoke detectors at required locations, and to inform people of fire information through the fire alarm system. This situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.4 and NFPA 72 (1999 ed.)_2.8.2.2 and 9.6.1.4 and NFPA 72 (1999 ed.), 2-3.4.3.1. Relocation or partial evacuation voice communication shall be through the fire alarm system per NFPA 72, 1999 edition, sections 3-8.4.3, 3-8.4.1.3.5 and 3-8.4.1. In addition, the system shall be protected per 3-.8.4.1.1.4 from the point at which the circuits exit the control unit until the point that they enter the notification zone.

FINDINGS INCLUDE:

1. On 8/29/2016 at 10:10 am, observation revealed on the 1st floor in the Main entrance, that the manual pull station was not located in accordance with NFPA 72 requirements. The pull station was not located within 5 feet of an exit. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff T (Facility Director).

2. On 8/25/2016 at 1:15 pm, observation revealed on the lower level floor in the electric room , that the smoke detector was not located in accordance with NFPA 72 requirements. The smoke detector was located 30 inches below the deck of the ceiling above. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff T (Facility Director).

3) On 8/25/2014 at 3:30 PM, during a record review and interview, it was determined that an overhead speaker system, that is not part of the fire alarm system, was used to inform staff, visitors and patients of fire conditions. After the speaker system announcement, then a separation action would activate the fire alarm system. The speaker system would then be use to relocate or inform staff, visitors and patient of information related to the fire, including evacuation. This condition was confirmed at the time of discovery by an interview with staff T (Facility Director) and staff Z, Safety Director.

Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, with no obstructions near the sprinkler, sprinkler coverage throughout the building, sprinkler coverage throughout the building, unobstructed water distribution, and no wall obstructions. This situation was not compliant with NFPA 13 (1999 ed.), 5-6.5; NFPA 101 (2000 ed.), 18.3.5.1; 18.3.5.1; NFPA 13 (1999 ed.), 5-6.5; 5-6.5; 5-6.5; NFPA 25 (1998 ed.), 1-11.1. .

FINDINGS INCLUDE:

1. On 8/29/2016 at 10:40 am, observation revealed on the 1st floor in the Radiology room (x- ray room), that items were placed within 18" below the sprinkler deflector that obstructed the discharge of sprinkler water from reaching the other side of the obstruction. The obstruction included the x-ray machine

2. On 08/24/2016 at 2:00 pm, observation revealed on the 2nd Floor in the bathroom of the administrative area, that the room was not sprinkled. All areas of new healthcare must be protected with sprinklers.

3. On 8/29/2016 at 1:00 pm, observation revealed on the 1st floor in the housekeeping by the surgery corridor, that the room was not sprinkled. All areas of new healthcare must be protected with sprinklers.

4. On 08/24/2016 at 10:55 am, observation revealed on the lower level floor in the receiving dock, that the discharge of sprinkler water was obstructed from reaching an unprotected area on the other side of a surface mounted light fixture. The light fixture was located 6 inches away and 7 inches below the adjacent sprinkler deflector.

5. On 08/24/2016 at 2:10 pm, observation revealed on the 2nd floor in the women's & men's locker room of the OB area and room 29, that the discharge of sprinkler water was obstructed from entering the shower by a header above the shower. The header was located in the men's locker room, 14 inches down from the sprinkler and 5 inches away. The women's locker room and room 29 have similar dimensions.

6. On 8/29/2016 at 10:50 am, observation revealed on the 1st floor in the MRI machine room (closet), that the ceiling did not provide a heat collection enclosure above the sprinkler and would permit heat to enter the void above the ceiling. As a result, the device would not operate with its designed response time. This situation was not compliant with NFPA 25 (1998 ed.), 1-11.1.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff T (Facility Director).

Based on observation, record review, and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, and unobstructed water distribution. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5.


FINDINGS INCLUDE:

1. On 08/25/2016 at 11:15 am, observation and interview revealed on the 1st floor in the visitor restroom room, that the discharge of sprinkler water was obstructed from reaching an unprotected area on the other side of a surface mounted light fixture. The light fixture was located 4 inches away and 3 inches below the adjacent sprinkler deflector.

