HospitalInspections.org

Based on a review of construction documents, observation and interview, it could not be determined if Building 5 and 6 were Type II (222) construction as required by 19.1.6.2 of the NFPA 101 Life Safety Code, 2000, for a 2 story, unsprinklered building. In the event the buildings were to catch on fire they could collapse before occupants could evacuate. The failed practice had the potential to affect all patients, staff and visitors. The findings were:

A. On 09/21/12 between the hours of 0900 and 1015 a review of documents and an inspection of Building 5 and 6 was done with the Interim Director of Maintenance. It could not be determined if the building was Type II (222) construction.

B. On 09/21/12 between the hours of 1015 and 1100 during an interview the Interim Director of Maintenance confirmed it could not be determined if the building was Type II (222) construction. No additional information was offered for review.

Based on a review of construction documents, observation and interview, it was determined that smoke barrier doors required to be self-closing or automatic-closing had the door closer removed. The door closer devices had been removed on two of two (adjacent to Nursing Stations in Buildings 5 and 6) doors. Failure to provide smoke barrier doors that were self or automatic closing during a fire or smoke event could result in the smoke during a fire not being contained thus affecting the health and safety of patients, staff and visitors of the hospital. The failed practice had the potential to affect all patients, staff and visitors of either Buildings 5 and 6. The findings follow:

A. On 09/21/12 between the hours of 1400 and 1600, while on tour in Buildings 5 and 6 with the Interim Director of Maintenance, a review of construction documents indicated the location of the smoke barriers and related doors. Observations with the plans revealed the fire rated doors at Nursing Stations in Building 5 and 6 had their self-closing device removed.

B. On 09/21/12 between the hours of 1400 and 1600, while accompanied on the tour of Buildings 5 and 6, the Interim Director of Maintenance confirmed the above findings. No additional information was offered for review.

Based on observation and interview, it was determined the laundry room in Buildings 5 and 6 were used for the storage of soiled linen in excess of 32 gallons. Unrated hazardous rooms are required to be sprinklered, have smoke resisting partitions and self-closing devices on the doors. There were no self-closing devices on the doors. Failure to provide a self-closing door for a hazardous room could result in smoke during a fire event not to be contained thus affecting the health and safety of patients, staff and visitors in the building. The failed practice had the potential to affect all patients, staff and visitors. The findings follow:

A. On 09/21/12 between the hours of 1400 and 1600 while on tour with the Interim Director of Maintenance of Building 5 and 6, the laundry rooms were used for the storage of soiled linen and laundry. The door to the rooms did not have a self-closing or automatic-closing device.

B. On 09/21/12 between the hours of 1400 and 1600 while on tour with the Interim Director of Maintenance. it was confirmed by interview the rooms were used for the storage of soiled linen and laundry and the doors to the rooms did not have self-closing devices. No additional information was offered for review.

Based on observations and interview, the Exit Access, the Means of Egress in the Dining/Activity Room in Unit B could not be determined. The Exit Access is required to be not less than 6 ft in clear and unobstructed width and can be defined by either an aisle or corridor. Exit Access establishes that portion of the means of egress to be maintained clear and unobstructed to provide occupants with a continuous and unobstructed way of travel to an Exit during a fire emergency. Failure to provide an exit access providing a clear and unobstructed way of travel to an exit can affect the health and safety of patients, staff and visitors of the hospital. The findings follow:

A. On 09/20/12 between the hours of 1000 and 1100 while on tour of Unit B with the Interim Director of Maintenance, a corridor used for Exit Access located on the South End of Unit B was observed to lead directly to a Dining/Activity Room where there were non-fixed chairs and tables. Entering the Dining/Activity Room from the corridor the continuous and unobstructed way of travel of Exit Access could not be determined as there was no longer a defined pathway to the Exit which was located across the room.

B. On 09/20/12 between the hours of 1100 and 1115 interview with the Interim Director of Maintenance, the above findings were confirmed. No additional information was offered for review.

