HospitalInspections.org

Based upon record review, the facility failed to document a specific written plan for the protection of all patients and for their evacuation in the event of an emergency. This has the potential of affecting staff preparation and experience in providing for the protection of all residents in the event of a fire. This facility has a capacity of 25 with a census of 4.

Findings include:

Record review on 01-13-16, of the facilities evacuation and emergency plans documentation showed that the plan was very extensive but did not indicate evacuation from immediate area of danger (x smoke zone) to (y smoke zone) located on the other side of the smoke barrier.

Maintenance Staff (A) verified the documentation.

Based on observation and interview, the facility failed to provide a properly maintained fire alarm system. The deficient practice of failing to have the Main Fire Alarm Panel communicating the alarm signal to the monitoring company would affect all of the building occupants. This facility has a capacity of 25 and a census of 4 residents.

Findings include:

Record review and interview of Maintenance Staff (A) on 01-13-16 at 10:00 a.m., revealed there was no documentation that the Monitoring Company was contacted after the activation of the Fire Alarm System during the fire drills.

Maintenance Staff (A) verified this documentation.

Observation and interview, revealed the facility failed to maintain the sprinkler system in accordance with the 1998 edition of NFPA 25, by ensuring that the facility failed to maintain the system with an acceptable clearance around sprinkler heads to prevent obstructions to spray patterns. This item could effect the operation of the heads by obstructing spray patterns. This facility with a capacity of 25 and a census of 4.

Findings include:

Observation and interview on 01-13-16 at approximately 11:04 a.m., revealed the Cardiac Rehabilitation Room contained a built in closet that extend to the ceiling. The closet was not provided with sprinkler protection.

Maintenance Staff (A) verified these observations.

(A)
Observation and interview revealed the facility failed to maintain the sprinkler system in accordance with the 1998 edition of NFPA 25, by ensuring that Wet System Sprinkler Riser gauges are calibrated. This item could effect the operation of the sprinkler system in the event of a fire emergency. This deficient practice affects all occupants in this facility with a capacity of 25 and a census of 4.

Findings include:

The facility failed to properly maintain the sprinkler system in accordance with NFPA 25 as evidenced by:

Observation and interview on 01-13-16 at approximately 10:55 a.m., showed the sprinkler riser located in the basement for the Boiler Room contained a gauge with no date. Gauges need to be replaced or recalculated every 5 years. Maintenance Staff was unable to verify the year of install for the gauge.

(B)
Based on observation and interview, the facility is not maintaining the sprinkler system in accordance with the 1998 edition of NFPA 25, 2-2.1.1, by ensuring that sprinkler heads are free of foreign material. This can effect the operation of the heads by obstructing spray patterns, delay the response time or even cause the heads to be inoperable which can compromise the effectiveness of the fire suppression system and place occupants at risk of injury in the event of a fire. This deficient practice affects all occupants including staff, visitors and residents in one of four smoke zones. The facility had a capacity of 25 and a census of 4 at the time of survey.

Findings include:

1. Observation and interview on 01-13-16 at approximately 9:44 a.m., revealed in the Main Entrance Corridor the sprinkler head next to the Reception Office was coated with dust that covered the fusible bulb.

2. Observation and interview on 01-13-16 at approximately 11:03 a.m., revealed in the Cardiac Rehabilitation Office the sprinkler head was coated with dust that covered the fusible bulb.

Maintenance Staff (A) verified these observations.

Based on observation and interview, the facility failed to ensure the buildings emergency generator was properly equipped with a remote manual stop mechanism in accordance with National Fire Protection Association (NFPA) 110, 1999 Edition. This deficient practice affects all occupants throughout the facility. This facility has a capacity of 25 and a census of 4.

Findings include:

Observations and interview on 01-13-16 at 12:30 p.m., revealed the facilities emergency generator was not equipped with a remote manual stop mechanism (emergency shut-off).

NFPA 110, 1999 edition 3-5.5.6

3-5.5.6* All level 1 and level 2 installations shall have a remote manual stop station of a type similar to a break glass station located outside the room housing the prime mover, where so installed or located elsewhere on the premises where the prime mover is located outside the building

A3-5.5.6 For level 1 and level 2 systems located outdoors the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified.

Based on observation and interview, it was determined the facility failed to maintain the buildings electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition, placing the Staff and Residents of the facility at risk in the event of a fire. The facility had a capacity of 25 and a census of 4 at the time of the survey.

Findings Include:

1. Observations and interview on 01-13-16 at 12:10 p.m., revealed the facility failed to maintain the electrical system in the X-Ray Corridor. Panel LNR breakers 43 & 45 were in the on position charged and labeled as spares.

2. Observation and interview on 01-13-16 at approximately 11:00 a.m., revealed the facility failed to prohibit the improper use of a surge-protectors. On the above date a surge-protector was piggy backed into another surge-protector under a desk in the Front Office used for computer equipment.

3. Observation and interview on 01-13-16 at approximately 11:34 a.m., revealed the facility failed to prohibit the improper use of a surge-protectors. On the above date a surge-protector was piggy backed into another surge-protector under a desk in the Medical Records Office used for computer equipment.

Maintenance Staff (A) verified these observations.

