HospitalInspections.org

Based on observation, the facility is not providing a firewall with a two-hour fire rating between the hospital and the clinic. This wall penetrated above the lay-in ceiling tile with building services (ductwork). This deficient practice affects all occupants including staff, visitors and patients. The facility has a capacity of 25 and a census of 10 patients.

Findings include:

1. Observations on 1/20/11, revealed that the two hour fire wall did not extend all the way to the roof deck. There was a gap between the sheetrock and rooftop.
2. Observations on 1/20/11, revealed the 90 minute door located within the two hour fire wall was not equipped with a self-closing device. Maintenance Staff A indicated that at one time it did have a closure on it but that it had been removed.

Maintenance Staff A observed these findings.

Based on observation and interview, it was determined the facility is a one-story building and consisted of a fire-resistive type I protected building. The facility failed to assure minimum building construction requirements were maintained. This facility has a capacity of 25 patients and at the time of the survey the census was 10.

Findings include:

1. Observations on 1/20/11, revealed numerous holes in the ceiling of the Old Laundry Room in the basement.
2. Observations on 1/20/11, revealed numerous holes throughout the corridor ceiling in the Cross-Over Corridor in the basement.
3. Observations on 1/20/11, revealed missing ceiling tile in the Women's Restroom located near the kitchen.
4. Observations on 1/20/11, revealed hole (approximately 6 inches by 8 inches) in the ceiling in the Basement Nurse's Storage Room.
5. Observations on 1/20/11, revealed a hole (approximately 1 inch in size) in the ceiling by the Basement Storage Room door.

Maintenance Staff A verified these observations.

Based on surveyor observation, the facility is not ensuring that doors to resident rooms, offices and other ancillary areas are free of impediments that would prevent the doors from being closed or that the doors are provided with suitable hardware that keep the doors shut tightly into their frames. This facility has a capacity of 25 and a census of 10 .

Findings include:

Observations on 1/20/11, revealed the corridor door to the Pharmacy had a kick-down hold-open device located on the bottom of the door. Maintenance Staff A verified this observation.

Based on observation and interview, the facility failed to maintain smoke doors to close and resist the passage of smoke. This facility has a capacity of 25 patients and a census of 10.

Findings include:

1. Observations on 1/20/11, revealed the smoke doors near Room 602 Waiting Area did not close and latch properly when tested.
2. Observations on 1/20/11, revealed the smoke doors to Radiology did not close and latch properly when tested.
3. Observations on 1/20/11, revealed the smoke doors going into Surgery did not close and latch properly when tested.
4. Observations on 1/20/11, revealed the smoke doors in the DON Office area did not close and latch properly when tested.

Maintenance Staff A verified these observations.

Based on observations, the facility failed to provide separation of hazardous areas from other compartments. The facility has a capacity of 25 and at the time of the survey the census was 10 patients.

Findings include:

1. Observations on 1/20/11, revealed the OPC Storage Room was greater than 50 square feet and was not equipped with a self-closing device.
2. Observations on 1/20/11, revealed the corridor door to the Decon Room in OP did not close and latch properly when tested.

Maintenance Staff A verified these observations.

Based on observations, the facility failed to maintain exits readily accessible at all times in accordance with 7.1. This deficient practice could affect staff utilizing some areas of the basement. This facility has a capacity of 25 patients and a census of 10.

Findings include:

1. Observations on 1/20/11, revealed a padlock on the following doors: Angie's Store Room, Business Office Store Room and the Records Room located within the business office store room. Exiting from inside this area could not be made without the use of a key for the padlock.
2. Observations on 1/20/11, revealed a deadbolt on the Maintenance Room door.

Maintenance Staff A verified these observations.

Based on observation, the facility failed to maintain the exit discharge lighting so that the failure of one bulb would not leave the path from the facility in darkness. One exit was equipped with a light fixture just outside the door that only had one light bulb. This facility has a capacity of 25 and a census of 10.

Findings include:

Observations on 1/20/11, revealed the West Exit in OP was equipped with a single source of light (bulb). Maintenance Staff A verified this observation.

Based on record review, the facility failed to test and document the emergency battery back-up lighting monthly and annually. This facility has a capacity of 25 patients and at the time of the survey the census was 10.

Findings include:

Observations on 1/20/11, revealed the absence of documentation for the testing of the emergency battery back-up lights located within the Radiology Department. Maintenance Staff A stated that he was unaware that these battery back-up emergency lights existed and has not been testing any of them. These lights are located in the following areas in Radiology: Room 402, 405, 409, 410, and Restroom.