Based on observation and interview, it was determined in 2 of 2 buildings (Buildings 5 and 6) the trash collection receptacles used for shredded documents were greater than a 32 gallon capacity and were not located in rooms protected as a hazardous area. Failure to limit the quantity and concentration of flammable material in non protected areas in the facility could result in a fire of scope and magnitude not easily contained or quickly handled by a fire extinguisher. The failed practice had the potential to affect all patients, staff and visitors. The findings follow:

A. On 08/21/12 between the hours of 0900 and 1100 while on tour with the Interim Director of Maintenance of Building 5 and 6 revealed the use of a trash collection receptacles for shredded documents exceeding 32 gallons capacity. The receptacles were observed at the Nursing Stations in Building 5 and 6. The containers were not stored in rooms protected as a hazardous area.

B. On 08/21/12 between the hours of 0900 and 1100 while on tour with the Interim Director of Maintenance, the findings were discussed and confirmed by interview the containers were greater than 32 gallons and not located in room protected as a hazardous area. No additional information was offered for review.

Based on observation and interview, it was determined in Unit B, 3 of 3 soiled linen and trash collection receptacles greater than a 32 gallon capacity were not stored in rooms protected as a hazardous area. Failure to limit the quantity and concentration of flammable material in non protected areas in the facility could result in a fire of scope and magnitude not easily contained or quickly handled by a fire extinguisher. The failed practice had the potential to affect all patients, staff and visitors. The findings follow:

A. On 09/20/12 between the hours of 0900 and 1000 while on tour with the Interim Director of Maintenance, soiled linen, trash receptacles and shredded document containers exceeded the 32 gallons capacity were observed not stored in rooms protected as a hazardous area as follows:

1) Soiled Linen containers were observed in a corridor near the Nursing Station of Unit B.

2) Trash receptacles were found in the Activity/Dining area of Unit B.

3) Shredded document containers were found in Office areas of Unit B.

B. On 09/20/12 between the hours of 0900 and 1000 while on tour with the Interim Director of Maintenance, the findings were discussed and confirmed by interview.

Based on a review of construction documents, observation and interview, it could not be determined if Building 5 and 6 were Type II (222) construction as required by 19.1.6.2 of the NFPA 101 Life Safety Code, 2000, for a 2 story, unsprinklered building. In the event the buildings were to catch on fire they could collapse before occupants could evacuate. The failed practice had the potential to affect all patients, staff and visitors. The findings were:

A. On 09/21/12 between the hours of 0900 and 1015 a review of documents and an inspection of Building 5 and 6 was done with the Interim Director of Maintenance. It could not be determined if the building was Type II (222) construction.

B. On 09/21/12 between the hours of 1015 and 1100 during an interview the Interim Director of Maintenance confirmed it could not be determined if the building was Type II (222) construction. No additional information was offered for review.

Based on a review of construction documents, observation and interview, it was determined that smoke barrier doors required to be self-closing or automatic-closing had the door closer removed. The door closer devices had been removed on two of two (adjacent to Nursing Stations in Buildings 5 and 6) doors. Failure to provide smoke barrier doors that were self or automatic closing during a fire or smoke event could result in the smoke during a fire not being contained thus affecting the health and safety of patients, staff and visitors of the hospital. The failed practice had the potential to affect all patients, staff and visitors of either Buildings 5 and 6. The findings follow:

A. On 09/21/12 between the hours of 1400 and 1600, while on tour in Buildings 5 and 6 with the Interim Director of Maintenance, a review of construction documents indicated the location of the smoke barriers and related doors. Observations with the plans revealed the fire rated doors at Nursing Stations in Building 5 and 6 had their self-closing device removed.

B. On 09/21/12 between the hours of 1400 and 1600, while accompanied on the tour of Buildings 5 and 6, the Interim Director of Maintenance confirmed the above findings. No additional information was offered for review.

