HospitalInspections.org

Based upon observations and staff interviews on May 8-15, 2017 between approximately 0800 and 1700 hours the facility 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:


S3-MedRoom - 5 inch round penetration in the ceiling

In building 28 across from activity center next to stairwell nine there is a 36" x 36" hole in sheet rock.


The above was discussed and acknowledged by the facility staff.

Based upon observations and staff interviews on May 8-15, 2017 between approximately 0800 and 1700 hours the facility has failed to maintain the exit discharge free of obstructions. This could cause an inability or delay in the evacuation of residents in the event of an emergency which would endanger residents, staff and/or visitors.

The findings include, but are not limited to:

Stairwell six and 9 have three locks all keyed differently to get out of building, at the time of the survey staff were unable to access all three keys to unlock the doors. This deficiency was corrected at time of survey.

Ground floor building 28 Corridor exit stairwell discharged to a courtyard with a locked gate, at the time of survey no staff had the key to unlock this gate.

The exit out of E2 and E1 goes into a gate that no one in the two wards have keys to.


THE ABOVE CITATIONS RESULTED IN AN IMMEDIATE JEOPARDY.

The above was discussed and acknowledged by the facility staff.

Based upon observations and staff interviews on May 8-15, 2017 between approximately 0800 and 1700 hours the facility has failed to maintain proper exit signage. This could potentially misdirect residents, staff and/or visitors during an emergency.

The findings include, but are not limited to:

C2 above fire separation doors by med room, exit sign has no illumination.

The above was discussed and acknowledged by the facility staff.

Based upon observations and staff interviews on May 8-15 between approximately 0800 and 1700 hours the facility has failed to maintain vertical openings between floors with a construction having a fire resistive rating of at least one hour. This could result in the passage of toxic products of combustion from one floor to another which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

The elevator lobby door in building C-9failed to close and latch.



The above was discussed and acknowledged by the facility maintenance staff.

Based upon observations and staff interviews on May 8, 15, 2017 between approximately 0800 and 1700 hours the facility has failed to maintain doors to hazardous areas as self or automatic closing. This could result in the spreading of the toxic products of combustion into the corridor in the event of a fire which would endanger residents, staff and/or visitors.

The findings include, but are not limited to:


Laundry chute in room a 019 laundry bags holding fire door open

The 1.5 hour fire door to the generator room is missing the key cylinder.

The above was discussed and acknowledged by the facility staff.

Based upon record review and staff interviews on May 8-15, 2017 between approximately 0800 and 1700 hours the facility has failed to conduct testing of the hood and duct fire suppression equipment protecting the commercial cooking equipment in the kitchen. This could result in the failure of the system to operate properly which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

ANSUL
The ANSUL system in Central Forensic treatment mall was last serviced in 2002.

There is no documentation of the range hood suppression system inspections.

The above was discussed and acknowledged by the facility staff.

Based upon observations and staff interviews on May 8-15, 2017 between approximately 0800 and 1700 hours the facility has failed to properly install alcohol based hand rub dispensers. Dispensers installed improperly could result in hand rub coming in contact with an electrical source resulting in a fire causing potential endanger to residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

S5-512 - Hand sanitizer over the light switch

E7 medication room hand sanitizer mounted over light switch

Exam room in E5 ABHR is directly above a power outlet.

C5-med room over light switch

The above was discussed and acknowledged by the facility staff.

Based upon record review and staff interviews on May 8-15, 2017 between approximately 0800 and 1700 hours the facility has failed to have appropriate testing of the fire alarm system which result in the failure of notification to staff of a problem to the fire sprinkler system or fire alarm system and could endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

The facility is unable to provide sensitivity testing showing pass/fail for building 21, 29

The fire alarm in building 27/28 was showing that it was in trouble since 4/29/17 on 5/15/2017


The person's responsible for conducting the tests were unable to articulate the standards from NFPA 72 and NFPA 25 for which to test the systems.

THE ABOVE CITATION RESULTED IN AN IMMEDIATE JEOPARDY.


The above was discussed and acknowledged by the facility staff.

