HospitalInspections.org

Based upon observations and staff interviews on 02/14/18 between approximately 1130 to 1140 hours the facility has failed to maintain fire resistive construction of the building capable of resisting the passage of smoke and fire into other compartments. This could allow the toxic product of combustion to move out of a room and into the exit access corridor and the smoke compartment which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
1. Penetrations into the overhead in the Oxygen Manifold Room.
2. Penetrations into the overhead in the Utility Power Room.
3. Penetrations into the overhead in the ATS Room.



The above was discussed and acknowledged by the facility staff.

Based upon record review and staff interviews on 02/14/18 at 1100 hours the facility has failed to test all fire rated doors in accordance with NFPA 80. This could lead to the doors not functioning as required in a fire, endangering those inside the building.

The findings include, but are not limited to:
There is no documentation of annual inventory, inspection and testing of fire rated doors.


The above was discussed and acknowledged by the facility staff.

Based upon observations and staff interviews on 02/14/18 at 1200 hours the facility has failed to maintain the ability of doors to be held open only by devices arranged to automatically close upon activation of the fire alarm. This could result in the passage of smoke or fire from one compartment into another compartment thereby exposing residents, staff and/or visitors to the toxic products of combustion.

The findings include, but are not limited to:
Soiled Utility Room 128 - door fails to close and latch.

The above was discussed and acknowledged by the facility staff.

Based on observation, record review and staff interview on 02/14/18 at 1030 hours the facility has failed to maintain the fire sprinkler system as required. This could result in the failure of the fire sprinkler system to operate properly in the event of a fire and allow the fire to increase in size and intensity which would endanger the residents, staff, and/or visitors within the facility.
The findings include, but are not limited to:
There is no documentation for quarterly maintenance and testing for 2nd quarter of 2017.
The above was discussed and acknowledged by the facility staff.

Based on record review and staff interview on 02/14/18 at 1045 hours the facility has failed to maintain and test the emergency generator in accordance with NFPA 110. This could result in a failure of the emergency power system which would leave the facility without egress and task lighting in the event of a power failure which would endanger the residents, staff, and/or visitors within the facility.

The findings include, but are not limited to:

Annual fuel quality test not completed.

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on 02/14/18 between approximately at 1145 hours the facility has failed to maintain construction of oxygen storage areas as being smoke and fire resistant. This could result in the products of combustion traveling from the hazardous area into the exit corridor in the event of a fire which could endanger patients, first-responders, staff, and/or visitors. In addition the facility has failed to maintain exterior storage locations as secured to prevent unauthorized access. This could allow for the tampering with or damage to of oxygen storage cylinders, which could endanger patients, staff, and/or visitors.

The findings include, but are not limited to:
Oxygen cylinders are being stored in Bio-hazard room within 5 feet of combustibles.

The above was discussed and acknowledged by the facility staff.

Based on record review and staff interview on 02/14/18 at 1230 hours the facility has failed to provide documentation of personnel concerned with the application, maintenance, and handling of medical gases and cylinders that are trained on the risk and provide continuing education. Failure to provide training and continuing education on the safe handling and use of gases and cylinders could place patients, visitors, and staff at risk of oxygen malfunctions.

The findings include, but are not limited to:
There is no documentation available to review concerning the education and training of personnel in oxygen application, maintenance and handling.

The above was discussed and acknowledged by the facility staff.