HospitalInspections.org

Based on observation and staff interview the facility failed to properly maintain exit discharge from one of four exits in accordance with the NFPA 101 (2012) 19.2.7, 7.1.6.2, 7.1.7. The deficient practice had a potential to affect all patients who used the exit.

Findings include

On 6/12/17 at 10:30 am, observation revealed that the exit discharge from the exit adjacent to the interview room had a 1 ½ inch change in elevation from the concrete stoop to the asphalt pavement surface, which is more than the allowable 1/4 inch. The deficiency was confirmed by the concurrent observation and interview with Staff O (facility manager), and at the time of exit conference with Staff C (administrator) and Staff N (executive director of human services) on 6/13/17 at 10 am.

Based on record review and staff interview, the facility failed to properly maintain the fire alarm system due to failure to (i) perform load voltage testing of fire alarm batteries in accordance with the NFPA 72 2010 edition Chapter 14 Tables 14.4.2.2 (6), 14.4.5(6), and (ii) document semiannual visual inspection of detectors in accordance with NFPA 72 Table 14.3.1(9). These deficient practices had a potential to affect all patients in the facility.

Findings include

1. On 6/12/17 at 2:45 pm, review of fire alarm maintenance records revealed that the load voltage testing of storage batteries in the fire alarm panel located in Room 316 in the Admin Building E.

2. On 6/12/17 at 2:45 pm, interview revealed that the facility failed to keep records of semiannual visual inspection of smoke and duct detectors.

These findings were confirmed at the time with Staff O (facility manager) and Staff EE (maintenance mechanic), and at the time of exit conference with Staff C (administrator) and Staff N (executive director of human services) on 6/13/17 at 10 am.

Based on observation and staff interview the facility failed to provide a compliant door in one smoke barrier in accordance with the NFPA 101 (2012) 19.3.7.8. The deficient practice had a potential to affect 8 of 16 patients.

Findings include

On 6/12/17 at 1:24 pm, observation revealed that the corridor door of the Staff Kitchenette was a smoke door in 1 hour fire-rated smoke barrier, but did not have a self-closing or automatic-closing device. The deficiency was confirmed by the concurrent observation and interview with Staff O (facility manager) and Staff EE (maintenance mechanic), and at the time of exit conference with Staff C (administrator) and Staff N (director of human services) on 6/13/17 at 10 am.

Based on observation and staff interview the facility failed to provide access panels on air ducts for maintenance of fire dampers in four heating, ventilating and air conditioning air ducts in accordance with the NFPA 101 (2012) 19.5.2.1, 9.2.1, NFPA 90A (2012) 4.3.5, NFPA 80 (2010) 19.4. The deficient practice had a potential to affect all patients.

Findings include

On 6/12/17 at 1:24 pm, observation revealed that fire dampers located in four air duct penetrations of 2-hour fire barrier walls were not maintained due to lack of access panels on duct surfaces to allow for inspection and testing of fire dampers. The 2-hour fire barrier wall separated the non health care occupancy Admin Building E from the hospital. The deficiency was confirmed by the concurrent observation and interview with Staff O (facility manager) and Staff EE (maintenance mechanic), and at the time of exit conference with Staff C (administrator) and Staff N (director of human services) on 6/13/17 at 10 am.

Based on observation and staff interview the facility failed to provide clear work space in front of electrical equipment in one room in accordance with the NFPA 101 (2012) 19.3.7.8, NFPA 70 (2011) Table 110.26(A)(1) and NFPA 110.26 (B). The deficient practice had a potential to affect all staff who used the room.

Findings include

On 6/12/17 at 11:15 am, observation revealed that the clear work space provided in front of the Transformer and the Main Breaker panel in the Electrical Room 323 was not 36 inch clear due to objects stored in front of the electrical equipment/panel.

The deficiency was confirmed by the concurrent observation and interview with Staff O (facility manager) and Staff EE (maintenance mechanic), and at the time of exit conference with Staff C (administrator) and Staff N (director of human services) on 6/13/17 at 10 am.