Based upon record review and staff interviews on May 8-15, 2017 between approximately 0800 and 1700 hours the facility has failed to provide an approved written policy for instituting a 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 facility is not following their fire watch policies. Per interview with the lead project manager they agreed that one of the steps (3B) is to notify the Office of the State Fire Marshal. They agreed that they have not been doing this.

Per interview, the facility is taking the fire alarm system off line for 8+ hours and not doing a fire watch.

The above was discussed and acknowledged by the facility staff.

Based upon observations and staff interviews on May 8-15, 2017 between approximately 0800 and 1700 hours the facility has failed to install 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 and allow the fire to increase in size and intensity which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

There was no sprinkler coverage in the daylight basement loading dock.

In building E-5 the sprinkler heads in the dinning room are with in two feet of each other causing a possible cold solder situation.

Central Forensic Services Dining services area (currently being used as a staff break room) in the treatment mall building 28 has an area that used to be a kitchen (now the break room). The pantry (small room in staff break room that holds food stuffs and dry goods) does not have sprinkler protection.

The above was discussed and acknowledged by the facility staff.

Based upon observations and staff interviews on May 8-15, 2017 between approximately 0800 and 1700 hours the facility failed to maintain 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 and allow the fire to increase in size and intensity which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

SPRINKLER HEAD DAMAGE/PAINTED
E5 room 151 sprinkler head needs replaced pushed up in the ceiling

E2 Sally-Port head painted
E2 A233, A234 heads damaged
E2 A232, A230 heads painted
E4 233 head missing fins
E4 240 fins bent
E4 250 head bent and pushed into wall
E4 shower room (possible recalled heads, the facility shall verify.)
E4 by room 224 sprinkler head painted
E4 by room 258 head pushed into ceiling
Sprinkler head in staff cleaning supply room C3-338 missing fins.

SPARE SPRINKLER HEADS MISSING

Building 28 sprinkler head box missing heads
Building 29 sprinkler head box missing heads
E4 263 sprinkler valve room, no spare heads
The facility was only able to show 4 sprinkler heads in boxes for buildings 27 and 28.

OBSTRUCTIONS

Sprinkler obstructed by wardrobe in room C-3 329.
Sprinkler head obstructed by wardrobe in room C-2 227.


ESCUTCHEON RINGS

E5 116 falling down
E7 111 falling down
E7 146 missing
E4 nurses station missing escutcheon rings
E4 by room 258 missing escutcheon ring
E4 by room 248 has hole around escutcheon ring


INTERNAL PIPE INSPECTIONS
The facility was unable to provide documentation for the following buildings: 15, 10, 16, 17, 18, 19, 20, 28, 29, 9, 26, 21
Building 28 dry system into E6 and E8 has a lot of corrosion per the report

ANNUAL INSPECTIONS

The facility was unable to provide any annual sprinkler inspection for any buildings.

THE ABOVE CITATION RESULTED IN AN IMMEDIATE JEOPARDY

BACKFLOW INSPECTIONS

The facility was unable to provide any backflow reports for any buildings.

The above was discussed and acknowledged by the facility staff.

Based upon record review and staff interviews on May 8-15, 2017 between approximately 0800 and 1700 hours the facility has failed to have an approved written policy for instituting as approved fire watch in the event of a failure of the sprinkler 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 facility is not following their fire watch policies. Per interviews with the lead project manager they agreed that one of the steps (3B) is to notify the Office of the State Fire Marshal. They agreed that they have not been doing this.

The above was discussed and acknowledged by the facility staff.

Based upon record review and observation on May 8-15, 2017 between approximately 0800 and 1700 hours the facility has failed to assure proper maintenance of the facilities portable fire extinguishers. This potentially delays a quick response to contain a fire from spreading which could expose and endanger residents, staff and/or visitors within the facility.

The findings include, but are not limited to:


F building fire extinguishers are over 75 for travel to each in Corridor's.

Nurses station in F4 extinguisher box won't open.

Staff members asked to unlock the fire extinguisher cabinets at the time of the survey were unable to unlock the cabinets due to not having the appropriate key.

In building E-7 the fire extinguisher #2951 in room 105 has not been inspected, initialed, and dated on a monthly basis.

The smoking area in the courtyard of building 28/29 there was a fire extinguisher that had an expired inspection tag dated 8/2015.

