HospitalInspections.org

This STANDARD is not met as evidenced by: Based on observations and staff interviews the facility failed to ensure that door openings closed to resist the passage of smoke to corridors. This potentially exposes residents to a smoke/fire environment. Findings include:


During the facility tour on 8/22/2012 at 10:30 am observations on the third floor revealed that the door to Storage Room 3376, which opened to the hospital corridor, had items stored in the room which blocked the door and kept it from closing when it was tested. Staff was immediately advised and the stored items were redistributed to other storage areas. Further observations at 10:45 am revealed that the break room boor (room 3362) did not latch when tested. Further observation on the second floor at 10:59 am revealed that the double doors in the corridor between the ICCU Suite and the OB Suite would not close and latch. Further observation on the 1st floor revealed that the double doors to Central Supply did not have a coordinator installed and the astragal blocked the doors, keeping them from properly closing and latching.


The above findings were acknowledged at the time by the Facilities Director.



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This STANDARD is not met as evidenced by: Based on observations and staff interviews the facility failed to maintain the integrity of smoke barriers per NFPA 101 (2000 edition), 8.3.6.1. This potentially allows the spread of smoke from one area to other areas of the facility, exposing residents to a smoke or fire environment. Findings include:


During the facility tour on 8/22/2012 at approximately 11:05 am, observations revealed an approximately ? inch diameter hole in the smoke fire barrier above the double doors in corridor 2400 (near the Lab). The hole appeared to have been made with a screwdriver and had a single wire run through it. Building maintenance filled the space around the wire with fire chalk within 30 minutes of our finding the penetration.


The above findings were acknowledged at the time by the Facilities Director.


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This STANDARD is not met as evidenced by: Based on observations and staff interviews the facility failed to ensure that the hyperbaric chamber was protected with a fire suppression system as required by NFPA 99. This potentially exposes residents and staff working in the hyperbaric chamber to a smoke/fire environment. Findings include:


During the facility tour on 8/21/2012 at 3:40 pm observations revealed that the hyperbaric chamber did not have a fire suppression system installed inside the chamber as required by NFPA 99 (1999 edition), Section 19-2.5.1.1. Observations revealed that the chamber has a water based fire extinguisher in side. Interview and record review at 9:30 am on 8/22/2012 with the Director of Diagnostic Imaging and Respiratory Therapy revealed that on January 190, 1985 the lack of a fire suppression system was brought to the attention of the State Fire Marshal and that in a letter dated January 28, 1986 the State Fire Marshal had come to the conclusion that due to the age of the hyperbaric chamber (approximately 1972) that requiring a sprinkler system in the chamber was not justify due to the cost. This issue does not appear to have been addressed since 1986.


The above findings were acknowledged at the time by the Facilities Director.


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This STANDARD is not met as evidenced by: Based on observations and staff interviews the facility failed to ensure that door openings closed to resist the passage of smoke to corridors. This potentially exposes residents to a smoke/fire environment. Findings include:


During the facility tour on 8/22/2012 at 10:30 am observations on the third floor revealed that the door to Storage Room 3376, which opened to the hospital corridor, had items stored in the room which blocked the door and kept it from closing when it was tested. Staff was immediately advised and the stored items were redistributed to other storage areas. Further observations at 10:45 am revealed that the break room boor (room 3362) did not latch when tested. Further observation on the second floor at 10:59 am revealed that the double doors in the corridor between the ICCU Suite and the OB Suite would not close and latch. Further observation on the 1st floor revealed that the double doors to Central Supply did not have a coordinator installed and the astragal blocked the doors, keeping them from properly closing and latching.


The above findings were acknowledged at the time by the Facilities Director.



.

This STANDARD is not met as evidenced by: Based on observations and staff interviews the facility failed to maintain the integrity of smoke barriers per NFPA 101 (2000 edition), 8.3.6.1. This potentially allows the spread of smoke from one area to other areas of the facility, exposing residents to a smoke or fire environment. Findings include:


During the facility tour on 8/22/2012 at approximately 11:05 am, observations revealed an approximately ½ inch diameter hole in the smoke fire barrier above the double doors in corridor 2400 (near the Lab). The hole appeared to have been made with a screwdriver and had a single wire run through it. Building maintenance filled the space around the wire with fire chalk within 30 minutes of our finding the penetration.


The above findings were acknowledged at the time by the Facilities Director.


.

This STANDARD is not met as evidenced by: Based on observations and staff interviews the facility failed to ensure that the hyperbaric chamber was protected with a fire suppression system as required by NFPA 99. This potentially exposes residents and staff working in the hyperbaric chamber to a smoke/fire environment. Findings include:


During the facility tour on 8/21/2012 at 3:40 pm observations revealed that the hyperbaric chamber did not have a fire suppression system installed inside the chamber as required by NFPA 99 (1999 edition), Section 19-2.5.1.1. Observations revealed that the chamber has a water based fire extinguisher in side. Interview and record review at 9:30 am on 8/22/2012 with the Director of Diagnostic Imaging and Respiratory Therapy revealed that on January 190, 1985 the lack of a fire suppression system was brought to the attention of the State Fire Marshal and that in a letter dated January 28, 1986 the State Fire Marshal had come to the conclusion that due to the age of the hyperbaric chamber (approximately 1972) that requiring a sprinkler system in the chamber was not justify due to the cost. This issue does not appear to have been addressed since 1986.


The above findings were acknowledged at the time by the Facilities Director.


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