HospitalInspections.org

Observations revealed that 2 of 10 hazardous areas are not in accordance with NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 18.3.2.1. This deficient practice could allow the products of combustion to travel from one area to another if a fire occurs within this hazardous area, which could negatively impact all patients, visitors and staff.

Findings include:
Observations during the facility tour on March 16, 2010, between 9:15 AM and 12:00 PM, revealed that in the basement:

1) Storage room 711 is not a 1-hour rated enclosure as the corridor wall has unsealed wire and conduit penetrations through it, and

2) The data room 718 has unsealed conduit sleeves through the floor slap above.

The Director of Maintenance verified these findings during the facility tour and during the exit conference.

Observations revealed that 2 of 15 hazardous areas are not in accordance with NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 19.3.2.1. This deficient practice could allow the products of combustion to travel from one area to another if a fire occurs within this hazardous area, which could negatively impact all patients, visitors and staff.

Findings include:
Observations during the facility tour on March 16, 2010, between 9:15 AM and 12:00 PM, revealed that in basement storage rooms 107 and 108 are not 1-hour rated enclosures.

1) The corridor walls of these rooms are not complete to the floor deck and have exposed metal top cord, and

2) The same walls have wire and conduit penetrations that have not been sealed properly.

The Director of Maintenance verified these findings during the facility tour and during the exit conference.

Observation revealed that some smoke detectors are not installed in accordance with NFPA "The National Fire Alarm Code" 1999 edition section 2-3.5.1. This could affect the staff occupying the rooms if a fire occures.

Findings include:
Observations during the facility tour on March 16, 2010, between 9:15 AM and 12:00 PM, revealed that two smoke detectors are within 3 feet of the supply air diffusers. One in room 105 and one in the corridor outside of room 105.

The Director of Maintenance verified these findings during the facility tour and during the exit conference.

Observation revealed that the staff on-call rooms do not meet the requirements of the Minnesota State Fire Code 2007 edition section 907.3.3.1 and 1027.1. This could affect the staff occupying the room by slowing their response to a fire and preventing their escape..

Findings include:
Observations during the facility tour on March 16, 2010, between 9:15 AM and 12:00 PM, observation revealed that:

1) The doctors' on-call room does not have a smoke detector within it, and

2) The lab on-call room does not have a smoke detector within it and the room does have a exterior window nor is it sprinkler protected.

The Director of Maintenance verified these findings during the facility tour and during the exit conference.

Observations revealed that 2 of 10 hazardous areas are not in accordance with NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 18.3.2.1. This deficient practice could allow the products of combustion to travel from one area to another if a fire occurs within this hazardous area, which could negatively impact all patients, visitors and staff.

Findings include:
Observations during the facility tour on March 16, 2010, between 9:15 AM and 12:00 PM, revealed that in the basement:

1) Storage room 711 is not a 1-hour rated enclosure as the corridor wall has unsealed wire and conduit penetrations through it, and

2) The data room 718 has unsealed conduit sleeves through the floor slap above.

The Director of Maintenance verified these findings during the facility tour and during the exit conference.

Observations revealed that 2 of 15 hazardous areas are not in accordance with NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 19.3.2.1. This deficient practice could allow the products of combustion to travel from one area to another if a fire occurs within this hazardous area, which could negatively impact all patients, visitors and staff.

Findings include:
Observations during the facility tour on March 16, 2010, between 9:15 AM and 12:00 PM, revealed that in basement storage rooms 107 and 108 are not 1-hour rated enclosures.

1) The corridor walls of these rooms are not complete to the floor deck and have exposed metal top cord, and

2) The same walls have wire and conduit penetrations that have not been sealed properly.

The Director of Maintenance verified these findings during the facility tour and during the exit conference.

Observation revealed that some smoke detectors are not installed in accordance with NFPA "The National Fire Alarm Code" 1999 edition section 2-3.5.1. This could affect the staff occupying the rooms if a fire occures.

Findings include:
Observations during the facility tour on March 16, 2010, between 9:15 AM and 12:00 PM, revealed that two smoke detectors are within 3 feet of the supply air diffusers. One in room 105 and one in the corridor outside of room 105.

The Director of Maintenance verified these findings during the facility tour and during the exit conference.

Observation revealed that the staff on-call rooms do not meet the requirements of the Minnesota State Fire Code 2007 edition section 907.3.3.1 and 1027.1. This could affect the staff occupying the room by slowing their response to a fire and preventing their escape..

Findings include:
Observations during the facility tour on March 16, 2010, between 9:15 AM and 12:00 PM, observation revealed that:

1) The doctors' on-call room does not have a smoke detector within it, and

2) The lab on-call room does not have a smoke detector within it and the room does have a exterior window nor is it sprinkler protected.

The Director of Maintenance verified these findings during the facility tour and during the exit conference.