HospitalInspections.org

Based on observation , the facility failed to maintain fire doors within the corridors so they would properly close and latch upon the activation of the fire alarm. Fire doors are to protect from the passage of smoke or heat in an emergency situation.

The findings include:
During the facility tour with the Director of Maintenance at 12:00 pm on 3/6/2013, it was found that 5 of the 8 fire doors in the corridor would not close and latch properly as per NFPA 101 chapter 19.

Based on record review and interview of the Director of Maintenance, the facility failed to maintain the Fire/Smoke dampers within the HVAC system and the supporting documentation. Fire dampers help to prevent the spread of fire and smoke from room to room by sealing the HVAC ducts in emergency situations. The dampers must be serviced to maintain proper operation

The Findings:
During document review with maintenance staff at 10:50am on 3/6/2013, it was found that documentation of maintenance and testing of the fire/smoke dampers were not present. It was confirmed by maintenance staff at that time that damper inspection and maintenance had not been done in accordance with NFPA 101, 8.3.6

Based on document review and interview with the Director of Maintenance, it was noted that the facility failed to maintain documentation on the exercising of the main and feeder breakers. Not exercising as required by the manufacturer can lead to corrosion among other issues which can cause delay or the inability to transfer power in a time of emergency.

The findings include:
During document review with the Director of Maintenance at 11:00am on 3/6/2013, it was found that the proper documentation for maintenance and testing was not being kept in accordance with NFPA 70, National Electrical Code. 9.1.2 for the exercise of the Main and Feeder Breaker. Interview with the Director of Maintenance stated that he had contacted a company to perform the inspection.