HospitalInspections.org

Citation Text for Tag 0012, Regulation K202 Bld 01

Juntunen, Jeff
Based on observation ceiling tiles were not in the grid work provided in several location throughout the facility. The tiles are required to be in place to trap heat from a fire, so that sprinkler heads will activate. This deficient practice could effect all occupants of the building in the event of a fire if the complete automatic fire sprinkler system did not operated as designed.

Findings Include:

During the facility tour on 9-26-13, between 8:30AM-5:00PM it was observed that the ceiling tiles were not in place as required by LSC(00) section 18.1.6.2. The maintenance staff shall ensure tiles are put back in place after work is completed abbe the ceiling

This deficient practice was confirmed by the Director of Plant Operations (PC) and Safety Officer (KH) at the time of exit.

Based on observation ceiling tiles were not in the grid work provided in several location throughout the facility. The tiles are required to be in place to trap heat from a fire, so that sprinkler heads will activate. This deficient practice could effect all occupants of the building in the event of a fire if the complete automatic fire sprinkler system did not operated as designed.

Findings Include:

During the facility tour on 9-26-13, between 8:30AM-5:00PM it was observed that the ceiling tiles were not in place as required by LSC(00) section 18.1.6.2. i.e. Computer lab storage room, medical records.

This deficient practice was confirmed by the Director of Plant Operations (PC) and Safety Officer (KH) at the time of exit.

Citation Text for Tag 0018, Regulation K202 Bld 01

Juntunen, Jeff
Based on observation several corridor room doors are being improper held open. This deficient practice could effect all building occupants in the event of a fire. Open doors would allow smoke to compromise the corridor exiting system.

Findings Include:

During the facility survey on 9-26-13 between 8:30AM-5:00PM, it was observed in several locations throughout the facility that wooden wedges of other objects were being used to hold doors open improperly. Doors that are required to be self closing shall comply with LSC(00) section 18-3.6.3.

This deficient practice was confirmed by Director of Plant Operations (PC) and Safety officer (KH) at the time of exit.

Based on observation several corridor room doors are being improper held open. This deficient practice could effect all building occupants in the event of a fire. Open doors would allow smoke to compromise the corridor exiting system.

Findings Include:

During the facility survey on 9-26-13 between 8:30AM-5:00PM, it was observed in several locations throughout the facility that wooden wedges of other objects were being used to hold doors open improperly. Doors that are required to be self closing shall comply with LSC(00) section 18-3.6.3.

This deficient practice was confirmed by Director of Plant Operations (PC) and Safety officer (KH) at the time of exit.

Based on observation, a lock has been installed, that requires a key to open, on the egress side of the door out of the northeast stairwell, at ground level. Locks are prohibited per LSC(00) section 19.2.2.2.5. This deficient practice could effect all building occupants in the event of an emergency.

Findings include:

During the facility tour on 9-26-13, between 8:00AM-5:00PM, it was observed the a key is need to release the lock on the egress side of the grade level door out of the northeast exit stairwell. Staff did not have the key to open this door.

This deficient practice was confirmed by the Plant Maintenance Director (PC) and the Safety Officer (KH) at the time of exit.

Based on observation, the exit from the NW stairwell is obstructed on both the interior and the exterior of the building. This deficient practice could affect all occupants of the building that may attempt to use this exit in the event of a fire or other emergency.

Findings include:

During the facility tour on 9-26-13 at 2:00 PM it was observed that the lowest level of the Northwest stairwell (by the Specialty Clinic) was obstructed by chairs on the interior of the building and by a picnic table on the exterior of the building. Exits are required to be maintained clear and unobstructed per LSC(00) section 18.2.3.3

This deficient practice was confirmed by the Director of Plant Operations (PC) and the Safety Officer (KH) at the time of exit.

Based on observation the doors from exam/treatment rooms within the Speciality Clinic are not the width as required by LSC(00)18.2.3.5. This deficient practice could effect all occupants of the clinic in the event of an evacuation for fire or other emergency.

Findings include:

During the facility tour on 9-26-13 at 2:30 PM it was confirmed by actual measurement that the doors from the exam/treatment rooms within the Speciality Clinic are not at least 41.5 inches in clear operable width. This clinic was a part of the 20012/20013 addition and remodeling project. The clinic is not 2 hour fire rated separated from the rest of the hospital.

