HospitalInspections.org

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to provide 2-hour rated construction at building separation wall in accordance with 2000 - NFPA 101, sections 19.1.1.4.1 and 8.2.3.2. The deficient practice could affect all 7 patients.


Findings include:

On facility tour between 7:15 AM and 10:15 AM on 09/10/2010 and 12:30 PM and 5:30 PM on 09/13/2010, observation revealed, that the following was found in the 2-hour rated building separation walls:

1. 1960 building - basement - between hospital and nursing home, open penetrations above the drop in ceiling
2. 2000 building - 1st floor - hospital to ambulance garage, the double doors are not 1-1/2 hours fire rated doors
3. 2000 building - 1st floor - west hospital to clinic, open penetrations above the drop in ceiling




These deficient practices were confirmed by the Maintenance Director (JF) and and Safety staff (TH) at the time of discovery.

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to provide proper enclosed vertical openings as per 2000 NFPA 101, sections 19.3.1.1 and 8.2.5.6. This deficient practice could affect all 7 patients.

Findings include:

On facility tour between 7:15 AM and 10:15 AM on 09/10/2010 , observation revealed, that in the 1960 building, the freight elevator between basement and 1st floor laundry room only has a wire mesh door. This creates a vertical shaft that does not have fire separation between floor.


These deficient practices were confirmed by the Administrator (TC), Maintenance Director (JF) and and Safety staff (TH) at the time of discovery.

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to maintain the hazardous rooms in accordance with the following requirements of 2000 NFPA 101, Section 19.3.2.1 . The deficient practice could affect all 7 patients.

Findings include:

On facility tour between 7:15 AM and 10:15 AM on 09/10/2010 and 12:30 PM and 5:30 PM on 09/13/2010, observation revealed that the following was found in the 1960 building:

1. Basement - maintenance repair shop, south wall has open penetrations above the drop in ceiling
2. Basement - boiler room, north wall has open penetrations
3. Basement - mechanical room AHU 16, south and east walls has open penetrations
4. Basement - central supply room - loading/shipping double doors:
a. no door closer on left door
b. no door coordinator
5. Basement - housekeeping/storage room, no door closer
6. Basement - paint storage room a. no door closer
b. open penetrations
7. Basement - sprinkler riser room/storage, open penetrations on west west
8. Basement - medical records office/storage room, open penetrations on south and west walls above the drop in ceiling



These deficient practices were confirmed by the Maintenance Director (JF) and and Safety staff (TH) at the time of discovery.

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to maintain a fire resistance rating of at least one hour in the exit component accordance with the following requirements of 2000 NFPA 101, Section 19.3.1.1, 8.2.5.2. The deficient practice could affect all 7 patients.

Findings include:

On facility tour between 7:15 AM and 10:15 AM on 09/10/2010 and 12:30 PM and 5:30 PM on 09/13/2010, observation revealed, that in the 1960 building the following was found:

1. Basement and 1st floor - lab stairwell, has an open penetration around the sprinkler piping
2. 1st floor - center stairwell, there is no fire rating label indicating that it is a 1 hr fire rated door



These deficient practices were confirmed by the Maintenance Director (JF) and and Safety staff (TH) at the time of discovery.

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to install exit signage in accordance with the requirements of 2000 NFPA 101, Sections 7.7.3, 7.10.1.4 and 7.10.4.

Findings include:

On facility tour between 12:30 PM and 5:30 PM on 09/13/2010, observation revealed, that in the 2000 building, the emergency room area, there are 3 exits that do not have exit signage above the doors.


This deficient practice was confirmed by the Maintenance Director (JF) and and Safety staff (TH) at the time of discovery.

This STANDARD is not met as evidenced by:

Based on documentation review and staff interview, the facility failed to assure fire drills were conducted once per shift per quarter for all staff under varying times and conditions as required by 2000 NFPA 101, Section 18.7.1.2. The deficient practice could affect all 7 patients.

Findings include:

On facility tour between 7:15 AM and 10:15 AM on 09/10/2010, the review of the fire drill documentation for the past 12 months (September 2009 to August 2010) revealed, that the fire drill was missed for the 1st Quarter of 2010, evening shift.


This deficient practice was confirmed by the Maintenance Director (JF) and and Safety staff (TH) at the time of discovery.

This STANDARD is not met as evidenced by:

Based on documentation review and staff interview, the facility failed to assure fire drills were conducted once per shift per quarter for all staff under varying times and conditions as required by 2000 NFPA 101, Section 19.7.1.2. The deficient practice could affect all 7 patients.

Findings include:

On facility tour between 7:15 AM and 10:15 AM on 09/10/2010, the review of the fire drill documentation for the past 12 months (September 2009 to August 2010) revealed, that the fire drill was missed for the 1st Quarter of 2010, evening shift.


This deficient practice was confirmed by the Maintenance Director (JF) and and Safety staff (TH) at the time of discovery.

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to install the fire alarm system in accordance with the requirements of the 1999 Edition of NFPA 72 and 2000 NFPA 101. The deficient practice could affect all 7 patients.

