HospitalInspections.org

Based on observation and interview the facility failed to ensure one of three stairwells are enclosed with at least one hour fire resistive construction. This deficit practice affects all patients and staff in that patient occupied compartment.

Findings include:

Observation at 10:00 A.M. on 06/09/10 during a tour of the south campus building revealed the self-closing mechanism attached to the door to the south stairway on the 5th floor did not close and latch the door securely in the door frame when manually tested.

Staff BB Emergency Management Officer confirmed at that time the door was not closing and latching in the door frame when tested.

The National Fire Protection Association 101 Life Safety Code, 2000 edition, section 19.3.1.1 states: "Any vertical opening shall be enclosed or protected in accordance with 8.2.5. Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating."

Based on observation and interview, the facility failed to store flammable products in the Cox North kitchen in accordance with 8.4.1.1 to prevent the spread of smoke or flame in the kitchen area, potentially endangering staff and visitors in the adjacent dining room. The facility census was 55 patients.

Findings included:

Observation on 6/8/10 at 11:00 A.M. showed a large box two thirds full of eight ounce cans of Sterno brand gelled fuel on a storage shelf near the back of the kitchen. The kitchen was not sprinkled and the facility is only partially sprinkled. The only available fire suppression equipment in the kitchen was the chemical system protecting the main cook line, stovetop, fryer and fire extinguishers near each door.

Review of the label on the Sterno showed each can contained eight ounces (total product of approximately 54 eight ounce containers is 27 pounds) of flammable liquid gel, with the warning printed on the label: " FLAMMABLE-Eye Irritant. "

During an interview on 6/8/10 at 11:15 A.M., the Director of Dietary Services said he would remove the cans and would look for an alternative place to store them. He expressed concern regarding lack of easy access for dietary staff. The hospital Safety Officer said they would look into acquiring an intermediate-sized fire resistant container for holding the limited number of flammables.

Based on observation and interview the facility failed to ensure one of three stairwells are enclosed with at least one hour fire resistive construction. This deficit practice affects all patients and staff in that patient occupied compartment.

Findings include:

Observation at 10:00 A.M. on 06/09/10 during a tour of the south campus building revealed the self-closing mechanism attached to the door to the south stairway on the 5th floor did not close and latch the door securely in the door frame when manually tested.

Staff BB Emergency Management Officer confirmed at that time the door was not closing and latching in the door frame when tested.

The National Fire Protection Association 101 Life Safety Code, 2000 edition, section 19.3.1.1 states: "Any vertical opening shall be enclosed or protected in accordance with 8.2.5. Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating."

Based on observation and interview, the facility failed to store flammable products in the Cox North kitchen in accordance with 8.4.1.1 to prevent the spread of smoke or flame in the kitchen area, potentially endangering staff and visitors in the adjacent dining room. The facility census was 55 patients.

Findings included:

Observation on 6/8/10 at 11:00 A.M. showed a large box two thirds full of eight ounce cans of Sterno brand gelled fuel on a storage shelf near the back of the kitchen. The kitchen was not sprinkled and the facility is only partially sprinkled. The only available fire suppression equipment in the kitchen was the chemical system protecting the main cook line, stovetop, fryer and fire extinguishers near each door.

Review of the label on the Sterno showed each can contained eight ounces (total product of approximately 54 eight ounce containers is 27 pounds) of flammable liquid gel, with the warning printed on the label: " FLAMMABLE-Eye Irritant. "

During an interview on 6/8/10 at 11:15 A.M., the Director of Dietary Services said he would remove the cans and would look for an alternative place to store them. He expressed concern regarding lack of easy access for dietary staff. The hospital Safety Officer said they would look into acquiring an intermediate-sized fire resistant container for holding the limited number of flammables.