HospitalInspections.org

Based on observation and interview, the facility did not maintain the fire and smoke resistive separation of two hazardous areas in accordance with NFPA 101 (2012 edition) 19.3.2.1, 8.4.3.5. The deficient practice could affect all outpatients in the wound center and an undetermined number of staff and visitors in 1 of 6 smoke compartments in the facility.

Findings Include:

On 01/07/19 between 11:50 am and 12:02 pm, observation revealed that the corridor doors of Storage Rooms 0C055 and 0A160, which are hazardous areas, did not have self-closing devices to provide required separation from other spaces. The deficient practice was confirmed by a concurrent interview with Staff M, Staff N, Staff O, Staff P, and Staff Q at the time of survey.

Based on observation and interview, the facility failed to provide smoke detection in one space open to the corridor in accordance with NFPA 101 (2012 edition) 19.3.6.1. This deficient practice could affect 4 inpatients and all outpatients receiving care and an undetermined number of staff and visitors in 1 of 6 smoke compartments in the facility.

Findings Include:
On 01/07/19 at 2:35 pm, observation revealed that there was no smoke detector coverage provided in the retail pharmacy space open to corridor on the main floor level. The deficient practice was confirmed by a concurrent interview with Staff M, Staff N, Staff O, Staff P, Staff Q, and Staff R at the time of survey.

Based on observation and interview, the facility did not provide sprinkler heads of proper temperature rating in accordance with NFPA 101 19.3.5.1, NFPA 13(2010) 8.3.2.1. The deficient practice affected an undetermined number of staff who work in and use the Kitchen area. The facility had a census of 4 patients on the day of survey with a licensed bed capacity of 25.

Findings Include

On 01/07/19 at 1:35 pm, observation revealed that three pendent sprinkler heads in the basement Kitchen, which were not near the kitchen hood and other areas allowed by Table 8.3.2.5(a), were not of ordinary temperature rating as required to protect any hazard in such an occupancy. Instead, these three sprinkler heads were of green color glass bulb indicating intermediate temperature rating of 200 or 212 deg F. This deficient practice was confirmed by a concurrent interview with Staff M, Staff N, Staff O, Staff P, Staff Q, and Staff R at the time of discovery.

Based on observation and interview, the facility failed to maintain corridor separation from one room in accordance with NFPA 101 (2012 edition) 19.3.6.3. This deficient practice could affect 4 inpatients and all outpatients receiving care and an undetermined number of staff and visitors in 1 of 6 smoke compartments in the facility.

Findings Include:

On 01/07/19 at 2:15 pm, observation revealed that the corridor door of the Clean Supply Room, Door number 1B095, in the old swing bed area did not latch. This deficient practice was by a concurrent interview with Staff M, Staff N, Staff O, Staff P, Staff Q, and Staff R at the time of discovery.