This deficient practice was confirmed by the Director of Plant Operations (PC) and the Safety Officer at the time of exit.

Based on observation, it was determined that the facility has failed to ensure that the exterior exit discharge path is provided with illumination in accordance with the LSC, Sections 19.2.8 and 7.8.1.4. This deficient practice could affect all residents, staff and visitors, if emergency exiting of the facility were necessary.

Findings include:

During the facility tour on 9-26-13 between 8:30AM-5:00PM , it was observed that there were not two bulbs to provide the required illumination of the discharge path of travel away from the building, from the northeast exit stairwell of the existing nursing home. All other exits are in compliance.

This deficient practice was confirmed by the facility Director of Maintenance (PC) and Safety Officer (KH) at the time of exit.

Based on review of available fire drill records the facility has not been conducting fire drills as required by LSC(00) section 18.7.1.2. This deficient practice could effect all building occupants, including patients, visitors and staff in the event of a fire.

Findings include:

At the conclusion of the inspection tour on 9-26-13 at 4:00 PM based on a review of available fire drill records that facility has failed to conduct drills as one per shift per quarter on all shifts. No afternoon shift drills 2nd quarter of 2013.

NOTE: This is the 3rd inspection in a row that lack of fire drills has been cited at this facility.

This deficient practice was confirmed by the Director of Plant Operation (PC) and Safety Officer (KH) at the time of exit.

Citation Text for Tag 0050, Regulation K202 Bld 02

Juntunen, Jeff

Based on review of available fire drill records the facility has not been conducting fire drills as required by LSC(00) section 18.7.1.2. This deficient practice could effect all building occupants, including patients, visitors and staff in the event of a fire.

Findings include:

At the conclusion of the inspection tour on 9-26-13 at 4:00 PM based on a review of available fire drill records that facility has failed to conduct drills as one per shift per quarter on all shifts. No afternoon shift drills 2nd quarter of 2013.

NOTE: This is the 3rd inspection in a row that lack of fire drills has been cited at this facility.

This deficient practice was confirmed by the Director of Plant Operation (PC) and Safety Officer (KH) at the time of exit.

Based on observation and interview, the facility's fire alarm system is not installed in conformance with NFPA 72. This deficient practice could affect all patients.

Findings include:

Based on observation during the facility tour on 9-26-13 at 3:30 PM, it was observed that there is not a system connected smoke detector within 10 feet of the panel. The fire alarm panel is located in the lower level large storage room.

This deficient practice was confirmed by Director of Plant Operation (PC) and Safety Officer (KH) at the time of exit.

Based on observations several smoke detectors in the facility still had dust covers on them from the construction project. This deficient practice could delay fire alarm activation and notification to occupants in the event of a fire.

Findings include:

During the facility tour on 9-26-13 between 8:30 AM-5:00 PM it was observed that several fire alarm connected smoke detectors had covers on them that would prevent smoke from entering the chamber and activating the fire alarm system. Ensuring that ALL devices are able to detect heat and or smoke is required as an ongoing part of the inspection program outlined in NFPA 72.

This deficient practice was confirm by the Director of Plant Operations (PC) and Safety Officer (KH) at the time of exit.

Based on observation the valves for the automatic pre-action sprinkler system are not supervised as required by MSFC(07) section 903.4.4. This deficient practice could effect all the occupants of the facility in the event the valves were tampered with, impairing the system.

Finding include:

During the facility tour at 11:00 AM it was ovserved that the valves were not secured in the open position on the automatic fire sprinkler system/pre-action system protecting the telephone equipment room. Nor, was the door locked to the room.

This deficient practice was confirmed by the Director of Plant Operation (PC) and Safety officer (KH) at the time of exit.

Based on observation 3 quick response sprinkler heads in the facility appeared to be clear in color and not red. If the fluid is not present in the bulbs, the heads my not activate under fire conditions. This deficient practice could effect all occupants of the building.

Findings include:

During the facility tour on 9-26-13 between 8:30 AM-5:00 PM it was observed that 3 quick response sprinkler heads appeared to not have fluid in them. They were located in the freezer in the kitchen, the body cooler by the loading dock, and the entry way by the time clock lower level. Ensuring the sprinkler system is in operating condition is required by NFPA 25.

