HospitalInspections.org

Based on observation and staff interview, the facility failed to provide 2-hour rated construction at building separation walls in accordance with 2000 - NFPA 101, sections 19.1.1.4.1 and 8.2.3.2.


Findings include:

On facility tour between 9:00 AM and 1:30 PM on 06/01- 02/2015, observation revealed the following:

1. The 2-hour fire rated building separation wall by room # 2303 has open penetrations around cables.
NOTE: Check ALL 2 hour fire walls for this deficiency

2. The 2-hour fire rated building separation wall between the Hospital (I-occupancy) and the Emergency Room garage (S- Occupancy), has no 90 minute fire rated doors


These deficient practices were confirmed by the Plant Operations Director (GM) and Facilities Coordinator (JH) 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 9:00 AM and 1:30 PM on 06/01- 02/2015, observation revealed that the lay-in ceiling panel on the 3rd floor of stairwell # 2 have open penetrations around conduit and joints that are not taped or mudded for the required fire rating needed for stairwell.

NOTE: Check all stairwells for this deficiency


This deficient practice was confirmed by the Plant Operations Director (GM) and Facilities Coordinator (JH) at the time of discovery.

Based on observation and staff interview, the facility failed to maintain the re-locking requirements in accordance with the requirements of 2000 NFPA 101, Chapter 19.2.2.2.2 and 2007 Minnesota State Fire Code 1008.1.11.

Findings include:

On facility tour between 9:00 AM and 1:30 PM on 06/01- 02/2015, observation revealed that the 3rd floor Labor and Delivery areas have magnetic door locks and that they automatically re-lock when the fire alarm system was reset after fire alarm activation.

This deficient practice was confirmed by the Plant Operations Director (GM) and Facilities Coordinator (JH) at the time of discovery.

Based on documentation review and staff interview, the facility failed to assure fire drills were conducted once per shift per quarter for all staff under varying times and conditions as required by 2000 NFPA 101, Section 18.7.1.2.


Findings include:

On facility tour between 9:00 AM and 1:30 PM on 06/01- 02/2015, the review of the fire drill documentation for the past 12 months (June 2014 to May 2015) revealed that the drills for the evening shifts were completed, but did not sufficiently vary the times that the drills were conducted - 1937, 1730, 1801 and 1942 hours


This deficient practice was confirmed by the Plant Operations Director (GM) and Facilities Coordinator (JH) at the time of discovery.


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

Based on documentation review and staff interview, the facility failed to assure fire drills were conducted once per shift per quarter for all staff under varying times and conditions as required by 2000 NFPA 101, Section 19.7.1.2.


Findings include:

On facility tour between 9:00 AM and 1:30 PM on 06/01- 02/2015, the review of the fire drill documentation for the past 12 months (June 2014 to May 2015) revealed that the drills for the evening shifts were completed, but did not sufficiently vary the times that the drills were conducted - 1937, 1730, 1801 and 1942 hours


This deficient practice was confirmed by the Plant Operations Director (GM) and Facilities Coordinator (JH) 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 and 9.6.

Findings include:

On facility tour between 9:00 AM and 1:30 PM on 06/01- 02/2015, observation revealed the following:

1. The following smoke detectors are installed with-in 3 ft. of HVAC supply or return vents
rooms # 3303, 3304, 3305 and in supply room across from room # 3306
NOTE: The entire facility needs to be checked for this deficiency
2. No smoke detection in the Chapel area that is open to corridor .
3. No smoke detection in room #3202 that is open to corridor.
4. No smoke detection in the center nurses station (not always used) that is open to the corridor.
5. No automatic smoke detection - with sounder base in On-call sleep room # 2512
NOTE: Check ALL On-call sleep rooms for this deficiency
6. No automatic smoke detection in observation room # 2515 which is located in emergency
room


These deficient practices were confirmed by the Plant Operations Director (GM) and Facilities Coordinator (JH) 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 19.3.5 and 9.7 and 1998 NFPA 25.


Findings include:

On facility tour between 9:00 AM and 1:30 PM on 06/01- 02/2015, observation revealed the following:

1. No records were found to indicate if all gauges on fire sprinkler system have been calibrated or replaced every 5 years
2. The dry type fire sprinkler heads in the Kitchen coolers/freezer, and those in the Lab cooler have a date of 2001 and have not been replaced every 10 years
3. Observation revealed that the spare sprinkler head box does not contain:
a. 2 spare fire sprinkler heads for each type head in the facility
b. There was no socket for the concealed sprinkler heads
c. There was no wrench for the regular sprinkler heads
4. No records to show that the 5 year internal check valve inspection had been done
5. No records to show that the 5 year internal pipe obstruction inspection had been done


These deficient practices were confirmed by the Plant Operations Director (GM) and Facilities Coordinator (JH) at the time of discovery.

Based on documentation review and staff interview, the facility's kitchen cooking hood fire extinguishing system was not maintained in accordance with 2000 NFPA 101 - 9.2.3 and 1998 NFPA 96 section 8.2.

Findings include:

On facility tour between 9:00 AM and 1:30 PM on 06/01- 02/2015, the review of the kitchen hood system inspection documentation for the past 12 months revealed that the kitchen hood fire extinguishing system was not inspected every 6 months. The documented inspections were done on 10/22/2013 and 02/06/2015.


This deficient practice was confirmed by the Plant Operations Director (GM) and Facilities Coordinator (JH) at the time of discovery.



