HospitalInspections.org

Based on observation, document review, and interview, the provider failed to provide egress doors as required at four of four cross-corridor exit door locations in building 3. Findings include:

1. Observation beginning at 9:45 a.m. on 8/15/23 revealed the cross-corridor doors from the hospital main building (building 3) to building 5 (clinic with the main entrance) were equipped with magnetic locks at the top of the ninety-minute fire-rated doors. The doors were marked as EXIT doors. Further observation revealed other cross-corridor doors with magnetic locks from building 3 to building 4, to the assisted living corridor, to the assisted living dietary area. A fifth set of magnet locks were in place for the cross-corridor doors from building 4 (wellness) to building 5 (clinic).

2. There was no documentation indicating the magnetically locked doors had been tested for function as being tied into the automatic sprinkler system or working as delayed egress magnetic locks. There was no required signage for delayed egress locks as required by NFPA 101 Section 7.2.1.6 at any of the door locations. There was no documentation of installation adherence to the Life Safety Code or installation approval by the authority having jurisdiction.

3. Interview with the environmental services director at the time of the above observation revealed the doors could have been locked by a button located at the nurse's station when a security threat was determined. Further interview with the administrator at 11:45 a.m. revealed the doors could have been unlocked with computer software by four or five people at the hospital. He stated the magnetic locks were installed approximately three years ago by the previous administrator.

Failure to provide egress doors as required increases the risk of death or injury due to fire.

The deficiency affected 100% of the building occupants.

Ref: 2012 NFPA 101 Section 19.2.2.2.4(3), 7.2.1.6.2(3)(a)

Based on observation, document review, and interview, the provider failed to provide egress doors as required at one of one cross-corridor exit door locations in building 4 (corridor connection to building 5). Findings include:

1. Observation beginning at 9:45 a.m. on 8/15/23 revealed the cross-corridor doors from the hospital wellness building (building 4) to building 3 (main hospital building) and building 5 (clinic with the main entrance) were equipped with magnetic locks at the top of the ninety-minute fire-rated doors. The doors were marked as EXIT doors.

2. There was no documentation indicating the magnetically locked doors had been tested for function as being tied into the automatic sprinkler system or working as delayed egress magnetic locks. There was no required signage for delayed egress locks as required by NFPA 101 Section 7.2.1.6 at any of the door locations. There was no documentation of installation adherence to the Life Safety Code or installation approval by the authority having jurisdiction.

3. Interview with the environmental services director at the time of the above observation revealed the doors could have been locked by a button located at the nurse's station when a security threat was determined. Further interview with the administrator at 11:45 a.m. revealed the doors could have been unlocked with computer software by four or five people at the hospital. He stated the magnetic locks were installed approximately three years ago by the previous administrator.

Failure to provide egress doors as required increases the risk of death or injury due to fire.

The deficiency affected 100% of the building occupants.

Ref: 2012 NFPA 101 Section 19.2.2.2.4(3), 7.2.1.6.2(3)(a)

Based on observation, document review, and interview, the provider failed to provide egress doors as required at two of two cross-corridor exit door locations in building 5 (corridor connection to buildings 3 and 4). Findings include:

1. Observation beginning at 9:45 a.m. on 8/15/23 revealed the cross-corridor doors from the hospital clinic building (building 5) to building 3 (main hospital building) and building 4 (wellness building) were equipped with magnetic locks at the top of the ninety-minute fire-rated doors. The doors were marked as EXIT doors.

2. There was no documentation indicating the magnetically locked doors had been tested for function as being tied into the automatic sprinkler system or working as delayed egress magnetic locks. There was no required signage for delayed egress locks as required by NFPA 101 Section 7.2.1.6 at any of the door locations. There was no documentation of installation adherence to the Life Safety Code or installation approval by the authority having jurisdiction.

3. Interview with the environmental services director at the time of the above observation revealed the doors could have been locked by a button located at the nurse's station when a security threat was determined. Further interview with the administrator at 11:45 a.m. revealed the doors could be unlocked with computer software by four or five people at the hospital. He stated the magnetic locks were installed approximately three years ago by the previous administrator.

Failure to provide egress doors as required increases the risk of death or injury due to fire.

The deficiency affected 100% of the building occupants.

Ref: 2012 NFPA 101 Section 19.2.2.2.4(3), 7.2.1.6.2(3)(a)

A. Based on record review and interview, the provider failed to continuously maintain automatic sprinklers in reliable operating condition (quarterly flow testing and 5-year obstruction inspection not done). Findings include:

1.a. Record review on 8/15/23 at 10:15 a.m. revealed no documentation the required quarterly flow tests had not been performed in 2020, 2021, 2022, and 2023. Quarterly flow testing and documentation is required by the National Fire Protection Association (NFPA) 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25 details all the required preventive maintenance for the NFPA 13 sprinkler system.
b. Record review on 8/15/23 at 10:20 a.m. revealed the 5-year internal obstruction inspection was last performed on 6/12/18. The inspection was two months overdue.