2. On 08/25/2016 at 11:46 am, observation revealed on the 1st floor in the patient room 5 toilet's room, that the discharge of sprinkler water was obstructed from reaching an unprotected area on the other side of a surface mounted light fixture. The light fixture was located 6 inches away and 1 inch below the adjacent sprinkler deflector. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5.

3. On 08/25/2016 at 11:20 am, interview and record review revealed on the 1st floor in the sprinkler room, that the sprinkler installation was not compliant. The minimum pressure was not maintained for the sprinkler system. On November 11, 2015 it was 45 psi on Feb 25, 2016 it was 50 psi and on May 17, 2016 it was 50 psi. The plans for the sprinkler system require the pressure to be 57 psi for the dry system and 55 psi for the wet system.

This condition was confirmed at the time of discovery by a concurrent observation, record review, and interview with staff T (Facility Director) and staff U (Maintenance).

Based on observation and interview, the facility did not provide and maintain linen/trash collection receptacles in compliance with the codes with properly sized storage containers for soiled/trash. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.7.5.5.

FINDINGS INCLUDE:

On 08/25/2016 at 10:40 am, observation and interview revealed on the 1st floor in the utility access hallway by the med gas storage room, that mobile collection receptacles exceeded the 32 gallon per 64 square foot maximum density when located outside of a hazardous area. There were two 32 gallon dirty linen containers, a 2' X 3' X 5' soiled linen cart, (4 bags inside) and a 2' 3' X 2.5' trash cart, and one 32 gallon trans can, all in the hallway.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff T (Facility Director).

Based on observation and interview, the facility did not provide and maintain linen/trash collection receptacles in compliance with the codes with properly sized storage containers for soiled/trash. This situation was not compliant with NFPA 101 (2000 ed.), 18.7.5.5.

FINDINGS INCLUDE:

1. On 08/24/2016 at 12:14 pm, observation revealed on the lower level floor in the kitchen, that mobile collection receptacles exceeded the 32 gallon per 64 square foot maximum density when located outside of a hazardous area. There were two 32 gallon trash cans & one 32 gallon plastic recycle container next to each other outside the kitchen by the tray return window.

2. On 08/24/2016 at 5:18 pm, observation revealed on 1st floor in the endo room, that mobile collection receptacles exceeded the 32 gallon per 64 square foot maximum density when located outside of a hazardous area. one 32 gallon and one 10 gallon waste container were next to each other.

3. On 8/29/2016 at 10:10 am, observation revealed on the 1st floor in the X-ray waiting area, that mobile collection receptacles exceeded the 32 gallon per 64 square foot maximum density when located outside of a hazardous area. There was a 32 gallon waste container and a 32 gallon recycle contain next to each other.

4. On 8/29/2016 at 12:05 pm, observation revealed on the 1st floor in the lab, that mobile collection receptacles exceeded the 32 gallon per 64 square foot maximum density when located outside of a hazardous area. There were several locations where there was more than 32 gallon waste containers in a 64 square foot area and some waste container were greater than 32 gallons.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff T (Facility Director).

Based on interview and observation, the facility did not have the proper equipment to remotely stop the emergency generator. This situation was not compliant with NFPA 110 (1999 ed.), 3-5.5.6.

FINDINGS INCLUDE:

On 08/24/2016 at 11:34 am, observation revealed that there was not an emergency stop switch outside the housing of the emergency generator located external to the building.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff T (Facility Director).

Based on observation and interview, the facility did not provide and maintain wall construction to protect the corridor from non-corridor spaces or with smoke detection in spaces that are open to the corridor. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.6.1.

FINDINGS INCLUDE:

On 8/29/2016 at 10:00 am, observation and interview revealed on the 1st floor in the welcome desk, main entrance, that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that are open to the corridor. The space did not have a smoke detector and, as an alternative, was not fully observable from a 24 hour occupied location.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff T (Facility Director).

Based on observation and interview, the facility did not provide and maintain wall construction to protect the corridor from non-corridor spaces with smoke detection in spaces that are open to the corridor, and no patient treatment in spaces that are open to the corridor. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.6.1 and 18.3.6.2.1, Exception 1.

