HospitalInspections.org

Based on observation and staff interviews, this facility failed to provide a firewall with a two-hour fire rating between the Hospital and the Community Health Center. In accordance with National Fire Protection Association 101. This deficient practice affects all occupants including staff, visitors and residents. This facility has a capacity of 99 and a census of 64 patience.

Findings include:


Observations and staff interviews on 02/29/12, revealed a heating duct(approximately 6 inches) that was penetrating the 2 hour wall between the Hospital and the Community Health Center. This duct did not have dampers to prohibit the transfer of smoke and fire across the two hour barrier.

Maintenance Staff A verified this observation.

Based on observations and staff interviews, the facility failed to assure minimum building construction requirements were maintained by ensuring that holes and gaps around penetrations are sealed with one-hour fire rated materials. This in accordance with National Fire Protection Association 101 This deficient practice affects the entire facility. The facility has a capacity of 99 and at the time of the survey had a census of 64.

Findings include:
1. Observations and staff interview on 02/29/12, revealed a gap (approximately 1/4 to 1/2 inch) around wires that were penetrating the smoke barrier above the East Door of the Mental Health Unit.

2. Observations and staff interviews on 02/ 29/12, revealed a gap (approximately 1/4 inch) around the wires located in the 4th Floor East Electrical Closet.

3. Observations and staff interviews on 02/ 29/12, revealed a gap(approximately 1/4 inch) around the sprinkler head located in the 4th Floor Staff Restroom.

4. Observations and staff interviews on 02/ 29/12, revealed a gap (approximately 1/4 to 1/2 inch) around a pipe in the East Stairway between the 3rd and 4th floor.

5. Observations and staff interviews on 02/ 29/12, revealed a gap(approximately 1/4 inch) around an electrical conduit located above the door to the 3rd Floor West Electric Room.

6. Observations and staff interviews on 02/ 29/12, revealed a gap (approximately 1/4 inch) around an electrical conduit located above the door in the electrical closet work station in OB outside Room 365.

7) Observations and staff interviews on 02/ 29/12, revealed a gap (approximately 1/4 inch) around an electrical conduit located above the smoke doors by 2nd Floor Rehab Services.

8) Observations and staff interviews on 02/ 29/12, revealed the fire retardant material on the metal beam above the doors to Rehab Services on the 2nd Floor had been removed.

9) Observations and staff interviews on 02/ 29/12, revealed a gap (approximately 1/4 inch) around an electrical conduit located above the double doors the Cancer Center on the first floor.

Maintenance Staff A verified these observations.

Based on observations and staff interviews, the facility failed to ensure that doors to rooms are provided with suitable hardware that keep the doors shut tightly into their frames. This affects 2 of 12 smoke zones as the doors would not prevent the spread smoke. The facility has a capacity for 99 and at the time of the survey the census was 64 patience.

Findings include:

1. Observations and staff interviews on 02/ 29/12, revealed the door on the Storage Room Main in Obstetrics did not close and latch properly when tested during this survey.

2. Observations and staff interviews on 02/ 29/12, revealed the smoke doors located by the Work Room in OB did not close and latch properly when tested during this survey.

3. Observations and staff interviews on 02/ 29/12, revealed the Soiled Utility Room 2A148A located on the Second Floor did not have the required hardware to close and latch the door.

4. Observations and staff interviews on 02/ 29/12, revealed the door to Storage Room located by the Old Smoking room on the 4th Floor did not have the required hardware to close and latch the door.

5. Observations and staff interviews on 02/ 29/12, revealed the smoke doors located by Room 410 on the Forth Floor failed to close and latch properly when tested during this survey.

Maintenance Staff A verified these Observations.

Based on observations and staff interview, the facility failed to provide unobstructed corridors that provides a clear path of egress. This in accordance with National Fire Protection Association 101. This affects 3 of 12 smoke zones This facility has a capacity of 99 with a census of 64.

Findings include:

1. Observations and staff interviews on 02/ 29/12, revealed wheel chairs being stored in the corridor by the Respiratory Therapy Room on the 4th Floor.

2. Observations and staff interviews on 02/ 29/12, revealed chairs stored in the corridor by Room 365 on the 3rd Floor.

3. Observations and staff interviews on 02/ 29/12, revealed that wheel chairs were being stored in the corridor by the Radiologists Office.

Maintenance Staff A verified these observations.

