HospitalInspections.org

Based on staff interview and a review of the available documentation, the facility has not maintained the fire alarm system testing and maintenance documentation in accordance with NFPA 72 National Fire Alarm Code 2010 edition 14.6.2. This deficient practice could affect 25 of 25 patients.


Findings include:

On 11/30/2020, at 10:30 a.m. during a review of all available fire alarm maintenance and testing documentation for the last 12 months, and an interview with the Maintenance Supervisor it was revealed that at the time of the inspection the facility's fire alarm test documentation did not contain a detailed list of all the devices that had been tested and the results of the testing completed on each device.


This deficient condition was confirmed by a Maintenance Supervisor.

Based on observation and interview, the facility had a corridor door that did not meet the requirements of NFPA 101 "The Life Safety Code" 2012 edition (LSC) section 19.3.6.4. This deficient practice could affect 25 patients.


Findings include:

On 11/30/2020, at 2:41 p.m. during the facility tour observations revealed that the corridor door to transformer room located on the lower level had a transfer grill / louver on the lower portion of the door.

This deficient condition was confirmed by a Maintenance Supervisor.

Based on observation and staff interview the facility failed to maintain 4 smoke barrier doors in accordance with the Life Safety Code (NFPA 101) 2012 edition section 8.5.4.1 and NFPA 80 the Standard for Fire Doors and Other Opening Protective's, 2010 edition, section 6.3.1.7.1. This deficient practice could allow the transfer of smoke from one smoke compartment to another making the corridors untenable. This condition could affect 10 of the 25 patients.

Findings include:

1. On 11/30/2020, at 2:10 p.m. during the facility tour observations revealed the cross corridor doors by patient room 298 had a center door gap that exceeds 1/8 inch.

2. On 11/30/2020, at 1:50 p.m. during the facility tour observations revealed the cross corridor doors by patient room 228 had a center door gap that exceeds 1/8 inch.

This deficient condition was confirmed by a Maintenance Supervisor.

Based on staff interview and a review of the available documentation, it was determined that the facility failed to vary the dates and times of the fire drills in accordance with the NFPA 101 "The Life Safety Code" 2012 edition (LSC) section 19.7.1.6, during the last 12 months. This deficient practice could affect 25 of 25 patients.


Findings include:

1. On 11/30/2020, at 11:00 a.m. during the review of all available fire drill documentation and interview with the Maintenance Supervisor it was revealed that the facility failed to vary the dates of the fire drills by conducting fire drill on the last day of the month as note by 4 fire drills conducted on the 30th of the month and 3 fire drills on the 31st of the month.

2. On 11/30/2020, at 11:00 a.m. during the review of all available fire drill documentation and interview with the Maintenance Supervisor it was revealed that the facility failed to vary the times of the day shift fire drills by conducting 3 fire drills in the 1 p.m. hour.


This deficient condition was confirmed by a Maintenance Supervisor.

Based on staff interview and a review of the available documentation, the facility has failed to provide a complete and current facility Risk Assessment in accordance with the NFPA 99 "Health Care Facilities Code" 2012 edition section 4.1. This deficient practice could affect 25 of 25 patients.


Findings include:

On 11/30/2020, at 10:45 a.m. during the documentation review and an interview with the Maintenance Supervisor it was revealed that the facility could not provide a completed utility risk assessment document at the time of the inspection.


This deficient condition was confirmed by a Maintenance Supervisor.

Based on observations and staff interview, that the oxygen storage room was not maintained in accordance with NFPA 99 Standards for Health Care Facilities 2012 Edition section 11.3.2.3. This deficient practice could create an oxygen enriched atmosphere that could contribute to rapid fire growth. This could negatively affect 10 of 25 patients.

Findings include:

1. On 11/30/2020 at 1:45 p.m., during the facility tour, observations revealed that the oxygen storage area is located in a closet that is located in office room 243 which did not have a self-closing door.

2. On 11/30/2020 at 1:45 p.m., during the facility tour, observations revealed that the oxygen cylinders located in the oxygen storage closet in office room 243 were being stored next to combustible materials that are being stored within the same closet space.


This deficient condition was confirmed by a Maintenance Supervisor.