HospitalInspections.org

Based on observations, the facility has failed to provide proper protection from 3 of several hazardous areas located throughout the facility in accordance with NFPA Life Safety Code 101 (2000 edition) section 19.3.2.1. This deficient practice could affect all patients, staff and visitors as smoke from a fire in this rooms could enter the corridor making it untenable.

Findings include:

1. On facility tour between 10:30 PM and 1:30 PM on 5/10/10, it was observed that the basement storage room had double doors were not fire rated and was not self-closing.


2. On facility tour between 10:30 PM and 1:30 PM on 5/10/10, it was observed that storage rooms 202 and the storage room across from room 102 were not self-closing and did not positively latch.

This was confirmed by the Maintenance Supervisor (PE).

Based on observations, the facility has failed to properly install a smoke detectors that are part of the buildings the fire alarm system. This deficient practice could affect the safety all patients, staff and visitors in the event the alarm system failed activate properly and quickly.

Findings include:

On facility tour between 10:30 AM and 1:30 PM on 5/10/10, observations reveled that the following smoke detectors were located within 36 inches of heating, ventilation and air conditioning (HVAC) supply diffuser,

1. Recovery Room
2. Cardiac Rehab Room
3. Exam Room C
4. Waiting Room
5. Business Office
6. Family Room


This was confirmed by the Maintenance Supervisor (PE).

Based on observations, the facility failed to limit the height of storage in accordance with NFPA 13 the Standard for the Installation of Sprinkler Systems (99). The failure to maintain the sprinkler system in compliance with NFPA 13 (99) could affect the proper operation and coverage of the fire sprinkler system. Failures to the system will affect the safety of all the patients, visitors and staff of the facility.

Findings include:

On facility tour between 10:30 PM and 1:30 PM on 5/10/10, it was observed that the facility failed to limit the height of the storage in the linen storage room 109. The clean linens that are stacked in the storage room are within 18 inches of a fire sprinkler head and will block the flow of that fire sprinkler head.


This was confirmed by the Maintenance Supervisor (PE).

Based on documentation review, the fire/smoke damper system has not been maintained in accordance with the requirements of NFPA 90(99) section 3-4.7. This deficient practice does not ensure the proper operation of the fire/smoke dampers and could allow smoke migration to negatively affect all patients, staff and visitors in the event of a fire.


Findings include:

On facility tour between 10:30 PM and 1:30 PM on 5/10/10, it was revealed during the review of facility fire and smoke damper test and inspection documentation and confirmed by interview with the Maintenance Supervisor (PE), that the facility failed to provide documentation that the fire and smoke dampers had been tested/inspected within the last 4 years in accordance with NFPA 90(99) section 3-4.7.

This was confirmed by the Maintenance Supervisor (PE).

Based on observations, the facility has failed to provide proper protection from 3 of several hazardous areas located throughout the facility in accordance with NFPA Life Safety Code 101 (2000 edition) section 19.3.2.1. This deficient practice could affect all patients, staff and visitors as smoke from a fire in this rooms could enter the corridor making it untenable.

Findings include:

1. On facility tour between 10:30 PM and 1:30 PM on 5/10/10, it was observed that the basement storage room had double doors were not fire rated and was not self-closing.


2. On facility tour between 10:30 PM and 1:30 PM on 5/10/10, it was observed that storage rooms 202 and the storage room across from room 102 were not self-closing and did not positively latch.

This was confirmed by the Maintenance Supervisor (PE).

Based on observations, the facility has failed to properly install a smoke detectors that are part of the buildings the fire alarm system. This deficient practice could affect the safety all patients, staff and visitors in the event the alarm system failed activate properly and quickly.

Findings include:

On facility tour between 10:30 AM and 1:30 PM on 5/10/10, observations reveled that the following smoke detectors were located within 36 inches of heating, ventilation and air conditioning (HVAC) supply diffuser,

1. Recovery Room
2. Cardiac Rehab Room
3. Exam Room C
4. Waiting Room
5. Business Office
6. Family Room


This was confirmed by the Maintenance Supervisor (PE).

Based on observations, the facility failed to limit the height of storage in accordance with NFPA 13 the Standard for the Installation of Sprinkler Systems (99). The failure to maintain the sprinkler system in compliance with NFPA 13 (99) could affect the proper operation and coverage of the fire sprinkler system. Failures to the system will affect the safety of all the patients, visitors and staff of the facility.

Findings include:

On facility tour between 10:30 PM and 1:30 PM on 5/10/10, it was observed that the facility failed to limit the height of the storage in the linen storage room 109. The clean linens that are stacked in the storage room are within 18 inches of a fire sprinkler head and will block the flow of that fire sprinkler head.


This was confirmed by the Maintenance Supervisor (PE).

Based on documentation review, the fire/smoke damper system has not been maintained in accordance with the requirements of NFPA 90(99) section 3-4.7. This deficient practice does not ensure the proper operation of the fire/smoke dampers and could allow smoke migration to negatively affect all patients, staff and visitors in the event of a fire.


Findings include:

On facility tour between 10:30 PM and 1:30 PM on 5/10/10, it was revealed during the review of facility fire and smoke damper test and inspection documentation and confirmed by interview with the Maintenance Supervisor (PE), that the facility failed to provide documentation that the fire and smoke dampers had been tested/inspected within the last 4 years in accordance with NFPA 90(99) section 3-4.7.

This was confirmed by the Maintenance Supervisor (PE).