HospitalInspections.org

Based on observation and interview, the facility failed to ensure hazardous area ' s construction is maintained.
The findings include:
1.Observation on 12/08/2015 at 8:52 AM, revealed the ceiling or the walls of the computer room /medical record room and the main medical records room was not smoke tight. (NFPA 101, 19.3.2.1)
2. Observation on 12/08/2015 at 9:56 AM, revealed penertration in the wall of the switch room. This finding was verified by the Maintenance Supervisor and acknowledged by the Administrator during the exit conference on 12/08/2015.

Based on observation the facility failed to maintain all emergency lights.

The findings included:

Observation on 12/08/2015 at 10:26 AM, revealed 2 of 2 emergency lights in the basement did not work when manually tested.



This finding was verified by the maintenance supervisor and acknowledge by the administrator during the exit conference on 12/08/15.

Based on observations the facility did not provide testing for all fire alarm system components. National Fire Protection Association (NFPA) 72, 7-5.

The findings included:

Observation on 12/08/15 at 9:02 AM, revealed that when after disconnecting phone line #1 from the fire alarm panel, the system never gave a trouble signal that the phone line had been disabled at the fire alarm annunciator at the nurse station.

This finding was verified by the maintenance supervisor during the exit conference on 12/08/15.

2-2 Inspection.
2-2.1 Sprinklers.
2-2.1.1*
Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.


Based on observation the facility failed to maintain all sprinkler heads.

The findings included:

1. Observation on 12/08/2015 starting at 9:06 AM, revealed the dark room, CT room, outside ultra sound, ambulance entrance, dietary above freezer, patients rooms 55, 56 has lint or corrosion build up.
2. Observation on 12/08/2015 at 8:31 AM, revealed a sprinkler deflector head in examine 1 was bent and needed replacing.


This finding was verified by the maintenance director during the tour and acknowledge by the administrator at the exit conference on 12/08/15.

Based on observation, the facility was using unapproved heaters.

The findings included:

Observation on 12/08/2015 at 8:54 AM, and 9:05 AM, revealed a space heater in these areas, director of medical records office and the pharmacy office.


These findings was verified by the maintenance director and acknowledged by the administrator during the exit conference on 12/08/15.

8.2.3.2.4.2*
Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows:
(1) The space between the penetrating item and the fire barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) * Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met:
a. The material shall be capable of maintaining the fire resistance of the fire barrier.
b. The material shall be protected by an approved device that is designed for the specific purpose.
(4) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the fire barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

This rule is not met evidence by:

Based on observation the facility failed to seal all penetrations in a fire barrier wall.

The findings included:

1. Observations on 12/08/2014 at 10:46 AM, revealed the 2 hr fire wall across from room 116 has penetrations around water pipes. The 2 hr fire wall across from the material management at the top of wall and the deck has used sheet rock mud to seal the gap and needs to be replaced with 2 hr rated caulk.
2. Observation on 12/08/2015 at 10:47 AM, the rated wall above the maintenance shop door has a penetration.


These findings were verified by the maintenance supervisor and acknowledged by the administrator during the exit conference on 12/08/2015

National Fire Protection Association (NFPA) 110, 5.3.1 (1999 edition)
The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.
Based on observation, the facility failed to provide battery-powered emergency lighting at the generator switch room.

The findings included:

Observation on 12/08/15 at 10:28 AM, revealed that no emergency lighting had been provided at the generator switch room.

These findings were verified by the maintenance supervisor and acknowledged by the administrator during the exit conference on 12/08/2015.

Based on observation, it was determined that the facility failed to maintain all electrical equipment.

The findings included:

Observation on 12/08/2015 at 9:58 AM, revealed electrical wires out of a electrical conduit was exposed and needed to be in junction box.


These findings were verified by the maintenance supervisor and acknowledged by the administrator during the exit conference on 12/08/2015.

Based on observation and interview, the facility failed to ensure hazardous area ' s construction is maintained.
The findings include:
1.Observation on 12/08/2015 at 8:52 AM, revealed the ceiling or the walls of the computer room /medical record room and the main medical records room was not smoke tight. (NFPA 101, 19.3.2.1)
2. Observation on 12/08/2015 at 9:56 AM, revealed penertration in the wall of the switch room. This finding was verified by the Maintenance Supervisor and acknowledged by the Administrator during the exit conference on 12/08/2015.

Based on observation the facility failed to maintain all emergency lights.

The findings included:

Observation on 12/08/2015 at 10:26 AM, revealed 2 of 2 emergency lights in the basement did not work when manually tested.



This finding was verified by the maintenance supervisor and acknowledge by the administrator during the exit conference on 12/08/15.

Based on observations the facility did not provide testing for all fire alarm system components. National Fire Protection Association (NFPA) 72, 7-5.

The findings included:

Observation on 12/08/15 at 9:02 AM, revealed that when after disconnecting phone line #1 from the fire alarm panel, the system never gave a trouble signal that the phone line had been disabled at the fire alarm annunciator at the nurse station.

This finding was verified by the maintenance supervisor during the exit conference on 12/08/15.

2-2 Inspection.
2-2.1 Sprinklers.
2-2.1.1*
Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.


Based on observation the facility failed to maintain all sprinkler heads.

The findings included:

1. Observation on 12/08/2015 starting at 9:06 AM, revealed the dark room, CT room, outside ultra sound, ambulance entrance, dietary above freezer, patients rooms 55, 56 has lint or corrosion build up.
2. Observation on 12/08/2015 at 8:31 AM, revealed a sprinkler deflector head in examine 1 was bent and needed replacing.


This finding was verified by the maintenance director during the tour and acknowledge by the administrator at the exit conference on 12/08/15.

Based on observation, the facility was using unapproved heaters.

The findings included:

Observation on 12/08/2015 at 8:54 AM, and 9:05 AM, revealed a space heater in these areas, director of medical records office and the pharmacy office.


These findings was verified by the maintenance director and acknowledged by the administrator during the exit conference on 12/08/15.

8.2.3.2.4.2*
Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows:
(1) The space between the penetrating item and the fire barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) * Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met:
a. The material shall be capable of maintaining the fire resistance of the fire barrier.
b. The material shall be protected by an approved device that is designed for the specific purpose.
(4) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the fire barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

This rule is not met evidence by:

Based on observation the facility failed to seal all penetrations in a fire barrier wall.

The findings included:

1. Observations on 12/08/2014 at 10:46 AM, revealed the 2 hr fire wall across from room 116 has penetrations around water pipes. The 2 hr fire wall across from the material management at the top of wall and the deck has used sheet rock mud to seal the gap and needs to be replaced with 2 hr rated caulk.
2. Observation on 12/08/2015 at 10:47 AM, the rated wall above the maintenance shop door has a penetration.


These findings were verified by the maintenance supervisor and acknowledged by the administrator during the exit conference on 12/08/2015

National Fire Protection Association (NFPA) 110, 5.3.1 (1999 edition)
The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.
Based on observation, the facility failed to provide battery-powered emergency lighting at the generator switch room.

The findings included:

Observation on 12/08/15 at 10:28 AM, revealed that no emergency lighting had been provided at the generator switch room.

These findings were verified by the maintenance supervisor and acknowledged by the administrator during the exit conference on 12/08/2015.

Based on observation, it was determined that the facility failed to maintain all electrical equipment.

The findings included:

Observation on 12/08/2015 at 9:58 AM, revealed electrical wires out of a electrical conduit was exposed and needed to be in junction box.


These findings were verified by the maintenance supervisor and acknowledged by the administrator during the exit conference on 12/08/2015.