HospitalInspections.org

Based on observation and interview, the facility failed to maintain the two-hour fire barrier that separated the Hospital facility from the Clinic. This deficient practice would allow fire and smoke to migrate between the two separate occupancies. The facility census was 1 patient.

Findings are:
Observations on 4-11-18 at 11:33 am revealed, unsealed penetrations around sprinkler pipe and cables in the two hour fire rated wall separating the Hospital from the Clinic.

During an interview on 4-11-18 at 11:33 am, Maintenance Staff A confirmed the penetrations in the two hour fire wall.

Based on observation and interview, the facility failed to provide required sprinkler components resulting in an unprotected gap around the sprinkler pipe. This deficient practice increased the potential for damage to the sprinkler resulting in a fire that could spread outside of the room of origin. The facility census was 1 patient.

Findings are:
Observation on 4-11-18 at 10:48 am revealed, missing escutcheon on the sprinkler in the Ultrasound Room which created an unprotected gap around the sprinkler pipe.

During an interview on 4-11-18 at 10:48 am, Maintenance Staff A confirmed the lack of an escutcheon which created a penetration in the ceiling.

Based on observation and interview, the facility failed to assure that corridor doors were not blocked open. This deficient practice would delay closing of the door and allow smoke, fire and gasses to spread into the exit corridor. The facility census was 1 patient.

Findings are:
Observation on 4-11-18 at 10:28 am revealed, the door to Pharmacy was blocked open by a rolling oxygen cart .

During an interview on 4-11-18 at 10:28 am, Maintenance Staff A confirmed the cart holding open the door to Pharmacy.

Based on observation and interview, the facility failed to assure that one of three smoke barrier walls were composed of materials that ensured at least a 30 minute fire resistance rating to prevent the passage of smoke and fire to another smoke zone. The facility census was 1 patient.

Findings are:
Observation on 4-11-18 at 11:08 am revealed, a large unsealed penetration in the smoke barrier wall above the ceiling tiles next to the Oxygen Storage Room and Patient Room 130.

During an interview on 4-11-18 at 11:08 am, Maintenance Staff A confirmed the penetration in the smoke barrier wall.

Based on observation and interview, the facility failed to assure the face plate for electrical outlets were not broken. This deficient practice would increase the potential for electrical shock. The facility census was 1 patient.

Findings are:
Observations on 4-11-18 at 10:35 am revealed, a broken electrical cover plate in the oxygen storage room.

During an interview on 4-11-18 at 10:35 am, Maintenance Staff A confirmed the cover plate was broken.

NFPA Standard:
2011, NFPA 70, 406.6 Receptacle Faceplates (Cover Plates).
Receptacle faceplates shall be installed so as to completely cover the opening and seat against the mounting surface.