HospitalInspections.org

Based upon observations, the critical access hospital failed to maintain doors protecting corridor openings.

Failure to maintain doors as required risks passage of the toxic products of combustion to travel into the corridor in the event of a fire.

Findings include:

During a tour of the critical access hospital on 12/15/10, it was observed that:

1. The door to room 306 failed to close and latch.

2. The double doors to the dining room in the long term care area failed to close and latch. The astrigal on the door leaf prevented the other door from closing, because the door coordinator failed to hold the astrigal-leafed door open until the other door leaf had passed.

3. The door to Emergency Room 1 failed to close and latch.

These observations were confirmed by the hospigtal director of maintenance.

Based upon observations, the critical access hospital failed to maintain Fire/Smoke barrier doors so that they closed and the latching devices operated properly.

Failure to maintain fire/smoke barrier doors risks the toxic products of combustion moving from
one smoke compartment to another.

Findings include:

During a tour of the critical access hospital on 12/15/10, it was observed that the smoke barrier doors near the Beauty Shop in the Long Term Care Wing failed to close and latch. This
was observed by members of the maintenance staff.

Based upon observations, the critical access hospital failed to maintain the required separation of hazardous areas from other spaces.

Failure to maintain required separation of hazardous areas from other spaces risks toxic products of combustion from a fire in the hazardous area spreading throughout the area.

Findings include:

During a tour of the critical access hospital on 12/15/10, it was observed that:

1. The door closer on the door to a storage room near room 304 has been removed. The door is no longer self or automatic closing.

2. The door separating the ambulance storage bays and the ambulance crew's sleeping area failed to close and latch.

3. A door had been removed that had separated a room containing numerous machines and a fume hood for the dispensing and mixing of medications. This is a hazardous area and is required to be separated from the exit access corridor. The door was replaced during the survey.

Based upon observations and staff interviews, the critical access hospital failed to maintain exit doors so that they were operable from egress side without special knowledge or tools.

Failure to maintain exit doors in an easily operable condition risks patients, staff and visitors not being able to exit in a timely manner in the event of an emergency.

Findings include:

During a tour of the critical access hospital on 12/15/10, it was observed that the automatic sliding doors at the emergency room exit were turned off. This prohibited the doors from
opening upon the approach of people on the egress side. In addition, the dead bolt for the door was engaged. This prohibited the door from being able to be pushed open.

Interviews with staff indicated that due to new security measures the hospital has had to lock down the doors to prevent unauthorized entry.

The doors could not be opened and reset without special knowledge.

Based on observation, the hospital failed to provide emergency lighting of at least 1? hour duration is provided in accordance with the requirements of the Code.

Failure to provide required emergency lighting risks inability of patients, staff and visitors to safely evacuate the facility.

Findings include:

During a tour of the hospital on 12/13/10, it was observed that the CT trailer was not equipped with functional emergency lighting. A flashlight plugged into a receptacle in the trailer did not operate when tested.

Based upon record reviews and interview, the critical access hospital failed to maintain its fire sprinkler system to ensure reliability of operation.

Failure to maintain the fire sprinkler system as required risks the fire sprinkler system failing to operate properly in the event of a fire.

Findings include:

Review of fire sprinkler maintenance records on 12/14/10 found that during the annual inspection of the fire sprinkler system conducted by Tyco Grinnell on April 19, 2010 the following deficiencies were noted:

a. Lack of 5 year inspection for proper pitch of the dry
sprinkler system.
b. Lack of 5 year internal pipe inspection
c. Lack of 5 year Fire Department Connection (FDC) Check
valve inspection.
d. Gauge calibration or replacement at 5 year intervals.

The above noted deficiencies had not been corrected according to the hospital director of maintenance.

Based upon observation and staff interviews, the critical access hospital failed to maintain the commercial kitchen hood filters free of accumulations of grease.

Failure to maintain the commercial kitchen hood filters free of accumulations of grease risks fire within the kitchen area.

Findings include:

During a tour of the critical access hospital kitchen on 12/15/10, it was observed that:

1. There was a significant build up of grease on the filters above the commercial cooking equipment.

2. Interviews with kitchen staff revealed conflicting information. One staff member stated that filters were to be cleaned every Saturday, but that she did not work on Saturday and did not know if that occured. Another Staff member indicated that maintenance personnel cleaned the filters but she did not know when.

