HospitalInspections.org

Based on observation and interview, the facility failed to ensure egress doors are not equipped with a latch or lock that requires the use of a tool, key or special knowledge to open in accordance with 2012 NFPA 101, 19.2.2.2.1 and 7.2.1.5.3. This deficient practice could affect 20 occupants in the event of an evacuation from the emergency department.

Findings Include:

On January 23, 2023 at approximately 10:25 AM, observation revealed a 270 degree thumb-turn claw deadbolt style lock installed in the main entrance sliding exit doors and the emergency department entrance doors. The emergency exit doors are equipped with a push to open emergency breakaway function. The lock on the doors will prohibit the breakaway release doors from releasing and also prohibit evacuation from occupants who do not have the special knowledge to unlock the 270 degree deadbolt claw style lock. These findings were confirmed with the Corporate Director of Facilities and Energy at the time of observation.

These findings were confirmed through interview with the Corporate Director of Facilities and Energy at the time of observation.

Based on observation and interview, the facility failed to ensure the means of egress is illuminated in accordance with 7.8, as required by 19.2.8. This deficient practice could affect 10 occupants in the event of an emergency evacuation.

Findings include:

On January 23, 2023 at approximately 11:25 AM, observation revealed the facility emergency egress stairwells are controlled by a light switch and do not produce constant illumination of the stairwell egress path. When the light switches were turned off the stairwell was dark with no other lighting, 2012 NFPA 101, 7.8.1.2 requires continuous illumination in the emergency egress corridors at all times without interruption. Interview with the Corporate Director of Facilities and Energy confirmed the stairwell egress path lights to the facility are switch controlled and can be turned off with no other lighting available.

These findings were confirmed through interview with the Corporate Director of Facilities and Energy at the time of observation.

Based on observation, record review and interview, the facility failed to ensure cooking facilities are protected in accordance with NFPA 96, unless meeting the requirements of 19.3.2.5.2, 19.3.2.5.3 or 19.3.2.4.4, as required by 19.3.2.5.1 through 19.3.2.5.5, 9.2.3 and TIA 12-2. This deficient practice could affect all occupants in the event of fire emergency.

Findings Include:
A. On January 23, 2023, at approximately 12:15 PM, record review revealed the facility failed to provide documentation the kitchen hood system was inspected/cleaned by a qualified and certified person per NFPA 96, 11.4. At approximately 1:00 PM, observation of the kitchen hood system between the hood filters and roof top fan was loaded with dust.

B. On January 23, 2023, at approximately 11:52 AM, observation revealed kitchen hood filters are of mesh type. Mesh type filter are not allowed unless evaluated as an integral part of a listed exhaust hood or listed in conjunction with a primary filter in accordance with UL 1046, per NFPA 96, 6.1.3.

The Supervisor of Facility Maintenance and Corporate Director of Facilities & Energy confirmed these findings during interview at the time of observation and record review.

Based on observation and interview, the facility failed to ensure a fire alarm system is installed in accordance with NFPA 70 and NFPA 72, as required by 19.3.4.1, 9.6 and 9.6.1.8. This deficient practice could affect all occupants in the event of fire emergency.

Findings Include:
On January 23, 2023, at approximately 1:10 PM, observation revealed the fire alarm electrical breaker for the clean agent suppression alarm system located in the transfer switch room did not have a breaker lock per NFPA 72, 10.5.5.2.2.

The Supervisor of Facility Maintenance confirmed these findings during interview at the time of observation.

Based on observation and interview, the facility failed to ensure the automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with 2011 NFPA 25. This deficient practice could affect all occupants in the event of a fire.

Findings Include:

1. On January 23, 2023 at approximately 12:00 PM, observation revealed the sprinkler head located above the emergency room desk is loaded with dust in violation of 2011 NFPA 101, 5.2.1.1.2, and may not function as designed when needed during a fire.

2. On January 23, 2023 at approximately 2:00 PM, observation revealed the sprinkler heads located in the kitchen dry storage area and the dirty utility room 239 have a manufacturer date of 1969. Sprinkler heads over 50 years old must be in accordance with 2011 NFPA 25, 5.3.1.1.1. This could potentially allow the sprinkler heads to fail when needed during a fire.

