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Based on observations and interview, the facility has failed to provide proper protection from several hazardous areas located throughout the facility in accordance with NFPA Life Safety Code 101 (2000 edition) section 19.3.2.1. This deficient practice could affect all patients, as smoke from a fire in these rooms could enter the corridor making it untenable.

Findings include:

On facility tour between 08:00 AM and 4:30 PM on 1/13/2015, it was observed that several hazardous areas were not properly maintained in accordance with 19.3.2.1. These rooms are:

1. The storage room doors for both Operating Rooms failed to self-close and latch,

2. The door sequencer for the trash room next to the Operating Room failed to properly close the door,

3. The door closer for the dry storage room in the Lab had been removed and,

4. The 1st floor Gift shop storage room had a friction door hold on it, not allowing it to self-close.



This deficient practice was verified by the Director of Plant Operations.

Based on observation and interview, the facility had 1 stairway enclosure that did not meet the required one (1) hour fire resistive construction. This deficient practice could affect 50 patients.

Findings include:

On facility tour between 08:00 AM and 4:30 PM on 1/13/2015, observation revealed in the 1st floor north GI stairwell that there were:

1. There were exposed cables and a wood board with data connections attached to it and,

2. There were duct work serving another area that is unprotected in the stairwell.

This deficient practice was verified by the Director of Plant Operations.

Based on review of records and interview, it was determined that the facility failed to vary the times for the required number of fire drills for each shift in the last 12-month period in accordance with NFPA 101 LSC (00) Section 19.7.1.2. This deficient practice could affect how staff react in the event of a fire. Improper reaction by staff would affect the safety of all patients.

Findings include:

On facility tour between 08:00 AM and 4:30 PM on 1/13/2015, a review of the available fire drill reports in 2014 revealed that the facility conducted Day-shift fire drills between the hours of 1:21 PM, 10:35 AM, 1:30 PM, 7:38 AM, 10:05 AM, Night-shift drills between 5:38 AM, 4:26 AM, 5:00 AM, 6:20 AM not at varied times as required by Section 19.7.1.2.

This deficient practice was confirmed by the Director of Plant Operations.

Based on observation and interview, the facility failed to maintain an automatic fire sprinkler system in accordance with NFPA 101 (2000) Chapter 19, Section 19.3.5 and NFPA 13 (1999) Chapter 5, Section 5-5.5.2.1. In a fire emergency, this deficient practice could adversely affect 20 of the 144 patients.
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FINDINGS INCLUDE:

On facility tour between 08:00 AM and 4:30 PM on 1/13/2015, it was observed in the 1st floor kitchen area that a janitor closet, and a room used to house the beverage dispensing equipment, each do not have a ceiling in close enough proximity to the fire sprinkler heads in each room to trap the heat from a fire so as to acitvate the fire sprinkler heads.


This deficient practice was confirmed by the Director of Plant Operations.

Based on observation and interview, the facility has failed to properly inspect and maintain the automatic sprinkler system in accordance with NFPA 101 LSC (00) section 19.7.6, 4.6.12. This deficient practice does not ensure that the fire sprinkler system is functioning properly and is fully operational in the event of a fire and could negatively affect patients.


Findings include:

On facility tour between 08:00 AM and 4:30 PM on 1/13/2015, it was observed that the facility's 1st floor kitchen dish washing area had several corroded sprinkler heads that were not in compliance with NFPA 13(99) and NFPA 25(98).



This deficient practice was verified by the Director of Plant Operations.

Based on documentation and staff interview, the facility failed to provide the proper documentation for testing the line isolators in accordance with the following requirements of 1999 NFPA 99. The deficient practice could affect all patients.

Findings include:

On facility tour between 08:00 AM and 4:30 PM on 1/13/2015, observation revealed that the facility had analog line isolators in the operating rooms and in C-section operating rooms that are being tested annually and not on a monthly basis in accordance with NFPA 99(99) edition.

