HospitalInspections.org

Based on observation and staff interview it was determined the facility failed to properly maintain exit signage.

This could place 11 patients at risk in the event of fire.

The findings include:

During a tour of the facility with Staff B on 12/04/2017 between 11:00 AM and 3:00 PM observation revealed that the exit signage throughout the facility failed on operate on battery power.

These findings were confirmed by Staff B at the time of discovery.

Reference: 2012 NFPA 101, Chapter 19, Section 19.2.10.1 and Chapter 7, Section 7.10.5.1

Based on observation and staff interview it was determined the facility failed to be protected throughout by an approved automatic sprinkler system in accordance with NFPA 13.

This could place 0 patients at risk in the event of fire.

The findings include:

During a tour of the facility with Staff B on 12/04/2017 between 11:00 AM and 3:00 PM observation revealed the following:

1. The storage closet in the administrator's office did not have an automatic fire sprinkler head installed in it.

2. The canopy at the emergency room ambulatory entrance is made of combustible construction and doesn't have automatic fire sprinkler heads installed.

These findings were confirmed by Staff B at the time of discovery.

Reference: 2012 NFPA 101, Chapter 19, Section 19.3.5.1, Chapter 9, Section 9.7.1.1

Based on record review and staff interview, the facility failed to maintain the fire sprinkler system as required.

This could place 11 patients at risk in the event of a fire.

The finding includes:

During a record review and staff interview with Staff B on 12/04/2017 between 11:00 AM and 3:00 PM it was observed that there was no record of the last 5 year fire sprinkler internal testing.

This finding was confirmed by Staff B at the time of discovery.

Reference: 2012 NFPA 101, Chapter 19, Section 19.3.5.1, Chapter 9, Sections 9.7.5, 9.7.7, & 9.7.8 and 2011 NFPA 25, Chapter 14, Section 14.2.1

Based on observation and staff interview it was determined the facility failed to maintain the smoke barrier wall with construction having a fire resistance rating of at least one-half hour.

This could place 11 patients at risk in the event of fire.

The findings include:

During a tour of the facility with Staff B on 12/04/2017 between 11:00 AM and 3:00 PM observation revealed that the smoke barrier within the building was not being properly maintained. The smoke barrier had unsealed penetrations, improperly sealed penetrations (use of sheetrock compound instead of fire caulk), and fire caulk on top of sheetrock compound.

These findings were confirmed by Staff B at the time of discovery.

Reference: 2012 NFPA 101 , Chapter 19, Sections 19.3.7.1, 19.3.7.3, Chapter 8 Sections 8.3.5, 8.5.2.1, 8.5.2.2, 8.5.7.4, 8.5.6.1, 8.5.6.2, 8.5.6.3, Chapter 4, Section 4.6.12.1