HospitalInspections.org

Based on observations it was determined that one of ten 1 1/2 -hour fire barrier doors tested wa not in accordance with NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 19.1.1.4.1. This deficient practice could allow the products of combustion to travel from the ambulance garage into the hospital building, which will negatively impact all 64 patients, staff and visitors of the facility.

Findings include:
Observations and testing of doors during the facility tour on September 4, 2013, between 08:30 am and 11:00 am, by surveyor 03005, revealed that the 1 1/2 hour fire rated corridor door into the ambulance garage was not latching.

This finding was verified by the maintenance staff during the facility tour and with the Director of Facilities, the CEO and other staff during the exit conference.

Based on observations it was determined that the smoke barriers are not in accordance with NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 8.3.6. This deficient practice could allow the products of combustion to travel throughout the building by passing through the smoke barrier, which will negatively impact all 64 of the patients, staff and visitors.

Findings include:
Observations of six smoke barriers, during the facility tour on September 4, 2013, between 08:30 am and 11:00 am, by surveyor 03006, revealed that:

1) The smoke barrier between the Acute Rehab and Med Surg wings has a 3 inch open wiring sleeve in the corridor above suspended ceiling,

2) The smoke barrier between Med Surg and Women's Health wings has a 3 inch open wiring sleeve in the corridor above suspended ceiling,

3) The smoke barrier between Women's Health and the main corridor has 2 wire penetrations through it that are not properly sealed, and

4) The smoke barrier by room 322 has holes in it that have not been sealed.

This finding was verified by the Director of Facilities during the facility tour and with the CEO and other staff during the exit conference.

Based on observations and an interview with staff it was determined that the exit discharge lighting is not in accordance with NFPA 101 "The Life Safety Code" 2000 edition (LSC) sections 18.2.8 and 7.8, This deficient practice could affect all 64 patients, staff and visitors using the north west exits, if the facility needs to be quickly evacuated and the exit lighting has failed.

Findings include:
Observations and an interview with the Director of Facilities during the facility tour on September 4, 2013, between 08:30 am and 11:00 am, by surveyor 03006, revealed that the exterior exit discharge lighting for the north west wing exits from the Acute Rehab, Med Surg and Women's Health have a single bulb unit and if the bulb fails the areas are left in total darkness.

This finding was verified by the Director of Facilities during the facility tour and with the CEO and other staff during the exit conference.

Based on observations it was determined that four smoke detectors are within 3 feet of openings into the HVAC system and not installed in accordance with NFPA 72 " The National Fire Alarm Code" 1999 edition section 2-3.5.1. Improper location of smoke detectors may allow a delay in alarming staff, causing a delay in the response to the fire emergency, which would negatively impact all 64 residents, staff and visitors of the facility.

Findings include:
Observations during the facility tour on September 4, 2013, between 08:30 am and 11:00 am, by surveyor 03006 and surveyor 03005, revealed that the following smoke detectors are within the air flow of the facility's air handling system;

1) The detector in the CT scan equipment room,

2) The detector in the corridor of Acute Rehab outside of room 250,

3) The detector in the corridor outside of the ambulance garage,

4) The detector in the main corridor outside of the bathrooms near the gift shop.

These findings were verified by the maintenance staff during the facility tour and with the Director of Facilities, the CEO and other staff during the exit conference.

Based on observations it was determined that the automatic sprinkler system has not been installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems 1999 edition. This deficient practice may allow a fire to grow which will negatively impact all 64 patients, staff and visitors near these locations.

Findings include:
Observations during the facility tour on September 4, 2013, between 08:30 am and 11:00 am, by surveyor 03005, revealed that the sprinkler heads in walk in coolers and the freezers are clear and may not operate as designed.

This finding was verified by the maintenance staff during the facility tour and with the Director of Facilities, the CEO and other staff during the exit conference.

Based on observations it was determined that the corridors have projections into them and do not comply with NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 18.7.2.3. This deficient practice could negatively affect all 64 patients, staff and visitors that may need to be quickly evacuated through these corridors.

