HospitalInspections.org

Based on observation and staff interview, this facility is not providing a firewall with a two-hour fire rating between the hospital and clinic. This deficient practice affects all occupants including staff, visitors and patients. The facility has a capacity of 22 with a census of 5 residents.

Findings include:

Observation and staff interview on 9/18/12, revealed a penetration, (approximately 1/2 inch by 1 inch), around communications cables extending through the two hour wall between the hospital and the clinic. Maintenance Staff A verified observations during the survey process.

Based on observation and staff interview, it was determined the facility was a three-story building consisting of protected non-combustible construction equipped with an automatic sprinkler system. The facility failed to assure minimum building construction requirements were maintained by ensuring that all ceiling tile assemblies are intact to resist the passage of smoke. The facility has a capacity of 22 with a census of 5 patients.

Findings include:

Observation and staff interview on 9/18/12, revealed a missing ceiling tile in the Second Floor Respiratory Equipment Room. Maintenance Staff A verified observations during the survey process.

Based on observations and staff interview, the facility is not ensuring that doors to rooms are free of impediments that would prevent the doors from being closed or that the doors are provided with suitable hardware that keep the doors shut tightly into their frames. The facility has a capacity of 22 with a census of 5 patients.

Findings include:

Observations and staff interview on 9/18/12, revealed the following deficiencies:

1) The door between the Cafeteria and Cardiopulmonary Rehabilitation did not close and latch.
2) There was a door wedge holding open the door to the Conference Room.
3) There was a chair holding open the door to the Ultrasound Room.
4) The door to the Whirlpool Room did not close and latch.

Maintenance Staff A verified observations during the survey process.

Based on observations and staff interview, the facility failed to maintain smoke doors to close and resist the passage of smoke as required. The deficient practice affects all occupants in the First and Second Floors. The facility has a capacity of 22 with a census of 5 patients.

Findings include:

Observation and staff interview on 9/18/12, revealed the following deficiencies:

1) The smoke doors to the Cafeteria Corridor did not close and latch.
2) The smoke doors to the Laboratory did not close and latch.

Maintenance Staff A verified observations during the survey process.

Based on observations and staff interview, the facility failed to provide separation of hazardous areas from other compartments in accordance with National Fire Protection Association (NFPA) Standard 101, The Life Safety Code, 2000 edition, 19.3.2.1. The facility is composed of protected non-combustible construction and is equipped with a sprinkler system. Where a sprinkler system option is used to provide separation, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. The facility has a capacity of 22 with a census of 5 patients.

Findings include:

Observations and staff interview on 9/18/12, revealed the following:

1) There was a penetration, (approximately 2 inches), around conduit and communications cables extending through the wall above the door in the Basement Hot Water Heater Room.
2) There was two holes in the wall, (one approximately 5 inches by 8 inches, and one approximately 5 inches by 7 inches), in the Basement Soiled Linen Room.
3) The door to the Purchasing Storage Room was not equipped with latching hardware.

Maintenance Staff A verified observations during the survey process.

Based on record review and staff interview, the facility failed to properly test the emergency egress lighting in accordance with National Fire Protection Association (NFPA) Standard 101, The Life Safety Code, 2000 edition, 7.9.3. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. This deficient practice affects all occupants of the facility. The facility has a capacity of 22 with a census of 5 residents.

Findings include:

Record review and staff interview on 9/18/12, revealed no documentation of a 90 minute annual test of the emergency lighting system. Maintenance Staff A verified record review during the survey process.

(A)
Based on observation and staff interview, the facility failed to provide a properly protect the primary power supply for the fire alarm system in accordance with the National Fire Protection Association (NFPA), Standard 72, 1999 edition, 1-5.2.5.2. This deficient practice affects all occupants of the building. The facility has a capacity of 22 with a census of 5 patients.

Findings include:

Observation and staff interview on 9/18/12, revealed that the circuit breaker supplying power to the fire alarm system was not mechanically protected. Maintenance Staff A verified observations during the survey process.


(B)
Based on observation and staff interview, the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, 1999 edition, 7-4.2, by ensuring the fire alarm system is maintained in normal operating condition. The facility has a capacity of 22 with a census of 5 patients

Findings include:

Observation and staff interview on 9/18/12, revealed that the fire alarm system was in trouble mode. The fire alarm control panel indicated a trouble of: "RTU - Fan shutdown."

