HospitalInspections.org

Based on observation, testing, and staff interviews it was determined the facility failed to maintain doors in corridors capable of resisting fire for at least 20 minutes and having no impediment to closing the doors.
The findings were:
During a tour of the facility with Staff M on 03/10/14 from 1:50 p.m. to 4:10 p.m. it was observed by testing that the ER smoke doors do not create a smoke resistant seal at their leading edges.
These findings were confirmed by Staff M at the time of discovery.

walls to provide at least a one half hour fire resistance rating.

The findings were:

During a tour of the facility with Staff M on 03/10/14 from 1:50 p.m. to 4:10 p.m. it was observed that there unprotected penetrations in smoke and fire walls in the below locations:

· Central Supply
· First floor Electrical Closet
· North Hall above ceiling at smoke doors

These finding were confirmed by Staff M at the time of discovery.

Based on observation and staff interviews it was determined the facility failed to maintain emergency lighting of at least one and one half hours duration.
The findings were:
During the tour of the facility with Staff M on 03/10/14 from 1:50 p.m. to 4:10 p.m. it was observed that no emergency lights are installed from the South Exit door of the facility to the public way.
These findings were confirmed by Staff M at the time of discovery.

Based on observation, review of facility fire drill records, and staff interviews it was determined the facility failed to ensure that drills are conducted one per shift per quarter..
The findings were:
During a review of facility fire drill records on 03/10/14 at approximately 1:15 p.m. it was determined the facility failed to conduct fire drills on the Third Shift for the past 12 months.
During a review of facility fire drill records on 03/10/14 at approximately 1:25 p.m. it was determined the facility is not conducting fire drills at unexpected times. Second shift drills were conducted between 3:35 and 4:30.
These findings were confirmed by Staff A at the time of discovery.

Based on a review of fire alarm inspection reports and staff interviews it was determined the facility failed to properly maintain the fire alarm system.
The findings were:
During a tour of the facility with Staff A on 03/10/14 from 1:50 p.m. to 4:10 p.m. it revealed that no sensitivity testing of the smoke detectors has occurred in over 3 years.
These findings were confirmed by Staff A at the time of discovery.

Based on observation and staff interview it was determined the facility fire sprinkler system is not maintained in accordance with NFPA 25.

The findings were:

During a tour of the facility with Staff M on 03/10/14 from 1:50 p.m. to 4:10 p.m. it was observed that a fire sprinkler head is pushed through the ceiling in the Lab.

These findings were confirmed by Staff M at the time of discovery.

Tag K 130
Based on observations and staff interviews it was determined that the facility failed to provide proper egress pathway from all exits to the public way and to provide proper identification of natural gas lies. NFPA 100 and the Gas Code.
The finding were:

During a tour of the facility with Staff M on 03/10/14 from 1:50 p.m. to 4:10 p.m. it was observed that the South exit from the facility does not have an all-weather surface from the door to the public way.
During a tour of the facility with Staff M on 03/10/14 from 1:50 p.m. to 4:10 p.m. it was observed that the natural gas line throughout the facility are not identified as required.
These findings were confirmed by Staff M at the time of discovery.

Based on observation and staff interview it was determined the facility failed to maintain the electrical wiring in accordance with NFPA 70, The National Electrical Code.

The finding were:

During a tour of the facility with Staff M on 03/10/14 from 1:50 p.m. to 4:10 p.m. it was observed that a knockout is missing from a disconnect box in the Kitchen next to the ice maker.

During a tour of the facility with Staff M on 03/10/14 from 1:50 p.m. to 4:10 p.m. it was observed that three water heaters are connected to an electrical source by a flexible power cord into an outlet. Must be hardwired.

During a tour of the facility with Staff M on 03/10/14 from 1:50 p.m. to 4:10 p.m. it was observed that extension cords are being used as permanent wiring in the Following areas.

· Boiler Room
· Kitchen
During a tour of the facility with Staff M on 03/10/14 from 1:50 p.m. to 4:10 p.m. it was observed that low voltage wires are strapped to natural gas lines in Central Supply.

These findings were confirmed by Staff M at the time of discovery.

