HospitalInspections.org

Based on observations and staff interview, this facility is not providing firewalls with a two-hour fire rating to separate areas of non-conforming construction within the facility. This deficient practice affects all occupants including staff, visitors and residents. The facility has a capacity of 25 with a census of 15 patients.

Findings include:

Observations and staff interview on 3/5/15, between 9:30 and 3:00 p.m., revealed the following deficiencies:

1. There was a gap, (approximately 3/16 inch), in the drywall of the 2 hour wall by Alcove #6 to the Medical-Surgical Wing.
2. There were three open pipes, (all approximately 2-1/2 inch), with communications lines through them, extending through the 2 hour wall by Alcove #6 to the Medical-Surgical Wing.
3. There was a gap, (approximately 1/4 inch), in the drywall of the 2 hour wall by the Nursery to the Medical-Surgical Wing.
4. There were three open pipes, (all approximately 2-1/2 inch), with communications lines through them, extending through the 2 hour wall by the Nursery to the Medical-Surgical Wing.
5. There were three penetrations, (all approximately 1/4 inch), around conduit and communications lines extending through the 2 hour wall by the LDRP Waiting Area.
6. There were two penetrations, (both approximately 1/4 inch), around two pipes extending through the 2 hour wall by the LDRP Waiting Area.
7. There was a penetration, (approximately 1/4 inch), around a sprinkler pipe and communications cables extending through the 2 hour wall by the LDRP Waiting Area.
8. There was a penetration, (approximately 1/4 inch), around two communications lines extending through the 2 hour wall by the CEO Office.

Maintenance Staff A verified observations during the survey process.

Based on observation and staff interview, it was determined the facility was a one-story building and consisted of protected combustible construction equipped with an automatic sprinkler system. The facility failed to assure minimum building construction requirements were maintained by ensuring that holes and gaps around penetrations are sealed with fire rated materials. The facility has a capacity of 25 with a census of 15 patients.

Findings include:

Observation and staff interview on 3/5/15 at 1:01 p.m., indicated a ceiling tile not flush with the ceiling tile grid in the Dialysis RO Room. Maintenance Staff A verified observations during the survey process.

Based on observations and staff interview, the facility is not ensuring that doors to rooms are provided with suitable hardware that keep the doors shut tightly into their frames. The facility has a capacity of 25 with a census of 15 patients.

Findings include:

Observations and staff interview on 3/5/15, at 12:56 p.m. and 1:03 p.m., revealed the following deficiencies:

1. The door to the Old OB Unit Housekeeping Closet did not close and latch properly when tested.
2. The corridor door to the RO Corridor did not close and latch properly when tested.

Maintenance Staff A verified observations during the survey process.

Based on record review and staff interview, the facility failed to provide a fire emergency plan and procedure policy that included specific information on evacuation from each smoke zone within the facility. The facility is also not ensuring that the policy in place is followed for all fire emergency events. The deficient practice affects all occupants of the facility. The facility has a capacity of 25 with a census of 15 residents.

Findings include:

1. Review of the facility's existing fire emergency plan and procedure policy revealed the policy did not contain specific information on evacuation form each smoke zone and from all departments of the building. Maintenance Staff A indicated that they were aware that the policy is vague and are planning to write a new policy.
2. Interview with Maintenance Staff A revealed that a fire had occurred on the morning of 3/5/15 in the Comfort Suite Room in the facility. Maintenance Staff A indicated that the fire alarm did not automatically activate and was not activated by a pull station. The facilities plan indicates that the R.A.C.E. response plan is to be followed during a fire emergency. The acronym stands for Rescue, Alarm, Contain and Extinguishment. The policy states that the fire alarm is to be activated in the alarm stage.

Based upon record review and staff interview, the facility failed to hold fire drills under varied conditions at different times of the day for four of four quarters reviewed. Fire drills shall be held at unexpected times under varying conditions, at least quarterly on each shift. This deficient practice has the potential of affecting staff preparation and experience in providing for the protection of all patients in the event of a fire. The facility has a capacity of 25 with a census of 15 patients.

Findings include:

Record review and staff interview on 3/5/15 at 10:55 a.m., revealed the facility held fire drills on the same date for more than one shift as follows: 3/31/14: 1st and 2nd Shifts. 6/30/14: 1st and 2nd Shifts. 12/31/14: 1st and 3rd Shifts. Maintenance Staff A verified record review during the survey process.