Findings include:

On facility tour between 12:30 PM and 5:30 PM on 09/13/2010, revealed that in the 1960 building, the following was found:

1. The smoke detectors in the following locations are not located at least 3 feet away from air supply and return vents as required by 1999 NFPA 72, Section 2-3.5.1:

a. 2nd floor - in corridor by west stairwell
b. 1st floor - in corridor by radiology room

2. 2nd floor - in med surgery supply room, there is a circuit expander panel for the fire alarm system that is not protected by a smoke detector that is interconnect to building fire alarm system as required by 1999 NFPA 72 Section 1-5.6

3. 2nd floor - doctors sleep room, does not have a chime /strobe

4. 2nd floor - OB lounge, that is open to the corridor is not protected by a smoke detector that is interconnect to building fire alarm system

5. The hospital Post Indicating Valve (PIV), located outside is locked but is not being monitored by the buildings fire alarm system



These deficient practices were confirmed by the Maintenance Director (JF) and and Safety staff (TH) at the time of discovery.

This STANDARD is not met as evidenced by:

Based on observation, the facility failed to provide proper coverage of the fire sprinkler system as per 1999 NFPA 13 5-8.5.2.3.


Findings include:

On facility tour between 12:30 PM and 5:30 PM on 09/13/2010, observation revealed, that the following was found:

In the 1960 building, the following was found:

1. 2nd floor - main pharmacy area, the fire sprinkler head is being blocked by shelving that does not have 18 inch clearance from the fire sprinkler deflector. This creates an obstruction for the fire sprinkler head.

2. 2nd floor - pharmacy patient pick window area, inside the office area, there is a shelving cabinet that does not have 18 inch clearance from the fire sprinkler deflector. This creates an obstruction for the fire sprinkler head.

In the 2000 building, the following was found:

1. 1st floor - emergency/surgery room - bay "C", the television set is located approximately 3-4 inches directly under neath the fire sprinkler head. This creates an obstruction for the fire sprinkler head.

2. 1st floor - emergency/surgery room - pelvic exam room, The privacy curtains does not have the proper 1/2 inch opening.


These deficient practices were confirmed by the Maintenance Director (JF) and and Safety staff (TH) at the time of discovery.

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to provide 2-hour rated construction at building separation wall in accordance with 2000 - NFPA 101, sections 19.1.1.4.1 and 8.2.3.2. The deficient practice could affect all 7 patients.


Findings include:

On facility tour between 7:15 AM and 10:15 AM on 09/10/2010 and 12:30 PM and 5:30 PM on 09/13/2010, observation revealed, that the following was found in the 2-hour rated building separation walls:

1. 1960 building - basement - between hospital and nursing home, open penetrations above the drop in ceiling
2. 2000 building - 1st floor - hospital to ambulance garage, the double doors are not 1-1/2 hours fire rated doors
3. 2000 building - 1st floor - west hospital to clinic, open penetrations above the drop in ceiling




These deficient practices were confirmed by the Maintenance Director (JF) and and Safety staff (TH) at the time of discovery.

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to provide proper enclosed vertical openings as per 2000 NFPA 101, sections 19.3.1.1 and 8.2.5.6. This deficient practice could affect all 7 patients.

Findings include:

On facility tour between 7:15 AM and 10:15 AM on 09/10/2010 , observation revealed, that in the 1960 building, the freight elevator between basement and 1st floor laundry room only has a wire mesh door. This creates a vertical shaft that does not have fire separation between floor.


These deficient practices were confirmed by the Administrator (TC), Maintenance Director (JF) and and Safety staff (TH) at the time of discovery.

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to maintain the hazardous rooms in accordance with the following requirements of 2000 NFPA 101, Section 19.3.2.1 . The deficient practice could affect all 7 patients.

Findings include:

On facility tour between 7:15 AM and 10:15 AM on 09/10/2010 and 12:30 PM and 5:30 PM on 09/13/2010, observation revealed that the following was found in the 1960 building:

1. Basement - maintenance repair shop, south wall has open penetrations above the drop in ceiling
2. Basement - boiler room, north wall has open penetrations
3. Basement - mechanical room AHU 16, south and east walls has open penetrations
4. Basement - central supply room - loading/shipping double doors:
a. no door closer on left door
b. no door coordinator
5. Basement - housekeeping/storage room, no door closer
6. Basement - paint storage room a. no door closer
b. open penetrations
7. Basement - sprinkler riser room/storage, open penetrations on west west
8. Basement - medical records office/storage room, open penetrations on south and west walls above the drop in ceiling



These deficient practices were confirmed by the Maintenance Director (JF) and and Safety staff (TH) at the time of discovery.

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to maintain a fire resistance rating of at least one hour in the exit component accordance with the following requirements of 2000 NFPA 101, Section 19.3.1.1, 8.2.5.2. The deficient practice could affect all 7 patients.

Findings include:

On facility tour between 7:15 AM and 10:15 AM on 09/10/2010 and 12:30 PM and 5:30 PM on 09/13/2010, observation revealed, that in the 1960 building the following was found:

1. Basement and 1st floor - lab stairwell, has an open penetration around the sprinkler piping
2. 1st floor - center stairwell, there is no fire rating label indicating that it is a 1 hr fire rated door



These deficient practices were confirmed by the Maintenance Director (JF) and and Safety staff (TH) at the time of discovery.

