HospitalInspections.org

Based upon observation and staff interview, the facility fails to assure that there is no impediment to the closing of doors protecting hazardous areas. The deficient practice would not prevent the passage of fire or smoke to other areas of the building, affecting 2 of 8 smoke zones. The facility has a capacity of 26 with a census of 8 at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 06/09/2010, between 9:30 a.m. and 4:30 p.m., it is observed that wood or plastic wedges are being used to hold open doors protecting hazardous areas, in the following locations: 2 rated doors, with closers, in Blood Bank/Laboratory area and 1 rated door, with closer, protecting a storage room in the Business Office.

Staff A was present, aware of the findings, and removed each of the wedges from the doors and area.

Based upon a review of records and staff interview, the facility fails to assure that fire drills are held at unexpected times, under varying conditions and at least once per shift per quarter. This has the potential of affecting staff preparation and experience in providing for the protection of all residents, staff and visitors in the event of a fire, affecting 8 of 8 smoke zones. The facility has a capacity of 26 with a census of 8 at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 06/08/2010, between 2:00 p.m. and 4:30 p.m., a review of fire drill records for the last 4 quarters revealed the following:

-- 1. Fire drills are conducted within close proximity of each other:
A. Fire Drills for the 1st Shift are conducted consistently on the last day of each month.
1. The dates and times of drills are as follows:
a. 06/30/09 - 2:15 p.m.;
b. 08/31/09 - 6:10 p.m.;
c. 03/31/10 - 2:45 p.m.;
d. 04/30/10 - 2:21 p.m.;
e. 05/31/10 - 6:30 p.m.
2. No drill records available for 4th Qtr 2009.

B. Fire Drills for the 2nd Shift are conducted consistently on the last day of each month, with one exception.
1. The dates and times of drills are as follows:
a. 08/31/09 - 6:10 p.m.;
b. 09/28/09 - 8:46 p.m.;
c. 01/31/10 - 8:35 p.m.;
d. 03/31/10 - 8:25 p.m.;
e. 04/30/10 - 8:15 p.m.
2. No drill records available for 4th Qtr 2009.

Staff A was present and acknowledged the results of the record review.

Based upon observation and staff interview, the facility fails to assure the fire alarm system is tested and maintained in accordance with NFPA 70 and NFPA 72. The deficient practice reduces the reliability of the fire alarm system, affecting 8 of 8 smoke zones. The facility has a capacity of 26 with a census of 8 at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 06/08/10, between 2:00 p.m. and 4:30 p.m., a review of records revealed the following:

-- 1. Last documented annual testing and maintenance of the fire alarm system was 08/19/2008;

Staff A acknowledged the results of the records review and stated that due to ongoing construction, annual maintenance and testing has not been completed. Fire Watch implemented.

Based upon observation and staff interview, the facility fails to assure the automatic sprinkler system is tested and maintained in accordance with NFPA 13 and NFPA 25. The deficient practice reduces the reliability of the sprinkler system, affecting 8 of 8 smoke zones. The facility has a capacity of 26 with a census of 8 at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 06/08/10, between 2:00 p.m. and 4:30 p.m., a review of records revealed the following:

-- 1. Last documented annual testing and maintenance of the wet pipe automatic sprinkler systems was 12/31/2008;
-- 2. No quarterly inspection and testing has been documented as completed since the annual testing completed on 12/31/2008.

Staff A acknowledged the results of the records review and stated that due to ongoing construction, annual and quarterly testing has not been completed. Fire Watch implemented.

During the tour conducted on 06/09/10, between 9:30 a.m. and 4:30 p.m., it is observed that no spare side-mount sprinkler head is provided to replace heads located in the facility's ambulance bay.

Staff A was present and acknowledged that no spare side-mount sprinkler heads are available. Staff A stated that he would contact the sprinkler company and obtain additional heads.

Based upon observation and staff interview, the facility fails to provide a remote annunciator at a continuously monitored location. The deficient practice reduces the reliability of the generator due to lack of early warning of a potential failure of the system, affecting 8 of 8 smoke zones. The facility has a capacity of 26 with a census of 8 at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 06/09/10, between 9:30 a.m. and 4:30 p.m., it is observed that the facility does not provide a remote annunciator or an audible and visible derangement signal device at a continuously monitored location.

Staff A was present and aware of the findings. Staff A contacted an outside vendor for arrangements to install a remote annunciator at the facility.

