HospitalInspections.org

While surveying the facility the inspector observed structural steel components that were missing required fire proofing material in the following areas:
1. Beams in the boiler room at the ceiling level.
2. Beams in the electrical room at the ceiling level.
The facility must maintain a construction classification of at least Type II(111) construction in accordance with NFPA 101 Life Safety Code, section 19.1.6.2 and NFPA 220 Standard on Types of Building Construction.

While surveying the facility the inspector observed through functional examination that the following doors serving as opening protectives in egress stairwell enclosures failed to latch mechanically as required by the standard:
1. The stairwell door located adjacent to room # 216 at the second floor level failed to latch mechanically with the force applied by the self-closing device on the door.
2. The stairwell door in the ICU unit failed to latch mechanically with the force applied by the self-closing device on the door.

While surveying the facility the inspector observed a gap of approximately one inch between the drywall panels serving as the smoke compartment separation above the suspended ceiling level at the Secret Gardens entrance to the OB unit. Expanding foam insulation was also observed sealing penetrations through the smoke barrier wall assembly above the suspended ceiling grid in violation of the standard.

While surveying the facility the inspector observed the following deficiencies relating to hazardous areas within the facility:
1. The lab draw area door opening into the corridor must be provided with a self closing device in accordance with NFPA 101 Life Safety Code, section 19.3.2.1(8). The door must positively latch in the closed position with the force applied by the self-closing device to be installed on the door. The lab employs a quantity of flammable/combustible liquids not exceeding 5 liters at any time.
2. The soiled utility closet door in the rehab area must self-close and positively latch in the closed position accordance with NFPA 101 Life Safety Code, section 19.3.2.1(5)(6). The closet was recently converted for use as a soiled utility area.

While surveying the facility the inspector observed the following deficiencies relating to exiting from the facility:
1. The boiler room exit door (discharging directly outside) opens with excessive force. The screen insert placed across the door opening at the time of inspection also serves to obstruct egress from the door. The door is a marked exit that serves the boiler room only.
2. The second floor corridor (adjacent to elevator "B") was found to be partially obstructed by the placement of chairs and plastic totes within the corridor space. At least eight feet of clear unobstructed width must be provided in the egress corridor at all times in accordance with the originally prescribed clear width of the corridor space.
3. The exit discharge from the medical records exit was not provided with ordinary illumination due to the non-functional status of the lighting fixture adjacent to exit. The lighting fixture was missing both bulbs at the time of inspection.

While reviewing facility records pertaining to facility fire drills the inspector observed the following deficiencies:
1. The facility failed to conduct second shift (1500 to 2300 hrs) drills at least once quarterly as evidenced by a gap of approximately four months between second shift drills. Between November 30, 2012 and March 26, 2013 no second shift drills were conducted according to facility fire drill records.
2. The facility failed to conduct third shift (2300 to 0700 hrs) drills at least once quarterly as evidenced by a gap of approximately four months between third shift drills. Between February 11, 2013 and June 22, 2013 no third shift drills were conducted according to facility fire drill records.

While reviewing facility records pertaining to required fire alarm system inspection and testing the inspector observed the following deficiencies noted on inspection reports with no documentation of corrective action retained by the facility available at the time of inspection:
1. In July of 2013 the control panel multiplex was identified as "failed" on the fire alarm system inspection report.
2. In July of 2013 the FACP batteries failed load testing as indicated on the fire alarm system inspection report.

While surveying the facility the inspector observed the following deficiencies relating to the building fire sprinkler system(s):
1. Thermostat lines in the compressor room were observed to be partially supported by fire sprinkler piping.
2. Thermostat wire was observed attached to fire sprinkler piping in the medical records storage room at the third floor level of the building.

While surveying the facility the inspector observed that portable fire extinguishers in the operating room suite had last been provided with required annual servicing in July of 2012. A period of approximately sixteen months had elapsed since the last annual servicing of the extinguishers had been conducted.