Maintenance Staff A verified observations during the survey process.

Based on observation and staff interview, 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 an air supply or return can impede the operation of the smoke detector. This facility has a capacity of 22 with a census of 5 patients.

Findings include:

Observation and staff interview on 9/18/12, revealed a smoke detector located in the Basement Corridor by Purchasing that was installed within 3 feet of an air supply or return. Maintenance Staff A verified observations during the survey process.

Based on record review, observations and staff interview, the facility failed to maintain and test a complete automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 25, 1998 edition. All smoke compartments in the building and all residents and staff could be affected by the deficient practice. The facility has a capacity of 22 with a census of 5 patients.

Findings include:

Record review, observations and staff interview on 9/18/12, revealed the following deficiencies:

1) There was no available documentation to indicate when the last 5 year sprinkler system inspection was conducted. The last annual sprinkler inspection report dated 3/20/12 indicated that the sprinkler system was due for a 5 year inspection consisting of calibrating or replacing gauges, internal pipe inspection and valve inspection.
2) There was no documentation of quarterly sprinkler system inspections for all quarters in 2011 and the 2nd Quarter of 2012.
3) A sidewall sprinkler was observed in the X-ray Hallway Electrical Closet. The sprinkler maintenance box did not contain spare sidewall sprinkler heads.
4) The sprinkler head in the Receiving Storage Room had dropped down, causing the a gap between the escutcheon and the ceiling tile assembly.

Maintenance Staff A verified record review and observations during the survey process.

Based on observation 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. The facility has a capacity of 22 with a census of 5 patients.

Findings include:

Observation and staff interview on 9/18/12, revealed that the facility failed to properly mount the fire extinguisher located in the Air Handler Room. Maintenance Staff A verified observations during the survey process.

Based on record review and staff interview, the facility failed to maintain the wet chemical extinguishing system in accordance with National Fire Protection Association (NFPA) Standard 17A, the standard for Wet Chemical Extinguishing Systems, 5-2.1. A monthly inspection of the system shall be conducted. The facility has a capacity of 20 with a census of 5 patients.

Findings include:

Record review and staff interview on 9/18/12, revealed that the facility is not providing monthly inspections of the Kitchen hood and duct extinguishment system. Maintenance Staff A verified record review during the survey process.

Based on observation and staff interview, the facility is not ensuring that all clothes dryers vent to the outside of the building in accordance with International Mechanical Code Section 504. Dryer exhaust systems shall be independent of all other systems and shall convey the moisture and any products of combustion to the outside of the building. The facility has a capacity of 22 with a census of 5 residents.

Findings include:

Observation and staff interview on 9/18/12, revealed that the clothes dryer in the Mechanical Room did not vent to the outside of the building. Maintenance Staff A verified observations during the survey process.

Based on record review and staff interview, the facility failed to maintain and test the emergency generator power supply as required. Emergency generators are required to be inspected weekly and exercised under load for 30 minutes per month and shall be in accordance with National Fire Protection Association (NFPA), Standard 99, 3.4.4.1, and NFPA 110, 8.4.2. The emergency generator would effect all smoke compartments and all facility staff and patients. The facility has a capacity of 22 with a census of 5 patients.

Findings include:

Record review and staff interview on 9/18/12, revealed no documentation of a weekly generator inspection for the first week of July 2012 for both the Caterpillar generator and the Katolight generator. There was a gap in log entries between 6/27/12 and 7/11/12. Maintenance Staff A verified record review during the survey process.

Based on observations and staff interview, it was determined 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. The facility has a capacity of 22 with a census of 5 patients.

Findings include:

Observations and staff interview on 9/18/12, revealed the following electrical system deficiencies:

1) There was a surge protector supplying power to a fan and a lamp in the Maintenance Office.
2) There was a surge protector supplying power to a grinder in the Maintenance Office.
3) There was a surge protector supplying power to another surge protector in the Maintenance Office.
4) Circuit Breaker #11 in Electrical Panel B-14, located in the Maintenance office, was in the tripped position. This breaker was not labeled.
5) There was a surge protector supplying power to two table saws in the Basement Storage Tunnel.
6) There was an extension cord supplying power to a surge protector in the Basement Storage Tunnel.

Maintenance Staff A verified observations during the survey process.

