HospitalInspections.org

Based on observation, the facility failed to maintain the integrity of the building construction, as evidenced by failing to repair and seal penetrations in the facility walls and ceilings, to prevent the spread of fire and smoke. This failure could result in the spread of smoke or fire, and affected 5 of 15 smoke compartments.

Findings:

During a tour of the facility with Staff on June 19, 2012, through June 21, 2012, the facility walls and ceilings were observed.

On 6/19/12:
1. At 1:15 p.m., there was a penetration around a pipe in the back wall of the Dialysis Storage room.

2. At 1:34 p.m., there was a conduit with wires running through and the center of the conduit was not sealed with fire stop in the Engineering Electrical room next to the Women's Center.

3. At 1.58 p.m., there was a 4 inch by 4 inch cut out in the ceiling of Labor Delivery Room LDR 1 storage room.

4. At 2:24 p.m., there was a 1 1/2 inch ceiling penetration in the storage room located next to Room 121.

5. At 3:12 p.m., there were 4 penetrations approximately 1/2 inch to 3/4 inch each in the back wall of Laboratory Room 51.

6. At 3:24 p.m., there was a 1/2 inch penetration next to the sprinkler escutcheon ring in Intensive Care Unit ICU room 65.

Based on observation, the facility failed to maintain corridor doors to prevent the transfer of fire or smoke. This was evidenced by doors that failed to latch, which would allow the transfer of fire and or smoke resulting in potential harm to patients in the affected smoke compartments. This affected 5 of 15 smoke compartments.

Findings:

During a tour of the facility and during fire alarm testing with facility Staff on June 19, 2012 through June 20, 2012, the corridor doors were observed.

On 6/19/12:
1. At 1:00 p.m., the corridor door to the Radiology Film Storage room failed to latch upon self-closure.

2. At 1:23 p.m., the corridor door to the Respiratory Therapy room failed to fully close and latch. The door had a self-closure but failed to fully close.

3. At 1:28 p.m., the corridor door to Cardiac Rehab failed to latch upon closure.

4. At 2:18 p.m., the corridor door to the Clean Linen room located next to room 118, failed to latch upon closure.

5. At 10:40 a.m., the corridor door to X-ray room 1 failed to latch upon self-closure.

Based on observation, the facility failed to maintain the integrity of the corridor doors connected to the fire alarm system arranged to automatically close upon activation of the fire alarm system. This was evidenced by doors that failed to release from the magnetic hold-open devices and close upon the activation of the fire alarm system. This could result in the spread of smoke or fire in the event of a fire, and affected 3 of 15 smoke compartments.

Findings:

During a tour of the facility and during fire alarm testing with facility Staff on June 19, 2012 through June 20, 2012, the corridor doors arranged to automatically close upon activation of the fire alarm system were observed.


On 6/20/12:
1. At 10:10 a.m., the following doors failed to latch upon release of its magnetic device during fire alarm testing: Corridor door to patient room 108, 109, and 114. The doors are required to release from hold open device and latch upon the activation of the fire alarm system, and were located in a non-sprinklered compartment.

2. At 10:12 a.m., the following doors failed to latch upon release of its magnetic device during fire alarm testing: corridor door to patient room 119 and 121. The doors are required to release from hold open device and latch upon the activation of the fire alarm system and were located in a non-sprinklered compartment.

3. At 10:20 a.m., the corridor door to patient room 126 failed to latch upon self-closure. The door is held open by a magnetic device and is required to release and latch upon upon activation of the fire alarm system.

Based on observation, the facility failed to maintain the hazardous areas, as evidenced by a door to a hazardous area that was not equipped with a self-closing device, and by a door that failed to latch upon self-closure. This failure could result in the transfer of fire and smoke resulting in potential harm to patients, and affected 2 of 15 smoke compartments.

Findings:

During a tour of the facility with facility Staff on June 19, 2012 through June 21, 2012, the hazardous storage areas were observed.

On 6/19/12:
1. At 1:19 p.m., the Pharmacy Storage Room was filed with boxes of records and the corridor door was not equipped with a self-closing device.

