HospitalInspections.org

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Based on observation and staff interview, the facility failed to ensure hazardous areas were protected from the corridor with self-closing doors in 1 of 12 smoke compartments. The findings were:

1. Observation on 11/04/15 at 4:00 PM of the basement dining area revealed the space was being utilized for storage. Further observation revealed the two doors leading from the space to the corridor were not self-closing. At the time of the observation the Facility Maintenance Manager acknowledged the doors were not provided with self-closing devices.

2. Observation on 11/04/15 at 4:05 PM of the basement IT storage area revealed the space was utilized for additional storage of combustible supplies. Further observation revealed the door from the space to the corridor was not provided with a self-closing device. At the time of the observation the Facility Maintenance Manger acknowledged the door was not provided with a self-closing device.

Ref:
2000 NFPA 101, Sections 39.3.2.1 and 8.4.1.3

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Based on observation and staff interview, the facility failed to arrange exit access so that exits are readily accessible at all times in 2 of 12 smoke compartments. The findings were:

1. Observation on 11/04/15 at 3:22 PM of the old hospital isolation utility room revealed the door lock required tight pinching, and more than one releasing operation to make the door operable. At the time of the observation the Facility Maintenance Manager acknowledged the door lock required more than one operation.

Ref:
2000 NFPA 101, Sections 39.2.2.2.1 and 7.2.1.5.4

2. Observation on 11/04/15 at 3:42 PM of the purchasing storage room revealed the door lock required tight pinching, and more than one releasing operation to make the door operable. At the time of the observation the Facility Maintenance Manager acknowledged the door lock required more than one operation.

Ref:
2000 NFPA 101, Sections 19.2.2.2.1 and 7.2.1.5.4

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Based on observation and staff interview, the facility failed to ensure that canopy structures constructed of combustible materials were sprinklered per the requirements of NFPA 13. The findings were:

Observation of the front entrance canopy on 11/04/15 at 1:30 PM revealed the construction materials used included Exterior Insulation Finishing System (EIFS), Stucco, and Kawal. Further observation revealed the canopy was not sprinkled. At the time of the observation it could not be established that the construction materials in the canopy assembly where of non-combustible or limited-combustible material. Interview with the Facility Administrator and the Facility Maintenance Manager following the observation could not provide documentation of the materials used in the construction of the canopy.

Ref:
2000 NFPA 101, Section 18.3.5.1 and 9.7.1.1
1999 NFPA 13, Section 5-13.8.1 and 1-4.2
S&C 07-29

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Based on observation and staff interview, the facility failed to provide anesthetizing locations with battery-powered emergency lighting units per NFPA 99. The findings were:

Observation of operating room #1 and #2 on 11/04/15 from 1:35 PM to 1:50 PM revealed that neither space was equipped with battery-powered emergency lighting units. At the time of the observation the Facility Maintenance Manager acknowledged the required lighting was not present, and was unaware this was a requirement.

Ref:
2000 NFPA 101, Section 19.3.2.3
1999 NFPA 99, Section 3-3.2.1.2(5e)

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Based on observation and staff interview, the facility failed to ensure hazardous areas were protected from the corridor with self-closing doors in 1 of 12 smoke compartments. The findings were:

1. Observation on 11/04/15 at 4:00 PM of the basement dining area revealed the space was being utilized for storage. Further observation revealed the two doors leading from the space to the corridor were not self-closing. At the time of the observation the Facility Maintenance Manager acknowledged the doors were not provided with self-closing devices.

2. Observation on 11/04/15 at 4:05 PM of the basement IT storage area revealed the space was utilized for additional storage of combustible supplies. Further observation revealed the door from the space to the corridor was not provided with a self-closing device. At the time of the observation the Facility Maintenance Manger acknowledged the door was not provided with a self-closing device.

Ref:
2000 NFPA 101, Sections 39.3.2.1 and 8.4.1.3

.
Based on observation and staff interview, the facility failed to arrange exit access so that exits are readily accessible at all times in 2 of 12 smoke compartments. The findings were:

1. Observation on 11/04/15 at 3:22 PM of the old hospital isolation utility room revealed the door lock required tight pinching, and more than one releasing operation to make the door operable. At the time of the observation the Facility Maintenance Manager acknowledged the door lock required more than one operation.

Ref:
2000 NFPA 101, Sections 39.2.2.2.1 and 7.2.1.5.4

2. Observation on 11/04/15 at 3:42 PM of the purchasing storage room revealed the door lock required tight pinching, and more than one releasing operation to make the door operable. At the time of the observation the Facility Maintenance Manager acknowledged the door lock required more than one operation.

Ref:
2000 NFPA 101, Sections 19.2.2.2.1 and 7.2.1.5.4

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Based on observation and staff interview, the facility failed to ensure that canopy structures constructed of combustible materials were sprinklered per the requirements of NFPA 13. The findings were:

Observation of the front entrance canopy on 11/04/15 at 1:30 PM revealed the construction materials used included Exterior Insulation Finishing System (EIFS), Stucco, and Kawal. Further observation revealed the canopy was not sprinkled. At the time of the observation it could not be established that the construction materials in the canopy assembly where of non-combustible or limited-combustible material. Interview with the Facility Administrator and the Facility Maintenance Manager following the observation could not provide documentation of the materials used in the construction of the canopy.

Ref:
2000 NFPA 101, Section 18.3.5.1 and 9.7.1.1
1999 NFPA 13, Section 5-13.8.1 and 1-4.2
S&C 07-29

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Based on observation and staff interview, the facility failed to provide anesthetizing locations with battery-powered emergency lighting units per NFPA 99. The findings were:

Observation of operating room #1 and #2 on 11/04/15 from 1:35 PM to 1:50 PM revealed that neither space was equipped with battery-powered emergency lighting units. At the time of the observation the Facility Maintenance Manager acknowledged the required lighting was not present, and was unaware this was a requirement.

Ref:
2000 NFPA 101, Section 19.3.2.3
1999 NFPA 99, Section 3-3.2.1.2(5e)