HospitalInspections.org

Based on observation and interview, the provider failed to maintain the fire-resistive characteristics of the two hour fire-resistive wall between the hospital and the clinic. The 90 minute fire-rated door at the hospital mammograpy area would not close and latch. Findings include:

1. Observation at 8:45 a.m. revealed a door located in the two hour wall between the clinic and the hospital at the mammography area. The door was a labeled 90 minute fire-rated door, but it would not close and latch under the power of the door closer. Interview with the maintenance person at the time of the interview confirmed that finding.

Based on observation and interview, the provider failed to meet the minimum construction standards of the 2000 Life Safety Code (LSC). The Type II (111) building had a combustible wood canopy attached to the building, thereby derating it to Type V (000) construction. Findings include:

1. Observation and interview revealed the building was a single story, noncombustible, Type II (111) structure without a complete automatic sprinkler system. The building had an exterior combustible wood canopy attached to it at the north exit from the service wing (kitchen and boiler room area). The canopy measured approximately 6 feet by 12 feet. The unprotected combustible canopy derates the building to Type V (000) which is allowed if the building is equipped with a complete automatic sprinkler system. Interview with the maintenance person at the time of the observation confirmed that finding.

Based on observation and interview, the provider failed to maintain corridor door fire ratings of 20 minutes (or equivalent) for the computer closet door at the receptionist's desk. The door had two louvers in it. Findings include:

1. Observation at 1:45 p.m. revealed the computer room door behind the receptionist's desk at the main entrance lobby and did not meet a 20 minute fire door equivalency. The door had two 8 inch by 12 inch louvers in it for ventilation. Interview with maintenance at the time of the observation confirmed that finding.

Based on observation and interview, the provider failed to maintain the 30 minute fire resistive rating of smoke barrier walls. The north side of the smoke barrier wall at the nurses' station had an unsealed opening. There was a one inch hole for coaxial cable that was not sealed with an approved fire-stop material. Findings include:

1. Observation at 2:30 p.m. revealed the north side of the smoke barrier wall at the nurses' station had an unsealed opening. There was a one inch hole for coaxial cable above the lay-in ceiling. The opening was not sealed with an approved fire-stop material. Interview with the maintenance person at the time of the observation confirmed that finding.

Based on observation, the provider failed to maintain at least two conforming exits from the basement. Findings include:

1. Observation on 8/07/12 revealed the basement was not provided with two approved means of egress. The basement boiler room was approximately 35 feet by 20 feet (700 square feet). The second exit discharged through the crawl space.

The building meets the FSES. Please mark an "F" in the completion date column to indicate the provider's intent to correct deficiencies identified in K000.

Based on record review and interview, the provider failed to maintain emergency lighting of at least one and one-half hour duration for five battery pack emergency lights (two in the maintenance electrical room, the nurses' station, emergency room, and the operating room). Findings include:

1. Record review dated 12/06/11 by Western States Fire Protection Co. indicated five battery pack emergency lights (two in the maintenance electrical room, the nurses' station, emergency room, and the operating room) failed the annual 90 minute load test. Interview with the maintenance person revealed he believed the batteries were not required to function since the battery pack lights received power from the emergency generator.

Based on observation and interview, the provider failed to install readily visible illuminated exit signs to direct occupants to reach the exits from the basement boiler room. Findings include:

1. Observation at 2:30 p.m. revealed the basement boiler room was approximately 35 feet by 20 feet (700 square feet) with the second exit discharging through the crawl space. There were not any illuminated exit signs marking the exits. Interview with the maintenance person at the time of the observations confirmed those findings.

Based on record review and interview, the provider failed to document the sounding of the fire alarm on fire drill sheets and if the alarm signal had been received at the monitoring agency (Sheriff's office) for three months (March and September 2011 and March 2012) for the 18 month period beginning January 2011. There was not a drill conducted for the second shift for the quarter including April/May/June 2012. Findings include:

1. Fire drill record review revealed no documentation indicating the sounding of the fire alarm on fire drill sheets and if the alarm signal had been received at the monitoring agency (Sheriff's office) for three months (March and September 2011 and March 2012) for the 18 month period beginning July 2011. Those months had drills at 2340, 0200, and 0100 hours respectively which are normally times for silent drills. It was noted the provider conducted one drill per month for the 12 month period beginning July 2011.

