HospitalInspections.org

Observations showed that a set of corridor doors do not comply with NFPA 101 "The Life Safety Code" 2000 Edition. If corridor doors do not latch and stay tightly within their frames a fire could spread beyond the room of origin and would negatively impact all the residents, visitors and staff.

Findings include:
Observations and testing of approximately fifty corridor doors, during the facility tour on September 15, 2010, between 9:00 am and 11:30 am, revealed that the corridor doors from the ER suite of rooms are not positively latching as required by LSC section 19.3.6.3.2.

The Maintenance Manager (RK) verified these findings during the inspection and at the exit conference with the Administrator (DS).

Observations revealed that one of thirty hazardous areas observed is not in accordance with NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 19.3.2.1. This deficient practice could allow the products of combustion to travel from one area to another if a fire occurs within one of these hazardous areas, which could negatively impact all the residents, staff and visitors.

Findings include:
Observations and testing of approximately fifty corridor doors, during the facility tour on September 15, 2010, between 9:00 am and 11:30 am, revealed the storage room near the helli-pad entrance, has an accordion style door that is not self-closing nor positive latching.

The Maintenance Manager (RK) verified these findings during the inspection and at the exit conference with the Administrator (DS).

Observations revealed that the facility has space heater in use, which is not allowed by NFPA 101 "The Life Safety Code" 2000 edition section 19.7.8. This deficient practice could negatively impact any resident, visitor and the staff of the business office if combustibles get to close to the unit and ignited.

Findings include:
Observations and testing of approximately fifty corridor doors, during the facility tour on September 15, 2010, between 9:00 am and 11:30 am, revealed that two small portable space heater, with exposed heating elements, was plugged in and in use in the doctor offices of the clinic suite.

The Maintenance Manager (RK) verified these findings during the inspection and at the exit conference with the Administrator (DS).

Observations revealed that the emergency generator is not installed in accordance with NFPA 110 The Standard for Emergency and Standby Power Systems 1999 edition. This deficient practice could allow the generator to have a problem that would go unnoticed by staff which could negatively impact the all patients, visitors and staff.

Findings include:
Observations and testing of approximately fifty corridor doors, during the facility tour on September 15, 2010, between 9:00 am and 11:30 am, revealed that the emergency generator does not have a remote alarm annunciator in a constantly attended location. The remote panel that provides individual displays indicating the generator is operating and when the battery charger is malfunctioning and individual displays with a common audible alarm that indicate low oil pressure, low coolant temp, excessive coolant temp, less than a 3 hour fuel supply, failure to start and overspeed required by NFPA 110 section 3-5.5.2 is not in a constantly attend location.

The Maintenance Manager (RK) verified these findings during the inspection and at the exit conference with the Administrator (DS).

Observations showed that a set of corridor doors do not comply with NFPA 101 "The Life Safety Code" 2000 Edition. If corridor doors do not latch and stay tightly within their frames a fire could spread beyond the room of origin and would negatively impact all the residents, visitors and staff.

Findings include:
Observations and testing of approximately fifty corridor doors, during the facility tour on September 15, 2010, between 9:00 am and 11:30 am, revealed that the corridor doors from the ER suite of rooms are not positively latching as required by LSC section 19.3.6.3.2.

The Maintenance Manager (RK) verified these findings during the inspection and at the exit conference with the Administrator (DS).

Observations revealed that one of thirty hazardous areas observed is not in accordance with NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 19.3.2.1. This deficient practice could allow the products of combustion to travel from one area to another if a fire occurs within one of these hazardous areas, which could negatively impact all the residents, staff and visitors.

Findings include:
Observations and testing of approximately fifty corridor doors, during the facility tour on September 15, 2010, between 9:00 am and 11:30 am, revealed the storage room near the helli-pad entrance, has an accordion style door that is not self-closing nor positive latching.

The Maintenance Manager (RK) verified these findings during the inspection and at the exit conference with the Administrator (DS).

Observations revealed that the facility has space heater in use, which is not allowed by NFPA 101 "The Life Safety Code" 2000 edition section 19.7.8. This deficient practice could negatively impact any resident, visitor and the staff of the business office if combustibles get to close to the unit and ignited.

Findings include:
Observations and testing of approximately fifty corridor doors, during the facility tour on September 15, 2010, between 9:00 am and 11:30 am, revealed that two small portable space heater, with exposed heating elements, was plugged in and in use in the doctor offices of the clinic suite.

The Maintenance Manager (RK) verified these findings during the inspection and at the exit conference with the Administrator (DS).

Observations revealed that the emergency generator is not installed in accordance with NFPA 110 The Standard for Emergency and Standby Power Systems 1999 edition. This deficient practice could allow the generator to have a problem that would go unnoticed by staff which could negatively impact the all patients, visitors and staff.

Findings include:
Observations and testing of approximately fifty corridor doors, during the facility tour on September 15, 2010, between 9:00 am and 11:30 am, revealed that the emergency generator does not have a remote alarm annunciator in a constantly attended location. The remote panel that provides individual displays indicating the generator is operating and when the battery charger is malfunctioning and individual displays with a common audible alarm that indicate low oil pressure, low coolant temp, excessive coolant temp, less than a 3 hour fuel supply, failure to start and overspeed required by NFPA 110 section 3-5.5.2 is not in a constantly attend location.

The Maintenance Manager (RK) verified these findings during the inspection and at the exit conference with the Administrator (DS).