HospitalInspections.org

Based on observations, the facility has failed to provide proper protection from 1 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 patients, staff and visitors as smoke from a fire in this rooms could enter the corridor making it untenable.

Findings include:

On facility tour between 9:00 AM and 4:00 PM on 8/19/10, it was observed that the Clean Linen storage room located adjacent to the Materials Management storage room was equipped with a door that does not meet the requirements for the one hour fire rated construction of a hazardous storage area.


This was confirmed by Facilities Manager (FC).

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to provide reliable lighting as required by 2000 NFPA 101, Section 19..2.9.1, 7.9.3, 7.10.9.

Findings include:

On facility tour between 9:00 AM and 4:00 PM on 08/19/2010, revealed the the following:

1. The review of the battery operated emergency lighting and exit sign testing documentation for the past 12 months revealed, that the facility failed to conduct monthly 30 second and yearly 90 minute testing and document such

2. The battery operated emergency lights by room # 4 and # 11, did not operated when tested



This deficient practice was confirmed by the Maintenance staff (PK) at the time of discovery.

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to provide reliable lighting as required by 2000 NFPA 101, Section 19..2.9.1, 7.9.3, 7.10.9.

Findings include:

On facility tour between 9:00 AM and 4:00 PM on 08/19/2010, the review of the battery operated emergency lighting and exit sign testing documentation for the past 12 months revealed, that the facility failed to conduct monthly 30 second and yearly 90 minute testing and document such.




This deficient practice was confirmed by the Maintenance staff (PK) at the time of discovery.

Based on an interview with staff, the facility has failed to ensure that emergency lighting has been tested in accordance with NFPA LSC (00) Section 7.9, 19.2.9.1. This deficient practice could affect all patients, staff and visitors in the event of an emergency evacuation during a power outage.

Findings include:

On facility tour between 9:00 AM and 4:00 PM on 8/19/10, during a documentation review and interview with the Facilities Manager (FC), it was revealed that there was no documentation for one of twelve monthly tests of the battery powered emergency lights throughout the facility per NFPA 101, 2000 Edition Chapter 19, sec 19.2.9.1.


This was confirmed by Facilities Manager (FC).

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to install the fire alarm system in accordance with the requirements of 2000 NFPA 101, Sections 19.3.4.1 and 9.6, as well as 1999 NFPA 72, Chapter 1.5.6.

Findings include:

On facility tour between 9:00 AM and 4:00 PM on 08/19/2010, observation revealed, that the main fire alarm panel, located in the front entrance vestibule was not protected with automatic smoke detection that is interconnected to the fire alarm panel.


This deficient practice was confirmed by the Maintenance staff (PK) at the time of discovery.

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to install the fire alarm system in accordance with the requirements of 2000 NFPA 101, Sections 19.3.4.1 and 9.6, as well as 1999 NFPA 72.
Findings include:

On facility tour between 9:00 AM and 4:00 PM on 08/19/2010, observation revealed, that the following was found:

1. Smoke detectors were place with-in 3 feet of air supply or return vent is not allowed per 1999 NFPA 72 Chapter 2-3.5.1, at the following locations:
a. in corridor by room # 6 and # 7

2. Main fire alarm panel, the batteries are over 4 years old. Date on both batteries are 07/12/2005. Per 1999 NFPA 72 Table 7-3.2 (6) (d) (1)



These deficient practices were confirmed by the Maintenance staff (PK) at the time of discovery.

Based on observations, the automatic sprinkler system is not installed and maintained 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 allow fire development that would reduce the egress conditions affecting all patients, staff and visitors of the facility.

Findings include:

On facility tour between 9:00 AM and 4:00 PM on 8/19/10, it was observed that the Radiology Room #3 was not protected by the facility's Automatic Fire sprinkler system. Fire sprinkler coverage is required in this area for the facility to be considered to be a fully fire sprinkler protected building.


This was confirmed by Facilities Manager (FC).

This STANDARD is not met as evidenced by:

Based on documentation review and staff interview, it was determined that the facility failed to maintain portable fire extinguishers in accordance with NFPA 101-2000 edition, Section 9.7.4.1 and NFPA 10.

