HospitalInspections.org

Based on observation and interview, the facility failed to ensure doors in the means of egress were operable with no more than one releasing device.

The findings include:

Observation and interview with the maintenance manager on 5/21/2019 at 9:38 AM confirmed 2 of 2 exit doors from the CT room required 2 releasing motions to exit. (NFPA 101-2012 Edition, 19.2.2.2.1 & 7.2.1.5.10.2)
The maintenance manager and human resource manager was present when the deficiencies were identified and acknowledged by the Administrator during the exit conference on 5/21/2019.

Based on observation and interview, the facility failed to ensure hazardous areas were provided with self-closing doors. (NFPA 101 2012 Edition 19.3.2.1.3)
This has the potential to affect 4 of 16 observed smoke compartments.

The findings include:

1. Observation and interview with the maintenance manager, on 5/21/2019 at 10:13 AM revealed the elevator equipment room door remained open and was not self-closing.
2. Observation and interview with the maintenance manager, on 5/21/2019 at 10:48 AM revealed the C-section room, used for storage, had its door propped open and was not self-closing.
3. Observation and interview with the maintenance manager, on 5/21/2019 at 1:40 PM revealed the 2-east wing was unoccupied and 11 observed resident rooms were being used to store combustibles, changing their intended use. The doors were open and not self-closing.
The maintenance manager and human resource manager was present when the deficiencies were identified and acknowledged by the Administrator during the exit conference on 5/21/2019.

Based on observation and interview, the facility failed to ensure sprinkler heads were maintained.
2012 NFPA 101 Sections 19.3.5, 9.7.1.1, 9.7.5, 19.7.6, 4.6.12
2010 NFPA 13 Section 8.3.3.2.
2011 NFPA 25 Section 5.2.1.1.2 (5)
This deficiency affected 3 of 16 smoke compartments.
The findings include:
1. Observation and interview with the maintenance manager on 5/21/2019 at 9:06 AM confirmed 2 of 3 loaded sprinklers at the East nurses station.
2. Observation and interview with the maintenance manager on 5/21/2019 at 9:08 AM confirmed 1 loaded sprinkler at the East employee breakroom.
3. Observation and interview with the maintenance manager on 5/21/2019 at 9:42 AM confirmed loaded sprinkler in the emergency department at beds #1 and #2.
4. Observation and interview with the maintenance manager on 5/21/2019 at 10:00 AM confirmed 1 upright sprinkler head deflector was slightly embedded into the concrete of the steam generator room's sterilizer ceiling.
The maintenance manager and human resource manager was present when the deficiencies were identified and acknowledged by the Administrator during the exit conference on 5/21/2019.

Based on observation and interview, the facility failed to ensure corridor doors were maintained.

The findings include:

Observation and interview with the maintenance manager, on 5/21/2019 at 9:19 AM revealed the clean utility room door across from room 206 had an undercut that exceeded 1". (NFPA 101, 19.3.6.3.4)

The maintenance manager and human resource manager was present when the deficiencies were identified and acknowledged by the Administrator during the exit conference on 5/21/2019.

Based on observation, record review and interview, the facility failed to maintain fire doors and conduct annual fire door inspections.(NFPA 101 (2010 edition) 19.7.6 & 4.6.12.1; NFPA 80 (2010 edition) 4.8.4.1, 5.2.1, 5.2.4.2 (7) 5.2.13.3, 6.3.1.7.1, 8.3.3.1,)
This deficiency affected 16 of 16 smoke compartments.
The findings include:
1. Record review with the maintenance manager on 5/21/2019 at 12:31 PM revealed there was no documentation of annual fire door inspections after July 10, 2017.
2. Observation and interview with the maintenance manager, on 5/21/2019 at 9:41 AM revealed the 1-1/2 hour rated wooden fire door to the emergency room had a hinge-side gap exceeding 1/8". (NFPA 80, 2010 edition 6.3.1.7.1)

3. Observation and interview with the maintenance manager, on 5/21/2019 at 9:43 AM revealed the fire door from the emergency room had a painted over label and three ¼ inch holes in the door. (NFPA 80, 2010 edition 5.2.4.2 (1)

4. Observation and interview with the maintenance manager, on 5/21/2019 at 9:55 AM revealed the stairwell fire door by surgery had a lower hinge-side gap and top edge gap exceeding 1/8". (NFPA 80, 2010 edition 6.3.1.7.1)

5 Observation and interview with the maintenance manager, on 5/21/2019 at 10:14 AM revealed the elevator equipment room door closer was not operating properly. Two of three door hinges had tapcon screws instead of fire door hardware. (NFPA 80, 2010 edition 5.2.4.2.(6)

6 Observation and interview with the maintenance manager, on 5/21/2019 at 10:25 AM revealed the stairwell fire door outside dietary had an undercut that exceeded ¾". (NFPA 80, 2010 edition 4.8.4.1)

7 Observation and interview with the maintenance manager, on 5/21/2019 at 10:47 AM revealed the OB-wing double fire doors were wedged open. (NFPA 80, 2010 edition 5.2.13.3)

The maintenance manager and human resource manager was present when the deficiencies were identified and acknowledged by the Administrator during the exit conference on 5/21/2019.

Based on record review and interview, the facility failed to ensure the emergency power supply system (EPSS) was capable of supplying emergency electrical power within 10-seconds and that the automatic transfer switch (ATS) is being maintained.

This has the potential to affect 16 of 16 smoke compartments in the event of a power failure; 7 of 7 inpatients, all patients in the emergency room, exit signs, emergency lighting throughout the facility, medical gas systems, nurse call system and ventilators, if in operation could be affected.
2012 NFPA 101 Sections 19.7.6, 9.1, 9.1.3.1
2010 NFPA 110 Section 8.3.1, 8.3.4.1(3)
2012 NFPA 99 Section 6.4.4.1.1.1 and 6.5.4.1.1.1

The findings include:

1. Record review of the Emergency Generator logs with the maintenance manager on 5/21/2019 at 12:30 PM revealed the emergency Generator failed to automatically transfer the load from the ATS on; 3/27/2018, 12/13/2018, 1/15/2019, 2/4/2019, 2/26/2019, and 3/15/2019. Initial report on 3/27/2019 stated, "First attempt of load test transfer failed to switch over..." and "Fixing problem is in progress."
2. Interview with the maintenance manager on 5/21/2019 at 12:31 PM confirmed the failed transfer and he stated he reported this initially during the safety committee meeting on 3/28/2018 and that the problem has not been corrected.
3. Interview with the maintenance manager on 5/21/2019 at 12:36 PM about the manual transfer necessary for emergency power, revealed there was no one who could manually transfer the electrical load to emergency power if he was not on site.
4. Interview with the maintenance manager on 5/21/2019 at 12:40 PM revealed he had received quotes to repair the ATS, however no corrective action has occurred.

The maintenance manager and human resource manager was present when the deficiencies were identified and acknowledged by the Administrator during the exit conference on 5/21/2019.