Based on observations and interview, the facility has failed to provide proper protection from several hazardous areas located throughout the facility in accordance with NFPA Life Safety Code 101 (2000 edition) section 19.3.2.1. This deficient practice could affect all patients, as smoke from a fire in these rooms could enter the corridor making it untenable.

Findings include:

On facility tour between 08:00 AM and 4:30 PM on 1/13/2015, it was observed that several hazardous areas were not properly maintained in accordance with 19.3.2.1. These rooms are:

1. The storage room doors for both Operating Rooms failed to self-close and latch,

2. The door sequencer for the trash room next to the Operating Room failed to properly close the door,

3. The door closer for the dry storage room in the Lab had been removed and,

4. The 1st floor Gift shop storage room had a friction door hold on it, not allowing it to self-close.



This deficient practice was verified by the Director of Plant Operations.

Based on observation and interview, the facility had 1 stairway enclosure that did not meet the required one (1) hour fire resistive construction. This deficient practice could affect 50 patients.

Findings include:

On facility tour between 08:00 AM and 4:30 PM on 1/13/2015, observation revealed in the 1st floor north GI stairwell that there were:

1. There were exposed cables and a wood board with data connections attached to it and,

2. There were duct work serving another area that is unprotected in the stairwell.

This deficient practice was verified by the Director of Plant Operations.

Based on review of records and interview, it was determined that the facility failed to vary the times for the required number of fire drills for each shift in the last 12-month period in accordance with NFPA 101 LSC (00) Section 19.7.1.2. This deficient practice could affect how staff react in the event of a fire. Improper reaction by staff would affect the safety of all patients.

Findings include:

On facility tour between 08:00 AM and 4:30 PM on 1/13/2015, a review of the available fire drill reports in 2014 revealed that the facility conducted Day-shift fire drills between the hours of 1:21 PM, 10:35 AM, 1:30 PM, 7:38 AM, 10:05 AM, Night-shift drills between 5:38 AM, 4:26 AM, 5:00 AM, 6:20 AM not at varied times as required by Section 19.7.1.2.

This deficient practice was confirmed by the Director of Plant Operations.

Based on observation and interview, the facility failed to maintain an automatic fire sprinkler system in accordance with NFPA 101 (2000) Chapter 19, Section 19.3.5 and NFPA 13 (1999) Chapter 5, Section 5-5.5.2.1. In a fire emergency, this deficient practice could adversely affect 20 of the 144 patients.
.
FINDINGS INCLUDE:

On facility tour between 08:00 AM and 4:30 PM on 1/13/2015, it was observed in the 1st floor kitchen area that a janitor closet, and a room used to house the beverage dispensing equipment, each do not have a ceiling in close enough proximity to the fire sprinkler heads in each room to trap the heat from a fire so as to acitvate the fire sprinkler heads.


This deficient practice was confirmed by the Director of Plant Operations.

Based on observation and interview, the facility has failed to properly inspect and maintain the automatic sprinkler system in accordance with NFPA 101 LSC (00) section 19.7.6, 4.6.12. This deficient practice does not ensure that the fire sprinkler system is functioning properly and is fully operational in the event of a fire and could negatively affect patients.


Findings include:

On facility tour between 08:00 AM and 4:30 PM on 1/13/2015, it was observed that the facility's 1st floor kitchen dish washing area had several corroded sprinkler heads that were not in compliance with NFPA 13(99) and NFPA 25(98).



This deficient practice was verified by the Director of Plant Operations.

Based on documentation and staff interview, the facility failed to provide the proper documentation for testing the line isolators in accordance with the following requirements of 1999 NFPA 99. The deficient practice could affect all patients.

Findings include:

On facility tour between 08:00 AM and 4:30 PM on 1/13/2015, observation revealed that the facility had analog line isolators in the operating rooms and in C-section operating rooms that are being tested annually and not on a monthly basis in accordance with NFPA 99(99) edition.