In Central Forensic Services the fire extinguisher by dietary services has an expired inspection tag dated 8/2015.

The Fire Extinguisher in Central Forensic Services treatment mall by motor control room is mounted approximately 6.5 feet from the floor.

The fire extinguishers in building 28/29 have no initials and date for the monthly inspections.

The fire extinguisher in building F-5 Room M -198 is missing the initials and dates for the monthly inspection.

In building C-5 staff were unable to open fire extinguisher cabinet in in room C5-220.


THE ABOVE CITATION RESULTED IN AN IMMEDIATE JEOPARDY.

The above was discussed and acknowledged by the facility staff.

Based upon observations and staff interviews on May 8-15 between approximately 0800 and 1700 hours the facility has failed to maintain doors on the corridor capable of resisting the passage of smoke. 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 shower room door that opens to the corridor in F-1 has through penetrations in the door.

The above was discussed and acknowledged by the facility maintenance staff.


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Based upon observations and staff interviews on May 8-15, 2017 between approximately 0800 and 1700 hours the facility 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:

S8-dayroom - door to the corridor not closing and latching
S8-365 - door to the corridor not closing and latching
S9-dayroom - door to the corridor not closing and latching

Corridor door B139b not latching

Building 28 sprinkler riser room fire door not closing

The fire door to the dishwasher room in Central Forensic Treatment Mall was wedged open.

The fire doors between F-3 and F-7 do not close when released from the open position due to dragging on the carpet.

ROLLDOWN FIRE CURTAINS
Buildings 13, 16, 17, 18, 20, 21, 27, 28, 29 have only had visual inspections of fusible links and have not been replaced per NFPA 80.

The following doors are not closing and latching:

Door to C9-364
Door to laundry C9-346
Door to dirty utility C9-341


The above was discussed and acknowledged by the facility staff.

Based upon observations and staff interviews on May 8-15, 2017 between approximately 0800 and 1700 hours the facility has failed to maintain smoke barrier walls to the required one hour fire resistive rating. This could result in the passage of smoke from one smoke compartment into another smoke compartment thereby exposing residents, staff and/or visitors to the toxic products of combustion.

The findings include, but are not limited to:

In S7-230 there is a penetration to the smoke barrier wall above the cross corridor smoke doors.


The above was discussed and acknowledged by the facility maintenance staff.

Based upon observations and staff interviews on May 8-15, 2017 between approximately 0800 and 1700 hours the facility has failed to maintain the fire separation doors in the building. This could result in the passage of smoke from one smoke compartment into another smoke compartment thereby exposing residents, staff and/or visitors to the toxic products of combustion.

The findings include, but are not limited to:

The cross corridor fire doors between building 28-29 have holes in doors, are missing hinge plates, and have holes in frame.

The 1.5 hour fire door to the generator room is missing the locking hardware causing a through penetration in the door.

In building 27 Ward E7 cross corridor fire separation doors next to Clinic had one half of the assemblie removed and replaced with a wood frame wall with sheetrock.

SMOKE SEALS

All doors in E6

NOT LATCHING

C5-236

Door to shower room drags on the floor C1

The above was discussed and acknowledged by the facility staff.

Based upon observations and staff interviews on May 8-15, 2017 between approximately 0800 and 1700 hours the facility has failed to properly maintain their elevators.

The findings include, but are not limited to:

The elevators are not checked for their monthly fire recalls

The above was discussed and acknowledged by the facility staff.

Based upon record review and staff interviews on May 8-15, 2017 between approximately 0800 and 1700 hours the facility has failed to provide fire drill records reflecting drills being conducted on all shifts for the past 12 months. This could potentially result in the staff not responding in a coordinated manner in the event of a fire or other emergency and endangering residents, staff and/or visitors.
The findings include, but are not limited to:
FIRE DRILLS
The facility is pre-announcing fire drills per documentation.
The fire drills took anywhere from 20 minutes to 5.5 hours which is not prompt and effective placing the staff and residents in possible harm.
The inspectors walked into building 28/29 and the fire alarm activated due to construction in the building, the inspectors observed staff failed to respond, no doors were closed.

THE ABOVE CITATION RESULTED IN AN IMMEDIATE JEOPARDY.

