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DECATUR COUNTY HOSPITAL
Multiple Occupancies - Construction Type
Tag No.: K0133
Based on observation and staff interview, the facility failed to maintain all 2 hour rated walls in accordance with National Fire Protection Association, 2012 Life Safety Code, existing edition, 19.1.3.2 and 8.2.1.3. The facility has a capacity of 11 with a census of 3 patients.
Findings include:
Observation and staff interview on 5/6/22 at 1:59 p.m., revealed a penetration, (1/4 inch), around communication lines extending through the 2- hour wall separating the Emergency Department from the Ambulance Garage. Administrative and Maintenance Staff verified observations during the survey process.
Sprinkler System - Out of Service
Tag No.: K0354
Based on record review and staff interview, the facility failed to provide a policy regarding the procedures to be taken in the event the sprinkler system is out of service for more than 10 hours in any 24 hour period in accordance with National Fire Protection Association, 2012 Life Safety Code, existing edition, 9.7.6. and NFPA 25, 2011 Edition. The deficient practice affects all occupants of the building. The facility has a capacity of 11 with a census of 3 patients.
Findings include:
Record review and staff interview on 5/6/22 at 12:55 p.m., revealed the facility's sprinkler system outage policy did not contain notification of the fire alarm company. Administrative Staff verified record review during the survey process.