HospitalInspections.org

Observations revealed that the 2-hour fire barrier between the hospital building (01) and the clinic to the east is not in accordance with NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 19.1.1.4.1. This deficient practice could allow the products of combustion to travel from occupancy to another, which could negatively impact all the patients, staff and guests of the facility.

Findings include:
Observations during the facility tour on June 30, 2010, between 10:00 AM and 12:30 PM, revealed that the 1 1/2 hour labeled fire door from Medical Records into the clinic was partially open and did not close when released from the approved hold open device.

The Maintenance staff (RA) verified this finding during the facility tour and during the exit conference.

Observations revealed that one of five smoke barrier doors was held open and did not meet NFPA 101 "The Life Safety Code" (2000 edition) section 7.2.1.8.2. This deficient practice could allow the products of combustion to travel from one smoke compartment to another which will negatively impact all the patients, staff and guests.

Findings include:
Observations during the facility tour on June 30, 2010, between 10:00 AM and 12:30 PM, revealed that the 1-hour labeled fire door from the EMS office room A155 to the corridor was held open with a friction catch and would not close upon fire alarm activation as required by LSC 7.2.1.8.2.

The Maintenance staff (RA) verified this finding during the facility tour and during the exit conference.

Observations revealed that the automatic sprinkler heads are not all in accordance with NFPA 25 Standard for the Testing and Maintenance of Water-based Fire Protection Systems 1999 edition section 2-3.2. Failing to maintain the automatic fire sprinkler system could affect all patients, staff and guests, if the sprinkler system fails to function properly in a fire emergency.

Findings include:
Observations during the facility tour on June 30, 2010, between 10:00 AM and 12:30 PM, revealed that the automatic sprinkler heads in the pool equipment room are corroded and need replacing.

The Maintenance staff (RA) verified this finding during the facility tour and during the exit conference.

Observations revealed that the compressed medical gases are not stored in accordance with NFPA 99 Health Care Facilities 1999 edition section 4-3.5.2.1. Not properly securing compressed gas cylinders can allow them to tip, damaging the cylinder or valve, which could cause the cylinder to release the gas into the room it is in and for the cylinder to become a projectile, which can injure any staff and guests in the area of the compressed gases storage room.

Findings include:
Observations during the facility tour on June 30, 2010, between 10:00 AM and 12:30 PM, revealed that 2 K-size compressed nitrogen cylinders were not properly secured within the compressed gases storage room.

The Maintenance staff (RA) verified this finding during the facility tour and during the exit conference.

Observations revealed that the 2-hour fire barrier between the hospital building (01) and the clinic to the east is not in accordance with NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 19.1.1.4.1. This deficient practice could allow the products of combustion to travel from occupancy to another, which could negatively impact all the patients, staff and guests of the facility.

Findings include:
Observations during the facility tour on June 30, 2010, between 10:00 AM and 12:30 PM, revealed that the 1 1/2 hour labeled fire door from Medical Records into the clinic was partially open and did not close when released from the approved hold open device.

The Maintenance staff (RA) verified this finding during the facility tour and during the exit conference.

Observations revealed that one of five smoke barrier doors was held open and did not meet NFPA 101 "The Life Safety Code" (2000 edition) section 7.2.1.8.2. This deficient practice could allow the products of combustion to travel from one smoke compartment to another which will negatively impact all the patients, staff and guests.

Findings include:
Observations during the facility tour on June 30, 2010, between 10:00 AM and 12:30 PM, revealed that the 1-hour labeled fire door from the EMS office room A155 to the corridor was held open with a friction catch and would not close upon fire alarm activation as required by LSC 7.2.1.8.2.

The Maintenance staff (RA) verified this finding during the facility tour and during the exit conference.

Observations revealed that the automatic sprinkler heads are not all in accordance with NFPA 25 Standard for the Testing and Maintenance of Water-based Fire Protection Systems 1999 edition section 2-3.2. Failing to maintain the automatic fire sprinkler system could affect all patients, staff and guests, if the sprinkler system fails to function properly in a fire emergency.

Findings include:
Observations during the facility tour on June 30, 2010, between 10:00 AM and 12:30 PM, revealed that the automatic sprinkler heads in the pool equipment room are corroded and need replacing.

The Maintenance staff (RA) verified this finding during the facility tour and during the exit conference.

Observations revealed that the compressed medical gases are not stored in accordance with NFPA 99 Health Care Facilities 1999 edition section 4-3.5.2.1. Not properly securing compressed gas cylinders can allow them to tip, damaging the cylinder or valve, which could cause the cylinder to release the gas into the room it is in and for the cylinder to become a projectile, which can injure any staff and guests in the area of the compressed gases storage room.

Findings include:
Observations during the facility tour on June 30, 2010, between 10:00 AM and 12:30 PM, revealed that 2 K-size compressed nitrogen cylinders were not properly secured within the compressed gases storage room.

The Maintenance staff (RA) verified this finding during the facility tour and during the exit conference.