HospitalInspections.org

Based on observation and interview, the facility did not provide and maintain wall construction to protect the corridor from non-corridor spaces with smoke detection in spaces that are open to the corridor, in accordance with NFPA 101 (2000 edition), 18.3.6.1. This deficiency had the potential to affect all inpatients, as well as an undetermined number of outpatients, staff, and visitors within smoke compartment " C " .
FINDINGS INCLUDE:
On 05/04/16 at 10:02 am, observation revealed on the 1st floor in the waiting room by door 9, that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that are open to the corridor. The space did not have a smoke detector and, as an alternative, was not fully observable from a 24 hour occupied location.
This condition was confirmed at the time of discovery by a concurrent observation and interview with staff R (Safety Consultant), staff S (Asst. Reg Dir of Fac) and staff T (Fac Mgr).
______________________________________

Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls with rated wall construction, in accordance with NFPA 101 (2000 edition), 18.3.7.3. This deficiency had the potential to affect an undetermined number of outpatients, staff, and visitors within smoke compartments " A " and " B " .
FINDINGS INCLUDE:
On 05/03/16 at 2:15 pm, observation revealed on the 1st floor in the radiology reception room, that the smoke barrier wall was not compliant. The pass through window located in the smoke barrier wall was protected with a fire shutter tied to a fusible link, however the shutter would not close upon activation of the fire alarm system.
This condition was confirmed at the time of discovery by a concurrent observation and interview with staff R (Safety Consultant), staff S (Asst. Reg Dir of Fac) and staff T (Fac Mgr).
______________________________________

Based on observation and interview, the facility did not provide and maintain smoke barrier door assemblies that meet code requirements for separation of smoke compartments with an adjacent smoke detector in accordance with NFPA 101(2000 ed.), 18.3.7.6 and 18.2.2.2.6, and NFPA 72(1999 ed.), 2-10.6. This deficiency had the potential to affect all patients, and an undetermined number of outpatients, staff and visitors within all smoke compartments.
FINDINGS INCLUDE:
1. On 05/03/16 at 1:11 pm, observation revealed on the 1st floor in the clinic and hospital lobby, door 1006A, that the smoke barrier door was magnetically held open and did not have a smoke detector located on either side of the door.
2. On 05/03/16 at 1:23 pm, observation revealed on the 1st floor in the office suite 1-4, that the smoke barrier door was magnetically held open and did not have a smoke detector located on either side of the door.
3. On 05/04/16 at 9:20 am, observation revealed on the 1st floor in the corridor just south of the hospital lobby waiting room, doors 1013, 1010C, 1425, 1010A and 1027, that the smoke barrier door was magnetically held open and did not have a smoke detector located on either side of the door.
4. On 05/04/16 at 10:09 am, observation revealed on the 1st floor in the corridor adjacent to the dining room, that the smoke barrier door was magnetically held open and did not have a smoke detector located on either side of the door.
This condition was confirmed at the time of discovery by a concurrent observation and interview with staff R (Safety Consultant), staff S (Asst. Reg Dir of Fac) and staff T (Fac Mgr).
______________________________________

Based on record review and interview, the facility did not conduct fire drills as required by the code to ensure that staff are familiar with fire response procedures with the required quantity of drills or ensure that the drills were held under varied conditions in accordance with NFPA 101 (2000 ed.), 18.7.1.2. This deficiency had the potential to affect all inpatients, outpatients, staff and visitors.
FINDINGS INCLUDE:
On 05/03/16 at 9:50 am, it was noted during a review of facility documents that the fire drill reports showed fire drills were not conducted quarterly on every shift. The 2015 4th quarter 1st shift drill was missing. Also 4 of 4 second shift drills and 4 of 4 third shift drills were held within one hour of each other.
This condition was confirmed at the time of discovery by interview with staff R (Safety Consultant), staff S (Asst. Reg Dir of Fac) and staff T (Fac Mgr).
______________________________________

Based on observation and interview the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25 (1998 ed.), 2-2.1.1. This deficiency had the potential to affect an undetermined number of staff and visitors within the kitchen and business office.
FINDINGS INCLUDE:
1. On 05/03/16 at 12:41 pm, observation revealed on the 1st floor in the kitchen, that sprinklers were not kept free of lint or other foreign material and maintained to keep the system fully operable as designed.
2. On 05/03/16 at 1:15 pm, observation revealed on the 1st floor in room 150, business office, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully operable as designed.
This condition was confirmed at the time of discovery by a concurrent observation and interview with staff R (Safety Consultant), staff S (Asst. Reg Dir of Fac) and staff T (Fac Mgr).
______________________________________