(A)
Based on observation, the facility failed to properly protect and label the primary power supply for the fire alarm system in accordance with the National Fire Protection Association (NFPA), Standard 72, 1999 edition, 1-5.2.5.2. This deficient practice affects all occupants of the building. This facility has a capacity of 25 and a census of 10 patients.

Findings include:

Observations on 1/20/11, revealed the circuit breaker for the fire alarms primary power supply was mechanically protected, however it was not properly labeled. Maintenance Staff A verified this observation.

(B)
Based on observations, the facility failed to provide a properly tested and maintained fire alarm system. The facility has 25 certified beds and at the time of the survey the census was 10.

Findings include:

Observations on 1/20/11, revealed smoke detectors that were not properly secured (hanging loose) in the following areas in the basement: AHU 5, Housekeeping Storage, Housekeeping Office, and in the corridor outside the housekeeping office. Maintenance Staff A verified these observations.

Based on observation, this facility is not assuring that the fire alarm system is installed and maintained in accordance with the National Fire Protection Association (NFPA) 72, 2-3.5, which requires that smoke detectors are not placed with direct airflow, nor closer than three feet to air supply or air return. Installation of smoke detectors close to a ceiling fan/air supply/air return can impede the operation of the smoke detector and can affect all occupants of the building. This facility has a capacity of 25 and a census of 10 .

Findings include:

Observations on 1/20/11, revealed the following areas (but not limited to) had smoke detectors located within three feet of an air supply, air return or ceiling fan: Community Education Room, corridor directly outside of the Community Education Room, corridor directly outside of the Cardiac Rehab Room, OPC Nurse Manager's Office, OPC Waiting area, corridor in OPC, near OPC Pharmacy, the Hospital Pharmacy and in the corridor by the door leading to the kitchen. Maintenance Staff A verified these observations.

Based on observation, record review, and staff interview, the facility failed to maintain and test the sprinkler system in accordance with the 1998 edition of NFPA 25. All smoke compartments and all occupants could be affected by this deficient practice. This facility has a capacity of 25 patients and a census of 10.

Findings include:

1. During record review and staff interview on 1/120/11, it was revealed that the facility failed to perform quarterly inspections on the sprinkler system. Maintenance Staff A indicated that he was unaware of this requirement and that he had not been conducting quarterly inspections on the sprinkler system.
2. Observations on 1/20/11, revealed a missing escutcheon plate in the HIS Hallway in the basement.

Maintenance Staff A verified these observations.

Based on observation, the facility failed to maintain the fire extinguishers as required by National Fire Protection Association (NFPA) Standard 10. This facility has a capacity of 25 patients and a census of 10.

Findings include:

Observations on 1/20/11, revealed the absence of monthly visual checks on the fire extinguisher located in the Server Room. This fire extinguisher was not labeled to properly show when the annual inspection had been performed on it as well. Maintenance Staff A verified this observation.

Based on observation, record review, and interview, the facility failed to provide a commercial cooking suppression system that is tested and maintained as required. The facility has 25 certified beds and at the time of the survey the facility census was 10.

Findings include:

1. During record review on 1/20/11, it was found that the commercial cooking suppression system had not been inspected two times per year. The last two inspection reports were dated 10/7/10 and 12/1/09. Maintenance Staff A indicated that he thought that the commercial cooking suppression sytem only had to be inspected once per year.
2. Observations on 1/20/11, revealed that the commercial cooking suppression system contained a combination of mesh and baffle filters.

Maintenance Staff A verified these observations.

Based on observations, the facility failed to provide drapery, curtains, and window blinds with provisions of National Fire Protection Association (NFPA) Standard 101 10.3. Based on observation, the facility could not provide documentation that the window blinds were flame resistant. The facility has a capacity of 25 and at the time of the survey the census was 10 patients.

Findings include:

Observations of the mini blinds in the OPC Nurse Manager's Office on 1/20/11, revealed they were not metal or aluminum and were not tagged as being flame retardant. Maintenance Staff A verified this observation.

Based on observations, it was determined the facility failed to maintain the buildings electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition. This facility has a capacity of 25 and a census of 10 patients.

Findings include:

1. Observations on 1/20/11, revealed a lamp plugged into a surge protector in the Main Entrance Waiting Area.
2. Observations on 1/20/11, revealed a space heater plugged into a surge protector in the Radiology Director's Office.
3. Observations on 1/20/11, revealed a space heater plugged into a surge protector in Room 909 (Public Relations).
4. Observations on 1/20/11, revealed an extension cord in Becky's Office.
5. Observations on 1/20/11, revealed breakers in Panel BB in the "on" position but were listed as "spares".

Maintenance Staff A verified these observations.

