HospitalInspections.org

Based on observation and staff interview, the facility failed to provide 2-hour fire rated construction at building separation wall in accordance with 2000 - NFPA 101, sections 18.1.1.4.1.


Findings include:

On facility tour between 8:00 AM and 4:00 PM on 09/23/2015, observation revealed, that the 2 hour fire rated building separation wall between the hospital and clinic on 1st floor. The 90 minute fire rated door did not shut and latch.


This deficient practice was confirmed by the Facility Maintenance Director (GT) at the time of discovery.

Based on observation and staff interview, the facility failed to provide 2-hour fire rated construction at building separation wall in accordance with 2000 - NFPA 101, sections 19.1.1.4.1.


Findings include:

On facility tour between 8:00 AM and 4:00 PM on 09/23/2015, observation revealed, that the 2 hour fire rated building separation wall between the hospital and nursing home on 1st floor. The 90 minute fire rated door did not shut and latch.


This deficient practice was confirmed by the Facility Maintenance Director (GT) at the time of discovery.

Based on observation and staff interview, the facility failed to maintain smoke-resisting partitions and doors in accordance with the following requirements of 2000 NFPA 101, Section 19.3.2.1.


Findings include:

On facility tour between 8:00 AM and 4:00 PM on 09/23/2015, observation revealed, that the following was found:

1. 1st floor - laundry room door to corridor will not shut and latch
2. 2nd floor - storage room # 268 (over 50 sq ft.):
a. no door closer
b. Tape on latch to prevent positive latching
3. 2nd floor - Utility storage room # 2057 (over 50 sq ft) will not shut/latch
4. 2nd - ICU - med storage room (over 50 sq ft) - has an open grate wood insert where
window should be

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

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.

Findings include:

On facility tour between 8:00 AM and 4:00 PM on 09/23/2015, observation revealed that the 1st floor - north stairwell next to POV, both doors into stairwell do not positively latch.


This deficient practice was confirmed by the Facility Maintenance Director (GT) at the time of discovery.

Based on observation and staff interview, the facility failed to provide reliable lighting as required by 2000 NFPA 101, Section 38..2.9.1, 7.9.3, 7.10.9. The deficient practice could affect all patients in these locations.

Findings include:

On facility tour between 8:00 AM and 4:00 PM on 09/23/2015, observation revealed that the following was found:

1. The following emergency lights did not operate when tested # 10009, 10016 and 10018
2. The following emergency EXIT signage - by north entrance did not operate when tested


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






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

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.


Findings include:

On facility tour between 8:00 AM and 4:00 PM on 09/23/2015, the review of the fire drill documentation for the past 12 months (September 2014 to August 2015) revealed that the drills for the following shifts were completed, but did not sufficiently vary the times that the drills were conducted:

Day: 1400, 1101, 1035 and 1425 hours
Evening: 1830, 1800, 1822 and 1635 hours

This deficient practice was confirmed by the Facility Maintenance Director (GT) at the time of discovery.




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

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.


Findings include:

On facility tour between 8:00 AM and 4:00 PM on 09/23/2015, the review of the fire drill documentation for the past 12 months (September 2014 to August 2015) revealed that the drills for the following shifts were completed, but did not sufficiently vary the times that the drills were conducted:

Day: 1400, 1101, 1035 and 1425 hours
Evening: 1830, 1800, 1822 and 1635 hours

This deficient practice was confirmed by the Facility Maintenance Director (GT) at the time of discovery.

Based on observation, the facility failed to install the fire alarm system in accordance with the requirements of 2000 NFPA 101, Sections 19.3.4.5.2, 19.3.6.1 and 9.6.

Findings include:

On facility tour between 8:00 AM and 4:00 PM on 09/23/2015, observation revealed that there is no automatic smoke detection with sounder base in 1st floor - ER on-call sleep room.


This deficient practice was confirmed by the Facility Maintenance Director (GT) at the time of discovery.

Based on observation and staff interview, the facility failed to assure medical gas zone control valve box are properly labeled as required by 1999 NFPA 99, Sections 4-3.1.2.3.

Findings include:

On facility tour between 8:00 AM and 4:00 PM on 09/23/2015, observation revealed, medical gas zone box by ER garage entrance does not have signage to what area that it controls.

NOTE: Found other zone boxes that are not labeled. Check entire facility


This deficient practice was confirmed by the Facility Maintenance Director (GT) at the time of discovery.