K-147
Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70 (1999 ed.), 400-8(1), with proper use of flexible cords. This deficiency had the potential to affect an undetermined number of staff with access to room 248
FINDINGS INCLUDE:
On 05/03/16 at 12:33 pm, observation revealed on the 1st floor in the room 248, that a flexible cord was used in a manner that is not permitted by the code. A flexible extension cord was used as a substitute for fixed wiring.
This condition was confirmed at the time of discovery by a concurrent observation and interview with staff R (Safety Consultant), staff S (Asst. Reg Dir of Fac) and staff T (Fac Mgr).
______________________________________

Based on record review and interview, the facility did not provide and use a program to respond to outages of the sprinkler system with complete procedures for responding to outages in accordance with NFPA 101 (2000 ed.), 9.7.6.1. This deficiency had the potential to affect all inpatients, outpatients, staff and visitors.
FINDINGS INCLUDE:
On 05/03/16 at 11:20 am, it was noted during a review of documents that the facility did not have an appropriate response to outages of the sprinkler system of more than 4 hours in a 24 hour period. The facility policy did not include notification of the DHS regional fire authority.
This condition was confirmed at the time of discovery by an interview with staff R (Safety Consultant), staff S (Asst. Reg Dir of Fac) and staff T (Fac Mgr).
______________________________________

Based on record review and interview, the facility did not provide and use a program to respond to outages of the fire alarm system with complete procedures for responding to outages in accordance with NFPA 101 (2000 ed.), 9.6.1.8. This deficiency had the potential to affect all inpatients, outpatients, staff and visitors.
FINDINGS INCLUDE:
On 05/03/16 at 11:25 am, it was noted during a review of documents that the facility did not have an appropriate response to outages of the fire alarm system of more than 4 hours in a 24 hour period. The facility policy did not include notification of the DHS regional fire authority.
This condition was confirmed at the time of discovery by an interview with staff R (Safety Consultant), staff S (Asst. Reg Dir of Fac) and staff T (Fac Mgr).
______________________________________

Based on observation and interview, the facility did not provide and maintain wall construction to protect the corridor from non-corridor spaces with smoke detection in spaces that are open to the corridor, in accordance with NFPA 101 (2000 edition), 18.3.6.1. This deficiency had the potential to affect all inpatients, as well as an undetermined number of outpatients, staff, and visitors within smoke compartment " C " .
FINDINGS INCLUDE:
On 05/04/16 at 10:02 am, observation revealed on the 1st floor in the waiting room by door 9, that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that are open to the corridor. The space did not have a smoke detector and, as an alternative, was not fully observable from a 24 hour occupied location.
This condition was confirmed at the time of discovery by a concurrent observation and interview with staff R (Safety Consultant), staff S (Asst. Reg Dir of Fac) and staff T (Fac Mgr).
______________________________________

Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls with rated wall construction, in accordance with NFPA 101 (2000 edition), 18.3.7.3. This deficiency had the potential to affect an undetermined number of outpatients, staff, and visitors within smoke compartments " A " and " B " .
FINDINGS INCLUDE:
On 05/03/16 at 2:15 pm, observation revealed on the 1st floor in the radiology reception room, that the smoke barrier wall was not compliant. The pass through window located in the smoke barrier wall was protected with a fire shutter tied to a fusible link, however the shutter would not close upon activation of the fire alarm system.
This condition was confirmed at the time of discovery by a concurrent observation and interview with staff R (Safety Consultant), staff S (Asst. Reg Dir of Fac) and staff T (Fac Mgr).
______________________________________