FINDINGS INCLUDE:

1. On 08/25/2016 at 10:23 am, observation revealed on the 1st floor in the kitchen, that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that are open to the corridor. The space did not have a smoke detector and, as an alternative, was not fully observable from a 24 hour occupied location.

2. On 08/25/2016 at 10:00 am, observation revealed on the 1st floor in the area open to corridor, that the area was not separated from the exit egress corridor by wall construction and was used for the treatment of patients. Patients 25 and 26 were receiving treatment from Staff BB, Activity Director.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff T (Facility Director).

Based on observation and interview, the facility did not provide corridor separation doors with compliant corridor doors, double doors with an astragal seal, positive latching Dutch doors, doors with positive-latching hardware, and corridor doors that would close when pushed or pulled. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.6.3.1.; 18.2.3.5-exception 4; 18.3.6.3.6.; 18.3.6.3.2.; and 18.3.6.3.3,

FINDINGS INCLUDE:

1. On 08/24/2016 at 2:15 pm, observation and interview revealed on the 2nd Floor floor in the administration suite, that the corridor was not compliant. The 'WON' door could not be closed from the outside or inside of the room without a special key for the key switch located in the corridor.

2. On 8/29/2016 at 10:20 am, observation and interview revealed on the 1st floor, in the entrance from the corridor into Emergency Department and the similar entrance into Urgent Care, that the room had double corridor doors with a gap at their meeting edges that were not sealed with an astragal to resist the passage of smoke.

3. On 08/25/2016 at 12:45 pm, observation and interview revealed on the 2nd Floor in the Pharmacy, that the door to the corridor was split in the middle to form a "Dutch door". The 'upper' door would not positively self-latch to the 'bottom' door or the frame.

4. On 8/29/2016 at 12:24 pm, observation and interview revealed on the 1st floor in the infusion entrance, that the corridor door would not positively self-latch when pushed to a closed position.

5. On 08/24/2016 at 10:48 am, observation and interview revealed on the lower level floor in the Maintenance Shop, that a pair of corridor doors did not close and latch automatically. The doors were installed with automatic closers and had an astragal to control smoke transmission, but the combination of devices prevented the doors from fully and automatically closing and latching.

6. On 8/25/2016 at 2:56 pm, observation and interview revealed on the lower level floor in the 'Edge', that a pair of corridor doors did not close and latch automatically. The doors were installed with automatic closers and had an astragal to control smoke transmission, but the combination of devices prevented the doors from fully and automatically closing and latching.

7. On 8/29/2016 at 12:16 pm, observation and interview revealed on the 1st floor in the lab, that the door to the corridor was held open with a electric hold open. The door would not release with a push or pull.

8. On 8/29/2016 at 12:50 pm, observation and interview revealed on the 1st floor in the old specialty clinic, that the door to the corridor was held open with a electric hold open. The door would not release with a push or pull.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff T (Facility Director).

Based on observation and interview, the facility did not ensure the path of egress was clearly identified by appropriate exit signs when the egress path is not readily apparent. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.10.1.4.

FINDINGS INCLUDE:

1. On 08/24/2016 at 1:05 pm, observation and interview revealed on the lower level floor near the cafeteria, that the path of egress was not readily apparent at the across corridor doors when the doors were closed. Exit signs were missing on both sides of the smoke barrier across corridor doors by the cafeteria.

2. On 8/29/2016 at 1:25 pm, observation and interview revealed on the penthouse floor in the penthouse, that the path of egress was not readily apparent and an exit sign was not provided. In the penthouse, the path to the second exit to the west is not apparent.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff T (Facility Director).

Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls with sealed wall penetrations. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.7.3.

FINDINGS INCLUDE:

On 08/25/2016 at 11:05 am, observation revealed on the 1st floor in the corridor by patient room 7A & 7B, above the across corridor doors, that penetrations were not sealed according to an approved method. The deficiency included 2 insulated pipe did not have fire caulk around the pipes.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff T (Facility Director).

