HospitalInspections.org

K-0321 Based upon observations made in the presence of the plant manager on 08-23-2017, it was determined that the facility did not maintain hazardous areas to be fire and smoke separated from other sections of the facility in accordance with NFPA 101 19.3.2, 19.3.2.1.5

This deficiency affected


Findings include:

1- During the facility tour it was observed that in the basement conference room the storage room door did not have a door closure. The door is required to be self-closing or automatic closing to the latch position in accordance with NFPA 101 19.3.2.1.
2- During the facility tour it was observed that the conference room storage/communication room in the basement is 1 hour rated and has had an electric powered fan cut into the wall to supply cooling from the conference room.
3- During the facility tour it was observed that there was several penetrations cut into the walls in the conference room storage/communication room in the basement.
4-During the facility tour it was observed that there was several penetrations in the storage room in the basement physical Therapy department.
5- During the facility tour it was observed that there was no door closure on the storage room in the Physical Therapy department.
6- During the facility tour it was observed that the fire rated roll down fire rated door at the basement kitchen serving area and Administrative area have been disable and will not close. They are also not being tested annually in accordance with NFPA 80 5.2.5. , 5.2.14 this finding was verified by the facility manager who stated that they had been disabled.
7- During the facility tour it was observed that there was several penetrations in the main boiler room.
8- During the facility tour it was observed that there was several penetrations in the main communication/I.T. closet in the basement.
9- During the facility tour it was observed that there was ½" holes/penetrations left in the pharmacy door from a old access control magnet that had been removed.

K-345: Based upon record review made in the presence of the plant manager on 08/23/2017, it was determined that the facility did not maintain the fire alarm system in accordance with NFPA 101 19.3.4.4 & 9.6.3.1.; and NFPA 72. Table 14.4.5 (6) (3), 14.6.2

This deficiency affected

Findings include:

1-During the record review the facility failed to provide documentation that the fire alarm control panel batteries had been tested under load two times in the last year, there was only one documented test. Batteries need to be tested semiannually in accordance with NFPA. 101 19.3.4.4. & 9.6.1.3.; and NFPA 72. Table 14.4.5 (6) (3)

K-0353 Based upon observations made in the presence of the plant manager on 08-23-2017, it was determined that the facility did not maintain the fire sprinkler system in accordance with NFPA 19.3.5.1.

This deficiency affected

Findings include:

1- During the record review the facility failed to provide documentation that the fire riser gauges had been replaced or calibrated in the last 5 years in accordance with NFPA 101 19.3.5.1, 9.7.5 and NFPA 25 9-2.8.2.

K-0511 Based upon observations made in the presence of the plant manager on 08-23-2017, it was determined that the facility did not maintain electrical equipment in accordance with NFPA 101 19.5.1.

This deficiency affected

Findings include:

1- During the facility tour it was observed that the electrical service panels in the hospital that were unlocked allowing unauthorized access to unqualified persons not in accordance with NFPA 19.5.1,9.1.2 and NFPA 70,110-31
2-During the facility tour it was observed that the electrical outlets in several areas were within 6 ft. of the sinks in the public restrooms, basement kitchen area, E.R. bay area, Employee restrooms, male and female locker rooms, central processing, class room sink and the medication storage room the decision was made that all areas would be checked by the facility director and upgraded as necessary. These outlets were not in accordance with. NFPA 101 Section 19.5.1, 9.1.2; 1999 NFPA 70 Article 210-8(7)
3-- During the facility tour electrical panels in Endo O.R. the line isolation panel were observed to be blocked. Service panels are to have a clear working space of 36" maintained in front of them at all times. NFPA 101 19.5.1, 9.1.2., NFPA 70, 110-26 (a)
4- During the facility tour electrical panels in OR #1 the line isolation panel were observed to be blocked. Service panels are to have a clear working space of 36" maintained in front of them at all times. NFPA 101 19.5.1, 9.1.2., NFPA 70, 110-26 (a)

K-0712 Based upon record review made in the presence of the plant manager on 08-23-2017, it was determined that the facility did not conduct fire drills held at unexpected times under varying conditions at least quarterly on each shift in accordance with NFPA 101 19.7.1.2.

This deficiency affected

Findings include:

During the record review the facility failed to provide documentation of 4 of the required 12 fire drills. The plant manager confirmed these findings. Fire drills shall be held at unexpected time under varying conditions at least quarterly on each shift in accordance with NFPA 101 19.7.1.2.

K-918 Based on observations made in the presence of the plant manager on 08-23-2017 it was determined that the facility did not maintain, inspect and exercise the facilities emergency generator set in accordance with NFPA 110 5.6.5.6

This deficiency affected


Findings include:


During the facility tour it was observed that the generator did not have a remote manual stop located outside of the enclosure. All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building in accordance with NFPA 110 5.6.5.6