Based on observation and staff interview, this facility is not providing a firewall with a two-hour fire rating between the hospital and clinic. This deficient practice affects all occupants including staff, visitors and patients. The facility has a capacity of 22 with a census of 5 residents.

Findings include:

Observation and staff interview on 9/18/12, revealed a penetration, (approximately 1/2 inch by 1 inch), around communications cables extending through the two hour wall between the hospital and the clinic. Maintenance Staff A verified observations during the survey process.

Based on observation and staff interview, it was determined the facility was a three-story building consisting of protected non-combustible construction equipped with an automatic sprinkler system. The facility failed to assure minimum building construction requirements were maintained by ensuring that all ceiling tile assemblies are intact to resist the passage of smoke. The facility has a capacity of 22 with a census of 5 patients.

Findings include:

Observation and staff interview on 9/18/12, revealed a missing ceiling tile in the Second Floor Respiratory Equipment Room. Maintenance Staff A verified observations during the survey process.

Based on observations and staff interview, the facility is not ensuring that doors to rooms are free of impediments that would prevent the doors from being closed or that the doors are provided with suitable hardware that keep the doors shut tightly into their frames. The facility has a capacity of 22 with a census of 5 patients.

Findings include:

Observations and staff interview on 9/18/12, revealed the following deficiencies:

1) The door between the Cafeteria and Cardiopulmonary Rehabilitation did not close and latch.
2) There was a door wedge holding open the door to the Conference Room.
3) There was a chair holding open the door to the Ultrasound Room.
4) The door to the Whirlpool Room did not close and latch.

Maintenance Staff A verified observations during the survey process.

Based on observations and staff interview, the facility failed to maintain smoke doors to close and resist the passage of smoke as required. The deficient practice affects all occupants in the First and Second Floors. The facility has a capacity of 22 with a census of 5 patients.

Findings include:

Observation and staff interview on 9/18/12, revealed the following deficiencies:

1) The smoke doors to the Cafeteria Corridor did not close and latch.
2) The smoke doors to the Laboratory did not close and latch.

Maintenance Staff A verified observations during the survey process.

Based on observations and staff interview, the facility failed to provide separation of hazardous areas from other compartments in accordance with National Fire Protection Association (NFPA) Standard 101, The Life Safety Code, 2000 edition, 19.3.2.1. The facility is composed of protected non-combustible construction and is equipped with a sprinkler system. Where a sprinkler system option is used to provide separation, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. The facility has a capacity of 22 with a census of 5 patients.

Findings include:

Observations and staff interview on 9/18/12, revealed the following:

1) There was a penetration, (approximately 2 inches), around conduit and communications cables extending through the wall above the door in the Basement Hot Water Heater Room.
2) There was two holes in the wall, (one approximately 5 inches by 8 inches, and one approximately 5 inches by 7 inches), in the Basement Soiled Linen Room.
3) The door to the Purchasing Storage Room was not equipped with latching hardware.

Maintenance Staff A verified observations during the survey process.

Based on record review and staff interview, the facility failed to properly test the emergency egress lighting in accordance with National Fire Protection Association (NFPA) Standard 101, The Life Safety Code, 2000 edition, 7.9.3. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. This deficient practice affects all occupants of the facility. The facility has a capacity of 22 with a census of 5 residents.

Findings include:

Record review and staff interview on 9/18/12, revealed no documentation of a 90 minute annual test of the emergency lighting system. Maintenance Staff A verified record review during the survey process.

(A)
Based on observation and staff interview, the facility failed to provide a properly protect the primary power supply for the fire alarm system in accordance with the National Fire Protection Association (NFPA), Standard 72, 1999 edition, 1-5.2.5.2. This deficient practice affects all occupants of the building. The facility has a capacity of 22 with a census of 5 patients.

Findings include:

Observation and staff interview on 9/18/12, revealed that the circuit breaker supplying power to the fire alarm system was not mechanically protected. Maintenance Staff A verified observations during the survey process.


(B)
Based on observation and staff interview, the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, 1999 edition, 7-4.2, by ensuring the fire alarm system is maintained in normal operating condition. The facility has a capacity of 22 with a census of 5 patients

Findings include:

Observation and staff interview on 9/18/12, revealed that the fire alarm system was in trouble mode. The fire alarm control panel indicated a trouble of: "RTU - Fan shutdown."

