HospitalInspections.org

Based on observation and interview, the facility failed to maintain a 2-hour separation in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.1.3.5), 2012 Edition. This facility has a capacity of 25 and a census of 5.

Findings include:

Observation and interview on 11/23/20 at 10:52 a.m., revealed a 1/2 inch open to the center conduit (with purple and orange communications wires) that penetrates the 2-hour fire barrier above the lay-in ceiling tile at the entrance to the Emergency Department.

The Director of Plant Operations and Maintenance Staff verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to maintain minimum construction requirements in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.1.6), 2012 Edition. This facility has a capacity of 25 and a census of 5.

Findings include:

Observation and interview on 11/23/20 at 11:10 a.m., revealed an approximate 2-1/2 by 4 inch hole, a red wire penetration with an approximate 1/2 inch gap, and a 3/4 inch open to the center conduit penetration in the 1-hour fire rated wall located above the lay-in ceiling tile between the Med Surgery Area and the ASU.

The Director of Plant Operations and Maintenance Staff verified these observations at the time of the survey process.

Based on observation and interview, the facility failed to ensure that required self-closing doors are maintained in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.2.2.2.7), 2012 Edition. This facility has a capacity of 25 and a census of 5.

Findings include:

1. Observation and interview on 11/23/20 at 10:59 a.m., revealed that the 1-1/2 hour fire rated door to Emergency Department Storage Room #1428A failed to fully self-close and positively latch within the door frame.

2. Observation and interview on 11/23/20 at 11:48 a.m., revealed that the back 1-1/2 hour fire rated door to the Hyperbaric Area failed to fully self-close and positively latch within the door frame.

The Director of Plant Operations and Maintenance Staff verified these observations at the time of the survey process.

Based on observation, interview, and testing, the facility failed to maintain emergency lighting fixtures in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-7.9), 2012 Edition. This facility has a capacity of 25 and a census of 5.

Findings include:

1. Observation, interview, and testing on 11/23/20 at 12:15 p.m., revealed that three of five battery backup emergency egress light fixtures in the Gym failed to illuminate when tested.

2. Observation, interview, and testing on 11/23/20 at 12:20 p.m., revealed that one of two bulbs for the dual light emergency egress fixtures labeled #16 and #17 in the Pool Area failed to illuminate when tested.

The Director of Plant Operations and Maintenance Staff verified these observations at the time of the survey process.

Based on record review and interview, the facility failed to test the fire alarm system on a semi-annual basis in accordance with National Fire Protection Association (NFPA) 72, National Fire Alarm and Signaling Code (Section-14.4.5), 2010 Edition.

Findings include:

Record review and interview on 11/23/20 at 1:30 p.m., revealed that the fire alarm system at the offsite Family Medicine of Oelwein Specialty Clinic is being tested on an annual basis. Test reports provided were dated 09/18/19 and 09/28/18.

The Director of Plant Operations and Maintenance Staff verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to maintain the sprinkler system in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems (Section-5.2.2.2), 2011 Edition and National Fire Protection Association (NFPA 13), Standard for the Installation of Sprinkler Systems (Section-6.2.7.2), 2010 Edition. This facility has a capacity of 25 and a census of 5.

Findings include:

1. Observation and interview on 11/23/20 at 11:00 a.m., revealed that the Emergency Department Air Handler Room contained gray speaker wire that was zip-tied to a portion of the sprinkler piping.

2. Observation and interview on 11/23/20 at 11:29 a.m., revealed that 3 of 8 quick response sprinklers in the Surgery Waiting Area were missing the escutcheon rings.

The Director of Plant Operations and Maintenance Staff verified these observations at the time of the survey process.

Based on observation and interview, the facility failed to maintain corridor doors in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.3.6.3.10), 2012 Edition. This facility has a capacity of 25 and a census of 5.

Findings include:

Observation and interview on 11/23/20 at 9:18 a.m., revealed that the corridor door to the Ryan Pharmacy was being held open with a wedge.

The Director of Plant Operations and Maintenance Staff verified this observation at the time of the survey process.

Based on record review and interview, the facility failed to document testing of hospital-grade electrical receptacles in accordance with National Fire Protection Association (NFPA) 99, Health Care Facilities Code (Section-6.3.4.1.1), 2012 Edition. This facility has a capacity of 25 and a census of 5.

Findings include:

Record review and interview on 11/23/20 at 9:59 a.m., revealed that the facility was unable to provide documentation for testing of hospital-grade electrical receptacles upon initial installation, replacement or servicing.

The Director of Plant Operations and Maintenance Staff verified this observation at the time of the survey process.