HospitalInspections.org

Based on observations and staff interview, it was determined the facility was a two-story building with basement composed of unprotected non-combustible construction. The facility failed to assure minimum building construction requirements were maintained by ensuring that holes and gaps around penetrations are sealed with fire rated materials to limit the transfer of smoke. The facility has a capacity of 25 and at the time of the survey the census was 15.

Findings include:

Observations and staff interview on 10/19/11 at 11:56 a.m., revealed the following
penetrations:

1) There was a penetration, (approximately 1 inch by 3 inches), around
communications cables extending through the north wall of the 1st Floor
Server Room by Outpatient Registration.

2) There was a penetration, (approximately 3/4 inch), around communications
cables extending through the north wall of the 1st Floor Server Room.

3) There was an open pipe penetration, (approximately 1 inch), extending through
the north wall of the 1st Floor Server Room.

Maintenance Staff A verified observations during the survey process.

Based on observations and staff interview, the facility failed to maintain two smoke barriers in accordance with National Fire Protection Association (NFPA) Standard 101, 2000 edition, 19.3.7.3. Smoke barriers shall be continuous from outside wall to outside wall and from floor to a roof extending through all concealed spaces. Smoke barriers shall have a fire resistance rating of not less than 1/2 hour. This deficient practice affects 15 out of 25 patients. This facility has a capacity of 25 and a census of 15.

Findings include:

1) Observation and staff interview on 10/19/11 at 11:42 a.m., revealed a penetration,
(approximately 4 inches by 5 inches), around a wire chase extending through the
smoke barrier wall by Room 15W.

2) Observation and staff interview on 10/19/11 at 12:30 p.m., revealed a
penetration, (approximately 1 inch), around pipes and communications cables
extending through the smoke barrier wall by the Kitchen.

Maintenance Staff A verified observations during the survey process.

(A)
Based on observation and staff interview, the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, 1999 edition, 5-5.3.2.1.6.2 by ensuring when the automatic dialer panel when placed in trouble from phone line failure, a trouble signal was sent to a location that is monitored 24 hours a day. This deficient practice affects all occupants of the facility. The facility has a capacity of 25 and at the time of the survey had a census of 15.

Findings include:

Observation on 10/19/11 at 2:06 p.m., revealed that a trouble signal was not sent to a location that is monitored 24 hours a day upon loss of a phone line to the automatic dialer. The Clarke County Sheriff's Office monitors the fire alarm system for the facility and also did not receive a loss of phone line trouble signal. Maintenance Staff A verified observations during the survey process.


(B)
Based on record review and staff interview, the facility failed to inspect and test the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, 1999 edition, Chapter 7. The fire alarm system shall be inspected and tested at the frequencies established in Chapter 7. This deficient practice affects all occupants of the campus. The campus has 25 certified beds and at the time of the revisit the census was 15.

Findings include:

Record review and staff interview on 2:14 p.m., revealed the following:

1. The facility did not have documentation of a fire alarm system inspection for the year 2011.

2. The facility did not have documentation of smoke detector sensitivity testing.

Maintenance Staff A verified observations during the survey process.


(C)
Based on observation and staff interview, the facility failed to properly protect the primary power supply for the fire alarm system in accordance with the National Fire Protection Association (NFPA), Standard 72, 1999 edition, 1-5.2.5.2. This deficient practice affects all occupants of the building. This facility has a capacity of 25 and a census of 15 residents.

Findings include:

Observation and staff interview on 10/19/11 at 12:12 p.m., revealed that the circuit breaker supplying power to the fire alarm system is not mechanically protected. The circuit breaker is labeled breaker #42 in Electrical Panel LP2, located in the same room as the main fire alarm panel. Maintenance Staff A verified observations during the survey process.

Based on observations and interview, this facility is not assuring that the fire alarm system is installed and maintained in accordance with National Fire Protection Association (NFPA) 72, 2-3.5, which requires that smoke detectors are not placed within direct airflow, nor closer that three feet to air supply or air return. Installation of a smoke detector close to a air supply or air return can impede the operation of the smoke detector. This facility has a capacity of 26 and a census of 15 residents.

Findings include:

Observations and interview with facility staff on 10/19/11 from 9:00 a.m. to 2:30 p.m., revealed the following locations where smoke detectors were located within three feet of an air supply or air return.

1) There was a smoke detector within approximately 15 inches of an air supply or
return in the 2nd Floor East Wing Supply Closet.

2) There was a smoke detector within approximately 12 inches of an air supply or
return in Room 4A East, located in the 2nd Floor East Wing.

3) There was a smoke detector within approximately 12 inches of an air supply or
return in Room 7 East, located in the 2nd Floor East Wing.

4) There was a smoke detector within approximately 12 inches of an air supply or
return in Room 5 East, located in the 2nd Floor East Wing.

5) There was a smoke detector within approximately 12 inches of an air supply or
return in the corridor outside Room 5 East, located in the 2nd Floor East Wing.

6) There was a smoke detector within approximately 12 inches of a an air supply or
return in the Soiled Work Room by Surgery.

Maintenance Staff A verified observations during the survey process.

Based on record review, observations and staff interview, the facility failed to maintain a complete automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 25, 1998 edition, by ensuring that the sprinkler system is maintained in working condition and all sprinkler heads are free of foreign material. This deficient practice affects all occupants of the building. The facility has 25 certified beds and at the time of the survey the census was 15.

Findings include,

1) Observation and staff interview on 10/19/11 at 12:36 p.m., revealed paint on a
sprinkler head located in Room E114 near the Kitchen.

2) Observation and staff interview on 10/19/11 at 12:48 p.m., revealed an
escutcheon that was not flush with the ceiling in the Conference Room of the
Old Outpatient Clinic.

3) Record review and staff interview on 10/19/11 at 12:40 p.m., revealed that the
weekly flow test of the fire pump was not conducted for two out of four weeks
in August of 2011.

Maintenance Staff A verified record review and observations during the survey process.

Based on record review and staff interview, the facility failed to maintain portable fire extinguishers in accordance with National Fire Protection Association (NFPA) Standard 10, Standard for Portable Fire Extinguishers, 1998 edition, by ensuring that all fire extinguishers are inspected monthly by facility staff. The facility has 25 licensed beds and at the time of the survey the census was 15.

Findings include:

Record review and staff interview on 10/19/11 at 10:55 a.m., revealed that the monthly inspection for September 2011 was not documented on the tag of the fire extinguisher in the Maintenance Office. Maintenance Staff A verified record review during the survey process.

Based on observations and staff interview, the facility failed to maintain the buildings electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition. The deficient practice affects all occupants of the facility. This facility has a capacity of 25 and a census of 15 residents.

Findings include:

1) Observation and staff interview on 10/19/11 at 11:18 a.m., revealed that the
facility failed to label all circuit breakers in Electrical Panel L3PH located in the
Old Penthouse.

2) Observation and staff interview on 10/19/11 at 12:22 p.m., revealed that the
facility failed to label all circuit breakers in the electrical panel located in the
Kitchen Storage Room.

3) Observation and staff interview on 10/19/11 at 12:44, revealed an open
electrical junction box on the north wall of the Boiler Room by the north exit
door.

Maintenance Staff A confirmed observations during the survey process.