HospitalInspections.org

Based on observation the facility failed to provide an acceptable 2 hour separation between the hospital and the assisted living facility.

The inspector observed while accompanied by the Maintenance Supervisor during the hours of the inspection from 9:00 am to 1:00 pm that there were penetrations in the 2 hour wall between the hospital and the assisted living facility.

Based on observation the facility failed to provide an acceptable documentation of wall coverings.

The inspector observed while accompanied by the Maintenance Supervisor during the hours of the inspection from 9:00 am to 1:00 pm that there were no records of flame spread data for the wall coverings.

Based on observation the facility failed to provide an acceptable documentation of wall coverings.

The inspector observed while accompanied by the Maintenance Supervisor during the hours of the inspection from 9:00 am to 1:00 pm that there were no records of flame spread data for the wall coverings.

Based on observation the facility failed to provide acceptable door hardware on the pharmacy door and the door on the interior ground level to the basement.

The inspector observed while accompanied by the Maintenance Supervisor during the hours of the inspection from 9:00 am to 1:00 pm that there was a gap between the two leaves of the dutch door. This must be smoke tight and requires a gasket or sweep to close the space between the upper and lower section. The basement door requires a positive latch that will prevent the door from opening in the event of a fire.

Based on observation the facility failed to provide acceptable smoker barrier separations.

The inspector observed while accompanied by the Maintenance Supervisor during the hours of the inspection from 9:00 am to 1:00 pm that there were several locations above the cross corridor doors that had penetrations in the smoke barrier walls. They were: 1) on the east wing near the lab, and 2) on the southeast wing near the elevator/stair.

Based on observation the facility failed to provide an acceptable separation between hazardous areas and the rest of the facility.

The inspector observed while accompanied by the Maintenance Supervisor during the hours of the inspection from 9:00 am to 1:00 pm that there multiple locations where hazardous areas were not properly separated from the rest of the building. They were: 1) the lab storage room did not have a closer, 2) the central supply room did not have a closer on the door, 3) the storage at central sterile did not have a door, a positive latch and a closer, and 4) the storage at purchasing did not have a closer on the door.

Based on observation the facility failed to provide an acceptable egress.

The inspector observed while accompanied by the Maintenance Supervisor during the hours of the inspection from 9:00 am to 1:00 pm that there were items stored in the egress pathway at the exit in the business office.

Based on observation the facility failed to provide an acceptable cross referencing of the fire alarm control panel and the panel and breaker supplying power.

The inspector observed while accompanied by the Maintenance Supervisor during the hours of the inspection from 9:00 am to 1:00 pm that breaker #6 in panel LSB was not colored red as required by NFPA.

Based on observation the facility failed to provide an acceptable fire extinguisher in the pharmacy.

The inspector observed while accompanied by the Maintenance Supervisor during the hours of the inspection from 9:00 am to 1:00 pm that there was an expired inspection sticker on the fire extinguisher.

Based on observation the facility failed to provide acceptable flame spread data for all curtains throughout the facility and the furniture in the waiting rooms.

The inspector observed while accompanied by the Maintenance Supervisor during the hours of the inspection from 9:00 am to 1:00 pm that there were no labeled curtains anywhere in the facility either for windows or cubicle curtains. All curtains must either have documentation or be labeled to pass NFPA 701. There was no documentation on the furniture in the waiting areas for fire retardant properties.

Based on observation the facility failed to provide records of grounding test of electrical receptacles per NFPA 99: 3-3.3.3. in patient care areas.

The inspector observed while accompanied by the Maintenance Supervisor during the hours of the inspection from 9:00 am to 1:00 pm that there was a contract for receptacle grounding tests but no data.

Based on observation the facility failed to provide an acceptable medical gas alarm system.

The inspector observed while accompanied by the Maintenance Supervisor during the hours of the inspection from 9:00 am to 1:00 pm that there was only one master alarm panel for the medical gas system and that it was located only at the nurse ' s station. NFPA requires a minimum of two master alarm panels.

Based on observation the facility failed to provide an acceptable test schedule of the essential electrical system.

The inspector observed while accompanied by the Maintenance Supervisor during the hours of the inspection from 9:00 am to 1:00 pm that there were no records of the following: 1) monthly operation of transfer switches, 2) monthly load test for at least 30% load, and 3) every 36 to 48 months at least a 4 hour test under full load conditions.

Based on observation the facility failed to provide acceptable critical outlets in the patient rooms.

The inspector observed while accompanied by the Maintenance Supervisor during the hours of the inspection from 9:00 am to 1:00 pm that there were no critical outlets in patient rooms on the east wing.