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to install exit signage in accordance with the requirements of 2000 NFPA 101, Sections 7.7.3, 7.10.1.4 and 7.10.4.

Findings include:

On facility tour between 12:30 PM and 5:30 PM on 09/13/2010, observation revealed, that in the 2000 building, the emergency room area, there are 3 exits that do not have exit signage above the doors.


This deficient practice was confirmed by the Maintenance Director (JF) and and Safety staff (TH) at the time of discovery.

This STANDARD is not met as evidenced by:

Based on documentation review and staff interview, the facility failed to assure fire drills were conducted once per shift per quarter for all staff under varying times and conditions as required by 2000 NFPA 101, Section 18.7.1.2. The deficient practice could affect all 7 patients.

Findings include:

On facility tour between 7:15 AM and 10:15 AM on 09/10/2010, the review of the fire drill documentation for the past 12 months (September 2009 to August 2010) revealed, that the fire drill was missed for the 1st Quarter of 2010, evening shift.


This deficient practice was confirmed by the Maintenance Director (JF) and and Safety staff (TH) at the time of discovery.

This STANDARD is not met as evidenced by:

Based on documentation review and staff interview, the facility failed to assure fire drills were conducted once per shift per quarter for all staff under varying times and conditions as required by 2000 NFPA 101, Section 19.7.1.2. The deficient practice could affect all 7 patients.

Findings include:

On facility tour between 7:15 AM and 10:15 AM on 09/10/2010, the review of the fire drill documentation for the past 12 months (September 2009 to August 2010) revealed, that the fire drill was missed for the 1st Quarter of 2010, evening shift.


This deficient practice was confirmed by the Maintenance Director (JF) and and Safety staff (TH) at the time of discovery.

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to install the fire alarm system in accordance with the requirements of the 1999 Edition of NFPA 72 and 2000 NFPA 101. The deficient practice could affect all 7 patients.

Findings include:

On facility tour between 12:30 PM and 5:30 PM on 09/13/2010, revealed that in the 1960 building, the following was found:

1. The smoke detectors in the following locations are not located at least 3 feet away from air supply and return vents as required by 1999 NFPA 72, Section 2-3.5.1:

a. 2nd floor - in corridor by west stairwell
b. 1st floor - in corridor by radiology room

2. 2nd floor - in med surgery supply room, there is a circuit expander panel for the fire alarm system that is not protected by a smoke detector that is interconnect to building fire alarm system as required by 1999 NFPA 72 Section 1-5.6

3. 2nd floor - doctors sleep room, does not have a chime /strobe

4. 2nd floor - OB lounge, that is open to the corridor is not protected by a smoke detector that is interconnect to building fire alarm system

5. The hospital Post Indicating Valve (PIV), located outside is locked but is not being monitored by the buildings fire alarm system



These deficient practices were confirmed by the Maintenance Director (JF) and and Safety staff (TH) at the time of discovery.

This STANDARD is not met as evidenced by:

Based on observation, the facility failed to provide proper coverage of the fire sprinkler system as per 1999 NFPA 13 5-8.5.2.3.


Findings include:

On facility tour between 12:30 PM and 5:30 PM on 09/13/2010, observation revealed, that the following was found:

In the 1960 building, the following was found:

1. 2nd floor - main pharmacy area, the fire sprinkler head is being blocked by shelving that does not have 18 inch clearance from the fire sprinkler deflector. This creates an obstruction for the fire sprinkler head.

2. 2nd floor - pharmacy patient pick window area, inside the office area, there is a shelving cabinet that does not have 18 inch clearance from the fire sprinkler deflector. This creates an obstruction for the fire sprinkler head.

In the 2000 building, the following was found:

1. 1st floor - emergency/surgery room - bay "C", the television set is located approximately 3-4 inches directly under neath the fire sprinkler head. This creates an obstruction for the fire sprinkler head.

2. 1st floor - emergency/surgery room - pelvic exam room, The privacy curtains does not have the proper 1/2 inch opening.


These deficient practices were confirmed by the Maintenance Director (JF) and and Safety staff (TH) at the time of discovery.

This STANDARD is not met as evidenced by:

Based on documentation review and staff interview, the facility failed to test the emergency generator in accordance with the requirements of 1967 NFPA 70, Article 700-12, 2000 NFPA 101 - 9.1.3 and 1999 NFPA 110. The deficient practice could affect all 7 patients.

Findings include:

On facility tour between 7:15 AM and 10:15 AM on 09/10/2010, , documentation review of the monthly emergency generator testing log (September 2009 to August 2010), indicated that 6 out of the 12 months, the emergency generator was not being tested under load of 30 percent or more of the nameplate rating of generator.



These deficient practices were confirmed by the Maintenance Director (JF) at the time of discovery.



*TEAM COMPOSITION*
Gary Schroeder, Life Safety Code Spc.