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MERCY HEALTH - URBANA HOSPITAL
No Description Available
Tag No.: K0052
Based on observations, staff interviews, and manufacturer's specifications for smoke detectors, the facility failed to ensure smoke detectors were located greater than 36 inches from air supply diffusers in accordance with the code at 9.6.1.3 and NFPA 72, A-2.3.5.1. This affected 13 smoke detectors on three floors of the facility. The facility had a census of 10 patients at the time of this survey.
Findings include:
A tour of the facility was conducted with Staff B on 07/26/11, between 9:10 AM and 2:15 PM, and on 07/27/11 between 4:00 PM and 4:30 PM. During this tour, smoke detectors were observed less than 36 inches from air supply diffusers and air returns. Staff B verified these smoke detectors were inner connnected into the fire alarm system, and verified the location of the detectors, as well as whether they were located close to an air supply diffuser or an air return grill. On 07/28/11, at 9:45 AM, Staff B stated the outside service company, used for inspecting and installing smoke detectors in this facility, verified per manufacturer's specifications and recommendations, these smoke detectors cannot be located within 36 inches of air supply diffusers or air returns. This was verified per review of the manufacturer's written specifications and installation of these smoke detectors.
Observations of the smoke detectors revealed the following locations:
On the first floor within 36 inches of air supply diffuser:
-Patient room 005 was observed approximately 1 foot away,
-Patient room 003 was observed approximately 2 and 1/2 feet away,
-Patient room 001 was observed approximately 1 and 1/2 feet away,
In the Operating Room Addition (OR) in the Back Hall
-By pathology room 1215, within 1 foot,
-By room 1220, within 1 foot,
-In Pack room 1233, within 2 feet,
-In staff lounge open use area (by the nursing station), within 2 feet.
On the ground floor within 36 inches of air supply diffuser:
- In the emergency department squad entrance, approximately 2 feet away
On the second floor within 36 inches of air supply diffuser:
-In the open use area by the elevator, within 1 foot
Within 36 inches of air return/exhaust on the first floor:
-In the ICU nurses station copy room approximately 2 and 1/2 feet away,
-Patient room 008 and Room 009 approximately 2 feet away,
-Patient room 016 approximately 1 foot away.
In the Operating Room Addition (OR),
-In utility room 1211, within 1 foot of an exhaust fan.
LIFE SAFETY CODE STANDARD
Tag No.: K0052
Based on observations, staff interviews, and manufacturer's specifications for smoke detectors, the facility failed to ensure smoke detectors were located greater than 36 inches from air supply diffusers in accordance with the code at 9.6.1.3 and NFPA 72, A-2.3.5.1. This affected 13 smoke detectors on three floors of the facility. The facility had a census of 10 patients at the time of this survey.
Findings include:
A tour of the facility was conducted with Staff B on 07/26/11, between 9:10 AM and 2:15 PM, and on 07/27/11 between 4:00 PM and 4:30 PM. During this tour, smoke detectors were observed less than 36 inches from air supply diffusers and air returns. Staff B verified these smoke detectors were inner connnected into the fire alarm system, and verified the location of the detectors, as well as whether they were located close to an air supply diffuser or an air return grill. On 07/28/11, at 9:45 AM, Staff B stated the outside service company, used for inspecting and installing smoke detectors in this facility, verified per manufacturer's specifications and recommendations, these smoke detectors cannot be located within 36 inches of air supply diffusers or air returns. This was verified per review of the manufacturer's written specifications and installation of these smoke detectors.
Observations of the smoke detectors revealed the following locations:
On the first floor within 36 inches of air supply diffuser:
-Patient room 005 was observed approximately 1 foot away,
-Patient room 003 was observed approximately 2 and 1/2 feet away,
-Patient room 001 was observed approximately 1 and 1/2 feet away,
In the Operating Room Addition (OR) in the Back Hall
-By pathology room 1215, within 1 foot,
-By room 1220, within 1 foot,
-In Pack room 1233, within 2 feet,
-In staff lounge open use area (by the nursing station), within 2 feet.
On the ground floor within 36 inches of air supply diffuser:
- In the emergency department squad entrance, approximately 2 feet away
On the second floor within 36 inches of air supply diffuser:
-In the open use area by the elevator, within 1 foot
Within 36 inches of air return/exhaust on the first floor:
-In the ICU nurses station copy room approximately 2 and 1/2 feet away,
-Patient room 008 and Room 009 approximately 2 feet away,
-Patient room 016 approximately 1 foot away.
In the Operating Room Addition (OR),
-In utility room 1211, within 1 foot of an exhaust fan.