HospitalInspections.org

This requirement is not met as evidenced by:

Based upon observations and staff interviews on March 3-4, 2015, Western State Hospital has failed to maintain fire resistive construction of the building capable of resisting the passage of smoke and fire into other compartments. This could allow the toxic product of combustion to move out of a room and into the exit access corridor and the smoke compartment which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
1. S-10 Room 501 a penetration was located in the mechanical room.
2. S-8 Room 328 missing escutcheon ring.
3. S-7 room 257, missing escutcheon ring.
4. Ceiling tiles were observed to be missing in room G19-07.
5. Unprotected wire penetrations were observed in the ceiling the electrical room of Building 20 C5 213.
6. Unprotected wire penetration was observed in the wall to the stairwell in Building 19 first floor.
7. Unprotected wire penetrations were observed in the electrical room C4 113 in Building 19.


The above was discussed and acknowledged by the maintenance staff.

Based upon observations and staff interviews on 3/3/2015 between approximately 1030 and 1500 hours Western State Hospital has failed to maintain interior finishes. This could allow the toxic product of combustion to rapidly propagate throughout the room and into the exit access corridor and the smoke compartment which would endanger the residents, staff and/or visitors within the smoke compartment.

The findings include, but are not limited to:

The following rooms were observed to have non-treated paper installed over the fire door windows:
1. Building 17 C8 215
2. Building 20 C6 322
The following areas were observed to have Plexiglas installed over fire rated glazing:
1. Building 20 C5 207.
2. Building 19 C2 229.


The above was discussed and acknowledged by the Facilities Manager.

This requirement is not met as evidenced by:

Based upon observations and staff interviews on March 3-4, 2015, Western State Hospital has failed to maintain corridor walls so that they will resist the passage of smoke. This could allow the toxic product of combustion to move out of a room and into the exit access corridor and the smoke compartment which would endanger the residents, staff and/or visitors within the smoke compartment.

The findings include, but are not limited to:
1. Building 28, above door C109b, a penetration was observed in the upper wall area.

The above was discussed and acknowledged by the maintenance staff.

This requirement is not met as evidenced by:

Based upon observations and staff interviews on March 3-4, 2015, Western State Hospital has failed to maintain doors without impediments to their closing and latching. This could result in a delay in getting the door to the room closed in the event of a fire. This could result in toxic products of combustion getting into the room and into the exit corridor which would endanger the residents, staff and/or visitors within the smoke compartment.

The findings include, but are not limited to:
1. Building 21, S-3, Room 318, fire door propped open.
2. Building 21, office doors in nurses stations which are fire rated and part of the fire wall or protection system were observed to be propped open.
3. The following doors were observed to not close and latch properly:
1. Building 17 elevator 17-1 ground floor elevator fire door observed to not latch.
2. Building 17 elevator 17-1 first floor elevator fire door observed to not latch.
3. Building 17 elevator 17-1 third floor elevator fire door observed to not latch.
4. Building 19 C3 ward break room observed to be held open with a door wedge.
5. Building 19 C3 312 Duty nurse door observed to be held open with a door wedge.
6. Building 19 C2 214 observed to not latch.
7. Building 20 C4 120 the self-closer was observed to be removed.
8. Building 20 C4 128 the fire door was observed to be altered into a dutch style door.

The above was discussed and acknowledged by the maintenance staff.

Based upon observations and staff interviews on March 3, 2015 between approximately 1030 and 1500 hours Western State Hospital has failed to maintain fire glazing. This could result in toxic products of combustion getting into the room and into the exit corridor which would endanger the residents, staff and/or visitors within the smoke compartment.
The findings include, but are not limited to:
The following locations were observed to have the fire rated glazing replaced with Plexiglas:
1. Building 19 C2 204.
2. Building 19 C2 232.
3. Building 19 C2 232.
4. Building 19 C1 129.
5. Building 19 C1 132.
6. Building 20 C4 107.
7. Building 20 C4 111.
8. Building 17 G17-32

This was observed and discussed with the facilities director.

Based upon observations and staff interviews on 3/3/2015 between approximately 1030 and 1500 hours Western State Hospital has failed to maintain the ability of doors to be held open only by devices arranged to automatically close such doors upon activation of the fire alarm. This could result in the passage of smoke or fire one compartment into another compartment thereby exposing residents, staff and/or visitors to the toxic products of combustion.

The findings include, but are not limited to:

Cross corridor fire doors by G19-01 was observed to not latch properly.
The 3 hour fire door between Building 19 and Building 9 was observed to not latch.


The above was discussed and acknowledged by the Facilities Manager.

This requirement is not met as evidenced by:
Based upon observations and staff interviews on March 3-4, 2015, Western State Hospital has failed to maintain the illumination of the means of egress so that in the event of the failure of a single bulb the means of egress will remain illuminated. This could result in tripping and fall injuries and/or delay in evacuation of residents, staff and/or visitors.

The findings include, but are not limited to:
1. Building 27, Medical Room 144 was observed to have a defective emergency egress light.
The above was discussed and acknowledged by the maintenance staff.