Based on record review and staff interview, the facility failed to inspect and test the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, 1999 edition, Chapter 7. The fire alarm system shall be inspected and tested at the frequencies established in Chapter 7. This deficient practice affects all occupants of the facility. The facility has a capacity of 25 with a census of 15 residents.

Findings include:

Record review and staff interview on 3/5/15 at 10:16 a.m. and 10:25 a.m., revealed the following deficiencies:

1. There was no available documentation of fire alarm inspections for 2014.
2. Review of fire alarm inspection reports dated 4/9/13 and 10/23/13 revealed no listing of alarm devices tested or locations of alarm devices tested.

Maintenance Staff A verified record review during the survey process.

Based on observation and staff interview, this facility is not assuring that the fire alarm system is installed and maintained in accordance with National Fire Protection Association (NFPA) 72, 2-3.5, which requires that smoke detectors are not placed within direct airflow, nor closer that three feet to air supply or air return. Installation of a smoke detector close to a ceiling fan can impede the operation of the smoke detector.

Findings include:

Observation and staff interview on 3/5/15 at 12:45 p.m., revealed a smoke detector installed within three feet of an air supply or return vent in the CAT Scan Room. Maintenance Staff A verified observations during the survey process.

Based on observation and staff interview, the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 25, 1998 edition. The deficient practice affects occupants in 1 out of 14 smoke zones in the facility. The facility has a capacity of 25 with a census of 15 residents.

Findings include:

Observation and staff interview on 3/5/15 at 2:50 p.m., revealed the facility failed to provide spare recessed style sprinkler heads. Recessed style sprinkler heads were observed in use in the facility. Maintenance Staff A verified observations during the survey process.

Based on record review and staff interview, the facility failed to maintain and test the emergency generator power supply as required. Emergency generators are required to be inspected weekly and exercised under load for 30 minutes per month and shall be in accordance with National Fire Protection Association (NFPA), Standard 99, 3.4.4.1, and NFPA 110, 8.4.2. The emergency generator would effect all smoke compartments and all facility staff and residents. The facility has a capacity of 25 with a census of 15 patients.

Findings include:

Record review and staff interview on 3/5/15 at 10:40 a.m., revealed the facility failed to exercise the generator at 30% of the nameplate value during a monthly test under load for February of 2015. Available documentation indicated that the generator nameplate rating is 500 kW. 30% of the nameplate rating would be 150 kW. The generator log entry for February of 2015 indicated the generator was operating at 148 kW. Maintenance Staff A verified record review during the survey process.

Based on observations and staff interview, 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. The facility has a capacity of 25 with a census of 15 patients.

Findings include:

Observations and staff interview on 3/5/15, from 9:30 a.m. to 3:00 p.m., revealed the following deficiencies:

1. There was a gap in electrical panel N(R), located in the Specialty Clinic Electrical Room.
2. There was an electrical junction box with a knock-out not covered in the basement corridor by the Boiler Room.
3. There was a broken light switch cover in the Boiler Room under Electrical Panel BDP1.

Maintenance Staff A verified observations during the survey process.

Based on record review and staff interview, this facility failed to provide the policy in place regarding the procedures to be taken in the event that the sprinkler system is out of service for more than four hours in any twenty-four hour period contained all applicable information. This deficient practice affects all occupants of the building, including staff, visitors and residents. This facility has a capacity of 25 with a census of 15 residents.

Findings include:

Record review and staff interview on 3/5/15 at 10:55 a.m., revealed no available documentation of a policy regarding the procedures to be taken in the event that the sprinkler system is out of service for more than four hours in any twenty-four hour period. Maintenance Staff A verified observations during the survey process.

Based on record review and staff interview, this facility failed to provide the policy in place regarding the procedures to be taken in the event that the fire alarm system is out of service for more than four hours in any twenty-four hour period contained all applicable information. This deficient practice affects all occupants of the building, including staff, visitors and residents. This facility has a capacity of 25 with a census of 15 residents.

Findings include:

Record review and staff interview on 3/5/15 at 10:55 a.m., revealed no available documentation of a policy regarding the procedures to be taken in the event that the fire alarm system is out of service for more than four hours in any twenty-four hour period. Maintenance Staff A verified observations during the survey process.