2. At 1:47 p.m., the Utility Room failed to latch upon self-closure in the Women's Center.

Based on observation, the facility failed to maintain and ensure Exit and Directional signs are fully illuminated, as evidenced by an exit sign that was not fully illuminated. This failure could result in delayed evacuation in the event of a fire or other emergency, resulting in potential harm to patients in the affected smoke compartment. This affected 1 of 15 smoke compartments.

Findings:

During a tour of the facility with Staff on June 19, 2012, through June 21, 2012, the exit and directional signs were observed.

On 6/19/12:
At 3:47 p.m., one of two light bulbs in the exit sign located next to the Staffing office was not working. This was acknowledged and confirmed by Staff.

Based on observation and interview, the facility failed to ensure audible devices in the facility provide an effective warning in the event of a fire or other emergency. This was evidenced by the failure of two audible devices. This could delay staff notification in the event of a fire, and could result in potential harm to patients in 2 of 15 smoke compartments.

NFPA 101, Life Safety Code (2000 Edition)
19.3.4.3.1 Occupant Notification. Occupant notification shall be accomplished automatically in accordance with 9.6.3.

9.6.3 Occupant Notification.
9.6.3.2 Notification shall be provided by audible and visible signals in accordance with 9.6.3.3 through 9.6.3.12.

Findings:

During fire alarm testing with facility Staff on June 20, 2012, the fire alarm devices were observed.

1. At 10:02 a.m., the chime in the corridor across from the Pharmacy Department failed to activate an audible alarm during the testing of the fire alarm system.

2. At 2:50 p.m., the chime located across from Operating Room 1, in the Surgery Suite failed to activate an audible alarm during the testing of the fire alarm system.

Based on observation, document review and interview, the facility failed to maintain the integrity of two battery powered smoke detection devices as evidenced by no documentation of a battery replacement program, inspecting and testing the two smoke detectors, and by the failure of the two smoke detectors to provide an audible alarm when tested. This could could result in failure to notify staff in the event of a fire in the facility and could result in potential harm to the occupants in 1 of 1 smoke compartments.

NFPA 101, 2000, 4.6.12 Maintenances and Testing.
4.6.12.1 Whenever or wherever any device, equipment, sytem, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

Findings:

During the testing of the fire alarm system with facility Staff on June 20, 2012, the fire alarm devices were tested and observed.

At 1:30 p.m., two of two battery powered smoke detectors failed to activate an audible alarm when the test button was pushed. The two smoke detectors were located in the Out Patient Behavioral Health Building. During interview, Staff stated the two smoke detectors were not on a maintenance program and was not sure when the batteries were last replaced.

Based on observation, the facility failed to maintain the electrical equipment and wiring in accordance with NFPA 70, National Electrical Code. This was evidenced by a power strip plugged into a power strip, the use of a wall adapter with no overcurrent protection, missing electrical cover plates, and a panel that was missing a blank space cover. These failure could increase the risk of an electrical fire, causing potential harm to patients in 6 of 15 smoke compartments.

NFPA 70 (1999 Edition), article 110-12(C) Integrity of Electrical Equipment and Connections. Internal parts of electrical equipment, including busbars, wiring terminals, insulators, and other surfaces, shall not be damaged or contaminated by foreign materials such as paint, plaster, cleaners, abrasive, or corrosive residues. There shall be no damaged parts that may adversely affect safe operation or mechanical strength of the equipment such as parts that are broken; bent; cut; or deteriorated by corrosion, chemical action, or overheating.

NFPA 70 (1999 edition) 370-25 In completed installations, each box shall have a cover, faceplate, or fixture canopy.

Findings:

During a tour of the facility with facility Staff on June 19, 2012, through June 21, 2012, the electrical equipment was observed.

On 6/19/12:
1. At 1:34 p.m., in the Engineering Electrical room Panel 11-B was missing a blank space cover.

2. At 2:11 p.m., a white extension cord with no overcurrent protection was plugged in to a power strip in the Pre Admissions Office.

3. At 3:00 p.m., the electrical outlet cover plate was missing behind the television in the Transitional Care Unit Activity Lounge.

4. At 3:12 p.m., the electrical outlet cover plate was missing in the left wall of the Emergency Department Doctor's office.

5. At 3:36 p.m., there was a four outlet adapter plugged into the wall that did not have overcurrent protection in the Pharmacy front office.