Based on observation and interview, the facility did not enclose hazardous rooms with closers on all rated doors, and doors with positive-latching hardware and the facility did not enclose hazardous rooms with rated doors. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1 and 18.3.6.3.4.; 18.3.2.1; 18.3.2.1; 8.2.3.2; 18.3.2.1 .

FINDINGS INCLUDE:

1. On 8/29/2016 at 12:10 pm, observation revealed on the 1st floor in the hazardous storage room in lab, that the door would not self-close because there was no closer on the door. The room size was between 50 and 100 square feet.

2. On 08/24/2016 at 1:40 pm, observation revealed on the 2nd Floor in the patient room 24, that the door in the hazard enclosure wall could not be verified of having at least a 45 minute rating. The room is used as hazardous combustible storage room.

3. On 08/24/2016 at 2:20 pm, observation revealed on the 2nd Floor in the medical records storage by the board room, that the door in the hazard enclosure wall could not be verified of having at least a 45 minute rating. The walls did not have a fire rating for one hour. .

4. On 8/29/2016 at 11:00 am, observation revealed on the 1st floor in the ambulance garage to ED , that the door would not positively self-latch when released because the latch was retracted. This is a fire rated door.

5. On 08/25/2016 at 12:50 pm, observation revealed on the 2nd Floor in the Pharmacy, a hazardous area, that the walls were not rated and the door could not be verified of having at least a 45 minute rating.

6. On 8/29/2016 at 12:40 pm, observation and interview revealed on the 1st floor in the storage room in the old spec clinic, that the door was magnetically held open and did not have a smoke detector.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff T (Facility Director).

Based on observation and interview, the facility did not provide egress paths at all times with no obstructions in the path of egress. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.5.1.1.

FINDINGS INCLUDE:

On 08/24/2016 at 10:35 am, observation and interview revealed on the 1st floor in the Utility access hallway, that the exit path was not readily accessible because a trash can was in front of the med gas storage room.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff T (Facility Director).

Based on observation and interview, the facility did not provide egress paths at all times with the required signage, multiple delayed-egress locks in the same egress path, no swinging door obstructions, and door hardware that operated with a single release motion. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.6.1 ; 18.2.2.2.2.4 (exception 2); 7.2.1.4.4; and this observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.4.4; 7.2.1.5.4; and 7.2.1.5.4.

FINDINGS INCLUDE:

1. On 08/24/2016 at 1:22 pm, observation and interview revealed on the 2nd Floor floor in the OBYGN Area, that a delayed egress lock (DEL) did not have the required signage on the door. The door are located from OBYGN to main lobby and in peds area.

2. On 08/24/2016 at 1:25 pm, observation and interview revealed on the 2nd Floor floor in the Peds area, that the path of egress required travel through more than two delayed egress locks (DEL) to exit the building

3. On 8/25/2016 at 2:22 pm, observation and interview revealed on the lower level floor in the ortho door to corridor, that one or more doors swung outward into the exit path and obstructed the path because when fully open the door 'stuck out' 2 feet into the corridor.

4. On 8/29/2016 at 10:30 am, observation and interview revealed on the 1st floor in the door from Radiologist and doors from staff bathroom to the corridor, that one or more doors swung outward into the exit path and obstructed the path because the door protruded more than 7 inches into the corridor when the door was fully open.

5. On 08/24/2016 at 3:15 pm, observation revealed on the 2nd floor in the C Section room, that the door release hardware required more than a single motion to release the door for exiting. The hardware included a dead bolt and a hand latch to open before the door would open.

6. On 08/24/2016 at 2:25 pm, observation revealed on the 2nd Floor floor in the door from administration area to connecting hallway, that the door release hardware required more than a single motion to release the door for exiting. The dead bolt lever was not large enough to grab and pull.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff T (Facility Director).

Based on observation and interview, the facility did not provide and maintain corridors and aisles that were at least the minimal clear width required by the code. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.2.3.3 where aisles used by others must be at least 44" wide.


FINDINGS INCLUDE:

On 08/24/2016 at 10:30 am, observation and interview revealed on the 1st floor in the Utility access hallway, that the clear and unobstructed width of the aisle is 36 inches.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff T (Facility Director).