Based on observation and interview, the facility did not provide and maintain smoke barrier door assemblies that meet code requirements for separation of smoke compartments with an adjacent smoke detector in accordance with NFPA 101(2000 ed.), 18.3.7.6 and 18.2.2.2.6, and NFPA 72(1999 ed.), 2-10.6. This deficiency had the potential to affect all patients, and an undetermined number of outpatients, staff and visitors within all smoke compartments.
FINDINGS INCLUDE:
1. On 05/03/16 at 1:11 pm, observation revealed on the 1st floor in the clinic and hospital lobby, door 1006A, that the smoke barrier door was magnetically held open and did not have a smoke detector located on either side of the door.
2. On 05/03/16 at 1:23 pm, observation revealed on the 1st floor in the office suite 1-4, that the smoke barrier door was magnetically held open and did not have a smoke detector located on either side of the door.
3. On 05/04/16 at 9:20 am, observation revealed on the 1st floor in the corridor just south of the hospital lobby waiting room, doors 1013, 1010C, 1425, 1010A and 1027, that the smoke barrier door was magnetically held open and did not have a smoke detector located on either side of the door.
4. On 05/04/16 at 10:09 am, observation revealed on the 1st floor in the corridor adjacent to the dining room, that the smoke barrier door was magnetically held open and did not have a smoke detector located on either side of the door.
This condition was confirmed at the time of discovery by a concurrent observation and interview with staff R (Safety Consultant), staff S (Asst. Reg Dir of Fac) and staff T (Fac Mgr).
______________________________________

Based on record review and interview, the facility did not conduct fire drills as required by the code to ensure that staff are familiar with fire response procedures with the required quantity of drills or ensure that the drills were held under varied conditions in accordance with NFPA 101 (2000 ed.), 18.7.1.2. This deficiency had the potential to affect all inpatients, outpatients, staff and visitors.
FINDINGS INCLUDE:
On 05/03/16 at 9:50 am, it was noted during a review of facility documents that the fire drill reports showed fire drills were not conducted quarterly on every shift. The 2015 4th quarter 1st shift drill was missing. Also 4 of 4 second shift drills and 4 of 4 third shift drills were held within one hour of each other.
This condition was confirmed at the time of discovery by interview with staff R (Safety Consultant), staff S (Asst. Reg Dir of Fac) and staff T (Fac Mgr).
______________________________________

Based on observation and interview the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25 (1998 ed.), 2-2.1.1. This deficiency had the potential to affect an undetermined number of staff and visitors within the kitchen and business office.
FINDINGS INCLUDE:
1. On 05/03/16 at 12:41 pm, observation revealed on the 1st floor in the kitchen, that sprinklers were not kept free of lint or other foreign material and maintained to keep the system fully operable as designed.
2. On 05/03/16 at 1:15 pm, observation revealed on the 1st floor in room 150, business office, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully operable as designed.
This condition was confirmed at the time of discovery by a concurrent observation and interview with staff R (Safety Consultant), staff S (Asst. Reg Dir of Fac) and staff T (Fac Mgr).
______________________________________

K-147
Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70 (1999 ed.), 400-8(1), with proper use of flexible cords. This deficiency had the potential to affect an undetermined number of staff with access to room 248
FINDINGS INCLUDE:
On 05/03/16 at 12:33 pm, observation revealed on the 1st floor in the room 248, that a flexible cord was used in a manner that is not permitted by the code. A flexible extension cord was used as a substitute for fixed wiring.
This condition was confirmed at the time of discovery by a concurrent observation and interview with staff R (Safety Consultant), staff S (Asst. Reg Dir of Fac) and staff T (Fac Mgr).
______________________________________

Based on record review and interview, the facility did not provide and use a program to respond to outages of the sprinkler system with complete procedures for responding to outages in accordance with NFPA 101 (2000 ed.), 9.7.6.1. This deficiency had the potential to affect all inpatients, outpatients, staff and visitors.
FINDINGS INCLUDE:
On 05/03/16 at 11:20 am, it was noted during a review of documents that the facility did not have an appropriate response to outages of the sprinkler system of more than 4 hours in a 24 hour period. The facility policy did not include notification of the DHS regional fire authority.
This condition was confirmed at the time of discovery by an interview with staff R (Safety Consultant), staff S (Asst. Reg Dir of Fac) and staff T (Fac Mgr).
______________________________________

Based on record review and interview, the facility did not provide and use a program to respond to outages of the fire alarm system with complete procedures for responding to outages in accordance with NFPA 101 (2000 ed.), 9.6.1.8. This deficiency had the potential to affect all inpatients, outpatients, staff and visitors.
FINDINGS INCLUDE:
On 05/03/16 at 11:25 am, it was noted during a review of documents that the facility did not have an appropriate response to outages of the fire alarm system of more than 4 hours in a 24 hour period. The facility policy did not include notification of the DHS regional fire authority.
This condition was confirmed at the time of discovery by an interview with staff R (Safety Consultant), staff S (Asst. Reg Dir of Fac) and staff T (Fac Mgr).
______________________________________