HospitalInspections.org

Based on observation, the facility failed to ensure fire barriers separating areas between which there are horizontal exits shall have a minimum 2 hour fire resistance rating in accordance with NFPA 101, 2012 Edition, Section 7.2.4.3.1. This deficiency effects 2 of 6 smoke compartments.

Findings include:

1. During an observation on 6/20/17 at 1:18 p.m., penetrations in the 2 hour fire barrier wall were observed above the lay in ceiling, on both the surgical suite side, and the labor and delivery suite.

Based on observation, the facility failed to ensure vertical openings were enclosed from floor to roof in accordance with NFPA 101, 2012 Edition, Sections 19.3.1 and 8.6.2. This deficiency effects 2 of 6 smoke compartments.

Findings include:

1. During an observation on 6/19/17 at 2:30 p.m., electric conduits were not sealed in the lay in ceiling in the IT room on the west corridor.

2. During an observation on 6/19/17 at 2:32 p.m., in an electrical room on the main hall across from a staff room, openings had not been sealed, where electric conduits created openings in the lay in ceiling.

Based on observation and interview, the facility failed to ensure doors to hazardous areas were self-closing, or automatic closing, in accordance with NFPA 101, 2012 Edition, Section 19.3.2.1.3. This deficiency effects 1 of 6 smoke compartments.

Findings include:

1. During an observation on 6/20/17 at 8:03 a.m., the laboratory did not have a self closing or automatic closing, door into the egress corridor.

2. During an observation on 6/20/17 at 7:37 a.m., the gift shop did not have a self closing, or automatic closing door.

In an interview on 6/20/17 at 7:37 a.m., staff member A stated the gift shop measured 12 feet by 12 feet in the main section, and 8 feet by 7 feet in the adjoining room.

Based on observation, record review and interview, the facility failed to have semi-annual load test completed on sealed lead acid batteries in the fire alarm control panel, in accordance with NFPA 72, 2010 Edition National Fire Alarm and Signaling Code, Table 14.4.5. 6. (3). This deficiency affects the entire facility.

Findings include:

1. During an observation on 6/20/17 at 9:13 a.m., the batteries in the Fire Alarm Control Panel had an install date of 11/14.

Review of the facility's records showed fire alarm inspections being completed 1/16, and 2/9/17. There was no evidence of a six month test on the the sealed lead acid batteries in between these dates.

In an interview on 6/20/17 at 11:30 a.m., staff member A said there was no other testing, on the sealed lead acid batteries.

Based on observation, the facility failed to ensure there was 18 inches of separation between storage, and the sprinkler, in accordance with NFPA 13, 2010 Edition, Standard for the Installation of Sprinkler Systems, Section 8.7.6, failed to ensure sprinklers were positioned and located, so as to provide satisfactory performance with respect to activation time in accordance with Section 8.1.1 (3)

Findings include:

1. During an observation on 6/19/17 at 1:43 p.m., storage in the walk in freezer was 13 inches below the sprinkler head.

2. During an observation on 6/19/17 at 2:12 p.m., the escutcheon ring was missing from the sprinkler head in resident room 114, as well as the bathroom in room 115.

3. During an observation on 6/19/17 at 2:20 p.m., there was an opening around the escutcheon ring of the sprinkler head in resident room 116.

4. During an observation on 6/19/17 at 2:25 p.m., in a storage room across from resident room 117 the shelf was 16 inches below the sprinkler head.

5. During an observation on 6/19/17 at 2:30 p.m., ceiling tiles were missing from the ceiling in the IT room, on the west corridor.

6. During an observation on 6/19/17 at 2:53 p.m., the escutcheon ring was missing from the sprinkler head, in resident room 134.

7. During an observation on 6/19/17 at 3:50 p.m., ceiling tiles were missing from the ceiling in the x-ray room.

8. During an observation on 6/20/17 at 8:13 a.m., there was an annular opening around a sprinkler head, in a business suite behind the kitchen.

Based on observations, the facility failed to ensure electrical wiring complied with NFPA 70, 2011 Edition, National Electric Code, Article 210.8(B)(5) shall have ground fault circuit interrupter (GFCI), near sinks, and failed to provide and maintain required working space about all electrical equipment to permit ready and safe operation in accordance with NFPA 70, 2011 Edition, Article 110.26 (A)(1)(2). These deficiencies affect 2 of 6 smoke compartments.

Findings include:

1. During an observation on 6/19/17 at 2:44 p.m., an electrical receptacle in a patient shower room was not GFCI. When tested it showed to be electrified.

2. During an observation on 6/20/17 at 8:00 a.m., an electrical panel in the lab was blocked by a stand containing pamphlets sitting on top of a file cabinet.

Based on record review and interview, the facility failed to ensure the operation of the damper, and verify that there is no damper interference, due to rust or bent, misaligned, damaged frame or blades, or defective hinges or other moving parts in accordance with NFPA 105, 2010 Edition, Standard for Smoke Door Assemblies and Other Opening Protectives, Section 6.5.1. This deficiency affects 2 smoke compartments in the basement.

Findings include:

1. Review of the facility's damper testing showed that in 5/16 dampers had been tested in the new surgical center. This documentation included the "Major Repair List." It showed that four dampers had not been hooked up.

In an interview on 6/20/17 at 1:25 p.m., staff member A said that one of the dampers did not get hooked up. This was the one in the basement electrical room.

Based on observations, the facility failed to ensure electrical equipment complied with N.F.P.A. 99, 2012 Edition, section 10.2.4, Adapters and Extension Cords.

Findings include:

1. During an observation on 6/20/17 at 11:10 a.m., a refrigorator was plugged into a power strip.

Based on observations, the facility failed to ensure electrical equipment complied with N.F.P.A. 99, 2012 Edition, section 10.2.4, Adapters and Extension Cords. This deficiency affects 1 smoke compartment.

Findings include:

1. During an observation on 6/20/17 at 8:25 a.m., a coffee maker and refrigorator were plugged into a power strip.