HospitalInspections.org

Based on observation and staff interview the facility failed to ensure vertical openings were fire rated in 2 of 7 smoke compartments. The findings were:

1. Observation of the center stairwell on 7/14/10 at 9:21 AM showed the west wall had an unsealed pipe chase that led into the adjacent mechanical room. The unsealed hole was 6 inches by 12 inches. At the time of the observation the plant operations supervisor reported he was aware of the fire separation requirement. He further reported that vertical shafts were not routinely inspected.

2. Observation of the elevator equipment room on 7/14/10 at 10:05 AM showed an unsealed wall penetration that opened into the one story elevator shaft. The hole was 8 inches by 12 inches.

Based on observation and staff interview the facility failed to ensure 2 of 4 smoke barriers were smoke resistant. The findings were:

Observation of the smoke barriers on 7/14/10 between 1 PM and 2 PM showed the barrier near the emergency room and the north barrier were not smoke resistant. The largest gap was 1 inch by 3 inches wide. At the time of the observation the plant operations supervisor reported he was aware of smoke resistant requirement. He further reported the barriers were only checked after work had been completed in the area. He could not explain why the holes had not been identified after the last project.

Based on observation and staff interview the facility failed to ensure hazardous areas were separated from use areas in 1 of 7 smoke compartments. The findings were:

1. Observation of the maintenance shop on 7/14/10 at 9:10 AM showed five unsealed pipe penetrations. The largest gap between the pipe and wall was 2 inches wide. At the time of observation the plant operations supervisor reported he was not aware the penetrations needed to be filled as the room had complete sprinkler coverage.

2. Observation of the purchasing storeroom on 7/14/10 at 10:22 AM showed there was an unsealed pipe chase. The unsealed space was used for a pipe chase and was 8 inches by 24 inches wide. At the time of observation the plant operations supervisor reported the hole was cut when the chiller water pipe loop was installed nearly 2 years ago. He further reported that hazardous areas were not routinely inspected to ensure they were smoke resistant.

3. Observation of the laundry room on 7/14/10 at 10:31 AM showed the corridor door frame leading the dirty laundry was not smoke resistant. The frame was missing an 18 inch long section of door stop along both jams near the bottom of the frame. At the time of observation the plant operations supervisor reported he was unaware that corridor door frames were required to have stops that would resist the passage of smoke.

Based on record review and staff interview the facility failed to ensure 1 of 2 emergency battery light tests was performed. The findings were:

Review of the emergency battery light testing records showed the annual 90 minute test had not been performed in the past 12 months. On 7/14/10 at 2:50 PM the plant operations supervisor confirmed the test had not been performed. He further reported that he was aware of the required test, but could not explain why it had been missed. The test was last performed on February 18, 2009.

Based on record review and staff interview the facility failed to ensure the fire alarm receiving device was tested for 2 of the past 12 months. The findings were:

Review of the fire alarm system testing records showed the receiving device had not been tested during the months of October 2009 and February 2010. On 7/14/10 at 2:50 PM the plant operations supervisor reported he was aware of the monthly testing requirement. He further confirmed the receiver had not been tested during the above mentioned months. he could not explain why the test was missed.

Based on observation, record review and staff interview the facility failed to ensure the waterflow alarm device was tested during 4 of the past 4 quarters and failed to ensure sprinkler were unobstructed in 1 of 7 smoke compartments. The findings were:

1. Observation of the sprinkler system on 7/14/10 at 10:25 AM showed seven sprinkler heads in the clean laundry room were obstructed by ceiling mounted lights. The sprinklers were installed within 12 inches of ceiling mounted lights and the bottom of the lights were below the bottom of the sprinkler deflectors. At the time of the observation the plant operations supervisor reported he was aware of the spacing requirement. He further reported that the system was inspected annually by an outside contractor, and they had not noted any obstructed sprinklers on their last report.

2. Review of the fire sprinkler sytem testing records showed the times to activation for waterflow alarm device had not been collected in the past year. On 7/14/10 at 2:50 PM the plant operations supervisor reported he was aware of the quarterly testing requirement. He further confirmed the times had not been collected over the past year. He could not explain why the times had not been collected.

Based on observation and staff interview the facility failed to ensure portable fire extinguishers received monthly inspections in 2 of 7 smoke compartments. The findings were:

Observation of the portable fire extinguishers on 7/14/10 between 10 AM and 12 PM showed the extinguisher in the east basement corridor and in X-ray room #1 had not been inspected on a monthly basis. The extinguishers had not been inspected during June 2010. At 10:18 AM the plant operations supervisor reported he was aware of the monthly inspection requirement. He further reported the inspection had recently been given to another individual who may not know where all of the extinguisher are located.

Based on observation and staff interview the facility failed to ensure temporary flexible electrical wiring did not replace fixed permanent wiring and failed to provided ground fault circuit interrupter (GFCI) protection in 4 of 7 smoke compartments. The findings were:

1. Observation of the electrical system on 7/14/10 at 9:15 AM showed the computer in the telephone room was plugged into a homemade corded four-plex which was, itself, plugged into a 2-way adapter. At the time of observation the plant operations supervisor reported he was aware electrical adapters were prohibited from being chained together, in-line. He further reported that the electrical system was inspected semi-annually. He could not explain why this issue had not been observed and changed.

2. Observation of the electrical system on 7/14/10 between 10 AM and 12 PM showed the sink in patient room #225 was located 40 inches from the sink and was not protected with a GFCI outlet. Further review showed all 25 patient rooms had the same configuration. At 10:47 AM the plant operations supervisor reported he was not aware existing outlets required GFCI protection.

