HospitalInspections.org

Based on observation by Deputy State Fire Marshal, the hospital failed to maintain construction requirements for the classification of construction.

Failure to maintain construction requirements risks spread of smoke and fire throughout the hospital.

Findings include:

During a tour of the hospital on 08/07 - 08/08/2012, the Deputy State Fire Marshal observed penetrations in the following locations:

a) Above ceiling tiles on the first floor waiting room by the vending machines
b) Around a duct system from the mechanical/electrical room on the first floor leading to the corridor behind Urgent Care
c) Above ceiling tiles on the 3rd floor by the elevators

These observed penetrations are documented by the Deputy State Fire Marshal as sealed and corrected by the end of the survey.

Based on observation and interviews conducted by Deputy State Fire Marshal, the hospital failed to maintain doors protecting corridor openings.

Failure to maintain doors protecting corridor openings risks spread of smoke and fire throughout the hospital.

Findings include:

During a tour of the hospital on 08/07 - 08/08/2012, the Deputy State Fire Marshal observed that fire doors did not close and latch in the following locations:

a) First floor doors to Bistro did not close and latch when activated
b) First floor fire doors to elevators #4 did not close and latch when activated
c) Third floor doors between reception and the great room did not close and latch

These observed penetrations are documented by the Deputy State Fire Marshal as adjusted and corrected by the end of the survey.

Based on document review conducted by Deputy State Fire Marshal, the hospital failed to maintain the automatic sprinkler system by failing to perform quarterly inspections.

Failure to perform required quarterly inspections of the automatic sprinkler system risks failure of the sprinkler system in the event of a fire.

Findings include:

During review of hospital automatic sprinkler documents on 08/07/2012, the Deputy State Fire Marshal found that documents revealed that quarterly automatic sprinkler inspections had not been performed since the 3rd quarter of 2011. There was no documentation of quarterly sprinkler inspections for the 4th quarter of 2011 or for the 1st or 2nd quarters of 2012.

The Deputy State Fire Marshal witnessed scheduling with the sprinkler inspection contractor for correction of this deficiency.

Based on observation by Deputy State Fire Marshal, the hospital failed to maintain pressurized gas storage in accordance with NFPA 99, 4-3.1.1.2.

Failure to maintain pressurized gas storage in accordance with the Code risks missile and explosive hazard exposures to patients, staff and visitors.

Findings include:

During a tour of the hospital on 08/07/2012, the Deputy State Fire Marshal observed that the kitchen staff had a pressurized carbon dioxide tank placed in the upright position without securing devices to prevent it from falling over.

The Deputy State Fire Marshal noted that the finding was corrected at the time of the observation.

Based on observation by Deputy State Fire Marshal, the hospital failed to maintain construction requirements for the classification of construction.

Failure to maintain construction requirements risks spread of smoke and fire throughout the hospital.

Findings include:

During a tour of the hospital on 08/07 - 08/08/2012, the Deputy State Fire Marshal observed penetrations in the following locations:

a) Above ceiling tiles on the first floor waiting room by the vending machines
b) Around a duct system from the mechanical/electrical room on the first floor leading to the corridor behind Urgent Care
c) Above ceiling tiles on the 3rd floor by the elevators

These observed penetrations are documented by the Deputy State Fire Marshal as sealed and corrected by the end of the survey.

Based on observation and interviews conducted by Deputy State Fire Marshal, the hospital failed to maintain doors protecting corridor openings.

Failure to maintain doors protecting corridor openings risks spread of smoke and fire throughout the hospital.

Findings include:

During a tour of the hospital on 08/07 - 08/08/2012, the Deputy State Fire Marshal observed that fire doors did not close and latch in the following locations:

a) First floor doors to Bistro did not close and latch when activated
b) First floor fire doors to elevators #4 did not close and latch when activated
c) Third floor doors between reception and the great room did not close and latch

These observed penetrations are documented by the Deputy State Fire Marshal as adjusted and corrected by the end of the survey.

Based on document review conducted by Deputy State Fire Marshal, the hospital failed to maintain the automatic sprinkler system by failing to perform quarterly inspections.

Failure to perform required quarterly inspections of the automatic sprinkler system risks failure of the sprinkler system in the event of a fire.

Findings include:

During review of hospital automatic sprinkler documents on 08/07/2012, the Deputy State Fire Marshal found that documents revealed that quarterly automatic sprinkler inspections had not been performed since the 3rd quarter of 2011. There was no documentation of quarterly sprinkler inspections for the 4th quarter of 2011 or for the 1st or 2nd quarters of 2012.

The Deputy State Fire Marshal witnessed scheduling with the sprinkler inspection contractor for correction of this deficiency.

Based on observation by Deputy State Fire Marshal, the hospital failed to maintain pressurized gas storage in accordance with NFPA 99, 4-3.1.1.2.

Failure to maintain pressurized gas storage in accordance with the Code risks missile and explosive hazard exposures to patients, staff and visitors.

Findings include:

During a tour of the hospital on 08/07/2012, the Deputy State Fire Marshal observed that the kitchen staff had a pressurized carbon dioxide tank placed in the upright position without securing devices to prevent it from falling over.

The Deputy State Fire Marshal noted that the finding was corrected at the time of the observation.