Maintenance Staff A verified observations during the survey process.

Based on observation and staff interview, 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 an air supply or return can impede the operation of the smoke detector. This facility has a capacity of 22 with a census of 5 patients.

Findings include:

Observation and staff interview on 9/18/12, revealed a smoke detector located in the Basement Corridor by Purchasing that was installed within 3 feet of an air supply or return. Maintenance Staff A verified observations during the survey process.

Based on record review, observations and staff interview, the facility failed to maintain and test a complete automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 25, 1998 edition. All smoke compartments in the building and all residents and staff could be affected by the deficient practice. The facility has a capacity of 22 with a census of 5 patients.

Findings include:

Record review, observations and staff interview on 9/18/12, revealed the following deficiencies:

1) There was no available documentation to indicate when the last 5 year sprinkler system inspection was conducted. The last annual sprinkler inspection report dated 3/20/12 indicated that the sprinkler system was due for a 5 year inspection consisting of calibrating or replacing gauges, internal pipe inspection and valve inspection.
2) There was no documentation of quarterly sprinkler system inspections for all quarters in 2011 and the 2nd Quarter of 2012.
3) A sidewall sprinkler was observed in the X-ray Hallway Electrical Closet. The sprinkler maintenance box did not contain spare sidewall sprinkler heads.
4) The sprinkler head in the Receiving Storage Room had dropped down, causing the a gap between the escutcheon and the ceiling tile assembly.

Maintenance Staff A verified record review and observations during the survey process.

Based on observation 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. The facility has a capacity of 22 with a census of 5 patients.

Findings include:

Observation and staff interview on 9/18/12, revealed that the facility failed to properly mount the fire extinguisher located in the Air Handler Room. Maintenance Staff A verified observations during the survey process.

Based on record review and staff interview, the facility failed to maintain the wet chemical extinguishing system in accordance with National Fire Protection Association (NFPA) Standard 17A, the standard for Wet Chemical Extinguishing Systems, 5-2.1. A monthly inspection of the system shall be conducted. The facility has a capacity of 20 with a census of 5 patients.

Findings include:

Record review and staff interview on 9/18/12, revealed that the facility is not providing monthly inspections of the Kitchen hood and duct extinguishment system. Maintenance Staff A verified record review during the survey process.

Based on observation and staff interview, the facility is not ensuring that all clothes dryers vent to the outside of the building in accordance with International Mechanical Code Section 504. Dryer exhaust systems shall be independent of all other systems and shall convey the moisture and any products of combustion to the outside of the building. The facility has a capacity of 22 with a census of 5 residents.

Findings include:

Observation and staff interview on 9/18/12, revealed that the clothes dryer in the Mechanical Room did not vent to the outside of the building. Maintenance Staff A verified observations during the survey process.

Based on record review and staff interview, the facility failed to maintain and test the emergency generator power supply as required. Emergency generators are required to be inspected weekly and exercised under load for 30 minutes per month and shall be in accordance with National Fire Protection Association (NFPA), Standard 99, 3.4.4.1, and NFPA 110, 8.4.2. The emergency generator would effect all smoke compartments and all facility staff and patients. The facility has a capacity of 22 with a census of 5 patients.

Findings include:

Record review and staff interview on 9/18/12, revealed no documentation of a weekly generator inspection for the first week of July 2012 for both the Caterpillar generator and the Katolight generator. There was a gap in log entries between 6/27/12 and 7/11/12. Maintenance Staff A verified record review during the survey process.

Based on observations and staff interview, it was determined 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. The facility has a capacity of 22 with a census of 5 patients.

Findings include:

Observations and staff interview on 9/18/12, revealed the following electrical system deficiencies:

1) There was a surge protector supplying power to a fan and a lamp in the Maintenance Office.
2) There was a surge protector supplying power to a grinder in the Maintenance Office.
3) There was a surge protector supplying power to another surge protector in the Maintenance Office.
4) Circuit Breaker #11 in Electrical Panel B-14, located in the Maintenance office, was in the tripped position. This breaker was not labeled.
5) There was a surge protector supplying power to two table saws in the Basement Storage Tunnel.
6) There was an extension cord supplying power to a surge protector in the Basement Storage Tunnel.

Maintenance Staff A verified observations during the survey process.