HospitalInspections.org

Based on observation and interview, the facility did not provide and maintain wall construction to protect the corridor from non-corridor spaces with 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 October 31, 2016 at 2:30 PM, it was observed that a wall to create a treatment room separated from the corridor has not been built as stated in the Plan of Correction. Previously, 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, 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 October 31, 2016 at 12:25 pm, observation and interview revealed on the 2nd Floor in the administration suite, that the corridor was not compliant. The 'WON' door can be closed from the outside or inside of the room with a special key for the key switch located in the corridor and in the room. Staff D, housekeeper, who was the only visible person in the suite, was asked to close the corridor door. Staff D attempted to pull the 'Won' door closed which Staff D could not do. When told, there was a switch nearby, Staff D turned the key and when the door did not move, gave up trying to close the door. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Facility Director) and staff D, (Housekeeper).

2. On October 31, 2016 at 3:15 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. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Facility Director).

3. On October 31, 2016 at 3:45 pm, 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. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (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 October 31, 2016 at 3:15 pm, observation revealed on the 2nd Floor in the medical records storage by the board room, that the door and door frame 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.

2. On October 31, 2016 at 3:20 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.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (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:

1. On October 31, 2016, at 1:05 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 K, cook, did not know what 'RACE' (Rescue, Alarm, Contain, Evacuate) was and was not familiar what to do in a fire except the Staff E knew what to do if there was a grease fire. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Facility Director) and staff K (cook)

2. On October 31, 2016 at 3:45 PM, during an interview with Staff B (Respiratory Therapist) and Staff C (Sleep Tech), staff did not know that in their response to a fire, that the C in RACE had been changed from calling 911 to contain the fire. Staff K (cook) also did not know this. The question had been asked only of these three individuals. 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 A (Facility Director), Staff B, Staff C and Staff K.

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 October 31, 2016 at 1:30 pm, 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 A (Facility Director).

2. On October 31, 2016 at 4:00 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. The speaker system announcement was done after the fire alarm was initiated. On the lower level, staff A (Facility Director) and staff J, Safety Director stated that the announcement of the location of the fire cannot be understood over the 'noise' of the fire alarm horns. This condition was confirmed at the time of discovery by an interview with staff A (Facility Director) and staff J, Safety 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 October 31, 2016 at 2:45 PM, observation revealed that the pressure gage on the sprinker system indicated 50 psi. Previously on Augugst 26, 2016, interview and record review revealed on the 1st floor in the sprinkler room, that the static pressure was recorded on November 11, 2015 at 45 psi; on Feb 25, 2016 at 50 psi and on May 17, 2016 at 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 A (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 October 31, at 2:05 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 was a 32 gallon dirty linen container next to a 28 gallon bio-waste container.

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