Based upon record review, the facility failed to document a specific written plan for the protection of all patients and for their evacuation in the event of an emergency. This has the potential of affecting staff preparation and experience in providing for the protection of all residents in the event of a fire. This facility has a capacity of 25 with a census of 4.

Findings include:

Record review on 01-13-16, of the facilities evacuation and emergency plans documentation showed that the plan was very extensive but did not indicate evacuation from immediate area of danger (x smoke zone) to (y smoke zone) located on the other side of the smoke barrier.

Maintenance Staff (A) verified the documentation.

Based on observation and interview, the facility failed to provide a properly maintained fire alarm system. The deficient practice of failing to have the Main Fire Alarm Panel communicating the alarm signal to the monitoring company would affect all of the building occupants. This facility has a capacity of 25 and a census of 4 residents.

Findings include:

Record review and interview of Maintenance Staff (A) on 01-13-16 at 10:00 a.m., revealed there was no documentation that the Monitoring Company was contacted after the activation of the Fire Alarm System during the fire drills.

Maintenance Staff (A) verified this documentation.

Observation and interview, revealed the facility failed to maintain the sprinkler system in accordance with the 1998 edition of NFPA 25, by ensuring that the facility failed to maintain the system with an acceptable clearance around sprinkler heads to prevent obstructions to spray patterns. This item could effect the operation of the heads by obstructing spray patterns. This facility with a capacity of 25 and a census of 4.

Findings include:

Observation and interview on 01-13-16 at approximately 11:04 a.m., revealed the Cardiac Rehabilitation Room contained a built in closet that extend to the ceiling. The closet was not provided with sprinkler protection.

Maintenance Staff (A) verified these observations.

(A)
Observation and interview revealed the facility failed to maintain the sprinkler system in accordance with the 1998 edition of NFPA 25, by ensuring that Wet System Sprinkler Riser gauges are calibrated. This item could effect the operation of the sprinkler system in the event of a fire emergency. This deficient practice affects all occupants in this facility with a capacity of 25 and a census of 4.

Findings include:

The facility failed to properly maintain the sprinkler system in accordance with NFPA 25 as evidenced by:

Observation and interview on 01-13-16 at approximately 10:55 a.m., showed the sprinkler riser located in the basement for the Boiler Room contained a gauge with no date. Gauges need to be replaced or recalculated every 5 years. Maintenance Staff was unable to verify the year of install for the gauge.

(B)
Based on observation and interview, the facility is not maintaining the sprinkler system in accordance with the 1998 edition of NFPA 25, 2-2.1.1, by ensuring that sprinkler heads are free of foreign material. This can effect the operation of the heads by obstructing spray patterns, delay the response time or even cause the heads to be inoperable which can compromise the effectiveness of the fire suppression system and place occupants at risk of injury in the event of a fire. This deficient practice affects all occupants including staff, visitors and residents in one of four smoke zones. The facility had a capacity of 25 and a census of 4 at the time of survey.

Findings include:

1. Observation and interview on 01-13-16 at approximately 9:44 a.m., revealed in the Main Entrance Corridor the sprinkler head next to the Reception Office was coated with dust that covered the fusible bulb.

2. Observation and interview on 01-13-16 at approximately 11:03 a.m., revealed in the Cardiac Rehabilitation Office the sprinkler head was coated with dust that covered the fusible bulb.

Maintenance Staff (A) verified these observations.

Based on observation and interview, the facility failed to ensure the buildings emergency generator was properly equipped with a remote manual stop mechanism in accordance with National Fire Protection Association (NFPA) 110, 1999 Edition. This deficient practice affects all occupants throughout the facility. This facility has a capacity of 25 and a census of 4.

Findings include:

Observations and interview on 01-13-16 at 12:30 p.m., revealed the facilities emergency generator was not equipped with a remote manual stop mechanism (emergency shut-off).

NFPA 110, 1999 edition 3-5.5.6

3-5.5.6* All level 1 and level 2 installations shall have a remote manual stop station of a type similar to a break glass station located outside the room housing the prime mover, where so installed or located elsewhere on the premises where the prime mover is located outside the building

A3-5.5.6 For level 1 and level 2 systems located outdoors the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified.

Based on observation and interview, it was determined the facility failed to maintain the buildings electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition, placing the Staff and Residents of the facility at risk in the event of a fire. The facility had a capacity of 25 and a census of 4 at the time of the survey.

Findings Include:

1. Observations and interview on 01-13-16 at 12:10 p.m., revealed the facility failed to maintain the electrical system in the X-Ray Corridor. Panel LNR breakers 43 & 45 were in the on position charged and labeled as spares.

2. Observation and interview on 01-13-16 at approximately 11:00 a.m., revealed the facility failed to prohibit the improper use of a surge-protectors. On the above date a surge-protector was piggy backed into another surge-protector under a desk in the Front Office used for computer equipment.

3. Observation and interview on 01-13-16 at approximately 11:34 a.m., revealed the facility failed to prohibit the improper use of a surge-protectors. On the above date a surge-protector was piggy backed into another surge-protector under a desk in the Medical Records Office used for computer equipment.

Maintenance Staff (A) verified these observations.