Fire drill record review revealed there was not a drill conducted for the second shift (1900-0700 [7 p.m.-7 a.m.]) for the quarter including April/May/June 2012. The first shift (0700-1900 [7 a.m.-7 p.m.]) had a drill each month in that time period at 0910, 1045, and 1400 hours respectively.

Interview with the maintenance person at the time of the record review confirmed those findings.

Based on observation and interview, the provider failed to install the north exit manual pull station at the proper height. The operating part of the pull station was situated 61 inches above the finished floor. Findings include:

1. Observation beginning at 8:45 a.m. revealed manual fire alarm pull stations were mounted so the operating part of the station was 61 inches above the finished floor at the following locations:
*Adjacent to the cross-corridor doors at the main entrance lobby
*Adjacent patient room 122
*Adjacent to CSR
The height for mounting a manual pull station is to have the operating part of the pull station between 42 to 54 inches above the finished floor.

The building meets the FSES. Please mark an "F" in the completion date column to indicate correction of the deficiencies identified in K000.

A. Based on record review and interview, the provider failed to maintain emergency lighting of at least one and one-half hour duration for one battery pack emergency light (generator room above the clinic). There was not a battery pack emergency light installed for the generator transfer switch location. Findings include:

1. Record review dated 12/06/11 by Western States Fire Protection Co. indicated one battery pack emergency light in the generator room failed the annual 90 minute load test. Interview with the maintenance person revealed he believed the battery was not required to function since light received power from the emergency generator.

2. Observation at 3:15 p.m. revealed the second floor generator transfer switch location was not equipped with battery pack emergency light illumination. Interview with the maintenance person at the time of the observation confirmed that finding.

B. Based on observation and interview, the provider failed to prove that a quilt displayed on the wall of the exit corridor had been treated with flame retardant in accordance with the provisions of the Life Safety Code. Findings include:

1. Observation at 3:20 p.m. revealed a large 6 x 7 foot decorative quilt on display in the exit corridor. Interview with the maintenance person reveals the staff were unaware if any fire treatment had ever been applied to the decorative blankets. He indicated that there was no flame retardant documentation on file to confirm or deny application.

C. Based on observation and interview, the provider failed to install terminal covers for the generator battery and failed to install a battery that was not maintenance-free. Findings include:

1. Observation at 3:05 p.m. revealed the generator battery did not have covers on the terminals. Interview with the maintenance person at the time of the observation confirmed that finding. He stated terminal covers would be provided as soon as possible.

2. Observation at 3:10 p.m. revealed the generator battery was a maintenance-free battery. The maintenance free battery did not allow for the required weekly specific gravity testing of the battery. Interview with the maintenance person at the time of the observation confirmed that finding.

D. Based on observation and interview, the provider failed to install permanent wiring for physical therapy. An extension cord was used for a treadmill. (See attached (NFPA 70) Article 305 Temporary Installations. Findings include:

1. Observation at 3:45 p.m. revealed an extension cord was used for a treadmill in physical therapy. Interview with the maintenance person at the time of the observation confirmed that finding.

Based on observation and interview, the provider failed to install permanent wiring for the kitchenette at the nurses' station. A power strip was used for the coffee maker in the kitchenette. A multiple tap and a power strip were used at the copier. (See attached (NFPA 70) Article 305 Temporary Installations.) Findings include:

1. Observation at 2:45 p.m. revealed a power strip was used for the coffee maker in the kitchenette. Interview with the maintenance person at the time of the observation revealed the cord on the coffee maker was too short for its location with respect to the electrical outlet. The power strip was being used like an extension cord.

2. Observation at 2:55 p.m. revealed the copier was equipped with a multiple tap and a power strip. Interview with the maintenance person at the time of the observation confirmed that finding.