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

Based on observation and staff interview, the facility failed to provide 2-hour rated construction at building separation walls in accordance with 2000 - NFPA 101, sections 19.1.1.4.1 and 8.2.3.2.


Findings include:

On facility tour between 9:00 AM and 1:30 PM on 06/01- 02/2015, observation revealed the following:

1. The 2-hour fire rated building separation wall by room # 2303 has open penetrations around cables.
NOTE: Check ALL 2 hour fire walls for this deficiency

2. The 2-hour fire rated building separation wall between the Hospital (I-occupancy) and the Emergency Room garage (S- Occupancy), has no 90 minute fire rated doors


These deficient practices were confirmed by the Plant Operations Director (GM) and Facilities Coordinator (JH) 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 9:00 AM and 1:30 PM on 06/01- 02/2015, observation revealed that the lay-in ceiling panel on the 3rd floor of stairwell # 2 have open penetrations around conduit and joints that are not taped or mudded for the required fire rating needed for stairwell.

NOTE: Check all stairwells for this deficiency


This deficient practice was confirmed by the Plant Operations Director (GM) and Facilities Coordinator (JH) at the time of discovery.

Based on observation and staff interview, the facility failed to maintain the re-locking requirements in accordance with the requirements of 2000 NFPA 101, Chapter 19.2.2.2.2 and 2007 Minnesota State Fire Code 1008.1.11.

Findings include:

On facility tour between 9:00 AM and 1:30 PM on 06/01- 02/2015, observation revealed that the 3rd floor Labor and Delivery areas have magnetic door locks and that they automatically re-lock when the fire alarm system was reset after fire alarm activation.

This deficient practice was confirmed by the Plant Operations Director (GM) and Facilities Coordinator (JH) at the time of discovery.

Based on documentation review and staff interview, the facility failed to assure fire drills were conducted once per shift per quarter for all staff under varying times and conditions as required by 2000 NFPA 101, Section 18.7.1.2.


Findings include:

On facility tour between 9:00 AM and 1:30 PM on 06/01- 02/2015, the review of the fire drill documentation for the past 12 months (June 2014 to May 2015) revealed that the drills for the evening shifts were completed, but did not sufficiently vary the times that the drills were conducted - 1937, 1730, 1801 and 1942 hours


This deficient practice was confirmed by the Plant Operations Director (GM) and Facilities Coordinator (JH) at the time of discovery.


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

Based on documentation review and staff interview, the facility failed to assure fire drills were conducted once per shift per quarter for all staff under varying times and conditions as required by 2000 NFPA 101, Section 19.7.1.2.


Findings include:

On facility tour between 9:00 AM and 1:30 PM on 06/01- 02/2015, the review of the fire drill documentation for the past 12 months (June 2014 to May 2015) revealed that the drills for the evening shifts were completed, but did not sufficiently vary the times that the drills were conducted - 1937, 1730, 1801 and 1942 hours


This deficient practice was confirmed by the Plant Operations Director (GM) and Facilities Coordinator (JH) 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 and 9.6.

Findings include:

On facility tour between 9:00 AM and 1:30 PM on 06/01- 02/2015, observation revealed the following:

1. The following smoke detectors are installed with-in 3 ft. of HVAC supply or return vents
rooms # 3303, 3304, 3305 and in supply room across from room # 3306
NOTE: The entire facility needs to be checked for this deficiency
2. No smoke detection in the Chapel area that is open to corridor .
3. No smoke detection in room #3202 that is open to corridor.
4. No smoke detection in the center nurses station (not always used) that is open to the corridor.
5. No automatic smoke detection - with sounder base in On-call sleep room # 2512
NOTE: Check ALL On-call sleep rooms for this deficiency
6. No automatic smoke detection in observation room # 2515 which is located in emergency
room


These deficient practices were confirmed by the Plant Operations Director (GM) and Facilities Coordinator (JH) 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 19.3.5 and 9.7 and 1998 NFPA 25.


Findings include:

On facility tour between 9:00 AM and 1:30 PM on 06/01- 02/2015, observation revealed the following:

1. No records were found to indicate if all gauges on fire sprinkler system have been calibrated or replaced every 5 years
2. The dry type fire sprinkler heads in the Kitchen coolers/freezer, and those in the Lab cooler have a date of 2001 and have not been replaced every 10 years
3. Observation revealed that the spare sprinkler head box does not contain:
a. 2 spare fire sprinkler heads for each type head in the facility
b. There was no socket for the concealed sprinkler heads
c. There was no wrench for the regular sprinkler heads
4. No records to show that the 5 year internal check valve inspection had been done
5. No records to show that the 5 year internal pipe obstruction inspection had been done


These deficient practices were confirmed by the Plant Operations Director (GM) and Facilities Coordinator (JH) at the time of discovery.

Based on documentation review and staff interview, the facility's kitchen cooking hood fire extinguishing system was not maintained in accordance with 2000 NFPA 101 - 9.2.3 and 1998 NFPA 96 section 8.2.

Findings include:

On facility tour between 9:00 AM and 1:30 PM on 06/01- 02/2015, the review of the kitchen hood system inspection documentation for the past 12 months revealed that the kitchen hood fire extinguishing system was not inspected every 6 months. The documented inspections were done on 10/22/2013 and 02/06/2015.


This deficient practice was confirmed by the Plant Operations Director (GM) and Facilities Coordinator (JH) at the time of discovery.



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