Findings include:
Observations during the facility tour on September 4, 2013, between 08:30 am and 11:00 am, by surveyor 03006, revealed that the tube type light fixtures in the corridor project 7 1/2 inches into the corridor width and are mounted at 6' 5" above the floor.

This finding was verified by the Director of Facilities during the facility tour and with the CEO and other staff during the exit conference.

Based on observations and an interview with staff it was determined that the waste flammable liquids in the laboratory are not stored in accordance with NFPA 30 Flammable and Combustible Liquids Code 1996 edition. This deficient practice could allow these products to fuel a fire, over whelming the sprinkler system, which will negatively impact any patients, staff and visitors in the laboratory area.

Findings include:
Observations and interview with laboratory staff during the facility tour on September 4, 2013, between 08:30 am and 11:00 am, by surveyor 03006, revealed that the laboratory staff are storing used flammable and combustible liquids under a sink and not in an approved flammable liquids storage cabinet.

This finding was verified by the Director of Facilities during the facility tour and with the CEO and other staff during the exit conference.

Based on observations it was determined that some electrical installations are not in accordance with NFPA 70 "The National Electrical Code 1999 edition. This deficiency could negatively effect any staff and visitors in this area of the facility.

Findings include:
Observations and testing of doors during the facility tour on September 4, 2013, between 08:30 am and 11:00 am, by surveyor 03006, revealed that power taps used in the ARU Training room are plugged into other power taps and not plugged directly into an outlet. Three are "daisy chained' together in one string and two in another.

This finding was verified by the Director of Facilities during the facility tour and with the CEO and other staff during the exit conference.

Based on observations it was determined that the alcohol based hand sanitizer dispensers installed in the facility are not in accordance with CFR 483.70 Alcohol Based Hand Rubs and the Minnesota State Fire Code (2007 edition). This deficient practice could allow the ignition of the waterless flammable hand sanitizer causing a fire that would negatively impact the patients, staff and visitors within the room that the dispensers are located in.

Findings include:
Observations during the facility tour on September 4, 2013, between 08:30 am and 11:00 am, by surveyor 03006, revealed various patient sleeping rooms have alcohol based hand sanitizers mounted to close to electrical light switches. the rooms observed include 306, 316, 318, 357, 358, and 359. The Director of Facilities stated that a new vendor was replacing all existing hand sanitizer dispensers throughout the facility.

This finding was verified by the Director of Facilities during the facility tour and with the CEO and other staff during the exit conference.

Based on observations it was determined that one of ten 1 1/2 -hour fire barrier doors tested wa not in accordance with NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 19.1.1.4.1. This deficient practice could allow the products of combustion to travel from the ambulance garage into the hospital building, which will negatively impact all 64 patients, staff and visitors of the facility.

Findings include:
Observations and testing of doors during the facility tour on September 4, 2013, between 08:30 am and 11:00 am, by surveyor 03005, revealed that the 1 1/2 hour fire rated corridor door into the ambulance garage was not latching.

This finding was verified by the maintenance staff during the facility tour and with the Director of Facilities, the CEO and other staff during the exit conference.

Based on observations it was determined that the smoke barriers are not in accordance with NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 8.3.6. This deficient practice could allow the products of combustion to travel throughout the building by passing through the smoke barrier, which will negatively impact all 64 of the patients, staff and visitors.

Findings include:
Observations of six smoke barriers, during the facility tour on September 4, 2013, between 08:30 am and 11:00 am, by surveyor 03006, revealed that:

1) The smoke barrier between the Acute Rehab and Med Surg wings has a 3 inch open wiring sleeve in the corridor above suspended ceiling,

2) The smoke barrier between Med Surg and Women's Health wings has a 3 inch open wiring sleeve in the corridor above suspended ceiling,

3) The smoke barrier between Women's Health and the main corridor has 2 wire penetrations through it that are not properly sealed, and

4) The smoke barrier by room 322 has holes in it that have not been sealed.

This finding was verified by the Director of Facilities during the facility tour and with the CEO and other staff during the exit conference.