B. Based on record review and interview, the provider failed to maintain automatic sprinklers in reliable operating condition (valve signage). Findings include:

1. Record review on 8/15/23 at 10:20 a.m. of the annual automatic fire sprinkler system report dated 4/7/23 revealed the sprinkler riser was missing signage for two control valves and one test and drain valve.

Interview with the environmental services director at the time of the above record review confirmed those conditions.

A. Based on record review and interview, the provider failed to continuously maintain automatic sprinklers in reliable operating condition (quarterly flow testing and a 5-year obstruction inspection not completed). Findings include:

1.a. Record review on 8/15/23 at 10:15 a.m. revealed no documentation that the required quarterly flow tests had been performed in 2020, 2021, 2022, and 2023. Quarterly flow testing and documentation is required by the National Fire Protection Association (NFPA) 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25 details all the required preventive maintenance for the NFPA 13 sprinkler system.
b. Record review on 8/15/23 at 10:20 a.m. revealed the 5-year internal obstruction inspection was last performed on 6/12/18. The inspection was two months overdue.

B. Based on record review and interview, the provider failed to maintain automatic sprinklers in reliable operating condition (valve signage). Findings include:

1. Record review on 8/15/23 at 10:20 a.m. of the annual automatic fire sprinkler system report dated 4/7/23 revealed the sprinkler riser was missing signage for two control valves and one test and drain valve.

Interview with the environmental services director at the time of the record review confirmed those conditions.

Failure to continuously maintain the automatic sprinkler system as required increases the risk of death or injury due to fire.

The deficiency affected three of numerous required tests on the automatic sprinkler system.

A. Based on record review and interview, the provider failed to continuously maintain automatic sprinklers in reliable operating condition (quarterly flow testing and a 5-year obstruction inspection not completed). Findings include:

1.a. Record review on 8/15/23 at 10:15 a.m. revealed no documentation the required quarterly flow tests had not been performed in 2020, 2021, 2022, and 2023. Quarterly flow testing and documentation is required by the National Fire Protection Association (NFPA) 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25 details all the required preventive maintenance for the NFPA 13 sprinkler system.
b. Record review on 8/15/23 at 10:20 a.m. revealed the 5-year internal obstruction inspection was last performed on 6/12/18. The inspection was two months overdue.

B. Based on record review and interview, the provider failed to maintain automatic sprinklers in reliable operating condition (valve signage). Findings include:

1. Record review on 8/15/23 at 10:20 a.m. of the annual automatic fire sprinkler system report dated 4/7/23 revealed the sprinkler riser was missing signage for two control valves and one test and drain valve.

Interview with the environmental services director at the time of the record review confirmed those conditions.

Based on record review and interview, the provider failed to ensure staff were familiar with the provider's fire drill procedures (inadequate number of required fire drills and corresponding documentation). Findings include:

1. Record review on 8/15/23 at 10:05 a.m. revealed there was no documentation of fire drills other than 7/6/23 (2:57 p.m.), 6/29/23 (19:30), 5/23/23 (11:40 a.m.), 4/7/23 (11:00 a.m.), 11/8/22 (3:15 p.m.), 1/28/21, (3:15 p.m.), 9/4/20, and 8/26/20. The provider had two nursing shifts for the hospital.

Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions per NFPA 101, Life Safety Code Section 19.7.1.4. Fire drills may be conducted without disturbing patients by choosing the location of the simulated emergency in advance and by closing the doors to the patients' rooms or wards in the vicinity prior to initiation of the drill. The purpose of the fire drill was to test and evaluate the efficiency, knowledge, and response of institutional personnel in implementing the facility fire emergency plan. Fire drills should be scheduled on a random basis to ensure that personnel in health care facilities are drilled not less than once in each 3-month period.

2. Record review on 8/15/23 at 10:10 a.m. revealed there was no documentation of transmission of the fire alarm signal during fire drills on the fire drill form. That documentation was to include verification of the time of the reception of the fire alarm signal at the monitoring agency and the individual at that location who verified the signal reception.

Interview with the environmental services director at the time of the record review confirmed those findings. He stated the provider did not perform all of the required fire drills during the Covid-19 pandemic.

The deficiency had the potential to affect 100% of the occupants of the building.

Based on observation and interview, the provider failed to install a remote stop button for the generator. Findings include:

1. Observation on 8/15/23 at 11:00 a.m. revealed there was not an emergency stop button installed for the generator at a remote location. Interview with the environmental services director at the time of the observation revealed there was an emergency stop button inside the generator casing enclosure. He was unaware of the remote stop requirement for the generator.

The deficiency affected a single location required to be equipped with a remote emergency stop.