Based on observation and interview, the facility did not adequately train staff on all the elements related to extinguishing a fire in the kitchen. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.7.1.3.


FINDINGS INCLUDE:

On 08/24/2016 at 12:08 pm, observation revealed on the lower level floor in the kitchen, that staff were not familiar with their responsibilities in the event of a fire. Staff AA, relief cook, did not know that an Ansell system should extinguish a fire on the grill, staff AA said that they would smother the fire on the stove, and they would use the ABC fire extinguisher instead of the K extinguisher. This situation was not compliant with NFPA 101 (2000 ed.), 18.7.1.3.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff T (Facility Director).

Based on record review, observation, and interview, the facility did not provide a fire alarm system that was installed according to NFPA 72 with manual pull stations at required locations, smoke detectors at required locations, and to inform people of fire information through the fire alarm system. This situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.4 and NFPA 72 (1999 ed.)_2.8.2.2 and 9.6.1.4 and NFPA 72 (1999 ed.), 2-3.4.3.1. Relocation or partial evacuation voice communication shall be through the fire alarm system per NFPA 72, 1999 edition, sections 3-8.4.3, 3-8.4.1.3.5 and 3-8.4.1. In addition, the system shall be protected per 3-.8.4.1.1.4 from the point at which the circuits exit the control unit until the point that they enter the notification zone.

FINDINGS INCLUDE:

1. On 8/29/2016 at 10:10 am, observation revealed on the 1st floor in the Main entrance, that the manual pull station was not located in accordance with NFPA 72 requirements. The pull station was not located within 5 feet of an exit. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff T (Facility Director).

2. On 8/25/2016 at 1:15 pm, observation revealed on the lower level floor in the electric room , that the smoke detector was not located in accordance with NFPA 72 requirements. The smoke detector was located 30 inches below the deck of the ceiling above. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff T (Facility Director).

3) On 8/25/2014 at 3:30 PM, during a record review and interview, it was determined that an overhead speaker system, that is not part of the fire alarm system, was used to inform staff, visitors and patients of fire conditions. After the speaker system announcement, then a separation action would activate the fire alarm system. The speaker system would then be use to relocate or inform staff, visitors and patient of information related to the fire, including evacuation. This condition was confirmed at the time of discovery by an interview with staff T (Facility Director) and staff Z, Safety Director.

Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, with no obstructions near the sprinkler, sprinkler coverage throughout the building, sprinkler coverage throughout the building, unobstructed water distribution, and no wall obstructions. This situation was not compliant with NFPA 13 (1999 ed.), 5-6.5; NFPA 101 (2000 ed.), 18.3.5.1; 18.3.5.1; NFPA 13 (1999 ed.), 5-6.5; 5-6.5; 5-6.5; NFPA 25 (1998 ed.), 1-11.1. .

FINDINGS INCLUDE:

1. On 8/29/2016 at 10:40 am, observation revealed on the 1st floor in the Radiology room (x- ray room), that items were placed within 18" below the sprinkler deflector that obstructed the discharge of sprinkler water from reaching the other side of the obstruction. The obstruction included the x-ray machine

2. On 08/24/2016 at 2:00 pm, observation revealed on the 2nd Floor in the bathroom of the administrative area, that the room was not sprinkled. All areas of new healthcare must be protected with sprinklers.

3. On 8/29/2016 at 1:00 pm, observation revealed on the 1st floor in the housekeeping by the surgery corridor, that the room was not sprinkled. All areas of new healthcare must be protected with sprinklers.

4. On 08/24/2016 at 10:55 am, observation revealed on the lower level floor in the receiving dock, that the discharge of sprinkler water was obstructed from reaching an unprotected area on the other side of a surface mounted light fixture. The light fixture was located 6 inches away and 7 inches below the adjacent sprinkler deflector.

5. On 08/24/2016 at 2:10 pm, observation revealed on the 2nd floor in the women's & men's locker room of the OB area and room 29, that the discharge of sprinkler water was obstructed from entering the shower by a header above the shower. The header was located in the men's locker room, 14 inches down from the sprinkler and 5 inches away. The women's locker room and room 29 have similar dimensions.