3. Staff could not present a log showing when the filters were cleaned.

Based upon observation and record review, the critical access hospital failed to maintain cubicle curtains to be in compliance with the required codes.

Failure to maintain cubicle curtains as required risks cubicle curtains not meeting the fire resistive requirements for hanging curtains. This also risks cubicle curtains obstructing fire sprinkler spray patterns.

Findings include:

During a tour of the critical access hospital on 12/15/10, it was found that:

1. The hospital maintenance department could not produce documentation to show that the cubicle curtains were in compliance with the fire resistive requirements found in NFPA
701.

2. Cubicle curtains in rooms 302, 302, 306 and 312 did not have a mesh top and did not have extender's that placed them 18 inches below the sprinkler heads. The curtains in their
current position would obstruct the sprinkler heads water pattern.

3. The cubicle curtains in Emergency Room #3 have a mesh that is to small to allow water to pass through and would obstruct the sprinkler water pattern from the sprinkler heads.

Based on observation, record review and interview, the hospital failed to ensure that the Type I EES is divided into the critical branch, life safety branch and the emergency system in accordance with NFPA 99.

Failure to divide the Type I EES as required risks failure of the essential electrical system.

Findings include:

During a tour of the hospital on 12/13/10, it was observed that the line drawing for the Type I Essential Electrical System (EES) located in the main switch gear room indicated that the EES was divided into three branches (Life Safety, Critical and Equipment) in accordance with the Code.

The downstream electrical panels for the Life Safety branch were labeled "LS 1" and LS 2". The downstream electrical panels for the Critical branch were labeled "CR 1" and "CR 2".

These panels were located by facilities management.

Panel LS 1 was found to include the following items not permitted by the Code:
- "Lights room #317" (nurses' station according to facilities management)
- "Nite lights patient rm"

Panel LS 2 was found to include the following items not permitted by the Code:
- "X-Ray Lab Emergency Computer
- "Router Hub Emergency Computer"

Panel CS1 was found to include the following items not permitted by the Code:
-"Door" (meaning the magnetic hold-open devices on smoke and fire doors, according to facilities management)

Based upon observations, the critical access hospital failed to maintain doors protecting corridor openings.

Failure to maintain doors as required risks passage of the toxic products of combustion to travel into the corridor in the event of a fire.

Findings include:

During a tour of the critical access hospital on 12/15/10, it was observed that:

1. The door to room 306 failed to close and latch.

2. The double doors to the dining room in the long term care area failed to close and latch. The astrigal on the door leaf prevented the other door from closing, because the door coordinator failed to hold the astrigal-leafed door open until the other door leaf had passed.

3. The door to Emergency Room 1 failed to close and latch.

These observations were confirmed by the hospigtal director of maintenance.

Based upon observations, the critical access hospital failed to maintain Fire/Smoke barrier doors so that they closed and the latching devices operated properly.

Failure to maintain fire/smoke barrier doors risks the toxic products of combustion moving from
one smoke compartment to another.

Findings include:

During a tour of the critical access hospital on 12/15/10, it was observed that the smoke barrier doors near the Beauty Shop in the Long Term Care Wing failed to close and latch. This
was observed by members of the maintenance staff.

Based upon observations, the critical access hospital failed to maintain the required separation of hazardous areas from other spaces.

Failure to maintain required separation of hazardous areas from other spaces risks toxic products of combustion from a fire in the hazardous area spreading throughout the area.

Findings include:

During a tour of the critical access hospital on 12/15/10, it was observed that:

1. The door closer on the door to a storage room near room 304 has been removed. The door is no longer self or automatic closing.

2. The door separating the ambulance storage bays and the ambulance crew's sleeping area failed to close and latch.

3. A door had been removed that had separated a room containing numerous machines and a fume hood for the dispensing and mixing of medications. This is a hazardous area and is required to be separated from the exit access corridor. The door was replaced during the survey.

Based upon observations and staff interviews, the critical access hospital failed to maintain exit doors so that they were operable from egress side without special knowledge or tools.

Failure to maintain exit doors in an easily operable condition risks patients, staff and visitors not being able to exit in a timely manner in the event of an emergency.