Based on observations and staff interviews, this facility failed to provide exits with lights according to National Fire Protection Association 101. These lights must be arranged so that the failure of any single lighting fixture(bulb) will not leave the area in darkness. This affects 1 of 12 zones. the facility has a capacity of 99 and a census of 64.

Findings include:

Observations and staff interviews on 02/ 29/12, revealed the lighting unit for the Lab Entrance was equipped with a single light fixture.

Maintenance Staff A verified this observation.

Based on observations and staff interviews , the facility failed to provide exit signs in accordance with 7.10 of National Fire Protection Association 101 with continuous illumination. This affects 1 of 12 smoke zones. At the time of this survey the facility had a capacity of 99 and a census of 64.

Findings include:

1. Observations and staff interviews on 02/ 29/12, revealed the absence of an exit light/sign at the exit located in the Visiting Specialists Area by Exam Room 1 on the 1st Floor.

2. Observations and staff interviews on 02/ 29/12, revealed the exit light/sign located at the back door of the Emergency Room was not illuminated at the time of this survey.

Maintenance Staff A verified these observations.

Based on observation and interviews, this facility is not assuring that the fire alarm system is installed and maintained in accordance with National Fire Protection Association (NFPA) 72, 2-3.5, which requires that smoke detectors are not placed within direct airflow, nor closer that three feet to air supply or air return. Installation of a smoke detector close to a ceiling fan can impede the operation of the smoke detector. This affects 2 of 12 zones. This facility has a capacity of 99 and a census of 64 patience.

Findings include:

1 .Observations and staff interviews on 02/ 29/12, revealed a smoke detector within 36 inches of a HVAC system. This detector was located in the Soiled Utility Room in the OB.

2. Observations and staff interviews on 02/ 29/12, revealed a smoke detector within 36 inches of a HVAC system. This detector was located in the Administration Hallway by the Kitchenette on the 3rd Floor.

Maintenance Staff A verified these observations.

Based on observations and interviews, the facility failed to maintain a complete automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 13, 1999 edition. This affects 2 of 12 smoke zones. The facility has a capacity of 99 and a census of 64.

Findings include:

Observations and staff interviews on 02/ 29/12, revealed the loading dock was not equipped with approved sprinkler protection.

Maintenance Staff A verified this observation.

Based on observations and interviews, the facility failed to maintain a complete automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 13, 1999 and National Fire Protection Association (NFPA) 25. Sprinklers shall be located so as to minimize obstructions to spray patterns. This affects 3 of 12 zones. The facility had a capacity of 99 and a census of 64

Findings include:

1. Observations and staff interviews on 02/29/12, revealed items in the Mental Health Storage Room West on the 4th Floor was stored to close to the sprinkler head.

2. Observations and staff interviews on 02/29/12, revealed items in the Lab Storage Room were being stored to close to a sprinkler head.

3. Observations and staff interviews on 02/29/12, revealed a missing esccusion plate on the sprinkler head located in the CT Control Room Restroom.

4. Observations and staff interviews on 02/29/12, revealed items in the Pre Admissions Storage Closet were being stored to close to the sprinkler heads.

Maintenance Staff A verified these observations.

Based on observations and staff interview, the facility failed to maintain portable fire extinguishers in accordance with National Fire Protection Association (NFPA) Standard 10, Standard for Portable Fire Extinguishers, 1998 edition. Fire extinguishers shall be conspicuously located where they are readily accessible and immediately available in the event of fire. Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. The facility has a capacity of 99 and at the time of the survey process the census was 64 patients.

Findings include:

1. Observations and staff interviews on 02/29/12, revealed the fire extinguisher located by the MRI Office did not have an inspection tag attached to it and no documentation was available stating it was inspected.

2. Observations and staff interviews on 02/29/12, revealed the fire extinguisher cabinet located by the Chemo Room on the first floor was covered with wall paper that matched the walls and could not be readily identified if needed.

Maintenance Staff A verified these observations.

Based on observations and staff interviews, the facility failed to maintain the buildings electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition. This affects 2 of 12 smoke zones. This facility has a capacity of 99 and a census of 64 patients.

Findings include:

1. Observations and staff interviews on 02/29/12, revealed an oxygen concentrator had been plugged into a surge protector. This was located in the Sleep Lab on the 4th Floor.

2. Observations and staff interviews on 02/29/12, revealed a fan plugged into an extension cord and a lamp plugged into a surge protector, these were located in the Medical Records Storage Room.

Maintenance Staff A verified these observations.

