HospitalInspections.org

Based on observation and interview the facility failed to ensure corridors are in accordance with NFPA 101, 2012 Edition, Chapter 7 and the means of egress is continuously maintained free of all obstructions to full use in case of emergency.

Findings:

On 08/30/17 at 12:28 pm the exit egress corridor located by central supply which was presupposed into materials storage and management was observed to have two wooden pallets with corrugated boxes of supplies stacked to a height of approximately 3.5 feet were protruding into the egress corridor pathway. The maintenance manager stated the supplies were dropped off and not put away yet.

Based on observation and interview the facility failed to ensure patient sleeping room doors were not equipped with key-locking devices which does not restrict egress from the patient room.

Findings:

On 08/30/17 10:25 am dead bolt keyed locks were observed to be installed on isolation rooms 208 and 209. The dead bolt lock on each door was keyed on both sides which required a key to open it from the egress side in each of the patient rooms. The maintenance manager stated they would remove the dead bolts from the isolation patient rooms.

Based on observation and interview the facility failed to ensure doors in a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress as required in accordance with NFPA 101, 2012 Edition, Chapter 19.2.2.2.6.

Findings:

On 08/30/17 at 11:15 am a magnetic lock was observed to be on the main automatic door entrance with a keyed lock located on the wall. The maintenance manager was asked to explain how the magnetic lock on the main south entrance/exit was locked. He stated the night charge nurse locks the main entrance magnetic locks so no one can come in at 10:00 pm each evening. The maintenance manager was asked when the electronic doors are locked, can people from inside exit at the door. He stated no. The maintenance manager was asked when the fire alarm goes off does it unlock the magnetic lock to the doors. He stated no.

On 08/30/17 at 11:24 am deadbolt locks were observed on the HR door near the main south entrance of the facility. Barrel latches were observed on the double doors leading into the emergency room which was repurposed into materials storage. Several staff offices were observed to be in rooms within the repurposed emergency room. The maintenance manager was asked when the locks were installed on the exit access doors. The maintenance manager stated the locks have been on the doors as long as he has been at the facility. He stated they would remove the locks.

Based on observation and interview the facility failed to ensure doors to hazardous areas or exit passageway were held open by a release device complying with NFPA 101, 2012 Edition, Chapter 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of: required manual fire alarm system; local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and automatic sprinkler system, if installed, and loss of power as required in NFPA 101, 2012 Edition, Chapters 19.2.2.2.7 and 19.2.2.2.8.

Findings:

On 08/30/17 at 11:07 am a medical records storage area located in the unsprinklered portion of the facility was observed to have the following: a door held in the open position; the door had no self-closing hardware installed; was a non-rated fire door installed on a fire rated door frame assembly. The maintenance manager was asked how the non-rated door was installed into a fire rated door assembly. He stated he did not know how or when that occurred.

Based on observation and interview the facility failed to ensure illumination of means of egress to include exit discharge is arranged in accordance with NFPA 101, 2012 Edition, Chapter 7.8 and shall be either continuously in operation or capable of automatic operation without manual intervention in accordance to NFPA 101, 2012 Edition Chapter 19.2.8.

Findings:

On 08/30/17 at 1:20 pm each of the designated exit discharges from the facility were observed to have lighting fixtures on normal power. The maintenance manager was asked if the exit discharge lighting would always illuminate when the emergency generator came on and there was no normal electrical power. He stated he did not know and could not confirm which lights would illuminate under generator power.

Based on observation and interview the facility failed to ensure hazardous areas were protected as required in NFPA 101, 2012 Edition, Chapter 8.7.1 and Chapter 19.3.2.1.

Findings:

On 08/31/17 at 10:51 am a medical records storage closet located in the unsprinklered position of the facility was observed to be without self-closing hardware. The maintenance manager stated they would add the required self-closing hardware to the hazardous area door.

On 08/31/17 at 12:37 pm two fire rated doors were observed to be installed on non-fire rated door assemblies. The maintenance manager was asked to locate the UL fire rating labels on each of the two door frame assemblies and he said there were no UL fire rated labels on the two door frames.