6. At 4:02 p.m., in the ED Directors office there was a power strip plugged into a power strip.

Based on observation, the facility failed to maintain the integrity of the building construction, as evidenced by failing to repair and seal penetrations in the facility walls and ceilings, to prevent the spread of fire and smoke. This failure could result in the spread of smoke or fire, and affected 5 of 15 smoke compartments.

Findings:

During a tour of the facility with Staff on June 19, 2012, through June 21, 2012, the facility walls and ceilings were observed.

On 6/19/12:
1. At 1:15 p.m., there was a penetration around a pipe in the back wall of the Dialysis Storage room.

2. At 1:34 p.m., there was a conduit with wires running through and the center of the conduit was not sealed with fire stop in the Engineering Electrical room next to the Women's Center.

3. At 1.58 p.m., there was a 4 inch by 4 inch cut out in the ceiling of Labor Delivery Room LDR 1 storage room.

4. At 2:24 p.m., there was a 1 1/2 inch ceiling penetration in the storage room located next to Room 121.

5. At 3:12 p.m., there were 4 penetrations approximately 1/2 inch to 3/4 inch each in the back wall of Laboratory Room 51.

6. At 3:24 p.m., there was a 1/2 inch penetration next to the sprinkler escutcheon ring in Intensive Care Unit ICU room 65.

Based on observation, the facility failed to maintain corridor doors to prevent the transfer of fire or smoke. This was evidenced by doors that failed to latch, which would allow the transfer of fire and or smoke resulting in potential harm to patients in the affected smoke compartments. This affected 5 of 15 smoke compartments.

Findings:

During a tour of the facility and during fire alarm testing with facility Staff on June 19, 2012 through June 20, 2012, the corridor doors were observed.

On 6/19/12:
1. At 1:00 p.m., the corridor door to the Radiology Film Storage room failed to latch upon self-closure.

2. At 1:23 p.m., the corridor door to the Respiratory Therapy room failed to fully close and latch. The door had a self-closure but failed to fully close.

3. At 1:28 p.m., the corridor door to Cardiac Rehab failed to latch upon closure.

4. At 2:18 p.m., the corridor door to the Clean Linen room located next to room 118, failed to latch upon closure.

5. At 10:40 a.m., the corridor door to X-ray room 1 failed to latch upon self-closure.

Based on observation, the facility failed to maintain the integrity of the corridor doors connected to the fire alarm system arranged to automatically close upon activation of the fire alarm system. This was evidenced by doors that failed to release from the magnetic hold-open devices and close upon the activation of the fire alarm system. This could result in the spread of smoke or fire in the event of a fire, and affected 3 of 15 smoke compartments.

Findings:

During a tour of the facility and during fire alarm testing with facility Staff on June 19, 2012 through June 20, 2012, the corridor doors arranged to automatically close upon activation of the fire alarm system were observed.


On 6/20/12:
1. At 10:10 a.m., the following doors failed to latch upon release of its magnetic device during fire alarm testing: Corridor door to patient room 108, 109, and 114. The doors are required to release from hold open device and latch upon the activation of the fire alarm system, and were located in a non-sprinklered compartment.

2. At 10:12 a.m., the following doors failed to latch upon release of its magnetic device during fire alarm testing: corridor door to patient room 119 and 121. The doors are required to release from hold open device and latch upon the activation of the fire alarm system and were located in a non-sprinklered compartment.

3. At 10:20 a.m., the corridor door to patient room 126 failed to latch upon self-closure. The door is held open by a magnetic device and is required to release and latch upon upon activation of the fire alarm system.

Based on observation, the facility failed to maintain the hazardous areas, as evidenced by a door to a hazardous area that was not equipped with a self-closing device, and by a door that failed to latch upon self-closure. This failure could result in the transfer of fire and smoke resulting in potential harm to patients, and affected 2 of 15 smoke compartments.

Findings:

During a tour of the facility with facility Staff on June 19, 2012 through June 21, 2012, the hazardous storage areas were observed.

On 6/19/12:
1. At 1:19 p.m., the Pharmacy Storage Room was filed with boxes of records and the corridor door was not equipped with a self-closing device.

