HospitalInspections.org

Based on observations and interview with the maintenance director during the tour of the facility it was determined the facility failed to maintain Exit Accessibility. This condition could endanger building occupants in the event of a fire or other types of emergencies requiring evacuation.

Findings include:

On 8/25/15 at 10:00 a.m. while on tour of the facility with the maintenance director it was observed the East wing maintenance corridor exit was obstructed with a large recycling bin, hand truck, and a flatbed cart. An interview was conducted with the maintenance director and confirmed the findings.
Per NFPA 101 (2000 Edition) 7.1.10.1 "Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency."

Based on observations and interview with the maintenance director, the facility failed to maintain battery back-up emergency lighting in the generator automatic transfer switch rooms for the generators. Battery back-up emergency lighting is required to ensure the safety of maintenance personnel in the event of a simultaneous failure of the public utility and the emergency generator.

Findings include:

On 8/25/15 at 11:30 a.m. while on tour of the facility with the Maintenance Director the generator automatic transfer switch gear rooms (2) for the 20 kW and the 50 kW generators it was observed that emergency lights were not installed, tested annually and or documented. Emergency lighting is required to service the generator and switch gear in the event of a simultaneous failure of the electric utility that serves the facility and the generator. An interview was conducted with the maintenance director and confirmed the findings.
Per NFPA 101 (2000 Edition) 7.9.3
Per NFPA 110 (1999 Edition) 7.3

Based on observations and interview with the maintenance director during the facility tour, the facility failed to maintain fire extinguishers. Fire extinguishers not maintained may delay action under hazardous conditions and endanger all building occupants.

Findings include:

During the facility tour with the maintenance director on 8/25/15 at 11:15 a.m. it was observed the following fire extinguishers' monthly and or annual inspections had not been completed:
1) fire extinguisher in box 21- last annual inspection was completed in 6/2014.
2) I.T. room fire extinguisher-no monthly inspections had been completed since annual done in 10/2014.
An interview was conducted with the maintenance director and confirmed the findings.
per NFPA 10 (1998 Edition) 4-1

Based on observations and interview with the maintenance director during facility tour, the facility failed to properly install ABHR (Alcohol Based Hand Rub) dispensers. ABHR installed above an ignition source can increase the chance of a hazardous situation and endanger persons utilizing the dispenser.

Findings include:

During the facility tour with the maintenance director on 8/25/15 at 10:15 a.m. it was found the ABHR dispensers were located over ignition sources in the following areas:
1) office room 125
2) staff lounge room 134
3) FCRC rooms 203, 205
4) addiction nurses station
An interview was conducted with the maintenance director at the time of each finding and confirmed the findings.
Per NFPA 101 (2000 Edition) 19.3.2.7(6)*

Based on observations and interview with the maintenance director during the tour of the facility it was determined the facility failed to maintain Exit Accessibility. This condition could endanger building occupants in the event of a fire or other types of emergencies requiring evacuation.

Findings include:

On 8/25/15 at 10:00 a.m. while on tour of the facility with the maintenance director it was observed the East wing maintenance corridor exit was obstructed with a large recycling bin, hand truck, and a flatbed cart. An interview was conducted with the maintenance director and confirmed the findings.
Per NFPA 101 (2000 Edition) 7.1.10.1 "Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency."

Based on observations and interview with the maintenance director, the facility failed to maintain battery back-up emergency lighting in the generator automatic transfer switch rooms for the generators. Battery back-up emergency lighting is required to ensure the safety of maintenance personnel in the event of a simultaneous failure of the public utility and the emergency generator.

Findings include:

On 8/25/15 at 11:30 a.m. while on tour of the facility with the Maintenance Director the generator automatic transfer switch gear rooms (2) for the 20 kW and the 50 kW generators it was observed that emergency lights were not installed, tested annually and or documented. Emergency lighting is required to service the generator and switch gear in the event of a simultaneous failure of the electric utility that serves the facility and the generator. An interview was conducted with the maintenance director and confirmed the findings.
Per NFPA 101 (2000 Edition) 7.9.3
Per NFPA 110 (1999 Edition) 7.3

Based on observations and interview with the maintenance director during the facility tour, the facility failed to maintain fire extinguishers. Fire extinguishers not maintained may delay action under hazardous conditions and endanger all building occupants.

Findings include:

During the facility tour with the maintenance director on 8/25/15 at 11:15 a.m. it was observed the following fire extinguishers' monthly and or annual inspections had not been completed:
1) fire extinguisher in box 21- last annual inspection was completed in 6/2014.
2) I.T. room fire extinguisher-no monthly inspections had been completed since annual done in 10/2014.
An interview was conducted with the maintenance director and confirmed the findings.
per NFPA 10 (1998 Edition) 4-1