Based on observation and staff interviews, this facility failed to provide a firewall with a two-hour fire rating between the Hospital and the Community Health Center. In accordance with National Fire Protection Association 101. This deficient practice affects all occupants including staff, visitors and residents. This facility has a capacity of 99 and a census of 64 patience.

Findings include:


Observations and staff interviews on 02/29/12, revealed a heating duct(approximately 6 inches) that was penetrating the 2 hour wall between the Hospital and the Community Health Center. This duct did not have dampers to prohibit the transfer of smoke and fire across the two hour barrier.

Maintenance Staff A verified this observation.

Based on observations and staff interviews, the facility failed to assure minimum building construction requirements were maintained by ensuring that holes and gaps around penetrations are sealed with one-hour fire rated materials. This in accordance with National Fire Protection Association 101 This deficient practice affects the entire facility. The facility has a capacity of 99 and at the time of the survey had a census of 64.

Findings include:
1. Observations and staff interview on 02/29/12, revealed a gap (approximately 1/4 to 1/2 inch) around wires that were penetrating the smoke barrier above the East Door of the Mental Health Unit.

2. Observations and staff interviews on 02/ 29/12, revealed a gap (approximately 1/4 inch) around the wires located in the 4th Floor East Electrical Closet.

3. Observations and staff interviews on 02/ 29/12, revealed a gap(approximately 1/4 inch) around the sprinkler head located in the 4th Floor Staff Restroom.

4. Observations and staff interviews on 02/ 29/12, revealed a gap (approximately 1/4 to 1/2 inch) around a pipe in the East Stairway between the 3rd and 4th floor.

5. Observations and staff interviews on 02/ 29/12, revealed a gap(approximately 1/4 inch) around an electrical conduit located above the door to the 3rd Floor West Electric Room.

6. Observations and staff interviews on 02/ 29/12, revealed a gap (approximately 1/4 inch) around an electrical conduit located above the door in the electrical closet work station in OB outside Room 365.

7) Observations and staff interviews on 02/ 29/12, revealed a gap (approximately 1/4 inch) around an electrical conduit located above the smoke doors by 2nd Floor Rehab Services.

8) Observations and staff interviews on 02/ 29/12, revealed the fire retardant material on the metal beam above the doors to Rehab Services on the 2nd Floor had been removed.

9) Observations and staff interviews on 02/ 29/12, revealed a gap (approximately 1/4 inch) around an electrical conduit located above the double doors the Cancer Center on the first floor.

Maintenance Staff A verified these observations.

Based on observations and staff interviews, the facility failed to ensure that doors to rooms are provided with suitable hardware that keep the doors shut tightly into their frames. This affects 2 of 12 smoke zones as the doors would not prevent the spread smoke. The facility has a capacity for 99 and at the time of the survey the census was 64 patience.

Findings include:

1. Observations and staff interviews on 02/ 29/12, revealed the door on the Storage Room Main in Obstetrics did not close and latch properly when tested during this survey.

2. Observations and staff interviews on 02/ 29/12, revealed the smoke doors located by the Work Room in OB did not close and latch properly when tested during this survey.

3. Observations and staff interviews on 02/ 29/12, revealed the Soiled Utility Room 2A148A located on the Second Floor did not have the required hardware to close and latch the door.

4. Observations and staff interviews on 02/ 29/12, revealed the door to Storage Room located by the Old Smoking room on the 4th Floor did not have the required hardware to close and latch the door.

5. Observations and staff interviews on 02/ 29/12, revealed the smoke doors located by Room 410 on the Forth Floor failed to close and latch properly when tested during this survey.

Maintenance Staff A verified these Observations.

Based on observations and staff interview, the facility failed to provide unobstructed corridors that provides a clear path of egress. This in accordance with National Fire Protection Association 101. This affects 3 of 12 smoke zones This facility has a capacity of 99 with a census of 64.

Findings include:

1. Observations and staff interviews on 02/ 29/12, revealed wheel chairs being stored in the corridor by the Respiratory Therapy Room on the 4th Floor.

2. Observations and staff interviews on 02/ 29/12, revealed chairs stored in the corridor by Room 365 on the 3rd Floor.

3. Observations and staff interviews on 02/ 29/12, revealed that wheel chairs were being stored in the corridor by the Radiologists Office.

Maintenance Staff A verified these observations.

