HospitalInspections.org

Based on observation and staff interview, the facility failed to install/maintain one stairwell exit to open from the egress side in accordance with NFPA 101 (2012) 19.2.2.2.4, 7.2.1.5.1, 7.2.1.6.1.1. The deficient practice affected one of two stairwell exits from the 2nd Floor and had a potential to affect 18 of 35 patients. The facility had a census of 35 with a licensed capacity of 62 beds on the day of survey.

Findings include

On 8/29/17 at 10:15 am, observation revealed that the south stairwell exit Door #233 with a 15-second delayed-egress locking system did not open when tested. A force applied to the panic bar release device did not initiate the irreversible process of opening the door in 15 seconds. The door was located in the 2nd Floor.

The deficiency was confirmed by the concurrent observation and interview with Staff R (director of plant operations), and Staff S (corporate director of plant operations), and at the time of exit conference with Staff B (hospital president), Staff C (divisional president), and Staff Y (chief clinical officer) on 8/29/17 at 2:20 pm.

Based on observation and staff interview, the facility failed to provide occupant notification to staff sleeping rooms in accordance with the NFPA 101 (2012) 19.3.4.3.1, NFPA 72 (2010) 9.6.3. The deficient practice had a potential to affect staff or guests who used the two overnight sleeping rooms.

Findings include

1. On 8/28/17 at 12:53 am, observation revealed that there was no audible and visual alarm, or visual alarm installed in the Guest Overnight room to notify occupant in the room when a fire alarm system is activated.

2. On 8/29/17 at 3:57 am, observation revealed that there was no audible and visual alarm, or visual alarm installed in the Doctor's Overnight room to notify occupant in the room when a fire alarm system is activated.

The deficiency was confirmed by the concurrent observation and interview with Staff R (director of plant operations), and Staff S (corporate director of plant operations), and at the time of exit conference with Staff B (hospital president), Staff C (divisional president), and Staff Y (chief clinical officer) on 8/29/17 at 2:20 pm.

Based on observation and staff interview, the facility failed to maintain the building sprinkler system in accordance with NFPA 101 (2012) 19.3.6.3.5, 9.7.5, NFPA 25(2011) 5.2.1.1.1. The deficient practice had a potential to affect 10 of 34 patients. The facility had a census of 34 with a licensed capacity of 62 beds on the day of survey.

Findings include

On 8/28/17 at 4:34 pm, observation revealed that two sprinkler heads in the Patient Room 312 on the 3rd Floor were dust and lint covered.

The deficiency was confirmed by the concurrent observation and interview with Staff R (director of plant operations), and Staff S (corporate director of plant operations), and at the time of exit conference with Staff B (hospital president), Staff C (divisional president), and Staff Y (chief clinical officer) on 8/29/17 at 2:20 pm.

Based on observation and staff interview, the facility failed to provide compliant corridor doors in accordance with NFPA 101 (2012) 19.3.6.3.5. The deficient practice had a potential to affect staff, visitors and patients who used the egress corridor adjacent to the Human Resources suite on the 1st Floor, where the doors are located.

Findings include

On 8/28/17 at 1:07 pm, observation revealed that the double doors to the Human Resources suite did not have a latching hardware to keep the doors closed. The doors were binding at the meeting edge which prevented from fully closing.

The deficiency was confirmed by the concurrent observation and interview with Staff R (director of plant operations), and Staff S (corporate director of plant operations), and at the time of exit conference with Staff B (hospital president), Staff C (divisional president), and Staff Y(chief clinical officer) on 8/29/17 at 2:20 pm.

Based on record review, observation and staff interview, the facility failed to maintain a compliant medical gas system in accordance with the NFPA 99 2012 edition 5.1.3.6.3.14. The deficient practice had a potential to affect all patients.

Findings include

On 8/28/17 at 11:15 am, observation revealed that the dew point of medical air was not maintained less than or equal to 35 deg. F. The dew point monitor located in the Medical Air Compressor room displayed a dew point of 37 deg, but did not activate alarms at the two master alarm panel locations as required. One alarm panel was located in the maintenance shop close to the med gas source equipment room, and the 2nd panel was located on the 2nd Floor nurse station.

A review of the dew point log of the August month on 8/29/17 between 11:15 and 2 pm revealed that the dew point of medical air in the piped-in medical gas system was 37 deg. F. on August 3, 2017 as well.

The deficiency was confirmed by the concurrent observation and interview with Staff R (director of plant operations), and Staff S (corporate director of plant operations), and at the time of exit conference with Staff B (hospital president), Staff C (divisional president), and Staff Y (chief clinical officer) on 8/29/17 at 2:20 pm.