HospitalInspections.org

The facility failed to ensure the construction type of the Wishek Hospital meets the required building construction in Chapter 19.

Observation determined the one-hour fire rated ceilings had multiple unsealed spaces.

The facility failed to provide corridors that were separated from use areas by walls with at least ? hour fire resistance rating.

Observation determined the basement and first floor corridor walls had multiple through-wall pipe, data cable, conduit, and duct penetrations that were not sealed with fire rated material installed according to the manufacturer's instructions.

The facility failed to ensure one (1) of one (1) smoke barrier was at least one-half hour fire resistant and smoke resistant.

Observation determined unsealed spaces around a through-wall conduit penetration in the first floor smoke barrier above the smoke doors.

The facility failed to ensure one (1) of eight (8) hazardous areas was enclosed with walls having one-hour fire rated construction.

Observation determined the corridor walls of the basement Boiler Room had spaces around multiple pipe penetrations lacking fire caulking installed in accordance with the manufacturer's UL listing. The spaces were filled with expanding foam sealant.

The facility failed to ensure illumination of means of egress.

Observation determined the light bulbs located in the light fixture at the top of the exit stair enclosure from the Operating Room were not illuminated.

The facility failed to ensure the illumination of means of egress, including exit discharge, is arranged so that a failure of a single lighting fixture (bulb) will not leave the area in darkness.

CMS allows a light fixture equipped with a single long life bulb with a quick strike feature to illuminate exit discharge.

Observation determined that the northeast exterior exit light fixture had a single high pressure sodium bulb fixture without quick strike capabilities.

The facility failed to ensure the fire alarm system was maintained, inspected and tested with approved components, devices or equipment installed according to NFPA 72 to provide effective warning of fire in any part of the building.
1) Review of the fire drill/fire alarm test records indicated the facility failed to document the monthly testing of fire alarm system during January, March, April, June, July, September and November 2010.
2) Observation determined an annunciator panel was not provided at a constantly occupied area (Nurses Station). The fire alarm annunciator panel was located in the Boiler Room. The annunciation panel must monitor the primary functions of fire alarm panel:
a) Audible and visible signals that indicate system trouble.
b) Visible signals that indicate which fire alarm zone is in alarm.
c) Audible and visible monitor of fire alarm system supervisory signal.

1) Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.Observation determined the east exit door had no exit sign.2) A sign with a directional indicator showing the direction of travel must be placed in every location where the direction of travel to reach the nearest exit is not apparent.Observation determined no directional exit signs were installed at locations in the corridor to indicate the direction of travel to reach the nearest exit.
3) Portable fire extinguishers must be installed to ensure they are not be obstructed or obscured from view. NFPA 10, Standard for Portable Fire Extinguishers. Observation determined the portable fire extinguisher for the lobby area was located on the counter by the sink in the Reception Room.4) When electrical hazards are identified, measures to abate such conditions shall be taken. NFPA 70, National Electrical Code.

Observation determined:

a) An adapter was in use in the Staff Kitchen to connect the refrigerator cord to the receptacle.
b) The electrical receptacle adjacent to the sink in the Staff Kitchen did not have ground fault circuit interrupter protection.

The facility failed to ensure electrical wiring installation met the requirements of the National Electrical Code.

Observation determined electrical wiring was not installed in conduit above the corridor suspended ceiling in the basement adjacent to the door to the Operating Room.

The facility failed to ensure the construction type of the Wishek Hospital meets the required building construction in Chapter 19.

Observation determined the one-hour fire rated ceilings had multiple unsealed spaces.

The facility failed to provide corridors that were separated from use areas by walls with at least ? hour fire resistance rating.

Observation determined the basement and first floor corridor walls had multiple through-wall pipe, data cable, conduit, and duct penetrations that were not sealed with fire rated material installed according to the manufacturer's instructions.

The facility failed to ensure one (1) of one (1) smoke barrier was at least one-half hour fire resistant and smoke resistant.

Observation determined unsealed spaces around a through-wall conduit penetration in the first floor smoke barrier above the smoke doors.

The facility failed to ensure one (1) of eight (8) hazardous areas was enclosed with walls having one-hour fire rated construction.

Observation determined the corridor walls of the basement Boiler Room had spaces around multiple pipe penetrations lacking fire caulking installed in accordance with the manufacturer's UL listing. The spaces were filled with expanding foam sealant.

The facility failed to ensure illumination of means of egress.

Observation determined the light bulbs located in the light fixture at the top of the exit stair enclosure from the Operating Room were not illuminated.

The facility failed to ensure the illumination of means of egress, including exit discharge, is arranged so that a failure of a single lighting fixture (bulb) will not leave the area in darkness.

CMS allows a light fixture equipped with a single long life bulb with a quick strike feature to illuminate exit discharge.

Observation determined that the northeast exterior exit light fixture had a single high pressure sodium bulb fixture without quick strike capabilities.

The facility failed to ensure the fire alarm system was maintained, inspected and tested with approved components, devices or equipment installed according to NFPA 72 to provide effective warning of fire in any part of the building.
1) Review of the fire drill/fire alarm test records indicated the facility failed to document the monthly testing of fire alarm system during January, March, April, June, July, September and November 2010.
2) Observation determined an annunciator panel was not provided at a constantly occupied area (Nurses Station). The fire alarm annunciator panel was located in the Boiler Room. The annunciation panel must monitor the primary functions of fire alarm panel:
a) Audible and visible signals that indicate system trouble.
b) Visible signals that indicate which fire alarm zone is in alarm.
c) Audible and visible monitor of fire alarm system supervisory signal.

1) Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.Observation determined the east exit door had no exit sign.2) A sign with a directional indicator showing the direction of travel must be placed in every location where the direction of travel to reach the nearest exit is not apparent.Observation determined no directional exit signs were installed at locations in the corridor to indicate the direction of travel to reach the nearest exit.
3) Portable fire extinguishers must be installed to ensure they are not be obstructed or obscured from view. NFPA 10, Standard for Portable Fire Extinguishers. Observation determined the portable fire extinguisher for the lobby area was located on the counter by the sink in the Reception Room.4) When electrical hazards are identified, measures to abate such conditions shall be taken. NFPA 70, National Electrical Code.

Observation determined:

a) An adapter was in use in the Staff Kitchen to connect the refrigerator cord to the receptacle.
b) The electrical receptacle adjacent to the sink in the Staff Kitchen did not have ground fault circuit interrupter protection.

The facility failed to ensure electrical wiring installation met the requirements of the National Electrical Code.

Observation determined electrical wiring was not installed in conduit above the corridor suspended ceiling in the basement adjacent to the door to the Operating Room.