Based on observation, the facility is not providing a firewall with a two-hour fire rating between the hospital and the clinic. This wall penetrated above the lay-in ceiling tile with building services (ductwork). This deficient practice affects all occupants including staff, visitors and patients. The facility has a capacity of 25 and a census of 10 patients.

Findings include:

1. Observations on 1/20/11, revealed that the two hour fire wall did not extend all the way to the roof deck. There was a gap between the sheetrock and rooftop.
2. Observations on 1/20/11, revealed the 90 minute door located within the two hour fire wall was not equipped with a self-closing device. Maintenance Staff A indicated that at one time it did have a closure on it but that it had been removed.

Maintenance Staff A observed these findings.

Based on observation and interview, it was determined the facility is a one-story building and consisted of a fire-resistive type I protected building. The facility failed to assure minimum building construction requirements were maintained. This facility has a capacity of 25 patients and at the time of the survey the census was 10.

Findings include:

1. Observations on 1/20/11, revealed numerous holes in the ceiling of the Old Laundry Room in the basement.
2. Observations on 1/20/11, revealed numerous holes throughout the corridor ceiling in the Cross-Over Corridor in the basement.
3. Observations on 1/20/11, revealed missing ceiling tile in the Women's Restroom located near the kitchen.
4. Observations on 1/20/11, revealed hole (approximately 6 inches by 8 inches) in the ceiling in the Basement Nurse's Storage Room.
5. Observations on 1/20/11, revealed a hole (approximately 1 inch in size) in the ceiling by the Basement Storage Room door.

Maintenance Staff A verified these observations.

Based on surveyor observation, the facility is not ensuring that doors to resident rooms, offices and other ancillary areas are free of impediments that would prevent the doors from being closed or that the doors are provided with suitable hardware that keep the doors shut tightly into their frames. This facility has a capacity of 25 and a census of 10 .

Findings include:

Observations on 1/20/11, revealed the corridor door to the Pharmacy had a kick-down hold-open device located on the bottom of the door. Maintenance Staff A verified this observation.

Based on observation and interview, the facility failed to maintain smoke doors to close and resist the passage of smoke. This facility has a capacity of 25 patients and a census of 10.

Findings include:

1. Observations on 1/20/11, revealed the smoke doors near Room 602 Waiting Area did not close and latch properly when tested.
2. Observations on 1/20/11, revealed the smoke doors to Radiology did not close and latch properly when tested.
3. Observations on 1/20/11, revealed the smoke doors going into Surgery did not close and latch properly when tested.
4. Observations on 1/20/11, revealed the smoke doors in the DON Office area did not close and latch properly when tested.

Maintenance Staff A verified these observations.

Based on observations, the facility failed to provide separation of hazardous areas from other compartments. The facility has a capacity of 25 and at the time of the survey the census was 10 patients.

Findings include:

1. Observations on 1/20/11, revealed the OPC Storage Room was greater than 50 square feet and was not equipped with a self-closing device.
2. Observations on 1/20/11, revealed the corridor door to the Decon Room in OP did not close and latch properly when tested.

Maintenance Staff A verified these observations.

Based on observations, the facility failed to maintain exits readily accessible at all times in accordance with 7.1. This deficient practice could affect staff utilizing some areas of the basement. This facility has a capacity of 25 patients and a census of 10.

Findings include:

1. Observations on 1/20/11, revealed a padlock on the following doors: Angie's Store Room, Business Office Store Room and the Records Room located within the business office store room. Exiting from inside this area could not be made without the use of a key for the padlock.
2. Observations on 1/20/11, revealed a deadbolt on the Maintenance Room door.

Maintenance Staff A verified these observations.

Based on observation, the facility failed to maintain the exit discharge lighting so that the failure of one bulb would not leave the path from the facility in darkness. One exit was equipped with a light fixture just outside the door that only had one light bulb. This facility has a capacity of 25 and a census of 10.

Findings include:

Observations on 1/20/11, revealed the West Exit in OP was equipped with a single source of light (bulb). Maintenance Staff A verified this observation.

Based on record review, the facility failed to test and document the emergency battery back-up lighting monthly and annually. This facility has a capacity of 25 patients and at the time of the survey the census was 10.

Findings include:

Observations on 1/20/11, revealed the absence of documentation for the testing of the emergency battery back-up lights located within the Radiology Department. Maintenance Staff A stated that he was unaware that these battery back-up emergency lights existed and has not been testing any of them. These lights are located in the following areas in Radiology: Room 402, 405, 409, 410, and Restroom.