Based on observations and staff interview, this facility is not providing firewalls with a two-hour fire rating to separate areas of non-conforming construction within the facility. This deficient practice affects all occupants including staff, visitors and residents. The facility has a capacity of 25 with a census of 15 patients.

Findings include:

Observations and staff interview on 3/5/15, between 9:30 and 3:00 p.m., revealed the following deficiencies:

1. There was a gap, (approximately 3/16 inch), in the drywall of the 2 hour wall by Alcove #6 to the Medical-Surgical Wing.
2. There were three open pipes, (all approximately 2-1/2 inch), with communications lines through them, extending through the 2 hour wall by Alcove #6 to the Medical-Surgical Wing.
3. There was a gap, (approximately 1/4 inch), in the drywall of the 2 hour wall by the Nursery to the Medical-Surgical Wing.
4. There were three open pipes, (all approximately 2-1/2 inch), with communications lines through them, extending through the 2 hour wall by the Nursery to the Medical-Surgical Wing.
5. There were three penetrations, (all approximately 1/4 inch), around conduit and communications lines extending through the 2 hour wall by the LDRP Waiting Area.
6. There were two penetrations, (both approximately 1/4 inch), around two pipes extending through the 2 hour wall by the LDRP Waiting Area.
7. There was a penetration, (approximately 1/4 inch), around a sprinkler pipe and communications cables extending through the 2 hour wall by the LDRP Waiting Area.
8. There was a penetration, (approximately 1/4 inch), around two communications lines extending through the 2 hour wall by the CEO Office.

Maintenance Staff A verified observations during the survey process.

Based on observation and staff interview, it was determined the facility was a one-story building and consisted of protected combustible construction equipped with an automatic sprinkler system. The facility failed to assure minimum building construction requirements were maintained by ensuring that holes and gaps around penetrations are sealed with fire rated materials. The facility has a capacity of 25 with a census of 15 patients.

Findings include:

Observation and staff interview on 3/5/15 at 1:01 p.m., indicated a ceiling tile not flush with the ceiling tile grid in the Dialysis RO Room. Maintenance Staff A verified observations during the survey process.

Based on observations and staff interview, the facility is not ensuring that doors to rooms are provided with suitable hardware that keep the doors shut tightly into their frames. The facility has a capacity of 25 with a census of 15 patients.

Findings include:

Observations and staff interview on 3/5/15, at 12:56 p.m. and 1:03 p.m., revealed the following deficiencies:

1. The door to the Old OB Unit Housekeeping Closet did not close and latch properly when tested.
2. The corridor door to the RO Corridor did not close and latch properly when tested.

Maintenance Staff A verified observations during the survey process.

Based on record review and staff interview, the facility failed to provide a fire emergency plan and procedure policy that included specific information on evacuation from each smoke zone within the facility. The facility is also not ensuring that the policy in place is followed for all fire emergency events. The deficient practice affects all occupants of the facility. The facility has a capacity of 25 with a census of 15 residents.

Findings include:

1. Review of the facility's existing fire emergency plan and procedure policy revealed the policy did not contain specific information on evacuation form each smoke zone and from all departments of the building. Maintenance Staff A indicated that they were aware that the policy is vague and are planning to write a new policy.
2. Interview with Maintenance Staff A revealed that a fire had occurred on the morning of 3/5/15 in the Comfort Suite Room in the facility. Maintenance Staff A indicated that the fire alarm did not automatically activate and was not activated by a pull station. The facilities plan indicates that the R.A.C.E. response plan is to be followed during a fire emergency. The acronym stands for Rescue, Alarm, Contain and Extinguishment. The policy states that the fire alarm is to be activated in the alarm stage.

Based upon record review and staff interview, the facility failed to hold fire drills under varied conditions at different times of the day for four of four quarters reviewed. Fire drills shall be held at unexpected times under varying conditions, at least quarterly on each shift. This deficient practice has the potential of affecting staff preparation and experience in providing for the protection of all patients in the event of a fire. The facility has a capacity of 25 with a census of 15 patients.

Findings include:

Record review and staff interview on 3/5/15 at 10:55 a.m., revealed the facility held fire drills on the same date for more than one shift as follows: 3/31/14: 1st and 2nd Shifts. 6/30/14: 1st and 2nd Shifts. 12/31/14: 1st and 3rd Shifts. Maintenance Staff A verified record review during the survey process.

