HospitalInspections.org

Based on an observation the facility failed to provide properly rated fire-resistance fire barrier doors. This deficient practice could affect patients, staff and visitors, if a fire was allowed to spread into the facility from an adjacent nonconforming building.

Findings include: On 8/5/14 at 11:35 AM, while accompanied by E-1 and E-2 an observation determined that on the second floor the designated 2-hour rated double egress doors between the hospital building and medical office building was deficient. Each door leaf contained a concealed vertical rod that latched into the upper door frame but failed to include a second latch point per door leaf. This is not per NFPA 101, Section 8.2 and 18.1.2.3 and 7.2.1.7, NFPA 80 1999 Edition Fire Doors and Windows.

Based on an observation of a hazardous area the facility failed to provide properly operating latching and self-closing door hardware that provides separation between hazardous areas and exit access corridors. This deficient practice could affect patients, staff and visitors if a fire could spread without proper fire separation.

Findings include: On 8/5/14 at 9:45 AM while accompanied by E-1 and E-2 an observation determined that the kitchen contained (2) exit doors along egress corridor 1039 that were not installed with door closers. Areas containing hazards higher than the adjacent area must be separated. Door closers are required per NFPA 101, section 18.3.2.1 and section 8.4.1.1.

Based on an observation the facility failed to maintain a properly functioning sprinkler system. This deficient practice could affect patients, staff and visitors, if the sprinkler system failed to operate properly due to improper maintenance.

Findings include: On 8/5/14 at 9:10 AM, while accompanied by E-1 and E-2 an observation determined that the exterior covered canopy contained (3) sprinkler heads that were rusty and corroded. This does not comply with NFPA 25, section 2-2.1.1.

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

Based on an observation the facility failed to provide properly rated fire-resistance fire barrier doors. This deficient practice could affect patients, staff and visitors, if a fire was allowed to spread into the facility from an adjacent nonconforming building.

Findings include: On 8/5/14 at 11:35 AM, while accompanied by E-1 and E-2 an observation determined that on the second floor the designated 2-hour rated double egress doors between the hospital building and medical office building was deficient. Each door leaf contained a concealed vertical rod that latched into the upper door frame but failed to include a second latch point per door leaf. This is not per NFPA 101, Section 8.2 and 18.1.2.3 and 7.2.1.7, NFPA 80 1999 Edition Fire Doors and Windows.

Based on an observation of a hazardous area the facility failed to provide properly operating latching and self-closing door hardware that provides separation between hazardous areas and exit access corridors. This deficient practice could affect patients, staff and visitors if a fire could spread without proper fire separation.

Findings include: On 8/5/14 at 9:45 AM while accompanied by E-1 and E-2 an observation determined that the kitchen contained (2) exit doors along egress corridor 1039 that were not installed with door closers. Areas containing hazards higher than the adjacent area must be separated. Door closers are required per NFPA 101, section 18.3.2.1 and section 8.4.1.1.

Based on an observation the facility failed to maintain a properly functioning sprinkler system. This deficient practice could affect patients, staff and visitors, if the sprinkler system failed to operate properly due to improper maintenance.

Findings include: On 8/5/14 at 9:10 AM, while accompanied by E-1 and E-2 an observation determined that the exterior covered canopy contained (3) sprinkler heads that were rusty and corroded. This does not comply with NFPA 25, section 2-2.1.1.

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.