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Based on observations, corridor doors were not equipped with latching hardware, preventing the doors from positively latching into their frames. In a fire emergency, this deficient practice could adversely affect 5 of 25 patients, staff and visitors.

FINDINGS INCLUDE:

On 09/18/2013 between 9:30 AM and 3:00 PM, observation revealed the corridor doors to the following rooms were not equipped with door latching hardware, and did not positively latch into their frames:
A). Anesthesia Recovery Room;
B). Central Supply Room.

These findings were verified with the assistant building engineer at the times of discovery.

Based upon a review of available documentation, the facility failed to maintain the building fire alarm system in accordance with NFPA 101 (00) Chapter 9, Section 9.6 and Chapter 19, Section 19.3.4.1. and NFPA 72 (1999 edition) Sections 7-3.2 and 7-5.2.2 and Table 7-3.1. In a fire emergency, this deficient practice could adversely affect 25 of 25 patients, staff and visitors.

FINDINGS INCLUDE:

On 09/18/2013 between 9:30 AM and 3:00 PM, during a review of the facility's annual Fire Alarm Inspection and Testing Form dated 08/12/2013, the Initiating and Supervisory Device Tests and Inspection section of the form identified multiple alarm initiating devices on the system, however, the portion of the form pertaining to the Visual/Functional Test results for Alarm Initiating Devices was left blank. As such, it could not be verified that visual and functional testing of each device on the fire alarm system had been properly conducted.

This finding was confirmed with the chief building engineer.

Based upon a review of available documentation, the facility failed to maintain the building fire alarm system in accordance with NFPA 101 (00) Chapter 9, Section 9.6 and Chapter 18, Section 18.3.4.1. and NFPA 72 (1999 edition) Sections 7-3.2 and 7-5.2.2 and Table 7-3.1. In a fire emergency, this deficient practice could adversely affect 25 of 25 patients, staff and visitors.

FINDINGS INCLUDE:

On 09/18/2013 between 9:30 AM and 3:00 PM, during a review of the facility's annual Fire Alarm Inspection and Testing Form dated 08/12/2013, the Initiating and Supervisory Device Tests and Inspection section of the form identified multiple alarm initiating devices on the system, however, the portion of the form pertaining to the Visual/Functional Test results for Alarm Initiating Devices was left blank. As such, it could not be verified that visual and functional testing of each device on the fire alarm system had been properly conducted.

This finding was confirmed with the chief building engineer.

Based on observation and staff interview, the facility failed to provide drapery materials meeting the requirements of NFPA 101 (2000), Chapter 10, Section 10.3.1. In a fire emergency, this deficient practice could adversely affect 25 of 25 patients, staff and visitors.

FINDINGS INCLUDE:

On 09/18/2013 between 9:30 AM and 3:00 PM, observation revealed window drapes and curtains installed in Patient Rooms on the 100-Wing corridor. Based upon a staff interview, it was confirmed that these window treatments were not flame resistant in accordance with NFPA 101 (00) and NFPA 701 (1999 edition).

This deficient practice was verified with the chief building engineer.

Based on observations, corridor doors were not equipped with latching hardware, preventing the doors from positively latching into their frames. In a fire emergency, this deficient practice could adversely affect 5 of 25 patients, staff and visitors.

FINDINGS INCLUDE:

On 09/18/2013 between 9:30 AM and 3:00 PM, observation revealed the corridor doors to the following rooms were not equipped with door latching hardware, and did not positively latch into their frames:
A). Anesthesia Recovery Room;
B). Central Supply Room.

These findings were verified with the assistant building engineer at the times of discovery.

Based upon a review of available documentation, the facility failed to maintain the building fire alarm system in accordance with NFPA 101 (00) Chapter 9, Section 9.6 and Chapter 19, Section 19.3.4.1. and NFPA 72 (1999 edition) Sections 7-3.2 and 7-5.2.2 and Table 7-3.1. In a fire emergency, this deficient practice could adversely affect 25 of 25 patients, staff and visitors.

FINDINGS INCLUDE:

On 09/18/2013 between 9:30 AM and 3:00 PM, during a review of the facility's annual Fire Alarm Inspection and Testing Form dated 08/12/2013, the Initiating and Supervisory Device Tests and Inspection section of the form identified multiple alarm initiating devices on the system, however, the portion of the form pertaining to the Visual/Functional Test results for Alarm Initiating Devices was left blank. As such, it could not be verified that visual and functional testing of each device on the fire alarm system had been properly conducted.

This finding was confirmed with the chief building engineer.

Based upon a review of available documentation, the facility failed to maintain the building fire alarm system in accordance with NFPA 101 (00) Chapter 9, Section 9.6 and Chapter 18, Section 18.3.4.1. and NFPA 72 (1999 edition) Sections 7-3.2 and 7-5.2.2 and Table 7-3.1. In a fire emergency, this deficient practice could adversely affect 25 of 25 patients, staff and visitors.

FINDINGS INCLUDE:

On 09/18/2013 between 9:30 AM and 3:00 PM, during a review of the facility's annual Fire Alarm Inspection and Testing Form dated 08/12/2013, the Initiating and Supervisory Device Tests and Inspection section of the form identified multiple alarm initiating devices on the system, however, the portion of the form pertaining to the Visual/Functional Test results for Alarm Initiating Devices was left blank. As such, it could not be verified that visual and functional testing of each device on the fire alarm system had been properly conducted.

This finding was confirmed with the chief building engineer.

Based on observation and staff interview, the facility failed to provide drapery materials meeting the requirements of NFPA 101 (2000), Chapter 10, Section 10.3.1. In a fire emergency, this deficient practice could adversely affect 25 of 25 patients, staff and visitors.

FINDINGS INCLUDE:

On 09/18/2013 between 9:30 AM and 3:00 PM, observation revealed window drapes and curtains installed in Patient Rooms on the 100-Wing corridor. Based upon a staff interview, it was confirmed that these window treatments were not flame resistant in accordance with NFPA 101 (00) and NFPA 701 (1999 edition).

This deficient practice was verified with the chief building engineer.