Based on record review and staff interview, the facility failed to inspect and test the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, 1999 edition, Chapter 7. The fire alarm system shall be inspected and tested at the frequencies established in Chapter 7. This deficient practice affects all occupants of the facility. The facility has a capacity of 25 with a census of 15 residents.

Findings include:

Record review and staff interview on 3/5/15 at 10:16 a.m. and 10:25 a.m., revealed the following deficiencies:

1. There was no available documentation of fire alarm inspections for 2014.
2. Review of fire alarm inspection reports dated 4/9/13 and 10/23/13 revealed no listing of alarm devices tested or locations of alarm devices tested.

Maintenance Staff A verified record review during the survey process.

Based on observation and staff interview, this facility is not assuring that the fire alarm system is installed and maintained in accordance with National Fire Protection Association (NFPA) 72, 2-3.5, which requires that smoke detectors are not placed within direct airflow, nor closer that three feet to air supply or air return. Installation of a smoke detector close to a ceiling fan can impede the operation of the smoke detector.

Findings include:

Observation and staff interview on 3/5/15 at 12:45 p.m., revealed a smoke detector installed within three feet of an air supply or return vent in the CAT Scan Room. Maintenance Staff A verified observations during the survey process.

Based on observation and staff interview, the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 25, 1998 edition. The deficient practice affects occupants in 1 out of 14 smoke zones in the facility. The facility has a capacity of 25 with a census of 15 residents.

Findings include:

Observation and staff interview on 3/5/15 at 2:50 p.m., revealed the facility failed to provide spare recessed style sprinkler heads. Recessed style sprinkler heads were observed in use in the facility. Maintenance Staff A verified observations during the survey process.

Based on record review and staff interview, the facility failed to maintain and test the emergency generator power supply as required. Emergency generators are required to be inspected weekly and exercised under load for 30 minutes per month and shall be in accordance with National Fire Protection Association (NFPA), Standard 99, 3.4.4.1, and NFPA 110, 8.4.2. The emergency generator would effect all smoke compartments and all facility staff and residents. The facility has a capacity of 25 with a census of 15 patients.

Findings include:

Record review and staff interview on 3/5/15 at 10:40 a.m., revealed the facility failed to exercise the generator at 30% of the nameplate value during a monthly test under load for February of 2015. Available documentation indicated that the generator nameplate rating is 500 kW. 30% of the nameplate rating would be 150 kW. The generator log entry for February of 2015 indicated the generator was operating at 148 kW. Maintenance Staff A verified record review during the survey process.

Based on observations and staff interview, 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. The facility has a capacity of 25 with a census of 15 patients.

Findings include:

Observations and staff interview on 3/5/15, from 9:30 a.m. to 3:00 p.m., revealed the following deficiencies:

1. There was a gap in electrical panel N(R), located in the Specialty Clinic Electrical Room.
2. There was an electrical junction box with a knock-out not covered in the basement corridor by the Boiler Room.
3. There was a broken light switch cover in the Boiler Room under Electrical Panel BDP1.

Maintenance Staff A verified observations during the survey process.

Based on record review and staff interview, this facility failed to provide the policy in place regarding the procedures to be taken in the event that the sprinkler system is out of service for more than four hours in any twenty-four hour period contained all applicable information. This deficient practice affects all occupants of the building, including staff, visitors and residents. This facility has a capacity of 25 with a census of 15 residents.

Findings include:

Record review and staff interview on 3/5/15 at 10:55 a.m., revealed no available documentation of a policy regarding the procedures to be taken in the event that the sprinkler system is out of service for more than four hours in any twenty-four hour period. Maintenance Staff A verified observations during the survey process.

Based on record review and staff interview, this facility failed to provide the policy in place regarding the procedures to be taken in the event that the fire alarm system is out of service for more than four hours in any twenty-four hour period contained all applicable information. This deficient practice affects all occupants of the building, including staff, visitors and residents. This facility has a capacity of 25 with a census of 15 residents.

Findings include:

Record review and staff interview on 3/5/15 at 10:55 a.m., revealed no available documentation of a policy regarding the procedures to be taken in the event that the fire alarm system is out of service for more than four hours in any twenty-four hour period. Maintenance Staff A verified observations during the survey process.