This requirement is not met as evidenced by:

Based upon record review and staff interviews on March 3-4, 2015, Western State Hospital has failed to have appropriate testing and maintenance of the fire alarm system which could result in the failure of notification of an emergency and endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
1. Buildings 17, 18, 19, 20,21, and 29 were observed to have fire alarm panels in trouble mode. Buildings 17 through 21 were reportedly malfunctioning due to specific identifiable and limited items. Building 29 fire alarm failure was found to be due to a system failure of smoke detection which might compromise the building fire alarm system.
2. Sensitivity testing for smoke detectors in zone type alarm areas.
3. Document review indicated Building 29, failure of the duct smoke detector system since October 2014. No fire watch policy was available upon request.

Condition of participation was not met due to immediate jeopardy involving item three with respect to Building 29.

The above was discussed and acknowledged by the maintenance staff.

Based upon record review and staff interviews on 3/4/2015 between approximately 1100 and 1400 hours Western State Hospital has failed to conduct testing of the fire sprinkler system as required. This could result in the failure of the fire sprinkler system to operate properly in the event of a fire which would endanger the residents, staff and/or visitors within the facility.


The findings include, but are not limited to:
During a review of the records it was observed that the 5 year internal pipe inspection had not been completed for the following buildings, 17, 18, 19, 20, 21, 28 and 29. The facilities manager stated the facility was unaware of the requirement until recently and has not had time to complete all buildings.

The above was discussed and acknowledged by the Facilities Manager.

This requirement is not met as evidenced by:

Based upon observations and staff interviews on March 3-4, 2015, Western State Hospital has failed to provide the proper equipment at the approved smoking area(s). This could result in the ignition of the combustible materials adjacent to the staff smoking area which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
1. Building 21, smoking area, open receptacle for cigarette debris.
2. Residents were observed to come out of Building 17 with cigarettes and lighters. This is in violation of the facilities smoking policy which states " storage of tobacco products: Mailbox type containers (lockers) and automatic lighters are available for patient use. Ward Staff will not store smoking material. "


The above was discussed and acknowledged by the maintenance staff.

Based upon observations and staff interviews on March 3, 2015, between approximately 1030 and 1500 hours Western State Hospital has failed to maintain lined chute doors without impediments to their closing and latching. This could result in a delay in getting the door to the room closed in the event of a fire. This could result in toxic products of combustion getting into the room and into the exit corridor which would endanger the residents, staff and/or visitors within the smoke compartment.

The findings include, but are not limited to:

The linen chute door located in Building 17 room C8 249 was observed to be missing the latch bolt.

The following doors were observed to not close and latch properly:

The above was discussed and acknowledged by the Facilities Manager.

This requirement is not met as evidenced by:

Based upon observations and staff interviews on March 3-4, 2015, Western State Hospital has failed to prohibit the use of furnishings or decorations of flammable material. This could result in the rapid spread of smoke and fire in the event of ignition which could potentially endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
1. Building 28, Ward F-7, Room 21, observed with a pillow case covering the door glass.
2. Building 28, Ward F-7, Room 4 through 10, observed to have excessive amounts of paper materials applied to the outside of the doors.
The above was discussed and acknowledged by the maintenance staff.

This requirement is not met as evidenced by:

Based upon observations and staff interviews on March 3-4, 2015, Western State Hospital has failed to have the emergency generator meet the requirements of the Fire Safety Code. This could result in conditions that would result in the failure of the emergency generator which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
1. The facility has failed to install remote shut off switches for emergency power generators.

The above was discussed and acknowledged by the maintenance staff.

This requirement is not met as evidenced by:

Based upon observations and staff interviews on March 3-4, 2015, Western State Hospital has failed to restrict the use of multi-plug outlets (power strips) or provide for proper electrical protection near electrical panels. This could endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
1. Building 21, S-10 Room 530, non hospital grade power strip observed in use.
2. Building 21, S-8, Room 330, non hospital grade power strip in use and also not secured to equipment.
3. Building 21, S-7 Room 227 daisy chained power strip. Non hospital grade.
4. Building 21, S-8 Room 321, missing electrical panel address for circuits.
5. Building 21, S-8 Room 321 and other electrical panels without the required working space.
6. The fire damper switch located by room C8 221 in Building 17 was observed to be broken.
7. The following electrical panels were observed have storage within the required clearances:
1. Building 17 C8 245 Janitor closet.
2. Building 17 C7 145 Janitor closet.




The above was discussed and acknowledged by the maintenance staff.

This requirement is not met as evidenced by:

Based upon record review and staff interviews on March 3-4, 2015, Western State Hospital has failed to have a written procedure for instituting as approved fire watch in the event of a failure of the fire sprinkler system. This could result in an inadequate fire watch which may result in a delay of fire detection and suppression, endangering residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
1. During document review, a request for fire watch policy was made and the facility was unable to provide the requested document.
The above was discussed and acknowledged by the maintenance staff.

This requirement is not met as evidenced by:

Based upon record review and staff interviews on March 3-4, 2015, Western State Hospital has failed to have a written procedure for instituting as approved fire watch in the event of a failure of the fire alarm system. This could result in an inadequate fire watch which may result in a delay of fire detection and suppression, potentially endangering residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
1. Document review indicated Building 29, failure of the duct smoke detector system since October 2014. No fire watch policy was available upon request.
The above was discussed and acknowledged by maintenance staff.