HospitalInspections.org

Based on observation and interview the facility failed to provide a self-closing device on all doors to hazardous areas and failed to provide a sprinkler system in a detached building on campus housing medical records. This deficient practice affects all current and former patients. The facility census was 11.

Findings included:

1. During a tour of the facility, conducted on the morning of 03/07/17, at 10:20 AM, a door, which opens into the patient corridor, to the soiled utility room was observed to be lacking a self-closing device to assure the door would remain closed at all times.

2. Staff CC, Facilities, confirmed at that time a self-closing device had not been provided for the door to the soiled utility room.

3. A tour of the free standing storage building on campus at 10:55 AM, showed shelves of medical records stored in a room approximately 16 feet by 24 feet in the wood frame constructed storage building. This is a non-sprinklered building.

4. Staff CC, Facilities, confirmed the storage building housing the medical records is not sprinklered.

Section 19.3.2.1.3 of the National Fire Protection Association (NFPA 101) states: The doors shall be self-closing or automatic closing.

Section 8.15.9 of the National Fire Protection Association (NFPA 13) states: Where books or medical records are stored in fixed open book shelves, sprinklers shall be installed in accordance with one of the following.

Based on observation and interview the facility failed to install a sprinkler system in accordance with the National Fire Protection Association 13, Standards for the Installation of Sprinkler Systems in all areas of the facility. This deficient practice affects all patients in the facility. The facility census was 11.

Findings included:

1. During a tour of the facility, conducted on the morning of 03/07/17 at 10:10 AM, standard sprinkler heads were observed mounted on the ceiling or walls in the patient room corridor while quick-response sprinkler heads were observed to have been mounted in the ceiling of the patient rooms.

2. Staff CC, Facilities, confirmed at that time two different types of sprinkler heads had been installed within the same compartment.

Section 8.3.3.2 of the National Fire Protection Association (NFPA 13) states: Where quick-response sprinklers are installed, all sprinklers within a compartment shall be quick-response unless otherwise permitted in 8.3.3.3.

Based on policy review the facility failed to develop a policy regarding the use of portable space-heating devices which contains all of the required elements. This deficient practice affects all occupants of the facility. The facility census was 11.

Findings included:

1. Review of the facility policy titled Fire Safety Plan dated 10/27/16 showed the following:

a. Electric Heaters-Hospital owned units are only used in special circumstances and when in use should be checked frequently by staff.

Section 19.7.8 of the National Fire Protection Association (NFPA 101) states: Portable space-heating devices shall be prohibited in all health care occupancies, unless both of the following criteria are met:
(1) Such devices are used only in nonsleeping staff and employee areas.
(2) The heating elements of such devices do not exceed 212 degrees Fahrenheit.

Based on record review and interview the facility failed to operate the emergency generators for a minimum of 30 minutes under load at least 12 times a year. This deficient practice affects all occupants of the facility. The facility census was 11.

Findings included:

1. Review of the generator operating record, conducted on the afternoon of 03/06/17, showed the 2 generators run automatically once a week but did not show when the generators operated under load nor for how long the generators operated under load.

2. During an interview on 03/07/17 at 9:15 AM, Staff CC, Facilities, stated the generators run under load every Tuesday for 5 to 10 minutes.

Section 6.4.4.1.1.4 (A) of the National Fire Protection Association (NFPA 99) states: Generator sets shall be tested 12 times a year, with testing intervals of not less than 20 days nor more than 40 days. Generator sets serving essential electrical systems shall be tested in accordance with NFPA 110, Standards for Emergency and Standby Power Systems, Chapter 8.