Findings include:

During a tour of the critical access hospital on 12/15/10, it was observed that the automatic sliding doors at the emergency room exit were turned off. This prohibited the doors from
opening upon the approach of people on the egress side. In addition, the dead bolt for the door was engaged. This prohibited the door from being able to be pushed open.

Interviews with staff indicated that due to new security measures the hospital has had to lock down the doors to prevent unauthorized entry.

The doors could not be opened and reset without special knowledge.

Based on observation, the hospital failed to provide emergency lighting of at least 1? hour duration is provided in accordance with the requirements of the Code.

Failure to provide required emergency lighting risks inability of patients, staff and visitors to safely evacuate the facility.

Findings include:

During a tour of the hospital on 12/13/10, it was observed that the CT trailer was not equipped with functional emergency lighting. A flashlight plugged into a receptacle in the trailer did not operate when tested.

Based upon record reviews and interview, the critical access hospital failed to maintain its fire sprinkler system to ensure reliability of operation.

Failure to maintain the fire sprinkler system as required risks the fire sprinkler system failing to operate properly in the event of a fire.

Findings include:

Review of fire sprinkler maintenance records on 12/14/10 found that during the annual inspection of the fire sprinkler system conducted by Tyco Grinnell on April 19, 2010 the following deficiencies were noted:

a. Lack of 5 year inspection for proper pitch of the dry
sprinkler system.
b. Lack of 5 year internal pipe inspection
c. Lack of 5 year Fire Department Connection (FDC) Check
valve inspection.
d. Gauge calibration or replacement at 5 year intervals.

The above noted deficiencies had not been corrected according to the hospital director of maintenance.

Based upon observation and staff interviews, the critical access hospital failed to maintain the commercial kitchen hood filters free of accumulations of grease.

Failure to maintain the commercial kitchen hood filters free of accumulations of grease risks fire within the kitchen area.

Findings include:

During a tour of the critical access hospital kitchen on 12/15/10, it was observed that:

1. There was a significant build up of grease on the filters above the commercial cooking equipment.

2. Interviews with kitchen staff revealed conflicting information. One staff member stated that filters were to be cleaned every Saturday, but that she did not work on Saturday and did not know if that occured. Another Staff member indicated that maintenance personnel cleaned the filters but she did not know when.

3. Staff could not present a log showing when the filters were cleaned.

Based upon observation and record review, the critical access hospital failed to maintain cubicle curtains to be in compliance with the required codes.

Failure to maintain cubicle curtains as required risks cubicle curtains not meeting the fire resistive requirements for hanging curtains. This also risks cubicle curtains obstructing fire sprinkler spray patterns.

Findings include:

During a tour of the critical access hospital on 12/15/10, it was found that:

1. The hospital maintenance department could not produce documentation to show that the cubicle curtains were in compliance with the fire resistive requirements found in NFPA
701.

2. Cubicle curtains in rooms 302, 302, 306 and 312 did not have a mesh top and did not have extender's that placed them 18 inches below the sprinkler heads. The curtains in their
current position would obstruct the sprinkler heads water pattern.

3. The cubicle curtains in Emergency Room #3 have a mesh that is to small to allow water to pass through and would obstruct the sprinkler water pattern from the sprinkler heads.

Based on observation, record review and interview, the hospital failed to ensure that the Type I EES is divided into the critical branch, life safety branch and the emergency system in accordance with NFPA 99.

Failure to divide the Type I EES as required risks failure of the essential electrical system.

Findings include:

During a tour of the hospital on 12/13/10, it was observed that the line drawing for the Type I Essential Electrical System (EES) located in the main switch gear room indicated that the EES was divided into three branches (Life Safety, Critical and Equipment) in accordance with the Code.

The downstream electrical panels for the Life Safety branch were labeled "LS 1" and LS 2". The downstream electrical panels for the Critical branch were labeled "CR 1" and "CR 2".

These panels were located by facilities management.

Panel LS 1 was found to include the following items not permitted by the Code:
- "Lights room #317" (nurses' station according to facilities management)
- "Nite lights patient rm"

Panel LS 2 was found to include the following items not permitted by the Code:
- "X-Ray Lab Emergency Computer
- "Router Hub Emergency Computer"

Panel CS1 was found to include the following items not permitted by the Code:
-"Door" (meaning the magnetic hold-open devices on smoke and fire doors, according to facilities management)