6. On 8/29/2016 at 10:50 am, observation revealed on the 1st floor in the MRI machine room (closet), that the ceiling did not provide a heat collection enclosure above the sprinkler and would permit heat to enter the void above the ceiling. As a result, the device would not operate with its designed response time. This situation was not compliant with NFPA 25 (1998 ed.), 1-11.1.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff T (Facility Director).

Based on observation, record review, and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, and unobstructed water distribution. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5.


FINDINGS INCLUDE:

1. On 08/25/2016 at 11:15 am, observation and interview revealed on the 1st floor in the visitor restroom room, that the discharge of sprinkler water was obstructed from reaching an unprotected area on the other side of a surface mounted light fixture. The light fixture was located 4 inches away and 3 inches below the adjacent sprinkler deflector.

2. On 08/25/2016 at 11:46 am, observation revealed on the 1st floor in the patient room 5 toilet's room, that the discharge of sprinkler water was obstructed from reaching an unprotected area on the other side of a surface mounted light fixture. The light fixture was located 6 inches away and 1 inch below the adjacent sprinkler deflector. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5.

3. On 08/25/2016 at 11:20 am, interview and record review revealed on the 1st floor in the sprinkler room, that the sprinkler installation was not compliant. The minimum pressure was not maintained for the sprinkler system. On November 11, 2015 it was 45 psi on Feb 25, 2016 it was 50 psi and on May 17, 2016 it was 50 psi. The plans for the sprinkler system require the pressure to be 57 psi for the dry system and 55 psi for the wet system.

This condition was confirmed at the time of discovery by a concurrent observation, record review, and interview with staff T (Facility Director) and staff U (Maintenance).

Based on observation and interview, the facility did not provide and maintain linen/trash collection receptacles in compliance with the codes with properly sized storage containers for soiled/trash. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.7.5.5.

FINDINGS INCLUDE:

On 08/25/2016 at 10:40 am, observation and interview revealed on the 1st floor in the utility access hallway by the med gas storage room, that mobile collection receptacles exceeded the 32 gallon per 64 square foot maximum density when located outside of a hazardous area. There were two 32 gallon dirty linen containers, a 2' X 3' X 5' soiled linen cart, (4 bags inside) and a 2' 3' X 2.5' trash cart, and one 32 gallon trans can, all in the hallway.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff T (Facility Director).

Based on observation and interview, the facility did not provide and maintain linen/trash collection receptacles in compliance with the codes with properly sized storage containers for soiled/trash. This situation was not compliant with NFPA 101 (2000 ed.), 18.7.5.5.

FINDINGS INCLUDE:

1. On 08/24/2016 at 12:14 pm, observation revealed on the lower level floor in the kitchen, that mobile collection receptacles exceeded the 32 gallon per 64 square foot maximum density when located outside of a hazardous area. There were two 32 gallon trash cans & one 32 gallon plastic recycle container next to each other outside the kitchen by the tray return window.

2. On 08/24/2016 at 5:18 pm, observation revealed on 1st floor in the endo room, that mobile collection receptacles exceeded the 32 gallon per 64 square foot maximum density when located outside of a hazardous area. one 32 gallon and one 10 gallon waste container were next to each other.

3. On 8/29/2016 at 10:10 am, observation revealed on the 1st floor in the X-ray waiting area, that mobile collection receptacles exceeded the 32 gallon per 64 square foot maximum density when located outside of a hazardous area. There was a 32 gallon waste container and a 32 gallon recycle contain next to each other.

4. On 8/29/2016 at 12:05 pm, observation revealed on the 1st floor in the lab, that mobile collection receptacles exceeded the 32 gallon per 64 square foot maximum density when located outside of a hazardous area. There were several locations where there was more than 32 gallon waste containers in a 64 square foot area and some waste container were greater than 32 gallons.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff T (Facility Director).

Based on interview and observation, the facility did not have the proper equipment to remotely stop the emergency generator. This situation was not compliant with NFPA 110 (1999 ed.), 3-5.5.6.

FINDINGS INCLUDE:

On 08/24/2016 at 11:34 am, observation revealed that there was not an emergency stop switch outside the housing of the emergency generator located external to the building.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff T (Facility Director).