Findings include:

On facility tour between 9:00 AM and 4:00 PM on 08/19/2010, the review of the fire extinguisher monthly inspection documentation for the past 12 months and observation revealed, that the facility failed to conduct monthly fire extinguisher inspection since the last annual inspection in April 2010.


This deficient practice was confirmed by the Maintenance staff (PK) at the time of discovery.




*TEAM COMPOSITION*
Gary Schroeder, Life Safety Code Spc.

This STANDARD is not met as evidenced by:

Based on documentation review and staff interview, it was determined that the facility failed to maintain portable fire extinguishers in accordance with NFPA 101-2000 edition, Section 9.7.4.1 and NFPA 10.

Findings include:

On facility tour between 9:00 AM and 4:00 PM on 08/19/2010, the review of the fire extinguisher monthly inspection documentation for the past 12 months and observation revealed, that the facility failed to conduct monthly fire extinguisher inspection since the last annual inspection in March 2010.


This deficient practice was confirmed by the Maintenance staff (PK) at the time of discovery.

This STANDARD is not met as evidenced by:

Based on documentation review and staff interview, it was determined that the facility failed to maintain portable fire extinguishers in accordance with NFPA 101-2000 edition, Section 9.7.4.1 and NFPA 10.

Findings include:

On facility tour between 9:00 AM and 4:00 PM on 08/19/2010, the review of the fire extinguisher monthly inspection documentation for the past 12 months and observation revealed, that the facility failed to conduct monthly fire extinguisher inspection since the last annual inspection in May 2010.


This deficient practice was confirmed by the Maintenance staff (PK) at the time of discovery.





*TEAM COMPOSITION*
Gary Schroeder, Life Safety Code Spc.

This STANDARD is not met as evidenced by:

Based on documentation review and staff interview, it was determined that the facility failed to maintain portable fire extinguishers in accordance with NFPA 101-2000 edition, Section 9.7.4.1 and NFPA 10.

Findings include:

On facility tour between 9:00 AM and 4:00 PM on 08/19/2010, the review of the fire extinguisher monthly inspection documentation for the past 12 months and observation revealed, that the facility failed to conduct monthly fire extinguisher inspection since the last annual inspection in September 2009.


This deficient practice was confirmed by the Maintenance staff (PK) at the time of discovery.

Based on observations the facility failed to keep the means of egress continuous and free of all obstructions or impediments to full instant use in the case of fire or other emergency, in accordance with NFPA Life Safety Code 101 (2000 edition) Chapter 7, Section 7.1.10. These obstructions could interfere with the convenient and effective removal of 5 of 25 patients, staff and visitors in an emergency situation, and impede fire fighting operations during a fire emergency.


Findings include:

On facility tour between 9:00 AM and 4:00 PM on 8/19/10, it was observed that there was equipment, chairs and other obstructions that were in the egress path of the East PT exit. These obstruction made the use of this exit unaccessible.

This was confirmed by Facilities Manager (FC).

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to assure oxygen cylinders are secured as required by 1999 NFPA 99, Sections 4-3.5.2.1 (B) 27.

Findings include:

On facility tour between 9:00 AM and 4:00 PM on 08/19/2010, observation revealed, in Procedure room # 1, there are (2) "E" cylinders that was not secured


This deficient practice was confirmed by the Maintenance staff (PK) at the time of discovery.




*TEAM COMPOSITION*
Gary Schroeder, Life Safety Code Spc.

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to provide no mounting of Alcohol Based Hand Rub (ABHR) dispensers directly over carpet in a non sprinkled building as requirements in Tentative Interim Amendment to 2000 NFPA 101, Sections 18.3.2.7.


Findings include:

On facility tour between 9:00 AM and 4:00 PM on 08/19/2010, observation revealed, that the Alcohol Based Hand Rub (ABHR) dispensers are mounted directly over carpet in a non fire sprinkled building. Example in room # 4.


NOTE: The entire facility needs to be checked for this deficiency.


This deficient practice was confirmed by the Maintenance staff (PK) at the time of discovery.



*TEAM COMPOSITION*
Gary Schroeder, Life Safety Code Spc.

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to provide no mounting of Alcohol Based Hand Rub (ABHR) dispensers directly over carpet in a non sprinkled building as requirements in Tentative Interim Amendment to 2000 NFPA 101, Sections 18.3.2.7.


