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Based on observation, the facility failed to provide free egress from all required exits by not using one of the approved methods listed in NFPA 101 by not providing a reliable means, available to the staff at all times, to unlock doors. This deficiency had the potential to effect 11 of 11. One of two exit discharge doors were deficient and one of two interior exit access cross corridor double doors were deficient.

Findings:

During the facility tour on May 18, 2021 between the hours of 9:15 a.m. to 1:00 p.m. the specialized care locking arrangement for the exit discharge doors and the interior access cross corridor double doors manual key override were either missing or not functioning. The specialized car locking arrangement doors were also lacking a manual overide key at each speialized care door location.

Louisiana State Fire Marshal Health Care Special Locking Memo 2019-02 dated March 30, 2019 states, "A means of manual mechanical unlocking must be provided at each door that is not in direct view of the remote release location. Doors must be keyed alike and be provided in accordance with ONE of the following conditions;
- The key must be carried by the staff responsible for patient evacuation whenever the locking system is operational and in use, or
- The key must be firmly affixed at the locked door location, so that it cannot be readily removed AND visual inspection shall be performed and recorded by the responsible nursing staff at appropriate periodic time intervals to insure that the key is in place and has not been removed, or - The key must be placed in a container equipped such that an audible alarm is provided at the locked door location, that can be heard or otherwise indicated at the remote release location, when opened for key removal/use, or
- The key must be placed in a glass container that must be broken for emergency access.
NOTE: Keypads, card readers, and other electrical devices are not acceptable as means of mechanically unlocking doors during emergency conditions.
B. "AUTOMATIC" RE-LOCKING, after remote release shall be PROHIBITED. A specific separate human action dedicated for re-locking doors is required and shall be permitted to occur at the remote control location or at each locked door location. Relocking shall be a distinctly separate action/operation and shall NOT be part of, or associated with, the releasing operation."

The interview with administrator and maintenance revealed the facility was not aware that one of the condition listed above is required in order to exit from the building.

Based on visual observation the facility failed to maintain the separation of hazardous areas from other parts of the building, including the egress corridor. Hazardous areas within a supervised sprinklered facility are required to be constructed to resist the passage of smoke and provide a door that self closes and self-latches properly. The deficient practice had the potential to affect 11 of 11 patients. There were two of three smoke compartments were separated from the hazardous areas.

Findings:

During the facility tour on May 18, 2021 between the hours of 9:15 a.m. to 1:00 p.m. the laundry room, supply room and the biohazard room interior access doors located near the nursing station were either not completely self closing or not self latching.

NFPA 101: 19.3.2.1 Hazardous Areas. Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.7.1.


NFPA 101: 19.3.2.1.1 An automatic extinguishing system, where used in hazardous areas, shall be permitted to be in accordance with 19.3.5.9.

NFPA 101:19.3.2.1.2* Where the sprinkler option of 19.3.2.1 is used, the areas shall be separated from other spaces by smoke partitions in accordance with Section 8.4.

NFPA 101: 19.3.2.1.3 The doors shall be self-closing or automatic-closing.

The interview with the Facilities Manager revealed the facility was not aware that the doors to the hazardous areas were required to self-close and self-latch in the frame.

The laundry room, supply room and the biohazard room interior access doors located near the nursing station were either not completely self closing or not self latching.

Based on visual observation and record review the facility failed to maintain documentation for fire drills conducted during each quarter on each shift. Fire drills provide training in procedures in cases of emergency. The deficient practice had the potential to affect 11 of 11 patients.. There were four of four quarters in 2020-2021 were deficient.

Findings:

During the record review on ay 18, 2021 between the hours of 9:15 a.m. to 1:00 p.m. the fire drill 6:00 p.m. to 6:00 a.m. shifts for the second quarter of the year 2020, the third quarter of the year 2020 and the first quarter of the year 2021 documentation was lacking. Additionally, the 6:00 a.m. to 6:00 p.m. fire drill shift was lacking for the fourth quarter of the year 2020.

NFPA 101:19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.

The interview with the administrator revealed the facility was not aware fire drills were not being held for each work shift of each quarter.

Based on record review, the facility failed to assure that a polarity, ground and retention resident / patient room electrical receptacle test had been conducted and documented. When the correct protocols are routinely completed by qualified personnel to the resident / patient electrical receptacle outlets chances of creating a unsafe electrical event or possible fire emergency are reduced or possibly eliminated. The deficient practice had the potential to affect 11 of 11 patients.

Findings:

During the record of review on May 18, 2021 between the hours of 9:15 a.m. to 1:00 p.m. the patient rooms had non-hospital grade electrical receptacles located throughout and lacked documentation for annual testing of polarity, ground and retention testing.

NFPA 99 6.3.3.2 Receptacle Testing in Patient Care Rooms 6.3.3.2.1
6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection.
6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified.
6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall not be less than 115 g (4oz.)
Section 3-3 Section 3-3.4.3.1 A record shall be maintained of the tests required by this chapter and associated repairs of modifications. At a minimum, this record shall contain date, the rooms or areas tested and an indication of which items have met or have failed to meet the performance requirements of the chapter.
6.3.4.1 Maintenance and Testing of Electrical System.
6.3.4.1.1 Where hospital-grade receptacles are required at patient bed locations and in locations where deep sedation or general anesthesia is administered, testing shall be performed after initial installation, replacement, or servicing of the device.
6.3.4.1.2 Additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data.
6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months.

The interview with the sdminsitrator revealed the facility was not aware that all documentation was not complete regarding the inspection/testing of the resident / patient electrical receptacles.