2. At 1:47 p.m., the Utility Room failed to latch upon self-closure in the Women's Center.

Based on observation, the facility failed to maintain and ensure Exit and Directional signs are fully illuminated, as evidenced by an exit sign that was not fully illuminated. This failure could result in delayed evacuation in the event of a fire or other emergency, resulting in potential harm to patients in the affected smoke compartment. This affected 1 of 15 smoke compartments.

Findings:

During a tour of the facility with Staff on June 19, 2012, through June 21, 2012, the exit and directional signs were observed.

On 6/19/12:
At 3:47 p.m., one of two light bulbs in the exit sign located next to the Staffing office was not working. This was acknowledged and confirmed by Staff.

Based on observation and interview, the facility failed to ensure audible devices in the facility provide an effective warning in the event of a fire or other emergency. This was evidenced by the failure of two audible devices. This could delay staff notification in the event of a fire, and could result in potential harm to patients in 2 of 15 smoke compartments.

NFPA 101, Life Safety Code (2000 Edition)
19.3.4.3.1 Occupant Notification. Occupant notification shall be accomplished automatically in accordance with 9.6.3.

9.6.3 Occupant Notification.
9.6.3.2 Notification shall be provided by audible and visible signals in accordance with 9.6.3.3 through 9.6.3.12.

Findings:

During fire alarm testing with facility Staff on June 20, 2012, the fire alarm devices were observed.

1. At 10:02 a.m., the chime in the corridor across from the Pharmacy Department failed to activate an audible alarm during the testing of the fire alarm system.

2. At 2:50 p.m., the chime located across from Operating Room 1, in the Surgery Suite failed to activate an audible alarm during the testing of the fire alarm system.

Based on observation, document review and interview, the facility failed to maintain the integrity of two battery powered smoke detection devices as evidenced by no documentation of a battery replacement program, inspecting and testing the two smoke detectors, and by the failure of the two smoke detectors to provide an audible alarm when tested. This could could result in failure to notify staff in the event of a fire in the facility and could result in potential harm to the occupants in 1 of 1 smoke compartments.

NFPA 101, 2000, 4.6.12 Maintenances and Testing.
4.6.12.1 Whenever or wherever any device, equipment, sytem, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

Findings:

During the testing of the fire alarm system with facility Staff on June 20, 2012, the fire alarm devices were tested and observed.

At 1:30 p.m., two of two battery powered smoke detectors failed to activate an audible alarm when the test button was pushed. The two smoke detectors were located in the Out Patient Behavioral Health Building. During interview, Staff stated the two smoke detectors were not on a maintenance program and was not sure when the batteries were last replaced.

Based on observation, the facility failed to maintain the electrical equipment and wiring in accordance with NFPA 70, National Electrical Code. This was evidenced by a power strip plugged into a power strip, the use of a wall adapter with no overcurrent protection, missing electrical cover plates, and a panel that was missing a blank space cover. These failure could increase the risk of an electrical fire, causing potential harm to patients in 6 of 15 smoke compartments.

NFPA 70 (1999 Edition), article 110-12(C) Integrity of Electrical Equipment and Connections. Internal parts of electrical equipment, including busbars, wiring terminals, insulators, and other surfaces, shall not be damaged or contaminated by foreign materials such as paint, plaster, cleaners, abrasive, or corrosive residues. There shall be no damaged parts that may adversely affect safe operation or mechanical strength of the equipment such as parts that are broken; bent; cut; or deteriorated by corrosion, chemical action, or overheating.

NFPA 70 (1999 edition) 370-25 In completed installations, each box shall have a cover, faceplate, or fixture canopy.

Findings:

During a tour of the facility with facility Staff on June 19, 2012, through June 21, 2012, the electrical equipment was observed.

On 6/19/12:
1. At 1:34 p.m., in the Engineering Electrical room Panel 11-B was missing a blank space cover.

2. At 2:11 p.m., a white extension cord with no overcurrent protection was plugged in to a power strip in the Pre Admissions Office.

3. At 3:00 p.m., the electrical outlet cover plate was missing behind the television in the Transitional Care Unit Activity Lounge.

4. At 3:12 p.m., the electrical outlet cover plate was missing in the left wall of the Emergency Department Doctor's office.

5. At 3:36 p.m., there was a four outlet adapter plugged into the wall that did not have overcurrent protection in the Pharmacy front office.

6. At 4:02 p.m., in the ED Directors office there was a power strip plugged into a power strip.