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Based on observation and interviews, the facility failed to properly maintain exit egress as per S&C letter 05-38. This deficiency practice affected one (1) of six (6) exits in the facility on day of survey.

Findings include:

On October 26, 2017 at 10:55 AM, observation revealed the exit egress near the Pharmacy lacked an all weather surface leading to the public way.

Based on observations, the facility failed to properly protect hazardous areas NFPA 101 section 19.3.2.1. This deficiency practice affected the entire facility on day of survey.

Findings include:

Observation during the building inspection on October 26, 2017 between 10:00 AM and 11:00 AM revealed the following hazardous areas lacked automatic door closers:

1) Clean Linen Room on the Acute Care Hall of the facility
2) Supply Room in Senior Care Unit of the facility
3) Storage Room near the Autoclave Room of the facility

Based on record review, the facility failed to properly insure the operability of the sprinkler system as required by NFPA 25 5.1.1.2. This deficiency practice affected the entire facility on day of survey.

Findings include:

On October 26, 2017 at 12:45 PM, the facility was unable to provide documentation of any quarterly inspections of the fire sprinkler system. The facility stated they were unaware of the requirement for quarterly inspections of the automatic fire sprinkler system.

Based on observation and testing, the facility failed to properly protect corridor openings as directed by NFPA 101 19.3.6.3.5. This deficiency practice affected the entire facility on day of survey.

Findings include:

On October 26, 2017 between 10:00 AM and 11:00 AM, observation revealed the corridor doors to the following rooms/ areas in the facility lacked positive latching hardware:

1. Soiled Utility/ Mop Closet
2. Autoclave Room
3. The top leaf of the Dutch door in the Pharmacy
4. Kitchen

Based on observation, the facility failed to properly protect corridor openings as directed by NFPA 101 19.3.6.4.1. This deficiency practice affected the entire facility on day of survey.

Findings include:

On October 26, 2017 at 11:17 AM, observation revealed air transfer grilles in the Clean Linen Room corridor door on the Acute Hall of the facility. The corridor door was incapable limiting the transfer of smoke throughout the facility.

Based on observations, the facility failed to properly maintain smoke barrier walls for the purpose of providing 1 half hour fire resistance as directed by NFPA 101 section 8.5.6. This deficiency affected all five (5) smoke compartments in the facility on the day of survey.

Findings Include:

On October 26, 2017 at 12:20 PM, observation revealed unsealed penetrations in all four (4) smoke barrier walls in the facility. The smoke barrier walls were located near the following areas of the facility:

1. Autoclave Room,
2. Administration Area
3. Pharmacy
4. Patient Room 112

Based on observations and testing, the facility failed to properly maintain door openings in smoke barrier walls as per NFPA 19.3.7.8. This deficiency practices affected two (2) of five (5) smoke compartments in the facility on day of facility.

Findings include:

On October 26, 2017, at 12:20 PM, observation revealed the smoke barrier doors in the Emergency Room and near the Autoclave Room were wedged open and were unable to resist passage of smoke throughout the facility.

Based on record review and interviews, the facility failed to properly perform fire drills as per NFPA 19 .7.1.2. This deficiency practice affected the entire facility on day of survey.


Findings include:

On October 26, 2017 at 12:50 PM, the fire drill documentation provided by the facility lacked following required information:

1. The time of the fire drill
2. The participants who conducted the fire drill
3. If the fire alarm system was activated during the fire drill,
4. The narrative of the events of the fire drill
5. The shift(s) on which the drill was performed.

Based on document review, the facility failed to properly inspect the emergency generator as per NFPA 110 8.4.1. This deficiency practice affected the entire facility on day of survey.

Findings include:

On October 26, 2017 at 12:55 the facility was unable to provide documentation weekly inspections and the annual certification inspection of the generator in the last year.

The facility stated they were unaware on the requirement of weekly inspections and could not find the documentation of the annual certification inspection of the generator.