HospitalInspections.org

Based on observation and staff interview, the facility failed to provide 2-hour rated construction at the building separation walls in accordance with 2000 - NFPA 101, sections 19.1.1.4, 19.1.2.3 and 8.2.3.2.


Findings include:

On facility tour between 8:00 AM and 2:00 PM on 08/14/2014, observation revealed the following in the 2-hour fire rated building separation walls between the following locations:

1. 1st floor kitchen:
a. double doors from hospital to assisted living will not latch
b. double doors from hospital to assisted living blocked open

2. 2nd floor - hospital to nursing home - open penetrations end conduit


These deficient practices were confirmed by the Director of Maintenance (JF) at the time of discovery.

Based on observation and staff interview, the facility failed to maintain smoke-resisting partitions and doors in accordance with the following requirements of 2000 NFPA 101, Section 19.3.2.1. The deficient practice could affect all 4 patients.


Findings include:

On facility tour between 8:00 AM and 2:00 PM on 08/14/2014, observation revealed that the following were found:

1. 2nd floor - storage room across from # 254 - does not latch
2. 2nd floor - soiled utility:
a. has friction door hold, holding door open
b. will not shut/latch
3. 2nd floor - Hospital Pharmacy - front and back entrance doors do not have a automatic door closer
4. 2nd floor clean linen room #237 - (over 50 sq ft) - does not have a automatic door closer
5. Basement - Central supply west door does not have a automatic door closer


These deficient practices were confirmed by the Director of Maintenance (JF) at the time of discovery.

Based on observation and staff interview, the facility failed to maintain a fire resistance rating of at least one hour in the exit component accordance with the following requirements of 2000 NFPA 101, Section 19.3.1.1, 8.2.5.2.


Findings include:

On facility tour between 8:00 AM and 2:00 PM on 08/14/2014, observation revealed, that the following stairwells have open penetrations around the sprinkler lines:

1. 2nd floor - in OB wing
2. 2nd west - in general surgery

NOTE: Check the entire facility for this deficiency


These deficient practices were confirmed by the Director of Maintenance (JF) at the time of discovery.

Based on observation and staff interview, the facility failed to provide reliable battery operated emergency lighting as required by 2000 NFPA 101, Section 19..2.9.1, and 7.9.2. The deficient practice could affect 1 patient when room is used.


Findings include:

On facility tour between 8:00 AM and 2:00 PM on 08/14/2014, observation revealed that the battery operated emergency lighting in the Endoscopy procedure room did not work when tested.

This deficient practice was confirmed by the Director of Maintenance (JF) at the time of discovery.

Based on observation, the facility failed to install the fire alarm system in accordance with the requirements of 2000 NFPA 101, Sections 19.3.4.5.2, 19.3.6.1, 9.6 and 1999 NFPA 72, Section 1-5.6. The deficient practice could affect all 4 patients.

Findings include:

On facility tour between 8:00 AM and 2:00 PM on 08/14/2014, observation revealed, that the following locations have fire alarm power supplies and or door hold open panels that are not protected by automatic smoke detection that is interconnected with fire alarm system:

1. Basement - Mechanical room # 98
2. 1st floor - Storage room # 180


This deficient practice was confirmed by the Director of Maintenance (JF) at the time of discovery.

Based on observation and staff interview, the facility failed to maintain the fire sprinkler system in accordance with the requirements of 2000 NFPA 101, Sections 19.3.4.1 and 9.6, as well as 1998 NFPA 25, section 1-11 and 2-2.1.


Findings include:

On facility tour between 8:00 AM and 2:00 PM on 08/14/2014, observation revealed that at the following was found:

1. 1st floor - Kitchen - Cooler and freezer have dry sprinkler heads that are over 10 years old
2. 1st floor - housekeeping closet:
a. missing ceiling tile
b. sprinkler head is an upright head and is located 3 feet off of ceiling


These deficient practices were confirmed by the Director of Maintenance (JF) at the time of discovery.

Based on documentation review and staff interview, that the facility's general ventilating and air conditioning system (HVAC) was not maintained in accordance with the LSC, Section 18.5.2.1 and NFPA 90A, Section 3-4.7. A noncompliant HVAC system could affect all 4 patients.

Findings include:

On facility tour between 8:00 AM and 2:00 PM on 08/14/2014, documentation review for fire damper testing for the past 4 years revealed, that the fire/smoke dampers have not been tested. Last documented test was on 03/25/2010.

This deficient practice was confirmed by the Director of Maintenance (JF) at the time of discovery.

Based on documentation review and staff interview, that the facility's general ventilating and air conditioning system (HVAC) was not maintained in accordance with the LSC, Section 19.5.2.1 and NFPA 90A, Section 3-4.7. A noncompliant HVAC system could affect all 4 patients.

Findings include:

On facility tour between 8:00 AM and 2:00 PM on 08/14/2014, documentation review for fire damper testing for the past 4 years revealed, that the fire/smoke dampers have not been tested. Last documented test was on 03/25/2010.

This deficient practice was confirmed by the Director of Maintenance (JF) at the time of discovery.

Based on observation and staff interview, the facility failed to provide 2-hour rated construction at the building separation walls in accordance with 2000 - NFPA 101, sections 19.1.1.4, 19.1.2.3 and 8.2.3.2.


