HospitalInspections.org

Based on interview and observation with staff, the facility failed to provide corridors separated from use areas by walls constructed with at least 1/2 hour fire resistance rating per 19.3.6.2.1. Findings:

1) Exit corridors were found
(a) to have unrated penetrations through rated corridor walls, including around wiring and conduit;
(b) to have outside vertical corners at rated wall intersections (above ceiling) with open gypsum board joints (no tape/bedding).

Based on observation and interview with staff, the facility failed to provide corridor doors with a means suitable for keeping the door closed. Findings:

1) Soiled Utility, located across from the nurse station, has doors that do not have latching hardware as required in 19.3.6.3.2.

Based on observation and interview with staff, the facility failed to provide all exits marked by approved, readily visible signs. Findings:

1) There were no exit signs in the Dining Room at the door leading into the exit corridor and at the door leading to the exterior.

Based on observation and interview with staff, the facility failed to provide smoke barriers of at least one-half hour fire resistance rating in accordance with Section 8.3. Findings:

1) Open penetrations were found in the smoke barriers, including around wiring, conduit, and structural members passing through the smoke barrier.

Based on observation and interview with staff, the facility failed to provide a piped in medical gas system complying with NFPA 99. Findings:

1) An Emergency Oxygen Supply Connection for connecting a temporary auxiliary source of supply for emergency or maintenance situations was not found Refer to NFPA 99 - 1999 Edition, Section 4-3.1.1.8(h).

2) No documentation was found re-certifying the medical gas system after the nitrous manifold was replaced in the medical gas room on 6-24-11. Refer to 4-3.4.1.

3) Medical gas copper piping was found to be in direct contact with galvanized supports (no isolation of dissimilar materials) in several locations in the facility.

Based on observation and interview with staff, the facility failed to provide documentation of inspection. Finding:
1) There is no documentation of an annual inspection and testing of the generator. Refer to NFPA 110 Section 8.4.