Based on observations and an interview with staff it was determined that the exit discharge lighting is not in accordance with NFPA 101 "The Life Safety Code" 2000 edition (LSC) sections 18.2.8 and 7.8, This deficient practice could affect all 64 patients, staff and visitors using the north west exits, if the facility needs to be quickly evacuated and the exit lighting has failed.

Findings include:
Observations and an interview with the Director of Facilities during the facility tour on September 4, 2013, between 08:30 am and 11:00 am, by surveyor 03006, revealed that the exterior exit discharge lighting for the north west wing exits from the Acute Rehab, Med Surg and Women's Health have a single bulb unit and if the bulb fails the areas are left in total darkness.

This finding was verified by the Director of Facilities during the facility tour and with the CEO and other staff during the exit conference.

Based on observations it was determined that four smoke detectors are within 3 feet of openings into the HVAC system and not installed in accordance with NFPA 72 " The National Fire Alarm Code" 1999 edition section 2-3.5.1. Improper location of smoke detectors may allow a delay in alarming staff, causing a delay in the response to the fire emergency, which would negatively impact all 64 residents, staff and visitors of the facility.

Findings include:
Observations during the facility tour on September 4, 2013, between 08:30 am and 11:00 am, by surveyor 03006 and surveyor 03005, revealed that the following smoke detectors are within the air flow of the facility's air handling system;

1) The detector in the CT scan equipment room,

2) The detector in the corridor of Acute Rehab outside of room 250,

3) The detector in the corridor outside of the ambulance garage,

4) The detector in the main corridor outside of the bathrooms near the gift shop.

These findings were verified by the maintenance staff during the facility tour and with the Director of Facilities, the CEO and other staff during the exit conference.

Based on observations it was determined that the automatic sprinkler system has not been installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems 1999 edition. This deficient practice may allow a fire to grow which will negatively impact all 64 patients, staff and visitors near these locations.

Findings include:
Observations during the facility tour on September 4, 2013, between 08:30 am and 11:00 am, by surveyor 03005, revealed that the sprinkler heads in walk in coolers and the freezers are clear and may not operate as designed.

This finding was verified by the maintenance staff during the facility tour and with the Director of Facilities, the CEO and other staff during the exit conference.

Based on observations it was determined that the corridors have projections into them and do not comply with NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 18.7.2.3. This deficient practice could negatively affect all 64 patients, staff and visitors that may need to be quickly evacuated through these corridors.

Findings include:
Observations during the facility tour on September 4, 2013, between 08:30 am and 11:00 am, by surveyor 03006, revealed that the tube type light fixtures in the corridor project 7 1/2 inches into the corridor width and are mounted at 6' 5" above the floor.

This finding was verified by the Director of Facilities during the facility tour and with the CEO and other staff during the exit conference.

Based on observations and an interview with staff it was determined that the waste flammable liquids in the laboratory are not stored in accordance with NFPA 30 Flammable and Combustible Liquids Code 1996 edition. This deficient practice could allow these products to fuel a fire, over whelming the sprinkler system, which will negatively impact any patients, staff and visitors in the laboratory area.

Findings include:
Observations and interview with laboratory staff during the facility tour on September 4, 2013, between 08:30 am and 11:00 am, by surveyor 03006, revealed that the laboratory staff are storing used flammable and combustible liquids under a sink and not in an approved flammable liquids storage cabinet.

This finding was verified by the Director of Facilities during the facility tour and with the CEO and other staff during the exit conference.

Based on observations it was determined that some electrical installations are not in accordance with NFPA 70 "The National Electrical Code 1999 edition. This deficiency could negatively effect any staff and visitors in this area of the facility.

Findings include:
Observations and testing of doors during the facility tour on September 4, 2013, between 08:30 am and 11:00 am, by surveyor 03006, revealed that power taps used in the ARU Training room are plugged into other power taps and not plugged directly into an outlet. Three are "daisy chained' together in one string and two in another.

This finding was verified by the Director of Facilities during the facility tour and with the CEO and other staff during the exit conference.