Based on observation and interview, the provider failed to maintain the fire-resistive characteristics of the two hour fire-resistive wall between the hospital and the clinic. The 90 minute fire-rated door at the hospital mammograpy area would not close and latch. Findings include:

1. Observation at 8:45 a.m. revealed a door located in the two hour wall between the clinic and the hospital at the mammography area. The door was a labeled 90 minute fire-rated door, but it would not close and latch under the power of the door closer. Interview with the maintenance person at the time of the interview confirmed that finding.

Based on observation and interview, the provider failed to meet the minimum construction standards of the 2000 Life Safety Code (LSC). The Type II (111) building had a combustible wood canopy attached to the building, thereby derating it to Type V (000) construction. Findings include:

1. Observation and interview revealed the building was a single story, noncombustible, Type II (111) structure without a complete automatic sprinkler system. The building had an exterior combustible wood canopy attached to it at the north exit from the service wing (kitchen and boiler room area). The canopy measured approximately 6 feet by 12 feet. The unprotected combustible canopy derates the building to Type V (000) which is allowed if the building is equipped with a complete automatic sprinkler system. Interview with the maintenance person at the time of the observation confirmed that finding.

Based on observation and interview, the provider failed to maintain corridor door fire ratings of 20 minutes (or equivalent) for the computer closet door at the receptionist's desk. The door had two louvers in it. Findings include:

1. Observation at 1:45 p.m. revealed the computer room door behind the receptionist's desk at the main entrance lobby and did not meet a 20 minute fire door equivalency. The door had two 8 inch by 12 inch louvers in it for ventilation. Interview with maintenance at the time of the observation confirmed that finding.

Based on observation and interview, the provider failed to maintain the 30 minute fire resistive rating of smoke barrier walls. The north side of the smoke barrier wall at the nurses' station had an unsealed opening. There was a one inch hole for coaxial cable that was not sealed with an approved fire-stop material. Findings include:

1. Observation at 2:30 p.m. revealed the north side of the smoke barrier wall at the nurses' station had an unsealed opening. There was a one inch hole for coaxial cable above the lay-in ceiling. The opening was not sealed with an approved fire-stop material. Interview with the maintenance person at the time of the observation confirmed that finding.

Based on observation, the provider failed to maintain at least two conforming exits from the basement. Findings include:

1. Observation on 8/07/12 revealed the basement was not provided with two approved means of egress. The basement boiler room was approximately 35 feet by 20 feet (700 square feet). The second exit discharged through the crawl space.

The building meets the FSES. Please mark an "F" in the completion date column to indicate the provider's intent to correct deficiencies identified in K000.

Based on record review and interview, the provider failed to maintain emergency lighting of at least one and one-half hour duration for five battery pack emergency lights (two in the maintenance electrical room, the nurses' station, emergency room, and the operating room). Findings include:

1. Record review dated 12/06/11 by Western States Fire Protection Co. indicated five battery pack emergency lights (two in the maintenance electrical room, the nurses' station, emergency room, and the operating room) failed the annual 90 minute load test. Interview with the maintenance person revealed he believed the batteries were not required to function since the battery pack lights received power from the emergency generator.

Based on observation and interview, the provider failed to install readily visible illuminated exit signs to direct occupants to reach the exits from the basement boiler room. Findings include:

1. Observation at 2:30 p.m. revealed the basement boiler room was approximately 35 feet by 20 feet (700 square feet) with the second exit discharging through the crawl space. There were not any illuminated exit signs marking the exits. Interview with the maintenance person at the time of the observations confirmed those findings.

Based on record review and interview, the provider failed to document the sounding of the fire alarm on fire drill sheets and if the alarm signal had been received at the monitoring agency (Sheriff's office) for three months (March and September 2011 and March 2012) for the 18 month period beginning January 2011. There was not a drill conducted for the second shift for the quarter including April/May/June 2012. Findings include:

1. Fire drill record review revealed no documentation indicating the sounding of the fire alarm on fire drill sheets and if the alarm signal had been received at the monitoring agency (Sheriff's office) for three months (March and September 2011 and March 2012) for the 18 month period beginning July 2011. Those months had drills at 2340, 0200, and 0100 hours respectively which are normally times for silent drills. It was noted the provider conducted one drill per month for the 12 month period beginning July 2011.

