HospitalInspections.org

Based upon observations made in the presence of the plant manager on 9/1/16, it was determined that the facility did not maintain the fire resistive rating of the roof assembly and walls to resist passage of smoke in accordance with NFPA 101 19.1.6.2.

This deficiency affected 1 of 8 smoke compartments.

Findings include:

During the tour of the facility it was observed that the wall above the ceiling in the emergency room corridor had a 4 inch penetration through the fire rated wall that was left unsealed. Openings in fire barrier walls shall be protected in accordance with NFPA 101 19.1.6.2; 8.2.1; 8.2.3.2.4.2.

Based upon observations made in the presence of the plant manager on 9/1/16, it was determined that the facility did not maintain corridor doors to be positively latching and to resist the passage of smoke in accordance with NFPA 101 19.3.6.3.2.

This deficiency affected 2 of 8 smoke compartments.

Findings include:

During the tour of the facility it was observed that the following doors were positively latching in accordance with NFPA 101 19.3.6.3.2. The door to the corridor from the physical therapy room was held open with a wedge at the floor, the door from the emergency room to the radiology department, and the door to operating room 4 all failed to latch when tested.

Based upon observations made in the presence of the plant manager on 9/1/16, it was determined that the facility did not maintain hazardous areas to be fire and smoke separated from other sections of the facility in accordance with NFPA 101 19.3.2.1.

This deficiency affected 2of 8 smoke compartments.

Findings include:

During the tour of the facility it was observed that the storeroom door at operating room 4 was being held open with the use of a 10 pound weight at the floor.

During the tour of the facility it was observed that the housekeeping room in the radiology department contained a ½ inch hole in a fire rated wall.

During the tour of the facility it was observed that the store room in same day surgery was over 64 square feet in size and needed to have a self-closing door, the door was lacking any such devise.

Based upon observations made in the presence of the plant manager and administrator on 9/1/16, it was determined that the facility did not provide an emergency lighting system in accordance with NFPA 101 19.2.9.1.

This deficiency affected 7of12 months of testing.

Findings Include:

During the record review portion of the survey the facility provided documentation for the 30 second monthly testing of the battery backup emergency lights for 5 of the last 12 months, with no test being documented for the annual 90 minute test in accordance with NFPA 101 19.2.9.1; 7.9.3.

Based upon staff interview and record review made in the presence of the plant manager on 9/1/16, it was determined that the facility did not conduct fire drills held at unexpected times under varying conditions at least quarterly on each shift in accordance with NFPA 101 19.7.1.2.

This deficiency affected 4 of 8 fire drills.

Findings include:

During the record review portion of the survey it was determined that the facility was conducting the night shift (6 pm to 6 am) fire drills at 7 pm with a silent coded announcement. In accordance with NFPA 101 19.7.1.2 fire drills are to be conducted at unexpected times under varying conditions with silent drills held between 9 pm and 6 am.

Based upon record review made in the presence of the plant manager on 9/1/16, it was determined that the facility did not maintain the fire alarm system in accordance with NFPA 101 19.3.4.4.& 9.6.1.4.; and NFPA 72.

This deficiency affected 1 of 2 battery tests.

Findings include:

During the record review portion of the survey it was determined that the facility had conducted only one battery load volt test on the fire alarm batteries. In accordance with NFPA 101 19.3.4.4; 9.6.1.4; and NFPA 72 Table 7-3.2 fire alarm batteries are to be load volt tested semiannually.

Based upon record review made in the presence of the plant manager on 9/1/16, it was determined that the facility did not maintain, inspect and exercise the facilities emergency generator set in accordance with NFPA 99.

This deficiency affected 1 of several generator tests.

Findings include:

During the record review portion of the survey it was determined that the facility failed to have the emergency generator load bank tested with in the last 12 months in accordance with NFPA 99 8-4.2, NFPA 110 Chapter 6. The facility provided no data to indicate that the generator was being run under load at greater that 30% of the name plate rating nor were that measuring the exhaust gasses.

Based upon observations made in the presence of the plant manager on 9/1/16, it was determined that the facility did not maintain electrical equipment in accordance with NFPA 101 19.5.1 and 9.1.2.

This deficiency affected 6 of 8 smoke compartments.

Findings include:

During the facility tour it was observed that the electrical service panels located in the facility corridors were found to be unlocked against unauthorized use.

During the facility tour it was observed that the nursery contained a power strip that was mounted to the wall in a permeant fashion, temporary wiring is not to be substituted for permeant wiring in accordance with NFPA 70.

During the facility tour it was observed that the registration area contained a power strip with another power strip plugged into it, this is not in accordance with the manufactures UL listing.