This deficient practice was confirmed by Plant Director of Operations (PC) and Safety Officer (KH) at the time of exit.

Based on observation, the sprinkler head in the lower level chute room (nursing home) does not meet the requirement for all heads in a smoke zone to be of the same type and style as required by NFPA 13 & 25. This deficient practice could effect all building occupants in the event of a fire.

Findings include:

During the facility tour on 9-26-13 between 8:30AM-5:00PM, it was observed that the fire sprinkler head in the chute room, located on the lower level of the nursing home, appeared to be an "old" style head. The rest of the area is protected by QR (quick response heads). Nor could the water supply to the head be verified, it appeared to be off of the domestic water supply.

This deficient practice was confirmed by the Director of Maintenance (PC) and Safety Officer (KH) at the time of exit.

Based on observation it could not be determined if all exam/treatment rooms had battery back up emergency lighting., as required by NFPA 99.

Findings include:

During the facility tour on 9-26-13, between 8:30 AM-5:00 PM, based on observation and interview with Director of Plan Operation (PC) it could not be determined if exam/treatment rooms 2083, 2084 & 2079 had battery operated back-up emergency lighting that would come on instantly in the event of a power failure from the public utility. This action would provide lighting until the facility emergency back up electrical generator came on line.

This deficient practice was confirmed by Director of Plant Operation (PC) and Safety Officer (KH) at the time of exit.

Citation Text for Tag 0012, Regulation K202 Bld 01

Juntunen, Jeff
Based on observation ceiling tiles were not in the grid work provided in several location throughout the facility. The tiles are required to be in place to trap heat from a fire, so that sprinkler heads will activate. This deficient practice could effect all occupants of the building in the event of a fire if the complete automatic fire sprinkler system did not operated as designed.

Findings Include:

During the facility tour on 9-26-13, between 8:30AM-5:00PM it was observed that the ceiling tiles were not in place as required by LSC(00) section 18.1.6.2. The maintenance staff shall ensure tiles are put back in place after work is completed abbe the ceiling

This deficient practice was confirmed by the Director of Plant Operations (PC) and Safety Officer (KH) at the time of exit.

Based on observation ceiling tiles were not in the grid work provided in several location throughout the facility. The tiles are required to be in place to trap heat from a fire, so that sprinkler heads will activate. This deficient practice could effect all occupants of the building in the event of a fire if the complete automatic fire sprinkler system did not operated as designed.

Findings Include:

During the facility tour on 9-26-13, between 8:30AM-5:00PM it was observed that the ceiling tiles were not in place as required by LSC(00) section 18.1.6.2. i.e. Computer lab storage room, medical records.

This deficient practice was confirmed by the Director of Plant Operations (PC) and Safety Officer (KH) at the time of exit.

Citation Text for Tag 0018, Regulation K202 Bld 01

Juntunen, Jeff
Based on observation several corridor room doors are being improper held open. This deficient practice could effect all building occupants in the event of a fire. Open doors would allow smoke to compromise the corridor exiting system.

Findings Include:

During the facility survey on 9-26-13 between 8:30AM-5:00PM, it was observed in several locations throughout the facility that wooden wedges of other objects were being used to hold doors open improperly. Doors that are required to be self closing shall comply with LSC(00) section 18-3.6.3.

This deficient practice was confirmed by Director of Plant Operations (PC) and Safety officer (KH) at the time of exit.

Based on observation several corridor room doors are being improper held open. This deficient practice could effect all building occupants in the event of a fire. Open doors would allow smoke to compromise the corridor exiting system.

Findings Include:

During the facility survey on 9-26-13 between 8:30AM-5:00PM, it was observed in several locations throughout the facility that wooden wedges of other objects were being used to hold doors open improperly. Doors that are required to be self closing shall comply with LSC(00) section 18-3.6.3.

This deficient practice was confirmed by Director of Plant Operations (PC) and Safety officer (KH) at the time of exit.

Based on observation, a lock has been installed, that requires a key to open, on the egress side of the door out of the northeast stairwell, at ground level. Locks are prohibited per LSC(00) section 19.2.2.2.5. This deficient practice could effect all building occupants in the event of an emergency.