Based upon observation and staff interview, the facility fails to assure that there is no impediment to the closing of doors protecting hazardous areas. The deficient practice would not prevent the passage of fire or smoke to other areas of the building, affecting 2 of 8 smoke zones. The facility has a capacity of 26 with a census of 8 at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 06/09/2010, between 9:30 a.m. and 4:30 p.m., it is observed that wood or plastic wedges are being used to hold open doors protecting hazardous areas, in the following locations: 2 rated doors, with closers, in Blood Bank/Laboratory area and 1 rated door, with closer, protecting a storage room in the Business Office.

Staff A was present, aware of the findings, and removed each of the wedges from the doors and area.

Based upon a review of records and staff interview, the facility fails to assure that fire drills are held at unexpected times, under varying conditions and at least once per shift per quarter. This has the potential of affecting staff preparation and experience in providing for the protection of all residents, staff and visitors in the event of a fire, affecting 8 of 8 smoke zones. The facility has a capacity of 26 with a census of 8 at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 06/08/2010, between 2:00 p.m. and 4:30 p.m., a review of fire drill records for the last 4 quarters revealed the following:

-- 1. Fire drills are conducted within close proximity of each other:
A. Fire Drills for the 1st Shift are conducted consistently on the last day of each month.
1. The dates and times of drills are as follows:
a. 06/30/09 - 2:15 p.m.;
b. 08/31/09 - 6:10 p.m.;
c. 03/31/10 - 2:45 p.m.;
d. 04/30/10 - 2:21 p.m.;
e. 05/31/10 - 6:30 p.m.
2. No drill records available for 4th Qtr 2009.

B. Fire Drills for the 2nd Shift are conducted consistently on the last day of each month, with one exception.
1. The dates and times of drills are as follows:
a. 08/31/09 - 6:10 p.m.;
b. 09/28/09 - 8:46 p.m.;
c. 01/31/10 - 8:35 p.m.;
d. 03/31/10 - 8:25 p.m.;
e. 04/30/10 - 8:15 p.m.
2. No drill records available for 4th Qtr 2009.

Staff A was present and acknowledged the results of the record review.

Based upon observation and staff interview, the facility fails to assure the fire alarm system is tested and maintained in accordance with NFPA 70 and NFPA 72. The deficient practice reduces the reliability of the fire alarm system, affecting 8 of 8 smoke zones. The facility has a capacity of 26 with a census of 8 at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 06/08/10, between 2:00 p.m. and 4:30 p.m., a review of records revealed the following:

-- 1. Last documented annual testing and maintenance of the fire alarm system was 08/19/2008;

Staff A acknowledged the results of the records review and stated that due to ongoing construction, annual maintenance and testing has not been completed. Fire Watch implemented.

Based upon observation and staff interview, the facility fails to assure the automatic sprinkler system is tested and maintained in accordance with NFPA 13 and NFPA 25. The deficient practice reduces the reliability of the sprinkler system, affecting 8 of 8 smoke zones. The facility has a capacity of 26 with a census of 8 at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 06/08/10, between 2:00 p.m. and 4:30 p.m., a review of records revealed the following:

-- 1. Last documented annual testing and maintenance of the wet pipe automatic sprinkler systems was 12/31/2008;
-- 2. No quarterly inspection and testing has been documented as completed since the annual testing completed on 12/31/2008.

Staff A acknowledged the results of the records review and stated that due to ongoing construction, annual and quarterly testing has not been completed. Fire Watch implemented.

During the tour conducted on 06/09/10, between 9:30 a.m. and 4:30 p.m., it is observed that no spare side-mount sprinkler head is provided to replace heads located in the facility's ambulance bay.

Staff A was present and acknowledged that no spare side-mount sprinkler heads are available. Staff A stated that he would contact the sprinkler company and obtain additional heads.

Based upon observation and staff interview, the facility fails to provide a remote annunciator at a continuously monitored location. The deficient practice reduces the reliability of the generator due to lack of early warning of a potential failure of the system, affecting 8 of 8 smoke zones. The facility has a capacity of 26 with a census of 8 at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 06/09/10, between 9:30 a.m. and 4:30 p.m., it is observed that the facility does not provide a remote annunciator or an audible and visible derangement signal device at a continuously monitored location.

Staff A was present and aware of the findings. Staff A contacted an outside vendor for arrangements to install a remote annunciator at the facility.