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

Based on observation and staff interview, the facility failed to provide 2-hour fire rated construction at building separation wall in accordance with 2000 - NFPA 101, sections 18.1.1.4.1.


Findings include:

On facility tour between 8:00 AM and 4:00 PM on 09/23/2015, observation revealed, that the 2 hour fire rated building separation wall between the hospital and clinic on 1st floor. The 90 minute fire rated door did not shut and latch.


This deficient practice was confirmed by the Facility Maintenance Director (GT) at the time of discovery.

Based on observation and staff interview, the facility failed to provide 2-hour fire rated construction at building separation wall in accordance with 2000 - NFPA 101, sections 19.1.1.4.1.


Findings include:

On facility tour between 8:00 AM and 4:00 PM on 09/23/2015, observation revealed, that the 2 hour fire rated building separation wall between the hospital and nursing home on 1st floor. The 90 minute fire rated door did not shut and latch.


This deficient practice was confirmed by the Facility Maintenance Director (GT) at the time of discovery.

Based on observation and staff interview, the facility failed to maintain smoke-resisting partitions and doors in accordance with the following requirements of 2000 NFPA 101, Section 19.3.2.1.


Findings include:

On facility tour between 8:00 AM and 4:00 PM on 09/23/2015, observation revealed, that the following was found:

1. 1st floor - laundry room door to corridor will not shut and latch
2. 2nd floor - storage room # 268 (over 50 sq ft.):
a. no door closer
b. Tape on latch to prevent positive latching
3. 2nd floor - Utility storage room # 2057 (over 50 sq ft) will not shut/latch
4. 2nd - ICU - med storage room (over 50 sq ft) - has an open grate wood insert where
window should be

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

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.

Findings include:

On facility tour between 8:00 AM and 4:00 PM on 09/23/2015, observation revealed that the 1st floor - north stairwell next to POV, both doors into stairwell do not positively latch.


This deficient practice was confirmed by the Facility Maintenance Director (GT) at the time of discovery.

Based on observation and staff interview, the facility failed to provide reliable lighting as required by 2000 NFPA 101, Section 38..2.9.1, 7.9.3, 7.10.9. The deficient practice could affect all patients in these locations.

Findings include:

On facility tour between 8:00 AM and 4:00 PM on 09/23/2015, observation revealed that the following was found:

1. The following emergency lights did not operate when tested # 10009, 10016 and 10018
2. The following emergency EXIT signage - by north entrance did not operate when tested


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






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

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.


Findings include:

On facility tour between 8:00 AM and 4:00 PM on 09/23/2015, the review of the fire drill documentation for the past 12 months (September 2014 to August 2015) revealed that the drills for the following shifts were completed, but did not sufficiently vary the times that the drills were conducted:

Day: 1400, 1101, 1035 and 1425 hours
Evening: 1830, 1800, 1822 and 1635 hours

This deficient practice was confirmed by the Facility Maintenance Director (GT) at the time of discovery.




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

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.


Findings include:

On facility tour between 8:00 AM and 4:00 PM on 09/23/2015, the review of the fire drill documentation for the past 12 months (September 2014 to August 2015) revealed that the drills for the following shifts were completed, but did not sufficiently vary the times that the drills were conducted:

Day: 1400, 1101, 1035 and 1425 hours
Evening: 1830, 1800, 1822 and 1635 hours

This deficient practice was confirmed by the Facility Maintenance Director (GT) at the time of discovery.

Based on observation, the facility failed to install the fire alarm system in accordance with the requirements of 2000 NFPA 101, Sections 19.3.4.5.2, 19.3.6.1 and 9.6.

Findings include:

On facility tour between 8:00 AM and 4:00 PM on 09/23/2015, observation revealed that there is no automatic smoke detection with sounder base in 1st floor - ER on-call sleep room.


This deficient practice was confirmed by the Facility Maintenance Director (GT) at the time of discovery.

Based on observation and staff interview, the facility failed to assure medical gas zone control valve box are properly labeled as required by 1999 NFPA 99, Sections 4-3.1.2.3.

Findings include:

On facility tour between 8:00 AM and 4:00 PM on 09/23/2015, observation revealed, medical gas zone box by ER garage entrance does not have signage to what area that it controls.

NOTE: Found other zone boxes that are not labeled. Check entire facility


This deficient practice was confirmed by the Facility Maintenance Director (GT) at the time of discovery.




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