Based on observations and staff interviews, this facility failed to provide exits with lights according to National Fire Protection Association 101. These lights must be arranged so that the failure of any single lighting fixture(bulb) will not leave the area in darkness. This affects 1 of 12 zones. the facility has a capacity of 99 and a census of 64.

Findings include:

Observations and staff interviews on 02/ 29/12, revealed the lighting unit for the Lab Entrance was equipped with a single light fixture.

Maintenance Staff A verified this observation.

Based on observations and staff interviews , the facility failed to provide exit signs in accordance with 7.10 of National Fire Protection Association 101 with continuous illumination. This affects 1 of 12 smoke zones. At the time of this survey the facility had a capacity of 99 and a census of 64.

Findings include:

1. Observations and staff interviews on 02/ 29/12, revealed the absence of an exit light/sign at the exit located in the Visiting Specialists Area by Exam Room 1 on the 1st Floor.

2. Observations and staff interviews on 02/ 29/12, revealed the exit light/sign located at the back door of the Emergency Room was not illuminated at the time of this survey.

Maintenance Staff A verified these observations.

Based on observation and interviews, this facility is not assuring that the fire alarm system is installed and maintained in accordance with National Fire Protection Association (NFPA) 72, 2-3.5, which requires that smoke detectors are not placed within direct airflow, nor closer that three feet to air supply or air return. Installation of a smoke detector close to a ceiling fan can impede the operation of the smoke detector. This affects 2 of 12 zones. This facility has a capacity of 99 and a census of 64 patience.

Findings include:

1 .Observations and staff interviews on 02/ 29/12, revealed a smoke detector within 36 inches of a HVAC system. This detector was located in the Soiled Utility Room in the OB.

2. Observations and staff interviews on 02/ 29/12, revealed a smoke detector within 36 inches of a HVAC system. This detector was located in the Administration Hallway by the Kitchenette on the 3rd Floor.

Maintenance Staff A verified these observations.

Based on observations and interviews, the facility failed to maintain a complete automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 13, 1999 edition. This affects 2 of 12 smoke zones. The facility has a capacity of 99 and a census of 64.

Findings include:

Observations and staff interviews on 02/ 29/12, revealed the loading dock was not equipped with approved sprinkler protection.

Maintenance Staff A verified this observation.

Based on observations and interviews, the facility failed to maintain a complete automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 13, 1999 and National Fire Protection Association (NFPA) 25. Sprinklers shall be located so as to minimize obstructions to spray patterns. This affects 3 of 12 zones. The facility had a capacity of 99 and a census of 64

Findings include:

1. Observations and staff interviews on 02/29/12, revealed items in the Mental Health Storage Room West on the 4th Floor was stored to close to the sprinkler head.

2. Observations and staff interviews on 02/29/12, revealed items in the Lab Storage Room were being stored to close to a sprinkler head.

3. Observations and staff interviews on 02/29/12, revealed a missing esccusion plate on the sprinkler head located in the CT Control Room Restroom.

4. Observations and staff interviews on 02/29/12, revealed items in the Pre Admissions Storage Closet were being stored to close to the sprinkler heads.

Maintenance Staff A verified these observations.

Based on observations and staff interview, the facility failed to maintain portable fire extinguishers in accordance with National Fire Protection Association (NFPA) Standard 10, Standard for Portable Fire Extinguishers, 1998 edition. Fire extinguishers shall be conspicuously located where they are readily accessible and immediately available in the event of fire. Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. The facility has a capacity of 99 and at the time of the survey process the census was 64 patients.

Findings include:

1. Observations and staff interviews on 02/29/12, revealed the fire extinguisher located by the MRI Office did not have an inspection tag attached to it and no documentation was available stating it was inspected.

2. Observations and staff interviews on 02/29/12, revealed the fire extinguisher cabinet located by the Chemo Room on the first floor was covered with wall paper that matched the walls and could not be readily identified if needed.

Maintenance Staff A verified these observations.

Based on observations and staff interviews, the facility failed to maintain the buildings electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition. This affects 2 of 12 smoke zones. This facility has a capacity of 99 and a census of 64 patients.

Findings include:

1. Observations and staff interviews on 02/29/12, revealed an oxygen concentrator had been plugged into a surge protector. This was located in the Sleep Lab on the 4th Floor.

2. Observations and staff interviews on 02/29/12, revealed a fan plugged into an extension cord and a lamp plugged into a surge protector, these were located in the Medical Records Storage Room.

Maintenance Staff A verified these observations.