Findings include:

On facility tour between 8:00 AM and 2:00 PM on 08/14/2014, observation revealed the following in the 2-hour fire rated building separation walls between the following locations:

1. 1st floor kitchen:
a. double doors from hospital to assisted living will not latch
b. double doors from hospital to assisted living blocked open

2. 2nd floor - hospital to nursing home - open penetrations end conduit


These deficient practices were confirmed by the Director of Maintenance (JF) at the time of discovery.

Based on observation and staff interview, the facility failed to maintain smoke-resisting partitions and doors in accordance with the following requirements of 2000 NFPA 101, Section 19.3.2.1. The deficient practice could affect all 4 patients.


Findings include:

On facility tour between 8:00 AM and 2:00 PM on 08/14/2014, observation revealed that the following were found:

1. 2nd floor - storage room across from # 254 - does not latch
2. 2nd floor - soiled utility:
a. has friction door hold, holding door open
b. will not shut/latch
3. 2nd floor - Hospital Pharmacy - front and back entrance doors do not have a automatic door closer
4. 2nd floor clean linen room #237 - (over 50 sq ft) - does not have a automatic door closer
5. Basement - Central supply west door does not have a automatic door closer


These deficient practices were confirmed by the Director of Maintenance (JF) at the time of discovery.

Based on observation and staff interview, the facility failed to maintain a fire resistance rating of at least one hour in the exit component accordance with the following requirements of 2000 NFPA 101, Section 19.3.1.1, 8.2.5.2.


Findings include:

On facility tour between 8:00 AM and 2:00 PM on 08/14/2014, observation revealed, that the following stairwells have open penetrations around the sprinkler lines:

1. 2nd floor - in OB wing
2. 2nd west - in general surgery

NOTE: Check the entire facility for this deficiency


These deficient practices were confirmed by the Director of Maintenance (JF) at the time of discovery.

Based on observation and staff interview, the facility failed to provide reliable battery operated emergency lighting as required by 2000 NFPA 101, Section 19..2.9.1, and 7.9.2. The deficient practice could affect 1 patient when room is used.


Findings include:

On facility tour between 8:00 AM and 2:00 PM on 08/14/2014, observation revealed that the battery operated emergency lighting in the Endoscopy procedure room did not work when tested.

This deficient practice was confirmed by the Director of Maintenance (JF) at the time of discovery.

Based on observation, the facility failed to install the fire alarm system in accordance with the requirements of 2000 NFPA 101, Sections 19.3.4.5.2, 19.3.6.1, 9.6 and 1999 NFPA 72, Section 1-5.6. The deficient practice could affect all 4 patients.

Findings include:

On facility tour between 8:00 AM and 2:00 PM on 08/14/2014, observation revealed, that the following locations have fire alarm power supplies and or door hold open panels that are not protected by automatic smoke detection that is interconnected with fire alarm system:

1. Basement - Mechanical room # 98
2. 1st floor - Storage room # 180


This deficient practice was confirmed by the Director of Maintenance (JF) at the time of discovery.

Based on observation and staff interview, the facility failed to maintain the fire sprinkler system in accordance with the requirements of 2000 NFPA 101, Sections 19.3.4.1 and 9.6, as well as 1998 NFPA 25, section 1-11 and 2-2.1.


Findings include:

On facility tour between 8:00 AM and 2:00 PM on 08/14/2014, observation revealed that at the following was found:

1. 1st floor - Kitchen - Cooler and freezer have dry sprinkler heads that are over 10 years old
2. 1st floor - housekeeping closet:
a. missing ceiling tile
b. sprinkler head is an upright head and is located 3 feet off of ceiling


These deficient practices were confirmed by the Director of Maintenance (JF) at the time of discovery.

Based on documentation review and staff interview, that the facility's general ventilating and air conditioning system (HVAC) was not maintained in accordance with the LSC, Section 18.5.2.1 and NFPA 90A, Section 3-4.7. A noncompliant HVAC system could affect all 4 patients.

Findings include:

On facility tour between 8:00 AM and 2:00 PM on 08/14/2014, documentation review for fire damper testing for the past 4 years revealed, that the fire/smoke dampers have not been tested. Last documented test was on 03/25/2010.

This deficient practice was confirmed by the Director of Maintenance (JF) at the time of discovery.

Based on documentation review and staff interview, that the facility's general ventilating and air conditioning system (HVAC) was not maintained in accordance with the LSC, Section 19.5.2.1 and NFPA 90A, Section 3-4.7. A noncompliant HVAC system could affect all 4 patients.

Findings include:

On facility tour between 8:00 AM and 2:00 PM on 08/14/2014, documentation review for fire damper testing for the past 4 years revealed, that the fire/smoke dampers have not been tested. Last documented test was on 03/25/2010.

This deficient practice was confirmed by the Director of Maintenance (JF) at the time of discovery.

Based on documentation review and staff interview, the facility failed to inspect the emergency generator in accordance with the requirements of 2000 NFPA 101 - 9.1.3 and 1999 NFPA 110 Chapter 6-4.1. The deficient practice could affect all 4 patients.

Findings include:

On facility tour between 8:00 AM and 2:00 PM on 08/14/2014, documentation review of the weekly inspection logs (August 2013 to August 2014) for the diesel emergency generator revealed that the weekly operational inspection were missed for the weeks of 2/24, 3/3/2014 and 9/30, 10/7,10/21, 10/28/13.

This deficient practice was confirmed by the Director of Maintenance (JF) at the time of discovery.



*TEAM COMPOSITION*
Gary Schroeder, Life Safety Code Spc.