HospitalInspections.org

Based on observations and confirmed by staff, the facility failed to assure that stairwells are maintained as required with the proper fire resistance rating.

THE FINDINGS INCLUDE:

Observation on 5/15/12 and 5/17/12 revealed that Stair #4 and Stair #3 are not enclosed as noted by the following:


- Stair #4 had unsealed penetrations to the floor levels on the tenth, ninth, and seventh floor levels. Unsealed penetrations were noted around lighting on the 10th floor level, around data wire on the 9th floor level, and around electrical metal tubing (EMT) on the 7th floor level. In addition, a "loose latch" mechanism on the stair door at the second floor level prevented the door from engaging in the latch mechanism when released from the open position.

-Stair #3 had unsealed penetrations to the electrical room(s) within the stair enclosure at the ninth, eighth, sixth, fifth, second, first, and ground floor levels. Unsealed penetrations were noted around E.M.T. on the 9th and 8th floor levels, around an open electrical box on the 6th floor level, and around data wire on the first and ground floor levels.

This was confirmed by and reviewed with the physical plant director.

Based on record review and staff interview, the facility failed to conduct fire drills as required.

THE FINDINGS INCLUDE:

- Record review of fire drill reports for the last seventeen (17) months on 5/15/12 revealed that drills are not conducted at varied times on the second (3 P.M. to 11 P.M.) and third (11 P.M. to 7 A.M.) shifts covering the entire eight (8) hours of each shift.
- The last six (6) second shift fire drills were conducted 25-minutes apart as follows:

4/30/12 at 6:22 P.M.,
2/22/12 at 6:12 P.M.,
12/13/11 at 6:37 P.M.,
9/29/11 at 6:20 P.M.,
5/31/11 at 630 P.M., and
2/28/11 at 6:15 P.M.

- The last four (4) third shift fire drills were conducted 10 minutes apart as follows:
3/27/12 at 6:25 A.M.,
10/27/11 at 6:35 A.M.,
6/22/11 at 6:26 A.M., and
3/31/11 at 6:25 A.M.,

This was confirmed by and reviewed with the physical plant director.

Based on observations and confirmed by staff, the facility failed to assure that stairwells are maintained as required with the proper fire resistance rating.

THE FINDINGS INCLUDE:

Observation on 5/15/12 and 5/17/12 revealed that Stair #4 and Stair #3 are not enclosed as noted by the following:


- Stair #4 had unsealed penetrations to the floor levels on the tenth, ninth, and seventh floor levels. Unsealed penetrations were noted around lighting on the 10th floor level, around data wire on the 9th floor level, and around electrical metal tubing (EMT) on the 7th floor level. In addition, a "loose latch" mechanism on the stair door at the second floor level prevented the door from engaging in the latch mechanism when released from the open position.

-Stair #3 had unsealed penetrations to the electrical room(s) within the stair enclosure at the ninth, eighth, sixth, fifth, second, first, and ground floor levels. Unsealed penetrations were noted around E.M.T. on the 9th and 8th floor levels, around an open electrical box on the 6th floor level, and around data wire on the first and ground floor levels.

This was confirmed by and reviewed with the physical plant director.

Based on record review and staff interview, the facility failed to conduct fire drills as required.

THE FINDINGS INCLUDE:

- Record review of fire drill reports for the last seventeen (17) months on 5/15/12 revealed that drills are not conducted at varied times on the second (3 P.M. to 11 P.M.) and third (11 P.M. to 7 A.M.) shifts covering the entire eight (8) hours of each shift.
- The last six (6) second shift fire drills were conducted 25-minutes apart as follows:

4/30/12 at 6:22 P.M.,
2/22/12 at 6:12 P.M.,
12/13/11 at 6:37 P.M.,
9/29/11 at 6:20 P.M.,
5/31/11 at 630 P.M., and
2/28/11 at 6:15 P.M.

- The last four (4) third shift fire drills were conducted 10 minutes apart as follows:
3/27/12 at 6:25 A.M.,
10/27/11 at 6:35 A.M.,
6/22/11 at 6:26 A.M., and
3/31/11 at 6:25 A.M.,

This was confirmed by and reviewed with the physical plant director.