HospitalInspections.org

Based on observations made on August 14, 2012, the facility failed to provide for an acceptable means of holding open a corridor door to a hazardous area.

The findings include:

In accordance with NFPA 101 and Section 7.2.1.8.2, in any building of low or ordinary hazard contents, as defined in 6.2.2.2 and 6.2.2.3, or where approved by the authority having jurisdiction, doors shall be permitted to be automatic-closing, provided that the following criteria are met:
(1) Upon release of the hold-open mechanism, the door becomes self-closing.
(2) The release device is designed so that the door instantly releases manually and upon release becomes self-closing, or the door can be readily closed.
(3) The automatic releasing mechanism or medium is activated by the operation of approved smoke detectors installed in accordance with the requirements for smoke detectors for door release service in NFPA 72, National Fire Alarm Code?.
(4) Upon loss of power to the hold-open device, the hold-open mechanism is released and the door becomes self-closing.
(5) The release by means of smoke detection of one door in a stair enclosure results in closing all doors serving that stair.

The corridor door to the soiled linen room in the lower level was examined at 8:51 p.m. on August 14, 2012. A magnetic catch device was in use to hold the door open. The device was not acceptable due to the lack of it being interconnected to the fire alarm system so as to conform to 7.2.1.8.2 of the Life Safety Code. Note: The magnetic catch device was disengaged after the observation was made and confirmed by the surveyor while on-site.

Based on observations made on August 13, 2012, the facility failed to maintain the electrical system in accordance with the standards of the National Electrical Code, NFPA 70, 1999 Edition and/or interpretations from the Centers for Medicare and Medicaid Services (CMS).

The findings include:

Extension cords (including power strips) or multiple adaptors used in health care shall be protected against overcurrent conditions by means acceptable to the National Electrical Code or the Authority Having Jurisdiction (CMS), one means of which is by providing power strips or multiple adaptors that have built-in circuit breakers with either 15 or 20 ampere ratings per Article 240-4 (b)(3) of NFPA 70 and previous interpretations from CMS. In accordance with Underwriter's Laboratories (UL) listing for power strips, relocatable power taps as identified under UL standard 1363 and listings starting with XBYS. There must be a reset or test button identified for the circuit breaker to be reset.

A "Phillips" model surge protected power strip was observed to be in use in exam room #1 of the Clinic at 4:24 p.m. on August 13, 2012. Upon examination, it could not be confirmed that the surge protected power strip was also supplied with a built-in circuit breaker. Note: The surge protected power strip was replaced with a power strip that had a built-in circuit breaker after the observation was made and confirmed by the surveyor while on-site.