(A)
Based on observation, the facility failed to properly protect and label the primary power supply for the fire alarm system in accordance with the National Fire Protection Association (NFPA), Standard 72, 1999 edition, 1-5.2.5.2. This deficient practice affects all occupants of the building. This facility has a capacity of 25 and a census of 10 patients.

Findings include:

Observations on 1/20/11, revealed the circuit breaker for the fire alarms primary power supply was mechanically protected, however it was not properly labeled. Maintenance Staff A verified this observation.

(B)
Based on observations, the facility failed to provide a properly tested and maintained fire alarm system. The facility has 25 certified beds and at the time of the survey the census was 10.

Findings include:

Observations on 1/20/11, revealed smoke detectors that were not properly secured (hanging loose) in the following areas in the basement: AHU 5, Housekeeping Storage, Housekeeping Office, and in the corridor outside the housekeeping office. Maintenance Staff A verified these observations.

Based on observation, this facility is not assuring that the fire alarm system is installed and maintained in accordance with the National Fire Protection Association (NFPA) 72, 2-3.5, which requires that smoke detectors are not placed with direct airflow, nor closer than three feet to air supply or air return. Installation of smoke detectors close to a ceiling fan/air supply/air return can impede the operation of the smoke detector and can affect all occupants of the building. This facility has a capacity of 25 and a census of 10 .

Findings include:

Observations on 1/20/11, revealed the following areas (but not limited to) had smoke detectors located within three feet of an air supply, air return or ceiling fan: Community Education Room, corridor directly outside of the Community Education Room, corridor directly outside of the Cardiac Rehab Room, OPC Nurse Manager's Office, OPC Waiting area, corridor in OPC, near OPC Pharmacy, the Hospital Pharmacy and in the corridor by the door leading to the kitchen. Maintenance Staff A verified these observations.

Based on observation, record review, and staff interview, the facility failed to maintain and test the sprinkler system in accordance with the 1998 edition of NFPA 25. All smoke compartments and all occupants could be affected by this deficient practice. This facility has a capacity of 25 patients and a census of 10.

Findings include:

1. During record review and staff interview on 1/120/11, it was revealed that the facility failed to perform quarterly inspections on the sprinkler system. Maintenance Staff A indicated that he was unaware of this requirement and that he had not been conducting quarterly inspections on the sprinkler system.
2. Observations on 1/20/11, revealed a missing escutcheon plate in the HIS Hallway in the basement.

Maintenance Staff A verified these observations.

Based on observation, the facility failed to maintain the fire extinguishers as required by National Fire Protection Association (NFPA) Standard 10. This facility has a capacity of 25 patients and a census of 10.

Findings include:

Observations on 1/20/11, revealed the absence of monthly visual checks on the fire extinguisher located in the Server Room. This fire extinguisher was not labeled to properly show when the annual inspection had been performed on it as well. Maintenance Staff A verified this observation.

Based on observation, record review, and interview, the facility failed to provide a commercial cooking suppression system that is tested and maintained as required. The facility has 25 certified beds and at the time of the survey the facility census was 10.

Findings include:

1. During record review on 1/20/11, it was found that the commercial cooking suppression system had not been inspected two times per year. The last two inspection reports were dated 10/7/10 and 12/1/09. Maintenance Staff A indicated that he thought that the commercial cooking suppression sytem only had to be inspected once per year.
2. Observations on 1/20/11, revealed that the commercial cooking suppression system contained a combination of mesh and baffle filters.

Maintenance Staff A verified these observations.

Based on observations, the facility failed to provide drapery, curtains, and window blinds with provisions of National Fire Protection Association (NFPA) Standard 101 10.3. Based on observation, the facility could not provide documentation that the window blinds were flame resistant. The facility has a capacity of 25 and at the time of the survey the census was 10 patients.

Findings include:

Observations of the mini blinds in the OPC Nurse Manager's Office on 1/20/11, revealed they were not metal or aluminum and were not tagged as being flame retardant. Maintenance Staff A verified this observation.

Based on observations, it was determined the facility failed to maintain the buildings electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition. This facility has a capacity of 25 and a census of 10 patients.

Findings include:

1. Observations on 1/20/11, revealed a lamp plugged into a surge protector in the Main Entrance Waiting Area.
2. Observations on 1/20/11, revealed a space heater plugged into a surge protector in the Radiology Director's Office.
3. Observations on 1/20/11, revealed a space heater plugged into a surge protector in Room 909 (Public Relations).
4. Observations on 1/20/11, revealed an extension cord in Becky's Office.
5. Observations on 1/20/11, revealed breakers in Panel BB in the "on" position but were listed as "spares".

Maintenance Staff A verified these observations.