Fire drill record review revealed there was not a drill conducted for the second shift (1900-0700 [7 p.m.-7 a.m.]) for the quarter including April/May/June 2012. The first shift (0700-1900 [7 a.m.-7 p.m.]) had a drill each month in that time period at 0910, 1045, and 1400 hours respectively.

Interview with the maintenance person at the time of the record review confirmed those findings.

Based on observation and interview, the provider failed to install the north exit manual pull station at the proper height. The operating part of the pull station was situated 61 inches above the finished floor. Findings include:

1. Observation beginning at 8:45 a.m. revealed manual fire alarm pull stations were mounted so the operating part of the station was 61 inches above the finished floor at the following locations:
*Adjacent to the cross-corridor doors at the main entrance lobby
*Adjacent patient room 122
*Adjacent to CSR
The height for mounting a manual pull station is to have the operating part of the pull station between 42 to 54 inches above the finished floor.

The building meets the FSES. Please mark an "F" in the completion date column to indicate correction of the deficiencies identified in K000.

A. Based on record review and interview, the provider failed to maintain emergency lighting of at least one and one-half hour duration for one battery pack emergency light (generator room above the clinic). There was not a battery pack emergency light installed for the generator transfer switch location. Findings include:

1. Record review dated 12/06/11 by Western States Fire Protection Co. indicated one battery pack emergency light in the generator room failed the annual 90 minute load test. Interview with the maintenance person revealed he believed the battery was not required to function since light received power from the emergency generator.

2. Observation at 3:15 p.m. revealed the second floor generator transfer switch location was not equipped with battery pack emergency light illumination. Interview with the maintenance person at the time of the observation confirmed that finding.

B. Based on observation and interview, the provider failed to prove that a quilt displayed on the wall of the exit corridor had been treated with flame retardant in accordance with the provisions of the Life Safety Code. Findings include:

1. Observation at 3:20 p.m. revealed a large 6 x 7 foot decorative quilt on display in the exit corridor. Interview with the maintenance person reveals the staff were unaware if any fire treatment had ever been applied to the decorative blankets. He indicated that there was no flame retardant documentation on file to confirm or deny application.

C. Based on observation and interview, the provider failed to install terminal covers for the generator battery and failed to install a battery that was not maintenance-free. Findings include:

1. Observation at 3:05 p.m. revealed the generator battery did not have covers on the terminals. Interview with the maintenance person at the time of the observation confirmed that finding. He stated terminal covers would be provided as soon as possible.

2. Observation at 3:10 p.m. revealed the generator battery was a maintenance-free battery. The maintenance free battery did not allow for the required weekly specific gravity testing of the battery. Interview with the maintenance person at the time of the observation confirmed that finding.

D. Based on observation and interview, the provider failed to install permanent wiring for physical therapy. An extension cord was used for a treadmill. (See attached (NFPA 70) Article 305 Temporary Installations. Findings include:

1. Observation at 3:45 p.m. revealed an extension cord was used for a treadmill in physical therapy. Interview with the maintenance person at the time of the observation confirmed that finding.

Based on observation and interview, the provider failed to install permanent wiring for the kitchenette at the nurses' station. A power strip was used for the coffee maker in the kitchenette. A multiple tap and a power strip were used at the copier. (See attached (NFPA 70) Article 305 Temporary Installations.) Findings include:

1. Observation at 2:45 p.m. revealed a power strip was used for the coffee maker in the kitchenette. Interview with the maintenance person at the time of the observation revealed the cord on the coffee maker was too short for its location with respect to the electrical outlet. The power strip was being used like an extension cord.

2. Observation at 2:55 p.m. revealed the copier was equipped with a multiple tap and a power strip. Interview with the maintenance person at the time of the observation confirmed that finding.