K-130 Not Met. Hospital auxiliary buildings surveyed utilizing NFPA Life safety Code 101 2009 Edition as adopted by MSRA Title 25 Section 2452.
1. Location Women's Center 24 Miles Way.
NFPA LSC Section 39.3.1.1 Protection of vertical openings.
Findings. Inspector observed and noted 2 fire doors in the vertical opening from lowere to upper level
were wedged open and one door was equipped with a hold open peg.
2. Location: Women's Center 24 Miles Way.
NFPA LSC Section 39.3.2 Protection from hazards.
Findings: Door to boiler room has louvers in it and is not 1 hr fire rated as required.
Outside air for combustion for boiler not provided as required.
Penetrations in boiler room wall not sealed as required.
3. Location: Professional Building 5 Miles Way.
Findings: LSC Section 39.3.1.1 Mechanical Room/ Storage Room.
Cleaning cart improperly stored in front of electrical distribution panel.
Improper electrical connection for transformer for security panel.
Fire door self closing device found disconnected.
4. Location : Family Care Center 19 St Andrews Lane.
NFPA 25 Sprinkler Maintenance.
Findings: Documentation not available for the required 5 year sprinkler obstruction/examination
Testing. System Installed December 2007.


25654

Miles Memorial Hospital: Fire sprinklers served by the building dry pipe fire sprinkler system that have been in service for 20 years must be replaced or representative samples must be tested by a certified testing laboratory in accordance with NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, section 5.3.1.1.1.5 (2008 edition). At the time of inspection the stock of spare fire sprinklers was dated circa 1980's indicating that fire sprinklers served by the dry pipe fire sprinkler system had been in service more than 20 years.
NOTE: The 2008 edition of NFPA 25 has been adopted by the State of Maine pursuant to Title 25 MRSA, section 2452. Federal regulations reference the 1998 edition of the standard.

While reviewing facility records pertaining to the inspection, testing, and maintenance of the facility EPSS generator the inspector observed that documentation of weekly inspections required by NFPA 110 Emergency and Standby Power Systems, section 6-4.1 was incomplete. No weekly inspections for August of 2013 had been documented and only two weekly inspections were recorded for July and October of 2013.

While surveying the facility the inspector observed a relocatable power tap used in lieu of permanent wiring located in the waiting area of patient registration. The relocatable power tap was found to be powering devices that are subject to regular use in a fixed location. The power cord for the relocatable power tap observed was also attached to the wall surface using wire staples.

While surveying the facility the inspector observed structural steel components that were missing required fire proofing material in the following areas:
1. Beams in the boiler room at the ceiling level.
2. Beams in the electrical room at the ceiling level.
The facility must maintain a construction classification of at least Type II(111) construction in accordance with NFPA 101 Life Safety Code, section 19.1.6.2 and NFPA 220 Standard on Types of Building Construction.

While surveying the facility the inspector observed through functional examination that the following doors serving as opening protectives in egress stairwell enclosures failed to latch mechanically as required by the standard:
1. The stairwell door located adjacent to room # 216 at the second floor level failed to latch mechanically with the force applied by the self-closing device on the door.
2. The stairwell door in the ICU unit failed to latch mechanically with the force applied by the self-closing device on the door.

While surveying the facility the inspector observed a gap of approximately one inch between the drywall panels serving as the smoke compartment separation above the suspended ceiling level at the Secret Gardens entrance to the OB unit. Expanding foam insulation was also observed sealing penetrations through the smoke barrier wall assembly above the suspended ceiling grid in violation of the standard.

While surveying the facility the inspector observed the following deficiencies relating to hazardous areas within the facility:
1. The lab draw area door opening into the corridor must be provided with a self closing device in accordance with NFPA 101 Life Safety Code, section 19.3.2.1(8). The door must positively latch in the closed position with the force applied by the self-closing device to be installed on the door. The lab employs a quantity of flammable/combustible liquids not exceeding 5 liters at any time.
2. The soiled utility closet door in the rehab area must self-close and positively latch in the closed position accordance with NFPA 101 Life Safety Code, section 19.3.2.1(5)(6). The closet was recently converted for use as a soiled utility area.

While surveying the facility the inspector observed the following deficiencies relating to exiting from the facility:
1. The boiler room exit door (discharging directly outside) opens with excessive force. The screen insert placed across the door opening at the time of inspection also serves to obstruct egress from the door. The door is a marked exit that serves the boiler room only.
2. The second floor corridor (adjacent to elevator "B") was found to be partially obstructed by the placement of chairs and plastic totes within the corridor space. At least eight feet of clear unobstructed width must be provided in the egress corridor at all times in accordance with the originally prescribed clear width of the corridor space.
3. The exit discharge from the medical records exit was not provided with ordinary illumination due to the non-functional status of the lighting fixture adjacent to exit. The lighting fixture was missing both bulbs at the time of inspection.