These findings were confirmed with the Corporate Director of Facilities and Energy at the time of observation.

Based on record review and interview, the facility failed to inspect and test annually in accordance with NFPA 101, 19.7.6, 8.3.3.1 and NFPA 80, Standard for Fire Doors and Other Opening Protectives 5.2, 5.2.3. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability. Written records of inspection and testing are maintained and are available for review. This deficient practice could affect all occupants in the event of a fire emergency.

Findings Include:
On January 23, 2023, at approximately 12:45 PM, record review revealed the facility failed to provide documentation, at the time of survey, of the annual inspection, testing and maintenance, of the building's fire door assemblies in compliance with NFPA 80, 2010 edition.

The Supervisor of Facility Maintenance confirmed these findings during interview at the time of record review.

Based on observation and interview, the facility failed to ensure portable space heating devices were prohibited or only used in non-sleeping staff areas where the heating elements do not exceed 212 degrees Fahrenheit as required by 19.7.8. This deficient practice could affect 15 occupants in the event of a space heater related fire.

Findings Include:

On January 23, 2023 at approximately 11:00 AM observation revealed a space heater under the main reception desk. The temperature of the heating element for the space heater could not be verified to be less than 212 degrees.

These findings were confirmed with the Corporate Director of Facilities and Energy at the time of observation.

Based on observation and interview, the facility failed to ensure a remote annunciator that is provided to operate outside of the generating room in a location readily observed by operating personnel. The annunciator is hard-wired to indicate alarm conditions of the emergency power source. A centralized computer system (e.g., building information system) is not to be substituted for the alarm annunciator as required by 6.4.1.1.17, 6.4.1.1.17.5, NFPA 99. This deficient practice could affect all occupants in the event of generator malfunction.

Findings Include:
On January 23, 2023, at approximately 11:52 AM, observation revealed the generator annunciator panel was located in janitor closet 264 which is not a readily observed location by operating personnel at a regular workstation per NFPA 99, 6.4.1.1.17 & NFPA 110, 5.6.6.

The Supervisor of Facility Maintenance confirmed these findings during interview at the time of observation.

Based on observation and interview, the facility failed to ensure required select receptacles in certain areas are supplied from the critical branch and they have a distinctive color marking as required by 6.4.2.2.6, 6.5.2.2.4.2, and 6.6.2.2.3.2 of NFPA 99. This deficient practice could affect all occupants in the event of electrical failure.

Findings Include:

On January 23 2023, at approximately 12:20 PM, observation revealed the medication only refrigerators located in the pharmacy and medication room are not connected to an outlet of select color to verify connection to the emergency back-up power system. 2012 NFPA 99, 6.4.2.2.4.2(3) requires select receptacles in Medication preparation areas and Pharmacy dispensing areas to be connected to the critical branch of the emergency back-up power system. Those select outlets would provide essential back-up power to the medicine only refrigerator units in the event of an emergency power outage.

These findings were confirmed during interview with Corporate Director of Facilities and Energy at the time of observation.

Based on observation and interview, the facility failed to ensure generators or other alternative power sources and associated equipment is capable of supplying service within 10 seconds, is maintained, inspected, tested and exercised in accordance with NFPA 110, and records are readily available as required by 6.4.4, 6.5.4 and 6.6.4 of NFPA 99, NFPA 110, NFPA 111 and 700.10 of NFPA 70. This deficient practice could affect all occupants in the event of fire emergency.

Findings Include:
1. On January 23, 2023, at approximately 11:21 AM, observation revealed the facility's diesel fuel tank safety labels are illegible located on the generator above ground diesel fuel tank. Updated labeling of the NFPA 704 placard and NO SMOKING, FLAMMABLE signs shall be located where it can be seen on approach by emergency responders as required by NFPA 30, 21.7.2.1, Identification for emergency responders. This could potentially delay proper response or expose the tank to hot work or heat source from parties not knowing the associated danger.

2. On January 23, 2023 at approximately 1:30 PM, observation revealed the facility does not have a battery backup illumination source for the generator transfer switches in the generator switch room. This could potentially allow the area to be in darkness if the generator fails to provide emergency power in an outage.

The Supervisor of Facility Maintenance and Corporate Director of Facilities & Energy confirmed these findings during interview at the time of observation.