Based on record review and interview the facility failed to ensure the automatic sprinkler metallic piping was internally inspected in accordance with NFPA 25, 2011 Edition, Chapter 14.2.1, 14.2.1.1, and 14.2.1.4.

Findings:

On 09/01/17 at 11:01 am record review showed the fire sprinkler system inspection did not include the five year internal inspection of metallic sprinkler piping and branch line conditions for the purpose of inspecting for the presence of foreign organic and inorganic material. The maintenance manager stated it has not been done and they will have their vendor complete it.

Based on observation and interview the facility failed to ensure corridor walls did not have non-fire rated window assemblies in corridor walls as required in NFPA 101, 2012 Edition, Chapter 19.3.6.2 and 19.3.6.2.7.

Findings:

On 08/31/17 at 12:31 pm a non-fire rated pass through window assembly opening with two raw wood shutters was observed in the corridor wall located in a non-sprinklered area located by the central supply which was repurposed into materials management storage. The maintenance manager was asked why the non-fire rated opening in the non-sprinklered area was in the egress corridor wall. He stated the opening had always been there.

Based on observation and interview the facility failed to ensure electrical wiring and equipment complied with NFPA 70, National Electric Code as required.

Findings:

On 08/31/17 at 10:58 am a Helmer refrigerator located in the laboratory on the 2nd floor was observed to be plugged into a power tap and not directly into a three prong electrical receptacle. The maintenance manager stated it will be plugged into a three prong grounded receptacle.

On 08/31/17 at 12:44 pm an insulin refrigerator and patient food refrigerator located on the 2nd floor were plugged into a power tap and not directly into a three prong grounded electrical receptacle.

On 08/31/17 at 1:11 pm a non-GFCI electrical receptacle was observed to be installed within 6 feet of a counter top water source located at the ICU nurses station. The maintenance manager stated they will correct that by installing a GFCI electrical receptacle.

On 09/01/17 at 2:25 pm an ultrasound machine was observed to have an inspection label that showed the device was last inspected in 04/16. The director of nurses stated it would be taken out of service and inspected.

Based on observation and interview the facility failed to ensure HVAC heating, ventilation and air conditioning complied with NFPA 101, 2012 edition, Chapter 9.2 and was installed in accordance with the manufacturer's specifications as required in NFPA 101, 2012 Edition, Chapter 19.5.2.1 and ASHRE 170.

Findings:

On 08/31/17 at 10:44 am a bathroom located on the 2nd floor across from the main entrance receptionist's desk did not have negative ventilation as required. The maintenance manager stated they would repair the vent.

On 08/31/17 at 12:38 pm a housekeeping closet located in the non-sprinklered area of the facility containing stored cleaning chemicals, five gallon container floor stripper, multiple containers of cleaning fluids, and approximately nine alcohol based hand rub containers had no HVAC ducting which provided required negative air ventilation from the room. The room was observed to be a repurposed room being currently used for a purpose it was not originally designed for. The maintenance manager stated they will either add the ventilation or move the stored items to an appropriate area.

Based on observation and interview the facility failed to ensure soiled linen containers exceeding 32 gallons were stored in a room protected as a hazardous area when not attended as required in NFPA 101, 2012 Edition, Chapter 19.7.5.7.

Findings:

On 08/31/17 at 1:35 pm two Linemaster soiled linen wheeled carts over 32 gallons each were observed stored open in the egress corridor on the 1st floor near the kitchen. The maintenance manager stated they would move the soiled linen carts to an appropriate area.

Based on record review and interview the facility failed to ensure completion of their building systems medical gas system risk assessment as required.

Findings:

On 08/31/17 at 12:45 pm during record review the safety director was asked for the building systems medical gas systems risk assessment and failed to provide the documentation.

Based on record review and interview the facility failed to ensure their building system risk assessment for their essential electrical systems was completed as required.

Findings:

On 08/31/17 at 10:20 am during record review the safety director was asked for the building systems essential electric system risk assessment documentation and the safety director failed to provide the documentation.