While reviewing facility records pertaining to facility fire drills the inspector observed the following deficiencies:
1. The facility failed to conduct second shift (1500 to 2300 hrs) drills at least once quarterly as evidenced by a gap of approximately four months between second shift drills. Between November 30, 2012 and March 26, 2013 no second shift drills were conducted according to facility fire drill records.
2. The facility failed to conduct third shift (2300 to 0700 hrs) drills at least once quarterly as evidenced by a gap of approximately four months between third shift drills. Between February 11, 2013 and June 22, 2013 no third shift drills were conducted according to facility fire drill records.

While reviewing facility records pertaining to required fire alarm system inspection and testing the inspector observed the following deficiencies noted on inspection reports with no documentation of corrective action retained by the facility available at the time of inspection:
1. In July of 2013 the control panel multiplex was identified as "failed" on the fire alarm system inspection report.
2. In July of 2013 the FACP batteries failed load testing as indicated on the fire alarm system inspection report.

While surveying the facility the inspector observed the following deficiencies relating to the building fire sprinkler system(s):
1. Thermostat lines in the compressor room were observed to be partially supported by fire sprinkler piping.
2. Thermostat wire was observed attached to fire sprinkler piping in the medical records storage room at the third floor level of the building.

While surveying the facility the inspector observed that portable fire extinguishers in the operating room suite had last been provided with required annual servicing in July of 2012. A period of approximately sixteen months had elapsed since the last annual servicing of the extinguishers had been conducted.

K-130 Not Met. Hospital auxiliary buildings surveyed utilizing NFPA Life safety Code 101 2009 Edition as adopted by MSRA Title 25 Section 2452.
1. Location Women's Center 24 Miles Way.
NFPA LSC Section 39.3.1.1 Protection of vertical openings.
Findings. Inspector observed and noted 2 fire doors in the vertical opening from lowere to upper level
were wedged open and one door was equipped with a hold open peg.
2. Location: Women's Center 24 Miles Way.
NFPA LSC Section 39.3.2 Protection from hazards.
Findings: Door to boiler room has louvers in it and is not 1 hr fire rated as required.
Outside air for combustion for boiler not provided as required.
Penetrations in boiler room wall not sealed as required.
3. Location: Professional Building 5 Miles Way.
Findings: LSC Section 39.3.1.1 Mechanical Room/ Storage Room.
Cleaning cart improperly stored in front of electrical distribution panel.
Improper electrical connection for transformer for security panel.
Fire door self closing device found disconnected.
4. Location : Family Care Center 19 St Andrews Lane.
NFPA 25 Sprinkler Maintenance.
Findings: Documentation not available for the required 5 year sprinkler obstruction/examination
Testing. System Installed December 2007.


25654

Miles Memorial Hospital: Fire sprinklers served by the building dry pipe fire sprinkler system that have been in service for 20 years must be replaced or representative samples must be tested by a certified testing laboratory in accordance with NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, section 5.3.1.1.1.5 (2008 edition). At the time of inspection the stock of spare fire sprinklers was dated circa 1980's indicating that fire sprinklers served by the dry pipe fire sprinkler system had been in service more than 20 years.
NOTE: The 2008 edition of NFPA 25 has been adopted by the State of Maine pursuant to Title 25 MRSA, section 2452. Federal regulations reference the 1998 edition of the standard.

While reviewing facility records pertaining to the inspection, testing, and maintenance of the facility EPSS generator the inspector observed that documentation of weekly inspections required by NFPA 110 Emergency and Standby Power Systems, section 6-4.1 was incomplete. No weekly inspections for August of 2013 had been documented and only two weekly inspections were recorded for July and October of 2013.

While surveying the facility the inspector observed a relocatable power tap used in lieu of permanent wiring located in the waiting area of patient registration. The relocatable power tap was found to be powering devices that are subject to regular use in a fixed location. The power cord for the relocatable power tap observed was also attached to the wall surface using wire staples.