Findings include:

On facility tour between 9:00 AM and 4:00 PM on 08/19/2010, observation revealed, that the Alcohol Based Hand Rub (ABHR) dispensers are mounted directly over carpet in a non fire sprinkled building. Example in rooms # 6 and #7.


NOTE: The entire facility needs to be checked for this deficiency.


This deficient practice was confirmed by the Maintenance staff (PK) at the time of discovery.



*TEAM COMPOSITION*
Gary Schroeder, Life Safety Code Spc.

Based on observations, the facility has failed to provide proper protection from 1 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 patients, staff and visitors as smoke from a fire in this rooms could enter the corridor making it untenable.

Findings include:

On facility tour between 9:00 AM and 4:00 PM on 8/19/10, it was observed that the Clean Linen storage room located adjacent to the Materials Management storage room was equipped with a door that does not meet the requirements for the one hour fire rated construction of a hazardous storage area.


This was confirmed by Facilities Manager (FC).

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to provide reliable lighting as required by 2000 NFPA 101, Section 19..2.9.1, 7.9.3, 7.10.9.

Findings include:

On facility tour between 9:00 AM and 4:00 PM on 08/19/2010, revealed the the following:

1. The review of the battery operated emergency lighting and exit sign testing documentation for the past 12 months revealed, that the facility failed to conduct monthly 30 second and yearly 90 minute testing and document such

2. The battery operated emergency lights by room # 4 and # 11, did not operated when tested



This deficient practice was confirmed by the Maintenance staff (PK) at the time of discovery.

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to provide reliable lighting as required by 2000 NFPA 101, Section 19..2.9.1, 7.9.3, 7.10.9.

Findings include:

On facility tour between 9:00 AM and 4:00 PM on 08/19/2010, the review of the battery operated emergency lighting and exit sign testing documentation for the past 12 months revealed, that the facility failed to conduct monthly 30 second and yearly 90 minute testing and document such.




This deficient practice was confirmed by the Maintenance staff (PK) at the time of discovery.

Based on an interview with staff, the facility has failed to ensure that emergency lighting has been tested in accordance with NFPA LSC (00) Section 7.9, 19.2.9.1. This deficient practice could affect all patients, staff and visitors in the event of an emergency evacuation during a power outage.

Findings include:

On facility tour between 9:00 AM and 4:00 PM on 8/19/10, during a documentation review and interview with the Facilities Manager (FC), it was revealed that there was no documentation for one of twelve monthly tests of the battery powered emergency lights throughout the facility per NFPA 101, 2000 Edition Chapter 19, sec 19.2.9.1.


This was confirmed by Facilities Manager (FC).

This STANDARD is not met as evidenced by:

Based on documentation review and staff interview, the facility failed to assure fire drills were conducted once per shift for all staff under varying times and conditions as required by 2000 NFPA 101, Section 19.7.1.2.

Findings include:

On facility tour between 9:00 AM and 4:00 PM on 08/19/2010, the review of the fire drill documentation for the past 12 months (June 2009 to July 2010) revealed, that the facility failed to conduct a fire drill.



This deficient practice was confirmed by the Maintenance staff (PK) at the time of discovery.

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to install the fire alarm system in accordance with the requirements of 2000 NFPA 101, Sections 19.3.4.1 and 9.6, as well as 1999 NFPA 72, Chapter 1.5.6.

Findings include:

On facility tour between 9:00 AM and 4:00 PM on 08/19/2010, observation revealed, that the main fire alarm panel, located in the front entrance vestibule was not protected with automatic smoke detection that is interconnected to the fire alarm panel.


This deficient practice was confirmed by the Maintenance staff (PK) at the time of discovery.

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to install the fire alarm system in accordance with the requirements of 2000 NFPA 101, Sections 19.3.4.1 and 9.6, as well as 1999 NFPA 72.
Findings include:

On facility tour between 9:00 AM and 4:00 PM on 08/19/2010, observation revealed, that the following was found:

1. Smoke detectors were place with-in 3 feet of air supply or return vent is not allowed per 1999 NFPA 72 Chapter 2-3.5.1, at the following locations:
a. in corridor by room # 6 and # 7

2. Main fire alarm panel, the batteries are over 4 years old. Date on both batteries are 07/12/2005. Per 1999 NFPA 72 Table 7-3.2 (6) (d) (1)



These deficient practices were confirmed by the Maintenance staff (PK) at the time of discovery.