The above was discussed and acknowledged by the facility staff.

Based upon record review and staff interviews on May 8-15, 2017 between approximately 0800 and 1700 hours the facility has has failed to provide the required equipment at the designated 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:

The patients are not being security wanded per facility policy after returning from smoking in building 27/28. This was observed on 5/15/2017. The facility stated in a previous POC that they would do this after a patient started a room on fire with a lighter that they smuggled into the facility.

The above was discussed and acknowledged by the facility staff.

Based upon record review and staff interviews on May 8-15, 2017 between approximately 0800 and 1700 hours the facility has failed to prohibit the use of portable electric heaters within the facility. This could result in a fire due to the ignition of combustible materials that would place residents, staff and/or visitors in danger.

The findings include, but are not limited to:

Room F270 heater plugged into extension cord (fixed the time inspection.)

Room F270 heater with no tip over device fixed at time of inspection

The Doctor office by E4 has an unapproved space heater.

The above was discussed and acknowledged by the facility staff.

Based upon record review and staff interviews on May 8-15, 2017 between approximately 0800 and 1700 hours the facility has failed to have a written risk assessment.

The findings include, but are not limited to:

The facility was unable to provide a risk assessment.

The above was discussed and acknowledged by the facility staff.

Based upon record review and staff interviews on May 8-15, 2017 between approximately 0800 and 1700 hours the facility has failed to have annual testing and maintenance conducted on the emergency generator. This could result in a failure of the emergency power system which would leave the facility without egress and work lighting in the event of a power failure which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

GENERATOR
Per the generator inspections the following have not been fixed:
Gen 1 3/9/17 block heater lacking coolant. Missing weekly inspections for September 2016.
Gen 2 4/4/17 radiator needs coolant. Missing weekly May-September.
Gen4 4/4/17 Engine has an oil leak on the right side, coolant leak on the left side. Missing weekly inspections May, July-September.
Gen5 Oil leak right side, coolant leak right side. Manifold lead left side missing weekly inspections for May 2016.


The above was discussed and acknowledged by the facility staff.

Based upon observations and staff interviews on May 8-15, 2017 between approximately 0800 and 1700 hours the facility has failed to restrict the use of multi-plug outlets (power strips) and extension cords to providing power to permitted electrical equipment. This could result in a fire from overheating of the plug strip due to the heavy power draw endangering the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

EXTENSION CORDS

Extension cord and use building F6 room E-272.
Extension cord and use building F 2 room F211 (fixed at the time of inspection.)
Extension cord plugged in to power strip with fridge raider plugged into power strip room F260 (fixed at the time of inspection.)
Room F270 heater plugged into extension cord fixed at time of inspection nurses station building at five power strips daisy chained (fixed at the time of inspection.)

Room E101 extension cord and use IT room.
E6 staff area has an extension cord plugging a microwave.


Room C167 extension cord plugged in the power strip with coffee maker plug-in it (fixed at the time of inspection.)
Extension cord in use C9-306 (fixed at time of inspection.)


POWERSTRIPS

S3-throughout - power strips in multiple patient rooms.
S-060 coffee pot plugged into the power strip.

Room F256 coffee maker plugged into power strip (fixed at the time of inspection.)

Room E168 microwave fridge raider coffee maker plugged in the power strip
E2 exam room has medical equipment plugged into a powerstrip that is not 1363A.
Building E7 power strip in exam room needs to be hospital grade.

D001 power strips daisy chained times three (fixed at the time of inspection.)
Room D067 power strip daisy chained (fixed at the time of inspection.)
D011 fridge raider plugged into power strip.



The above was discussed and acknowledged by the facility staff.

Based upon observations and staff interviews on May 8-15 between approximately 0800 and 1700 hours the facility has failed to safely fix electrical issues. This could lead to staff, visitors, and patients being exposed to electrical fires and shocks.

The findings include, but are not limited to:


OPEN JUNCTION BOXES:

Building 27 Room 009 was missing a junction box.

The generator room in building 27/28 had an open junction box.

C2-234 open junction box. in interstitial space above ceiling

C5 has an open junction box. interstitial space by room 215 at smoke separation doors.


The above was discussed and acknowledged by the facility staff.