HospitalInspections.org

Based on observation and staff interview, the facility failed to ensure access to exits were marked by approved, readily visible signs in all cases where the exit or way to reach exit was not readily apparent to the occupants. Doors, passages or stairways that were not a way of exit that were likely to be mistaken for an exit have a sign designating "No Exit". The facility had a census of 23 patients at the time of survey. Potentially all patients, staff and visitors could be affected.

Findings include:

Tour of the facility was conducted on 07/25/16 between 2:00 P.M. and 4:15 P.M. with Staff H, Staff I and Staff T. Observation of the facility revealed two exit passageway stairwells (M1 and M2) at each end of the facility. Following stairwell M2 to the first floor of the host facility, revealed the stairwell continued to a lower level. A lighted exit sign at the first floor stairwell landing pointed to a door which lead to the exit passageway and the discharge to the public way. Interview of Staff H revealed the M2 stairwell was heavily used by host facility staff /visitors thus it was not feasible to gate the stairwell as a "no exit". Additionally, Staff H indicated there was an exit passageway at the lower level of the host facilty but the primary means of egress was located on the first floor.

On 07/26/16, at 2:35 P.M., observation continued with Staff H and I of the M2 stairwell to the lower level of the host facilty. Discharge of the stairwell was located near an elevator lobby with no visible signage to direct the way out from that point. The finding was confirmed by Staff H and I. Staff I stated exit signage to direct the way out would be installed and was observed to be in place on the lower level of Stairwell M2 discharge by 07/27/16.

Based on review of facility schematics, facility tour and staff interview, the facility failed to ensure that smoke barriers were constructed to provide at least a one half hour fire resistance rating and constructed in accordance with 8.3. The facility had a census of 23 patients at the time of survey. Potentially all patients, staff and visitors could be affected.

Findings include:

Tour of the facility was conducted on 07/25/16 between 2:00 P.M. and 4:15 P.M. with Staff H, Staff I and Staff T. Review of the facility schematic revealed a smoke barrier wall which separated the facility into two smoke compartments. Observation of the doors located within the smoke barrier wall revealed the double corridor doors were held open on devices which released upon activation of the fire alarm system.

Testing of the smoke barrier doors for proper closure and smoke resistant function was conducted by manual release from the magnetic hold-open devices. The south door failed to close and align with the north door by two to three inches. Staff present on tour confirmed the observation.

On 07/28/16 at the exit conference, additional information was provided by Staff H which was documentation of preventative maintenance testing of the smoke doors conducted on 10/15/15. The doors were noted to pass at that time.

Based on observation and staff interview, the facility failed to ensure that when an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protected hazardous areas, the area was separated from other spaces by smoke resisting partitions and doors. The facility had a census of 23 patients at the time of survey. Potentially all patients, staff and visitors could be affected.

Findings include:

Tour of the facility was conducted on 07/25/16 between 2:00 P.M. and 4:15 P.M. with Staff H, Staff I and Staff T. Review of the facilty schematic revealed a hazardous area (biohazards room) located near the elevator lobby of the facilty. Observation of the hazardous area revealed a small room where soiled mattresses and trash were stored in large containers. The biohazards room was protected with an automatic sprinkler system.

Observation of the ceiling tiles revealed at least two ceiling tiles with broken corners and pieces of the tiles were missing. Additional tiles were noted to fit poorly in the metal grids designed to hold tiles in place. Staff present on tour confirmed that intact ceiling tiles were to act as a smoke resistant barrier since the room was protected with a sprinkler system. Staff T confirmed the broken and poorly fitted ceiling tiles did not provide a smoke resistant barrier.

Based on review of facilty policy and procedure, review of facility fire drill documentation, staff interview and facility tour, the facility failed to ensure that fire drills included the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills were to be held at unexpected times under varying conditions, at least quarterly on each shift. The staff was to be familiar with procedures. The facility had a census of 23 patients at the time of survey. Potentially all patients, staff and visitors could be affected.

Findings include:

On 07/25/16, during the entrance conference the facility was asked to provide fire drills conducted in the past 12 months. The facility staff were noted to work 12 hour shifts.

Review of the documented fire drills on 07/25/16 revealed the location of the "fire incident" for the majority of the drills occurred on other floors and areas of the host facilty. The fire response form, question two, asked if the alarm was pulled (simulated) A box was to be marked yes or no in response to the question.

Interview on 07/26/16 at 8:35 A.M., of Staff G, the safety officer, revealed that when fire alarms sounded in the host facilty they were also heard on the sixth floor location of the long term acute care (LTAC) hospital. Staff G indicated that staff response to the fire alarm was to be evaluated and documented as a fire drill or event if the alarm was activated by a smoke detector. Staff G confirmed that no fire alarm pull station was activated on the sixth floor LTAC location as part of a fire drill procedure. Staff G confirmed that when the host activated the fire alarm then he/she documented it for use as fire drill training.

During tour of the facility on 07/25/16 between 2:00 P.M. and 4:15 P.M. with Staff H, Staff I and Staff T, a patient evacuation chair for evacuation down steps was observed in the main elevator lobby area of the facility. Staff G was interviewed regarding the use of the evacuation chair. Staff G stated that staff were curious about the chair and had asked for training on use of the chair but that none had been provided.

Further interview of Staff G regarding fire procedures and evacuation procedures for the facility revealed that doors within the corridor were not to be obstructed. Staff G did not identify the facility was divided into two smoke compartments and that horizontal evacuation was first before vertical evacuation to a lower floor in accordance with the facility fire plan, page two.

On 07/27/16 between 9:22 A.M. and 9:41 A.M., Staff B, C, J and K were interviewed regarding the facility fire safety plan. None of the staff interviewed noted the facility was divided into two smoke compartments and that horizontal evacuation was to be done prior to vertical evacuation if needed. Four of four staff confirmed they were aware of the evacuation chair for patients but had not received any information regarding it's use.

Review of the facilty fire plan noted that every employee must be familiar with the departmental responsibilities and fire plan which included evacuation routes.

On 07/28/16 at 9:45 A.M. interveiw of Staff G, H, I, C and F revealed the host facilty had trained emergency response staff who were specifically trained on the use of the patient evacuation chair. The host facility emergency response team would assist the facilty with any vertical evacuation if needed. The facility staff were not expected to use the patient evacuation chair but could be educated on the use of the chair. Facility staff also confirmed that further education regarding horizontal evacuation into another smoke compartment was needed. Additionally it was confirmed the facility was not conducting it's own fire drills by activation of the fire alarm and relied on the host facilty to activate the fire alarm for that purpose.

Based on observation and staff interview, the facility failed to ensure medical gas storage areas were identified with a precautionary sign in accordance with 8-3.1.11.3 of the code. The facility had a census of 23 patients at the time of survey. Potentially all patients, staff and visitors could be affected.

Findings include:

1) Tour of the facility was conducted on 07/25/16 with Staff H, Staff I and Staff T. At 3:30 PM the facility's Materials Management room was inspected. The facility schematic identified the room as a hazardous area.

The room was observed to contain 13 E size oxygen tanks, 12 in a storage rack and one (1) attached to a piece of respiratory equipment. At least four (4) additional E size oxygen tanks were observed in a fire rated storage cabinet. Observation outside the storage room revealed there was no posted cautionary sign to indicate the room contained medical gases. Staff H, Staff I and Staff T confirmed this finding at the time of discovery. Observation of the materials management room again on 07/28/16 at 11:35 A.M. revealed no cautionary sign to warn of medical gas storage within the room.