Based upon observations made in the presence of the plant manager on 9/1/16, it was determined that the facility did not maintain the fire resistive rating of the roof assembly and walls to resist passage of smoke in accordance with NFPA 101 19.1.6.2.

This deficiency affected 1 of 8 smoke compartments.

Findings include:

During the tour of the facility it was observed that the wall above the ceiling in the emergency room corridor had a 4 inch penetration through the fire rated wall that was left unsealed. Openings in fire barrier walls shall be protected in accordance with NFPA 101 19.1.6.2; 8.2.1; 8.2.3.2.4.2.

Based upon observations made in the presence of the plant manager on 9/1/16, it was determined that the facility did not maintain corridor doors to be positively latching and to resist the passage of smoke in accordance with NFPA 101 19.3.6.3.2.

This deficiency affected 2 of 8 smoke compartments.

Findings include:

During the tour of the facility it was observed that the following doors were positively latching in accordance with NFPA 101 19.3.6.3.2. The door to the corridor from the physical therapy room was held open with a wedge at the floor, the door from the emergency room to the radiology department, and the door to operating room 4 all failed to latch when tested.

Based upon observations made in the presence of the plant manager on 9/1/16, it was determined that the facility did not maintain hazardous areas to be fire and smoke separated from other sections of the facility in accordance with NFPA 101 19.3.2.1.

This deficiency affected 2of 8 smoke compartments.

Findings include:

During the tour of the facility it was observed that the storeroom door at operating room 4 was being held open with the use of a 10 pound weight at the floor.

During the tour of the facility it was observed that the housekeeping room in the radiology department contained a ½ inch hole in a fire rated wall.

During the tour of the facility it was observed that the store room in same day surgery was over 64 square feet in size and needed to have a self-closing door, the door was lacking any such devise.

Based upon observations made in the presence of the plant manager and administrator on 9/1/16, it was determined that the facility did not provide an emergency lighting system in accordance with NFPA 101 19.2.9.1.

This deficiency affected 7of12 months of testing.

Findings Include:

During the record review portion of the survey the facility provided documentation for the 30 second monthly testing of the battery backup emergency lights for 5 of the last 12 months, with no test being documented for the annual 90 minute test in accordance with NFPA 101 19.2.9.1; 7.9.3.

Based upon staff interview and record review made in the presence of the plant manager on 9/1/16, it was determined that the facility did not conduct fire drills held at unexpected times under varying conditions at least quarterly on each shift in accordance with NFPA 101 19.7.1.2.

This deficiency affected 4 of 8 fire drills.

Findings include:

During the record review portion of the survey it was determined that the facility was conducting the night shift (6 pm to 6 am) fire drills at 7 pm with a silent coded announcement. In accordance with NFPA 101 19.7.1.2 fire drills are to be conducted at unexpected times under varying conditions with silent drills held between 9 pm and 6 am.

Based upon record review made in the presence of the plant manager on 9/1/16, it was determined that the facility did not maintain the fire alarm system in accordance with NFPA 101 19.3.4.4.& 9.6.1.4.; and NFPA 72.

This deficiency affected 1 of 2 battery tests.

Findings include:

During the record review portion of the survey it was determined that the facility had conducted only one battery load volt test on the fire alarm batteries. In accordance with NFPA 101 19.3.4.4; 9.6.1.4; and NFPA 72 Table 7-3.2 fire alarm batteries are to be load volt tested semiannually.

Based upon record review made in the presence of the plant manager on 9/1/16, it was determined that the facility did not maintain, inspect and exercise the facilities emergency generator set in accordance with NFPA 99.

This deficiency affected 1 of several generator tests.

Findings include:

During the record review portion of the survey it was determined that the facility failed to have the emergency generator load bank tested with in the last 12 months in accordance with NFPA 99 8-4.2, NFPA 110 Chapter 6. The facility provided no data to indicate that the generator was being run under load at greater that 30% of the name plate rating nor were that measuring the exhaust gasses.

Based upon observations made in the presence of the plant manager on 9/1/16, it was determined that the facility did not maintain electrical equipment in accordance with NFPA 101 19.5.1 and 9.1.2.

This deficiency affected 6 of 8 smoke compartments.

Findings include:

During the facility tour it was observed that the electrical service panels located in the facility corridors were found to be unlocked against unauthorized use.

During the facility tour it was observed that the nursery contained a power strip that was mounted to the wall in a permeant fashion, temporary wiring is not to be substituted for permeant wiring in accordance with NFPA 70.

During the facility tour it was observed that the registration area contained a power strip with another power strip plugged into it, this is not in accordance with the manufactures UL listing.