Based on observation and staff interview the facility failed to ensure vertical openings were fire rated in 2 of 7 smoke compartments. The findings were:

1. Observation of the center stairwell on 7/14/10 at 9:21 AM showed the west wall had an unsealed pipe chase that led into the adjacent mechanical room. The unsealed hole was 6 inches by 12 inches. At the time of the observation the plant operations supervisor reported he was aware of the fire separation requirement. He further reported that vertical shafts were not routinely inspected.

2. Observation of the elevator equipment room on 7/14/10 at 10:05 AM showed an unsealed wall penetration that opened into the one story elevator shaft. The hole was 8 inches by 12 inches.

Based on observation and staff interview the facility failed to ensure 2 of 4 smoke barriers were smoke resistant. The findings were:

Observation of the smoke barriers on 7/14/10 between 1 PM and 2 PM showed the barrier near the emergency room and the north barrier were not smoke resistant. The largest gap was 1 inch by 3 inches wide. At the time of the observation the plant operations supervisor reported he was aware of smoke resistant requirement. He further reported the barriers were only checked after work had been completed in the area. He could not explain why the holes had not been identified after the last project.

Based on observation and staff interview the facility failed to ensure hazardous areas were separated from use areas in 1 of 7 smoke compartments. The findings were:

1. Observation of the maintenance shop on 7/14/10 at 9:10 AM showed five unsealed pipe penetrations. The largest gap between the pipe and wall was 2 inches wide. At the time of observation the plant operations supervisor reported he was not aware the penetrations needed to be filled as the room had complete sprinkler coverage.

2. Observation of the purchasing storeroom on 7/14/10 at 10:22 AM showed there was an unsealed pipe chase. The unsealed space was used for a pipe chase and was 8 inches by 24 inches wide. At the time of observation the plant operations supervisor reported the hole was cut when the chiller water pipe loop was installed nearly 2 years ago. He further reported that hazardous areas were not routinely inspected to ensure they were smoke resistant.

3. Observation of the laundry room on 7/14/10 at 10:31 AM showed the corridor door frame leading the dirty laundry was not smoke resistant. The frame was missing an 18 inch long section of door stop along both jams near the bottom of the frame. At the time of observation the plant operations supervisor reported he was unaware that corridor door frames were required to have stops that would resist the passage of smoke.

Based on record review and staff interview the facility failed to ensure 1 of 2 emergency battery light tests was performed. The findings were:

Review of the emergency battery light testing records showed the annual 90 minute test had not been performed in the past 12 months. On 7/14/10 at 2:50 PM the plant operations supervisor confirmed the test had not been performed. He further reported that he was aware of the required test, but could not explain why it had been missed. The test was last performed on February 18, 2009.

Based on record review and staff interview the facility failed to ensure the fire alarm receiving device was tested for 2 of the past 12 months. The findings were:

Review of the fire alarm system testing records showed the receiving device had not been tested during the months of October 2009 and February 2010. On 7/14/10 at 2:50 PM the plant operations supervisor reported he was aware of the monthly testing requirement. He further confirmed the receiver had not been tested during the above mentioned months. he could not explain why the test was missed.

Based on observation, record review and staff interview the facility failed to ensure the waterflow alarm device was tested during 4 of the past 4 quarters and failed to ensure sprinkler were unobstructed in 1 of 7 smoke compartments. The findings were:

1. Observation of the sprinkler system on 7/14/10 at 10:25 AM showed seven sprinkler heads in the clean laundry room were obstructed by ceiling mounted lights. The sprinklers were installed within 12 inches of ceiling mounted lights and the bottom of the lights were below the bottom of the sprinkler deflectors. At the time of the observation the plant operations supervisor reported he was aware of the spacing requirement. He further reported that the system was inspected annually by an outside contractor, and they had not noted any obstructed sprinklers on their last report.

2. Review of the fire sprinkler sytem testing records showed the times to activation for waterflow alarm device had not been collected in the past year. On 7/14/10 at 2:50 PM the plant operations supervisor reported he was aware of the quarterly testing requirement. He further confirmed the times had not been collected over the past year. He could not explain why the times had not been collected.

Based on observation and staff interview the facility failed to ensure portable fire extinguishers received monthly inspections in 2 of 7 smoke compartments. The findings were:

Observation of the portable fire extinguishers on 7/14/10 between 10 AM and 12 PM showed the extinguisher in the east basement corridor and in X-ray room #1 had not been inspected on a monthly basis. The extinguishers had not been inspected during June 2010. At 10:18 AM the plant operations supervisor reported he was aware of the monthly inspection requirement. He further reported the inspection had recently been given to another individual who may not know where all of the extinguisher are located.

Based on observation and staff interview the facility failed to ensure temporary flexible electrical wiring did not replace fixed permanent wiring and failed to provided ground fault circuit interrupter (GFCI) protection in 4 of 7 smoke compartments. The findings were:

1. Observation of the electrical system on 7/14/10 at 9:15 AM showed the computer in the telephone room was plugged into a homemade corded four-plex which was, itself, plugged into a 2-way adapter. At the time of observation the plant operations supervisor reported he was aware electrical adapters were prohibited from being chained together, in-line. He further reported that the electrical system was inspected semi-annually. He could not explain why this issue had not been observed and changed.

2. Observation of the electrical system on 7/14/10 between 10 AM and 12 PM showed the sink in patient room #225 was located 40 inches from the sink and was not protected with a GFCI outlet. Further review showed all 25 patient rooms had the same configuration. At 10:47 AM the plant operations supervisor reported he was not aware existing outlets required GFCI protection.