Based on observation, testing, and staff interviews it was determined the facility failed to maintain doors in corridors capable of resisting fire for at least 20 minutes and having no impediment to closing the doors.
The findings were:
During a tour of the facility with Staff M on 03/10/14 from 1:50 p.m. to 4:10 p.m. it was observed by testing that the ER smoke doors do not create a smoke resistant seal at their leading edges.
These findings were confirmed by Staff M at the time of discovery.

walls to provide at least a one half hour fire resistance rating.

The findings were:

During a tour of the facility with Staff M on 03/10/14 from 1:50 p.m. to 4:10 p.m. it was observed that there unprotected penetrations in smoke and fire walls in the below locations:

· Central Supply
· First floor Electrical Closet
· North Hall above ceiling at smoke doors

These finding were confirmed by Staff M at the time of discovery.

Based on observation and staff interviews it was determined the facility failed to maintain emergency lighting of at least one and one half hours duration.
The findings were:
During the tour of the facility with Staff M on 03/10/14 from 1:50 p.m. to 4:10 p.m. it was observed that no emergency lights are installed from the South Exit door of the facility to the public way.
These findings were confirmed by Staff M at the time of discovery.

Based on observation, review of facility fire drill records, and staff interviews it was determined the facility failed to ensure that drills are conducted one per shift per quarter..
The findings were:
During a review of facility fire drill records on 03/10/14 at approximately 1:15 p.m. it was determined the facility failed to conduct fire drills on the Third Shift for the past 12 months.
During a review of facility fire drill records on 03/10/14 at approximately 1:25 p.m. it was determined the facility is not conducting fire drills at unexpected times. Second shift drills were conducted between 3:35 and 4:30.
These findings were confirmed by Staff A at the time of discovery.

Based on a review of fire alarm inspection reports and staff interviews it was determined the facility failed to properly maintain the fire alarm system.
The findings were:
During a tour of the facility with Staff A on 03/10/14 from 1:50 p.m. to 4:10 p.m. it revealed that no sensitivity testing of the smoke detectors has occurred in over 3 years.
These findings were confirmed by Staff A at the time of discovery.

Based on observation and staff interview it was determined the facility fire sprinkler system is not maintained in accordance with NFPA 25.

The findings were:

During a tour of the facility with Staff M on 03/10/14 from 1:50 p.m. to 4:10 p.m. it was observed that a fire sprinkler head is pushed through the ceiling in the Lab.

These findings were confirmed by Staff M at the time of discovery.

Tag K 130
Based on observations and staff interviews it was determined that the facility failed to provide proper egress pathway from all exits to the public way and to provide proper identification of natural gas lies. NFPA 100 and the Gas Code.
The finding were:

During a tour of the facility with Staff M on 03/10/14 from 1:50 p.m. to 4:10 p.m. it was observed that the South exit from the facility does not have an all-weather surface from the door to the public way.
During a tour of the facility with Staff M on 03/10/14 from 1:50 p.m. to 4:10 p.m. it was observed that the natural gas line throughout the facility are not identified as required.
These findings were confirmed by Staff M at the time of discovery.

Based on observation and staff interview it was determined the facility failed to maintain the electrical wiring in accordance with NFPA 70, The National Electrical Code.

The finding were:

During a tour of the facility with Staff M on 03/10/14 from 1:50 p.m. to 4:10 p.m. it was observed that a knockout is missing from a disconnect box in the Kitchen next to the ice maker.

During a tour of the facility with Staff M on 03/10/14 from 1:50 p.m. to 4:10 p.m. it was observed that three water heaters are connected to an electrical source by a flexible power cord into an outlet. Must be hardwired.

During a tour of the facility with Staff M on 03/10/14 from 1:50 p.m. to 4:10 p.m. it was observed that extension cords are being used as permanent wiring in the Following areas.

· Boiler Room
· Kitchen
During a tour of the facility with Staff M on 03/10/14 from 1:50 p.m. to 4:10 p.m. it was observed that low voltage wires are strapped to natural gas lines in Central Supply.

These findings were confirmed by Staff M at the time of discovery.