HospitalInspections.org

Based on observation and staff interview, the facility failed to ensure safety to patients due to the glass vision panels on both sets of double smoke doors were no longer transparent. This did not meet the requirements of NFPA 101 7.7.1 and 7.1.6.2. This deficient practice affected the entire facility.
Findings include
During a tour of the facility with Staff B (director) and Staff C (maintenance technician) on 10/18/2010 at 1:32 pm, Surveyor 12316 observed that two sets of double smoke doors in the smoke barrier had glass vision panels that were no longer maintained clear and transparent to allow occupants to see on the other side of smoke doors as intended and required by the life safety code NFPA 101.18.3.7.7 requirement. When interviewed on 10/18/2010 at 1:33 pm, Staff B stated that a film was put on the glass vision panels to prevent viewing of patients in the Trauma and patient rooms on the other side of smoke doors and afford privacy to patients.
The above deficiency was acknowledged by both director and maintenance technician at the time of discovery, and also confirmed with the director at the exit conference on 10/19/2010 at 1:45 pm.

Based on record review and staff interview, the facility failed to conduct separate fire drills on each of two 12-hr shifts in accordance with NFPA 101 18.7.1.2. This deficient practice had the potential to affect all patients, staff and visitors.

Findings include

During a review of the facility documents with Staff B (director) and Staff C (maintenance technician) on 10/18/2010 at 2:30 pm, Surveyor #12316 discovered that fire drills were conducted on 9/11/2009 at 7:02 am, 12/3/2009 at 7 am, on 3/17/2010 at 7:05 am, on 5/11/2010 at 7:07 am, and on 7/13/2010 at 7:02 am. All the above fire drills were conducted in the 1st Shift 7 am to 7 pm for each quarter, but there were no separate fire drills conducted during the period of 2nd Shift as required. Furthermore, all 1st Shift drills were conducted between 7 am 7:30 am, and not at varied times.

When interviewed on 10/18/2010 at 3 pm, Staff C stated that fire drills were conducted to "catch both shifts" and held "usually between 7 am and 7:30 am."

The deficiency was confirmed at the time of discovery by a concurrent interview with the director and maintenance technician, and at the exit conference with Staff A (team leader, RN), director, and maintenance technician on 10/19/2010 at 1:45 pm.

Based on record review and staff interview, the facility failed to annually test the automatic transmission equipment (automatic dialer) of the fire alarm system to verify annunciation of trouble signals from phone line failure in the facility fire alarm system in accordance with the NFPA 101 9.6.1.4, NFPA 72 (1999) 7.3.2 7.2.2, 1-5.4.6, 1-5.4.6.1. This deficient practice had the potential to affect all patients, staff and visitors.

Findings include

During a review of the facility documents with Staff B (director) and Staff C (maintenance technician) on 10/18/2010 at 2:30 pm, Surveyor #12316 discovered that the reports were not available to verify that the automatic transmission equipment (automatic dialer component) of the fire alarm system was tested. The additional information on the SimplexGrinnell fire alarm testing, received from the facility on 10/22/2010, did not show that the automatic transmission equipment of the fire alarm system was tested during the November 20, 2009 inspection and testing of the fire alarm system to verify that the trouble signals from phone line failure were annunciated at the fire alarm panel, and remote annunciator located in the entrance vestibule in accordance with NFPA 72 1-5.4.6 and 1-5.4.6.1 and NFPA 72 Table 7-2.2.

The current fire alarm control panel with the automatic dialer panel was installed in 2005, when the building was constructed.
The deficiency was confirmed at the time of phone interview with the director on 10/22/2010 at 12:15 pm.

Based on observation and staff interview, the facility failed to ensure safety to patients due to the glass vision panels on both sets of double smoke doors were no longer transparent. This did not meet the requirements of NFPA 101 7.7.1 and 7.1.6.2. This deficient practice affected the entire facility.
Findings include
During a tour of the facility with Staff B (director) and Staff C (maintenance technician) on 10/18/2010 at 1:32 pm, Surveyor 12316 observed that two sets of double smoke doors in the smoke barrier had glass vision panels that were no longer maintained clear and transparent to allow occupants to see on the other side of smoke doors as intended and required by the life safety code NFPA 101.18.3.7.7 requirement. When interviewed on 10/18/2010 at 1:33 pm, Staff B stated that a film was put on the glass vision panels to prevent viewing of patients in the Trauma and patient rooms on the other side of smoke doors and afford privacy to patients.
The above deficiency was acknowledged by both director and maintenance technician at the time of discovery, and also confirmed with the director at the exit conference on 10/19/2010 at 1:45 pm.

Based on record review and staff interview, the facility failed to conduct separate fire drills on each of two 12-hr shifts in accordance with NFPA 101 18.7.1.2. This deficient practice had the potential to affect all patients, staff and visitors.

Findings include

During a review of the facility documents with Staff B (director) and Staff C (maintenance technician) on 10/18/2010 at 2:30 pm, Surveyor #12316 discovered that fire drills were conducted on 9/11/2009 at 7:02 am, 12/3/2009 at 7 am, on 3/17/2010 at 7:05 am, on 5/11/2010 at 7:07 am, and on 7/13/2010 at 7:02 am. All the above fire drills were conducted in the 1st Shift 7 am to 7 pm for each quarter, but there were no separate fire drills conducted during the period of 2nd Shift as required. Furthermore, all 1st Shift drills were conducted between 7 am 7:30 am, and not at varied times.

When interviewed on 10/18/2010 at 3 pm, Staff C stated that fire drills were conducted to "catch both shifts" and held "usually between 7 am and 7:30 am."

The deficiency was confirmed at the time of discovery by a concurrent interview with the director and maintenance technician, and at the exit conference with Staff A (team leader, RN), director, and maintenance technician on 10/19/2010 at 1:45 pm.

Based on record review and staff interview, the facility failed to annually test the automatic transmission equipment (automatic dialer) of the fire alarm system to verify annunciation of trouble signals from phone line failure in the facility fire alarm system in accordance with the NFPA 101 9.6.1.4, NFPA 72 (1999) 7.3.2 7.2.2, 1-5.4.6, 1-5.4.6.1. This deficient practice had the potential to affect all patients, staff and visitors.

Findings include

During a review of the facility documents with Staff B (director) and Staff C (maintenance technician) on 10/18/2010 at 2:30 pm, Surveyor #12316 discovered that the reports were not available to verify that the automatic transmission equipment (automatic dialer component) of the fire alarm system was tested. The additional information on the SimplexGrinnell fire alarm testing, received from the facility on 10/22/2010, did not show that the automatic transmission equipment of the fire alarm system was tested during the November 20, 2009 inspection and testing of the fire alarm system to verify that the trouble signals from phone line failure were annunciated at the fire alarm panel, and remote annunciator located in the entrance vestibule in accordance with NFPA 72 1-5.4.6 and 1-5.4.6.1 and NFPA 72 Table 7-2.2.

The current fire alarm control panel with the automatic dialer panel was installed in 2005, when the building was constructed.
The deficiency was confirmed at the time of phone interview with the director on 10/22/2010 at 12:15 pm.