Findings include:

During the facility tour on 9-26-13, between 8:00AM-5:00PM, it was observed the a key is need to release the lock on the egress side of the grade level door out of the northeast exit stairwell. Staff did not have the key to open this door.

This deficient practice was confirmed by the Plant Maintenance Director (PC) and the Safety Officer (KH) at the time of exit.

Based on observation, the exit from the NW stairwell is obstructed on both the interior and the exterior of the building. This deficient practice could affect all occupants of the building that may attempt to use this exit in the event of a fire or other emergency.

Findings include:

During the facility tour on 9-26-13 at 2:00 PM it was observed that the lowest level of the Northwest stairwell (by the Specialty Clinic) was obstructed by chairs on the interior of the building and by a picnic table on the exterior of the building. Exits are required to be maintained clear and unobstructed per LSC(00) section 18.2.3.3

This deficient practice was confirmed by the Director of Plant Operations (PC) and the Safety Officer (KH) at the time of exit.

Based on observation the doors from exam/treatment rooms within the Speciality Clinic are not the width as required by LSC(00)18.2.3.5. This deficient practice could effect all occupants of the clinic in the event of an evacuation for fire or other emergency.

Findings include:

During the facility tour on 9-26-13 at 2:30 PM it was confirmed by actual measurement that the doors from the exam/treatment rooms within the Speciality Clinic are not at least 41.5 inches in clear operable width. This clinic was a part of the 20012/20013 addition and remodeling project. The clinic is not 2 hour fire rated separated from the rest of the hospital.

This deficient practice was confirmed by the Director of Plant Operations (PC) and the Safety Officer at the time of exit.

Based on observation, it was determined that the facility has failed to ensure that the exterior exit discharge path is provided with illumination in accordance with the LSC, Sections 19.2.8 and 7.8.1.4. This deficient practice could affect all residents, staff and visitors, if emergency exiting of the facility were necessary.

Findings include:

During the facility tour on 9-26-13 between 8:30AM-5:00PM , it was observed that there were not two bulbs to provide the required illumination of the discharge path of travel away from the building, from the northeast exit stairwell of the existing nursing home. All other exits are in compliance.

This deficient practice was confirmed by the facility Director of Maintenance (PC) and Safety Officer (KH) at the time of exit.

Based on review of available fire drill records the facility has not been conducting fire drills as required by LSC(00) section 18.7.1.2. This deficient practice could effect all building occupants, including patients, visitors and staff in the event of a fire.

Findings include:

At the conclusion of the inspection tour on 9-26-13 at 4:00 PM based on a review of available fire drill records that facility has failed to conduct drills as one per shift per quarter on all shifts. No afternoon shift drills 2nd quarter of 2013.

NOTE: This is the 3rd inspection in a row that lack of fire drills has been cited at this facility.

This deficient practice was confirmed by the Director of Plant Operation (PC) and Safety Officer (KH) at the time of exit.

Citation Text for Tag 0050, Regulation K202 Bld 02

Juntunen, Jeff

Based on review of available fire drill records the facility has not been conducting fire drills as required by LSC(00) section 18.7.1.2. This deficient practice could effect all building occupants, including patients, visitors and staff in the event of a fire.

Findings include:

At the conclusion of the inspection tour on 9-26-13 at 4:00 PM based on a review of available fire drill records that facility has failed to conduct drills as one per shift per quarter on all shifts. No afternoon shift drills 2nd quarter of 2013.

NOTE: This is the 3rd inspection in a row that lack of fire drills has been cited at this facility.

This deficient practice was confirmed by the Director of Plant Operation (PC) and Safety Officer (KH) at the time of exit.

Based on observation facility staff did not have keys to re-set the fire alarm manual pull stations and the audible fire alarm evacuation signal did not sound throughout the facility. These deficient practices could delay the re-setting of the fire alarm system. Lack of fire alarm audible evacuation signal could effect all building occupants.

Findings include:

As a part of this facility inspection a fire drill was conducted on 9-26-13 at 1:20 PM. A staff person was instructed to pull the manual fire alarm pull station as a routine component of the drill. When the pull station was activated the general fire alarm evacuation signal did not sound throughout the facility as required by NFPA 72. Upon conclusion of the drill, no one had a key to re-set the pull station that had been activated.

These deficient practices were confirmed by the Director of Plant Operations (PC) and the Safety officer (KH) at the time of exit.

