HospitalInspections.org

Based on observations and interviews the facility failed to ensure that door openings in emergency department exit corridor closed to resist the passage of smoke and/or fire. This deficiency had the potential to expose patients, staff, and visitors to a smoke or fire environment. Findings:


Observations on 6/12/15 between 8:30 am - 11:45 am with Maintenance Staff #1 revealed the:

-corridor door B-104, failed to latch when closed;
-corridor door B-105, failed to close due to a high transition strip; and
-corridor door B-135, failed to close due to obstruction of a large garbage can.

The finding were acknowledged during the tour by Maintenance Staff #1 and acknowledge during the exit by the Administrator and Maintenance Staff #1.

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Based on observations and interview the facility failed to ensure the doors on self-closure devises closed upon release of the hold-open devise. These findings placed patient, staff, and visitors at risk for smoke and or fire exposure. Findings:

Observation during the facility tour on 6/12/15 between 8:30 am - 11:45 am revealed the following doors on self-closure devices, failed to operate as designed and close upon release.

Observation of door A-153 that leads from the kitchen to an exit corridor failed to close upon release of the self-closing device.

Observation of door A-166 that leads from the housekeeping storage, to an exit corridor failed to close upon release of the self-closing device.

Observation of door C-115 that leads from the soiled utility room on the nursing unit to an exit corridor failed to close upon release of the self-closing device.

These finding were acknowledged during the tour by Maintenance Staff #1 and acknowledge during the exit by the Administrator and Maintenance Staff #1.



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Based on interview and record review the facility failed to ensure quarterly inspection report records were maintained and available upon request for the fire sprinkler system. Findings:

Record review on 6/12/15 of the sprinkler system records revealed only an annual inspection of the sprinklers had been provided.

Maintenance Staff #1 was asked if there were any quarterly inspections completed and stated he was unsure and would find out. The facility failed to provide quarterly inspections by the time of exit.

The Administrator and Maintenance Staff were made aware of the requirement for quarterly inspections at the time of exit.

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Based on observation and interview the facility failed to ensure a remote manual shut off was located outside of the generator room. Failure to not have a means to shut down the generator in the event of a fire within the generator room would potentially place all patients, staff, and visitors at risk for smoke and or fire injury. Findings:


During the facility tour Maintenance Staff #1 stated the only emergency shut off for the generator was located within the generator room.

These finding were acknowledged during the tour by Maintenance Staff #1 and acknowledge during the exit by the Administrator and Maintenance Staff #1.


NFPA 110 (1999 edition): 3-5.5.6 states, "All level 1 & level 2 installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover..."


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Based on observations the facility failed to ensure power strips were safely and appropriately used. These deficiencies had the potential to expose occupants to a smoke or fire environment, electrocution, and/or loss of services. Findings:


Observations during the facility life safety tour on 6/12/15 between 8:30 am - 11:45 am with Maintenance Staff #1 revealed 1500 watt heaters plugged into power strip cords in offices B172; B173 and B177.


In addition, the heater in office B172 was plugged into one power strip cord the was directly plugged into a second power strip cord.


Further observation in office B177 revealed the 1500 watt heater was plugged into a strip cord that was not visible due to the multiple loose papers on top of it.

These finding were acknowledged during the tour by Maintenance Staff #1 and acknowledge during the exit by the Administrator and Maintenance Staff #1.

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Based on observations and interviews the facility failed to ensure that door openings in emergency department exit corridor closed to resist the passage of smoke and/or fire. This deficiency had the potential to expose patients, staff, and visitors to a smoke or fire environment. Findings:


Observations on 6/12/15 between 8:30 am - 11:45 am with Maintenance Staff #1 revealed the:

-corridor door B-104, failed to latch when closed;
-corridor door B-105, failed to close due to a high transition strip; and
-corridor door B-135, failed to close due to obstruction of a large garbage can.

The finding were acknowledged during the tour by Maintenance Staff #1 and acknowledge during the exit by the Administrator and Maintenance Staff #1.

.

Based on observations and interview the facility failed to ensure the doors on self-closure devises closed upon release of the hold-open devise. These findings placed patient, staff, and visitors at risk for smoke and or fire exposure. Findings:

Observation during the facility tour on 6/12/15 between 8:30 am - 11:45 am revealed the following doors on self-closure devices, failed to operate as designed and close upon release.

Observation of door A-153 that leads from the kitchen to an exit corridor failed to close upon release of the self-closing device.

Observation of door A-166 that leads from the housekeeping storage, to an exit corridor failed to close upon release of the self-closing device.

Observation of door C-115 that leads from the soiled utility room on the nursing unit to an exit corridor failed to close upon release of the self-closing device.

These finding were acknowledged during the tour by Maintenance Staff #1 and acknowledge during the exit by the Administrator and Maintenance Staff #1.



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Based on interview and record review the facility failed to ensure quarterly inspection report records were maintained and available upon request for the fire sprinkler system. Findings:

Record review on 6/12/15 of the sprinkler system records revealed only an annual inspection of the sprinklers had been provided.

Maintenance Staff #1 was asked if there were any quarterly inspections completed and stated he was unsure and would find out. The facility failed to provide quarterly inspections by the time of exit.

The Administrator and Maintenance Staff were made aware of the requirement for quarterly inspections at the time of exit.

.

Based on observation and interview the facility failed to ensure a remote manual shut off was located outside of the generator room. Failure to not have a means to shut down the generator in the event of a fire within the generator room would potentially place all patients, staff, and visitors at risk for smoke and or fire injury. Findings:


During the facility tour Maintenance Staff #1 stated the only emergency shut off for the generator was located within the generator room.

These finding were acknowledged during the tour by Maintenance Staff #1 and acknowledge during the exit by the Administrator and Maintenance Staff #1.


NFPA 110 (1999 edition): 3-5.5.6 states, "All level 1 & level 2 installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover..."


.

Based on observations the facility failed to ensure power strips were safely and appropriately used. These deficiencies had the potential to expose occupants to a smoke or fire environment, electrocution, and/or loss of services. Findings:


Observations during the facility life safety tour on 6/12/15 between 8:30 am - 11:45 am with Maintenance Staff #1 revealed 1500 watt heaters plugged into power strip cords in offices B172; B173 and B177.


In addition, the heater in office B172 was plugged into one power strip cord the was directly plugged into a second power strip cord.


Further observation in office B177 revealed the 1500 watt heater was plugged into a strip cord that was not visible due to the multiple loose papers on top of it.

These finding were acknowledged during the tour by Maintenance Staff #1 and acknowledge during the exit by the Administrator and Maintenance Staff #1.

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