Based on observation the facility failed to provide an acceptable 2 hour separation between the hospital and the assisted living facility.

The inspector observed while accompanied by the Maintenance Supervisor during the hours of the inspection from 9:00 am to 1:00 pm that there were penetrations in the 2 hour wall between the hospital and the assisted living facility.

Based on observation the facility failed to provide an acceptable documentation of wall coverings.

The inspector observed while accompanied by the Maintenance Supervisor during the hours of the inspection from 9:00 am to 1:00 pm that there were no records of flame spread data for the wall coverings.

Based on observation the facility failed to provide an acceptable documentation of wall coverings.

The inspector observed while accompanied by the Maintenance Supervisor during the hours of the inspection from 9:00 am to 1:00 pm that there were no records of flame spread data for the wall coverings.

Based on observation the facility failed to provide acceptable door hardware on the pharmacy door and the door on the interior ground level to the basement.

The inspector observed while accompanied by the Maintenance Supervisor during the hours of the inspection from 9:00 am to 1:00 pm that there was a gap between the two leaves of the dutch door. This must be smoke tight and requires a gasket or sweep to close the space between the upper and lower section. The basement door requires a positive latch that will prevent the door from opening in the event of a fire.

Based on observation the facility failed to provide acceptable smoker barrier separations.

The inspector observed while accompanied by the Maintenance Supervisor during the hours of the inspection from 9:00 am to 1:00 pm that there were several locations above the cross corridor doors that had penetrations in the smoke barrier walls. They were: 1) on the east wing near the lab, and 2) on the southeast wing near the elevator/stair.

Based on observation the facility failed to provide an acceptable separation between hazardous areas and the rest of the facility.

The inspector observed while accompanied by the Maintenance Supervisor during the hours of the inspection from 9:00 am to 1:00 pm that there multiple locations where hazardous areas were not properly separated from the rest of the building. They were: 1) the lab storage room did not have a closer, 2) the central supply room did not have a closer on the door, 3) the storage at central sterile did not have a door, a positive latch and a closer, and 4) the storage at purchasing did not have a closer on the door.

Based on observation the facility failed to provide an acceptable egress.

The inspector observed while accompanied by the Maintenance Supervisor during the hours of the inspection from 9:00 am to 1:00 pm that there were items stored in the egress pathway at the exit in the business office.

Based on observation the facility failed to provide an acceptable cross referencing of the fire alarm control panel and the panel and breaker supplying power.

The inspector observed while accompanied by the Maintenance Supervisor during the hours of the inspection from 9:00 am to 1:00 pm that breaker #6 in panel LSB was not colored red as required by NFPA.

Based on observation the facility failed to provide an acceptable fire extinguisher in the pharmacy.

The inspector observed while accompanied by the Maintenance Supervisor during the hours of the inspection from 9:00 am to 1:00 pm that there was an expired inspection sticker on the fire extinguisher.

Based on observation the facility failed to provide acceptable flame spread data for all curtains throughout the facility and the furniture in the waiting rooms.

The inspector observed while accompanied by the Maintenance Supervisor during the hours of the inspection from 9:00 am to 1:00 pm that there were no labeled curtains anywhere in the facility either for windows or cubicle curtains. All curtains must either have documentation or be labeled to pass NFPA 701. There was no documentation on the furniture in the waiting areas for fire retardant properties.

Based on observation the facility failed to provide records of grounding test of electrical receptacles per NFPA 99: 3-3.3.3. in patient care areas.

The inspector observed while accompanied by the Maintenance Supervisor during the hours of the inspection from 9:00 am to 1:00 pm that there was a contract for receptacle grounding tests but no data.

Based on observation the facility failed to provide an acceptable medical gas alarm system.

The inspector observed while accompanied by the Maintenance Supervisor during the hours of the inspection from 9:00 am to 1:00 pm that there was only one master alarm panel for the medical gas system and that it was located only at the nurse ' s station. NFPA requires a minimum of two master alarm panels.

Based on observation the facility failed to provide an acceptable test schedule of the essential electrical system.

The inspector observed while accompanied by the Maintenance Supervisor during the hours of the inspection from 9:00 am to 1:00 pm that there were no records of the following: 1) monthly operation of transfer switches, 2) monthly load test for at least 30% load, and 3) every 36 to 48 months at least a 4 hour test under full load conditions.

Based on observation the facility failed to provide acceptable critical outlets in the patient rooms.

The inspector observed while accompanied by the Maintenance Supervisor during the hours of the inspection from 9:00 am to 1:00 pm that there were no critical outlets in patient rooms on the east wing.