Based on observation and interview, the facility's fire alarm system is not installed in conformance with NFPA 72. This deficient practice could affect all patients.

Findings include:

Based on observation during the facility tour on 9-26-13 at 3:30 PM, it was observed that there is not a system connected smoke detector within 10 feet of the panel. The fire alarm panel is located in the lower level large storage room.

This deficient practice was confirmed by Director of Plant Operation (PC) and Safety Officer (KH) at the time of exit.

Based on observations several smoke detectors in the facility still had dust covers on them from the construction project. This deficient practice could delay fire alarm activation and notification to occupants in the event of a fire.

Findings include:

During the facility tour on 9-26-13 between 8:30 AM-5:00 PM it was observed that several fire alarm connected smoke detectors had covers on them that would prevent smoke from entering the chamber and activating the fire alarm system. Ensuring that ALL devices are able to detect heat and or smoke is required as an ongoing part of the inspection program outlined in NFPA 72.

This deficient practice was confirm by the Director of Plant Operations (PC) and Safety Officer (KH) at the time of exit.

Based on observation the valves for the automatic pre-action sprinkler system are not supervised as required by MSFC(07) section 903.4.4. This deficient practice could effect all the occupants of the facility in the event the valves were tampered with, impairing the system.

Finding include:

During the facility tour at 11:00 AM it was ovserved that the valves were not secured in the open position on the automatic fire sprinkler system/pre-action system protecting the telephone equipment room. Nor, was the door locked to the room.

This deficient practice was confirmed by the Director of Plant Operation (PC) and Safety officer (KH) at the time of exit.

Based on observation 3 quick response sprinkler heads in the facility appeared to be clear in color and not red. If the fluid is not present in the bulbs, the heads my not activate under fire conditions. This deficient practice could effect all occupants of the building.

Findings include:

During the facility tour on 9-26-13 between 8:30 AM-5:00 PM it was observed that 3 quick response sprinkler heads appeared to not have fluid in them. They were located in the freezer in the kitchen, the body cooler by the loading dock, and the entry way by the time clock lower level. Ensuring the sprinkler system is in operating condition is required by NFPA 25.

This deficient practice was confirmed by Plant Director of Operations (PC) and Safety Officer (KH) at the time of exit.

Based on observation, the sprinkler head in the lower level chute room (nursing home) does not meet the requirement for all heads in a smoke zone to be of the same type and style as required by NFPA 13 & 25. This deficient practice could effect all building occupants in the event of a fire.

Findings include:

During the facility tour on 9-26-13 between 8:30AM-5:00PM, it was observed that the fire sprinkler head in the chute room, located on the lower level of the nursing home, appeared to be an "old" style head. The rest of the area is protected by QR (quick response heads). Nor could the water supply to the head be verified, it appeared to be off of the domestic water supply.

This deficient practice was confirmed by the Director of Maintenance (PC) and Safety Officer (KH) at the time of exit.

Based on observation it could not be determined if all exam/treatment rooms had battery back up emergency lighting., as required by NFPA 99.

Findings include:

During the facility tour on 9-26-13, between 8:30 AM-5:00 PM, based on observation and interview with Director of Plan Operation (PC) it could not be determined if exam/treatment rooms 2083, 2084 & 2079 had battery operated back-up emergency lighting that would come on instantly in the event of a power failure from the public utility. This action would provide lighting until the facility emergency back up electrical generator came on line.

This deficient practice was confirmed by Director of Plant Operation (PC) and Safety Officer (KH) at the time of exit.

Based on interview with the Director of Plant Operations (PC) the newly installed back up emergency electrical generators have not been commissioned as required by MSFC(07) section 104.7.2. In the event the generators were to not function as designed it could effect all occupants of the facility.

Findings include:

Based on interview with the Director of Plant Operations (PC) at the conclusion of the tour on 9-26-13, it was discovered that the facility has not had the new emergency electrical generators (2) evaluating to ensure proper installation by an independent 3rd party. At the start of the remodeling/additions the facility was notified that this would be a requirement prior to Fire Marshal clearance of the project. To date the evaluation has not been conducted or scheduled.

This deficient practice was confirmed by Director of Plant Operation (PC) and Safety Officer (KH) at the time of exit.