Based on observations, the automatic sprinkler system is not installed and maintained 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 allow fire development that would reduce the egress conditions affecting all patients, staff and visitors of the facility.

Findings include:

On facility tour between 9:00 AM and 4:00 PM on 8/19/10, it was observed that the Radiology Room #3 was not protected by the facility's Automatic Fire sprinkler system. Fire sprinkler coverage is required in this area for the facility to be considered to be a fully fire sprinkler protected building.


This was confirmed by Facilities Manager (FC).

This STANDARD is not met as evidenced by:

Based on documentation review and staff interview, it was determined that the facility failed to maintain portable fire extinguishers in accordance with NFPA 101-2000 edition, Section 9.7.4.1 and NFPA 10.

Findings include:

On facility tour between 9:00 AM and 4:00 PM on 08/19/2010, the review of the fire extinguisher monthly inspection documentation for the past 12 months and observation revealed, that the facility failed to conduct monthly fire extinguisher inspection since the last annual inspection in April 2010.


This deficient practice was confirmed by the Maintenance staff (PK) at the time of discovery.




*TEAM COMPOSITION*
Gary Schroeder, Life Safety Code Spc.

This STANDARD is not met as evidenced by:

Based on documentation review and staff interview, it was determined that the facility failed to maintain portable fire extinguishers in accordance with NFPA 101-2000 edition, Section 9.7.4.1 and NFPA 10.

Findings include:

On facility tour between 9:00 AM and 4:00 PM on 08/19/2010, the review of the fire extinguisher monthly inspection documentation for the past 12 months and observation revealed, that the facility failed to conduct monthly fire extinguisher inspection since the last annual inspection in March 2010.


This deficient practice was confirmed by the Maintenance staff (PK) at the time of discovery.

This STANDARD is not met as evidenced by:

Based on documentation review and staff interview, it was determined that the facility failed to maintain portable fire extinguishers in accordance with NFPA 101-2000 edition, Section 9.7.4.1 and NFPA 10.

Findings include:

On facility tour between 9:00 AM and 4:00 PM on 08/19/2010, the review of the fire extinguisher monthly inspection documentation for the past 12 months and observation revealed, that the facility failed to conduct monthly fire extinguisher inspection since the last annual inspection in May 2010.


This deficient practice was confirmed by the Maintenance staff (PK) at the time of discovery.





*TEAM COMPOSITION*
Gary Schroeder, Life Safety Code Spc.

This STANDARD is not met as evidenced by:

Based on documentation review and staff interview, it was determined that the facility failed to maintain portable fire extinguishers in accordance with NFPA 101-2000 edition, Section 9.7.4.1 and NFPA 10.

Findings include:

On facility tour between 9:00 AM and 4:00 PM on 08/19/2010, the review of the fire extinguisher monthly inspection documentation for the past 12 months and observation revealed, that the facility failed to conduct monthly fire extinguisher inspection since the last annual inspection in September 2009.


This deficient practice was confirmed by the Maintenance staff (PK) at the time of discovery.

Based on observations the facility failed to keep the means of egress continuous and free of all obstructions or impediments to full instant use in the case of fire or other emergency, in accordance with NFPA Life Safety Code 101 (2000 edition) Chapter 7, Section 7.1.10. These obstructions could interfere with the convenient and effective removal of 5 of 25 patients, staff and visitors in an emergency situation, and impede fire fighting operations during a fire emergency.


Findings include:

On facility tour between 9:00 AM and 4:00 PM on 8/19/10, it was observed that there was equipment, chairs and other obstructions that were in the egress path of the East PT exit. These obstruction made the use of this exit unaccessible.

This was confirmed by Facilities Manager (FC).

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to assure oxygen cylinders are secured as required by 1999 NFPA 99, Sections 4-3.5.2.1 (B) 27.

Findings include:

On facility tour between 9:00 AM and 4:00 PM on 08/19/2010, observation revealed, in Procedure room # 1, there are (2) "E" cylinders that was not secured


This deficient practice was confirmed by the Maintenance staff (PK) at the time of discovery.




*TEAM COMPOSITION*
Gary Schroeder, Life Safety Code Spc.