HospitalInspections.org

Based on observations, the facility has failed to provide the proper corridor separation from use areas. This deficient practice could affect the exiting of all patients, staff and visitors within the smoke compartment.

Findings include:
On facility tour between 02:00 PM on 11/14/2011 and 04:00 PM on 11/16/2011, it was observed that the following use areas are not separated from the corridor and did not meet the exceptions to NFPA 101, 2000 Ed., Section 19.3.6.1. These open areas are not protected with automatic smoke detection.
Areas Include :
1) Central Building North Section 2nd floor lobby waiting area.
2) 2nd floor West Lounge by room 2610.

Based on observation, the facility failed to maintain corridor openings as required by LSC(00) Section 19.3.1.1. This deficient practice could affect all patients, staff and visitors Within the smoke compartments.

Findings include:
On facility tour between 02:00 PM on 11/14/2011 and 04:00 PM on 11/16/2011, it was observed that the following
corridor doors are held open with electric magnetic devices inter-connected to the fire alarm system but do not have automatic smoke detection within 5 feet of the doors as required in the following areas:
1) 1st floor Housekeeping Room C1172.
2) 2nd floor Room C2539.

Based on observation smoke detectors were located within 36 inches of HVAC deflectors on the 6th floor surgery area. This deficient practice could effect all building occupants in the vent of a fire emergency and cause delay of the fire alarm activation.

Findings include:

On facility tour between 02:00 PM on 11/14/2011 and 04:00 PM on 11/16/2011, it was observed that the folowing fire alarm system connected smoke detectors were located within 36 inches of the HVAC deflectors (supply and or return) in the following locations.
1) 3rd floor West building in Rooms W3640, W3602.
2) 2nd floor West building Room W2605 and Nursery.
3) 5th floor Central building in Rooms C5422, C5430, C5474 and in the corridor by room C5458.

Observations revealed that the oxygen storage rooms are not in accordance with NFPA 99 Standards for Health Care Facilities (1999 edition). This deficient practice could create an oxygen enriched atmosphere that could contribute to rapid fire growth. This could negatively impact all patients, staff and visitors within the smoke compartment.

Findings include:
On facility tour between 02:00 PM on 11/14/2011 and 04:00 PM on 11/16/2011, it was observed that in the 1st floor Oxygen Room C1312, three E-size tanks were not secured in storage racks as required.

Heliotropes shall be maintained in accordance with the 2007 MN State Fire Code. Section 1107.

Findings include:
On facility tour between 02:00 PM on 11/14/2011 and 04:00 PM on 11/16/2011, it was observed that the helistop, which is located at ground level, away from the main building, did not have an 80-BC fire extinguisher located in the helistop area as required by the 2007 MN State Fire Code, Section 1107.7.

Based on observations, the facility has failed to provide the proper corridor separation from use areas. This deficient practice could affect the exiting of all patients, staff and visitors within the smoke compartment.

Findings include:
On facility tour between 02:00 PM on 11/14/2011 and 04:00 PM on 11/16/2011, it was observed that the following use areas are not separated from the corridor and did not meet the exceptions to NFPA 101, 2000 Ed., Section 19.3.6.1. These open areas are not protected with automatic smoke detection.
Areas Include :
1) Central Building North Section 2nd floor lobby waiting area.
2) 2nd floor West Lounge by room 2610.

Based on observation, the facility failed to maintain corridor openings as required by LSC(00) Section 19.3.1.1. This deficient practice could affect all patients, staff and visitors Within the smoke compartments.

Findings include:
On facility tour between 02:00 PM on 11/14/2011 and 04:00 PM on 11/16/2011, it was observed that the following
corridor doors are held open with electric magnetic devices inter-connected to the fire alarm system but do not have automatic smoke detection within 5 feet of the doors as required in the following areas:
1) 1st floor Housekeeping Room C1172.
2) 2nd floor Room C2539.

Based on observation smoke detectors were located within 36 inches of HVAC deflectors on the 6th floor surgery area. This deficient practice could effect all building occupants in the vent of a fire emergency and cause delay of the fire alarm activation.

Findings include:

On facility tour between 02:00 PM on 11/14/2011 and 04:00 PM on 11/16/2011, it was observed that the folowing fire alarm system connected smoke detectors were located within 36 inches of the HVAC deflectors (supply and or return) in the following locations.
1) 3rd floor West building in Rooms W3640, W3602.
2) 2nd floor West building Room W2605 and Nursery.
3) 5th floor Central building in Rooms C5422, C5430, C5474 and in the corridor by room C5458.

Observations revealed that the oxygen storage rooms are not in accordance with NFPA 99 Standards for Health Care Facilities (1999 edition). This deficient practice could create an oxygen enriched atmosphere that could contribute to rapid fire growth. This could negatively impact all patients, staff and visitors within the smoke compartment.

Findings include:
On facility tour between 02:00 PM on 11/14/2011 and 04:00 PM on 11/16/2011, it was observed that in the 1st floor Oxygen Room C1312, three E-size tanks were not secured in storage racks as required.

Heliotropes shall be maintained in accordance with the 2007 MN State Fire Code. Section 1107.

Findings include:
On facility tour between 02:00 PM on 11/14/2011 and 04:00 PM on 11/16/2011, it was observed that the helistop, which is located at ground level, away from the main building, did not have an 80-BC fire extinguisher located in the helistop area as required by the 2007 MN State Fire Code, Section 1107.7.