HospitalInspections.org

Based on observation and interview with staff, the facility failed to provide a building construction type complying with 19.1.6,
Finding:
The building is constructed with masonry load bearing walls and a roof structure of unprotected steel beams and bar joists. The building is one-story and a construction type that is required to have roof framing protected with materials capable of one-hour fire resistance rating or the building is to be fully protected with a fire sprinkler system.

Based on observation and interview with staff, the facility failed to provide doors with a means suitable for keeping the door closed, 19.3.6.3 Findings:
The corridor doors to the X-Ray, Hospitality Room, Linen Room, and PT Office do not have latching hardware as required by 19.3.6.3..

Based on observation and review of fire drill reports, the facility failed to maintain written records of fire drills as required by NFPA 72, 19.7.1.2. Findings:
Fire drill reports were not complete for 12-14-07, 7-15-08, and 11-19-09. The fire drill records had remarks and recommendations and deficiencies that did not have a follow up with written documentation as required by NFPA 72.

Based on observation, interview with staff, and review of fire alarm reports the facility failed to provide written records for testing the fire alarm system in accordance with NFPA 70 and 72, 0.6.1.4,
Findings:
(1) There was no report for the test due in February 2010.
(2) The 2009 report was not signed by a representative from the facility and the vendor as required by NFPA 72.
(3) The 2008 annual report was not available for review.

Based on observation, interview with staff, and review of the annual fire suppression inspection report conducted by Simplex Grinnell on 2-24-2010, the facility has not maintained the partial sprinkler system for certain hazardous areas in accordance with NFPA 25. Findings:
Deficiencies that were identified by Simplex Grinnell on 2-24-2010 have not been corrected. Examples: A sprinkler head is obstructed in medical records, a pendent sprinkler is too far off wall in hallway, a sprinkler is obstructed in riser room, and the system is not installed in accordance with NFPA 13 and cannot be inspected in accordance with NFPA 25.

Based on observation, interview with staff, and review of log sheets for the emergency generator, the facility failed to provide written records as required by NFPA 99, NFPA 110, and LSC 3.4.1. Findings:
The log sheets did not document running under load or who conducted the test.

Based on observation and interview with staff, the facility failed to provide a building construction type complying with 19.1.6,
Finding:
The building is constructed with masonry load bearing walls and a roof structure of unprotected steel beams and bar joists. The building is one-story and a construction type that is required to have roof framing protected with materials capable of one-hour fire resistance rating or the building is to be fully protected with a fire sprinkler system.

Based on observation and interview with staff, the facility failed to provide doors with a means suitable for keeping the door closed, 19.3.6.3 Findings:
The corridor doors to the X-Ray, Hospitality Room, Linen Room, and PT Office do not have latching hardware as required by 19.3.6.3..

Based on observation and review of fire drill reports, the facility failed to maintain written records of fire drills as required by NFPA 72, 19.7.1.2. Findings:
Fire drill reports were not complete for 12-14-07, 7-15-08, and 11-19-09. The fire drill records had remarks and recommendations and deficiencies that did not have a follow up with written documentation as required by NFPA 72.

Based on observation, interview with staff, and review of fire alarm reports the facility failed to provide written records for testing the fire alarm system in accordance with NFPA 70 and 72, 0.6.1.4,
Findings:
(1) There was no report for the test due in February 2010.
(2) The 2009 report was not signed by a representative from the facility and the vendor as required by NFPA 72.
(3) The 2008 annual report was not available for review.

Based on observation, interview with staff, and review of the annual fire suppression inspection report conducted by Simplex Grinnell on 2-24-2010, the facility has not maintained the partial sprinkler system for certain hazardous areas in accordance with NFPA 25. Findings:
Deficiencies that were identified by Simplex Grinnell on 2-24-2010 have not been corrected. Examples: A sprinkler head is obstructed in medical records, a pendent sprinkler is too far off wall in hallway, a sprinkler is obstructed in riser room, and the system is not installed in accordance with NFPA 13 and cannot be inspected in accordance with NFPA 25.

Based on observation, interview with staff, and review of log sheets for the emergency generator, the facility failed to provide written records as required by NFPA 99, NFPA 110, and LSC 3.4.1. Findings:
The log sheets did not document running under load or who conducted the test.