Based on observation and interview, it was determined the laundry room in Buildings 5 and 6 were used for the storage of soiled linen in excess of 32 gallons. Unrated hazardous rooms are required to be sprinklered, have smoke resisting partitions and self-closing devices on the doors. There were no self-closing devices on the doors. Failure to provide a self-closing door for a hazardous room could result in smoke during a fire event not to be contained thus affecting the health and safety of patients, staff and visitors in the building. The failed practice had the potential to affect all patients, staff and visitors. The findings follow:

A. On 09/21/12 between the hours of 1400 and 1600 while on tour with the Interim Director of Maintenance of Building 5 and 6, the laundry rooms were used for the storage of soiled linen and laundry. The door to the rooms did not have a self-closing or automatic-closing device.

B. On 09/21/12 between the hours of 1400 and 1600 while on tour with the Interim Director of Maintenance. it was confirmed by interview the rooms were used for the storage of soiled linen and laundry and the doors to the rooms did not have self-closing devices. No additional information was offered for review.

Based on observations and interview, the Exit Access, the Means of Egress in the Dining/Activity Room in Unit B could not be determined. The Exit Access is required to be not less than 6 ft in clear and unobstructed width and can be defined by either an aisle or corridor. Exit Access establishes that portion of the means of egress to be maintained clear and unobstructed to provide occupants with a continuous and unobstructed way of travel to an Exit during a fire emergency. Failure to provide an exit access providing a clear and unobstructed way of travel to an exit can affect the health and safety of patients, staff and visitors of the hospital. The findings follow:

A. On 09/20/12 between the hours of 1000 and 1100 while on tour of Unit B with the Interim Director of Maintenance, a corridor used for Exit Access located on the South End of Unit B was observed to lead directly to a Dining/Activity Room where there were non-fixed chairs and tables. Entering the Dining/Activity Room from the corridor the continuous and unobstructed way of travel of Exit Access could not be determined as there was no longer a defined pathway to the Exit which was located across the room.

B. On 09/20/12 between the hours of 1100 and 1115 interview with the Interim Director of Maintenance, the above findings were confirmed. No additional information was offered for review.

Based on observation and interview, it was determined in 2 of 2 buildings (Buildings 5 and 6) the trash collection receptacles used for shredded documents were greater than a 32 gallon capacity and were not located in rooms protected as a hazardous area. Failure to limit the quantity and concentration of flammable material in non protected areas in the facility could result in a fire of scope and magnitude not easily contained or quickly handled by a fire extinguisher. The failed practice had the potential to affect all patients, staff and visitors. The findings follow:

A. On 08/21/12 between the hours of 0900 and 1100 while on tour with the Interim Director of Maintenance of Building 5 and 6 revealed the use of a trash collection receptacles for shredded documents exceeding 32 gallons capacity. The receptacles were observed at the Nursing Stations in Building 5 and 6. The containers were not stored in rooms protected as a hazardous area.

B. On 08/21/12 between the hours of 0900 and 1100 while on tour with the Interim Director of Maintenance, the findings were discussed and confirmed by interview the containers were greater than 32 gallons and not located in room protected as a hazardous area. No additional information was offered for review.

Based on observation and interview, it was determined in Unit B, 3 of 3 soiled linen and trash collection receptacles greater than a 32 gallon capacity were not stored in rooms protected as a hazardous area. Failure to limit the quantity and concentration of flammable material in non protected areas in the facility could result in a fire of scope and magnitude not easily contained or quickly handled by a fire extinguisher. The failed practice had the potential to affect all patients, staff and visitors. The findings follow:

A. On 09/20/12 between the hours of 0900 and 1000 while on tour with the Interim Director of Maintenance, soiled linen, trash receptacles and shredded document containers exceeded the 32 gallons capacity were observed not stored in rooms protected as a hazardous area as follows:

1) Soiled Linen containers were observed in a corridor near the Nursing Station of Unit B.

2) Trash receptacles were found in the Activity/Dining area of Unit B.

3) Shredded document containers were found in Office areas of Unit B.

B. On 09/20/12 between the hours of 0900 and 1000 while on tour with the Interim Director of Maintenance, the findings were discussed and confirmed by interview.