HospitalInspections.org

Observations revealed that one of three smoke barriers were not in accordance with NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 8.3.6. This deficient practice could allow the products of combustion to travel throughout the building by passing through the smoke barrier, which will negatively impact all of the patients, staff and visitors.

Findings include:
During the facility tour on March 14, 2012, between 1:45 pm and 4:15 pm, observations revealed that the south fire barrier between the existing hospital and the 1969 addition has unsealed gaps around the wire bundle that penetrates through the wall found about the corridor ceiling.

The Director of Maintenance (BJ) verified these findings during the inspection and at the exit conference.

An interview with staff, observations and testing of all the exit doors revealed that the some exit and some exit access doors are not in accordance with not NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 7.2.1.5 nor do they meet the Minnesota State Fire Code section 1008.11. These deficient practices could negatively affect all patients, staff and visitors of wing effected if they need to be quickly evacuated the facility.

Findings include:
During the facility tour on March 14, 2012, between 1:45 pm and 4:15 pm, testing, observations and an interview with staff, revealed that:

1. The business office corridor doors use two operation to open doors due to the dead bolt locks,

2. The OR lock was broken on the room side making it difficult to open from the room side when the door is locked,

3. The magnetic locks used in the ER/ OR suite on egress doors do not have a remote release device in accordance with the Minnesota State Fire Code section 1008.1.11.

The Director of Maintenance (BJ) verified these findings during the inspection and at the exit conference.

Observations revealed that three of six exit discharges are not illuminated in accordance with NFPA 101 "The Life Safety Code" (LSC) 2000 edition, section 19.2.8. Lack of proper lighting for exit discharges could cause the slowing of evacuation of the facility, negatively impacting all residents as well as staff and visitors using these exits.

Findings include:
During the facility tour on March 14, 2012, between 1:45 pm and 4:15 pm, observations revealed that the exit discharge lighting could not be verified as being on the emergency generator for the south east exit, the boiler room exit and the west south exit.

The Director of Maintenance (BJ) verified these findings during the inspection and at the exit conference.

Observations revealed that three of six exit discharges are not illuminated in accordance with NFPA 101 "The Life Safety Code" (LSC) 2000 edition, section 19.2.8. Lack of proper lighting for exit discharges could cause the slowing of evacuation of the facility, negatively impacting all residents as well as staff and visitors using these exits.

Findings include:
During the facility tour on March 14, 2012, between 1:45 pm and 4:15 pm, observations revealed that the south east, the boiler room and the west south exit discharges do not have 2 lighting fixtures that cover the exit discharges to insure a single bulb failure does not allow the area to be in total darkness.

The Director of Maintenance (BJ) verified these findings during the inspection and at the exit conference.

Observations revealed that the bulk oxygen storage is not in accordance with the Minnesota State Fire Code section 312.1 Vehicle Impact Protection. This deficient practice could allow a the oxygen tank do be impacted, causing a release of oxygen and allowing a fire to grow and become more intense which could negatively impact the safety of any patients, staff or visitor if they are near the area of the tank.

Findings include:
During the facility tour on March 14, 2012, between 1:45 pm and 4:15 pm, observations revealed that the outside bulk liquid oxygen storage tank is not protected against vehicle impact with the required guard posts of steel that are 4 inches in diameter, filled with concrete, spaced not more than 4 feet on center, not less than 3 feet deep in a concrete footing of not less than a 15-inch diameter, with the top of the posts not less than 3 feet above the ground and not less than 3 feet from the tank as required by MSFC section 312.1.

The Director of Maintenance (BJ) verified these findings during the inspection and at the exit conference.

An interview with staff and a review of facility documentation revealed that the emergency generator may not maintained in accordance with NFPA 110 The Standard for Emergency and Standby Power Systems 1999 edition. This deficient practice could allow the generator to fail with the loss of power to the facility which could negatively impact the all the patients, staff and visitors.

Findings include:
During the facility tour on March 14, 2012, between 1:45 pm and 4:15 pm, a review of facility generator testing documentation and an interview with the Director of Maintenance (BJ) revealed the documentation is incomplete and does not indicate the weekly inspections of the fuel, oil level, cooling system, exhaust system, the battery, and the electrical circuits. Nor does the monthly testing indicate the time it is run, the coolant temperature, the load, for a minimum of 30 minutes, at not less than 30 percent of the generator ' s nameplate rating as list in NFPA 110.

The Director of Maintenance (BJ) verified these findings during the inspection and at the exit conference.

Observations revealed that one of three smoke barriers were not in accordance with NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 8.3.6. This deficient practice could allow the products of combustion to travel throughout the building by passing through the smoke barrier, which will negatively impact all of the patients, staff and visitors.

Findings include:
During the facility tour on March 14, 2012, between 1:45 pm and 4:15 pm, observations revealed that the south fire barrier between the existing hospital and the 1969 addition has unsealed gaps around the wire bundle that penetrates through the wall found about the corridor ceiling.

The Director of Maintenance (BJ) verified these findings during the inspection and at the exit conference.

An interview with staff, observations and testing of all the exit doors revealed that the some exit and some exit access doors are not in accordance with not NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 7.2.1.5 nor do they meet the Minnesota State Fire Code section 1008.11. These deficient practices could negatively affect all patients, staff and visitors of wing effected if they need to be quickly evacuated the facility.

Findings include:
During the facility tour on March 14, 2012, between 1:45 pm and 4:15 pm, testing, observations and an interview with staff, revealed that:

1. The business office corridor doors use two operation to open doors due to the dead bolt locks,

2. The OR lock was broken on the room side making it difficult to open from the room side when the door is locked,

3. The magnetic locks used in the ER/ OR suite on egress doors do not have a remote release device in accordance with the Minnesota State Fire Code section 1008.1.11.

The Director of Maintenance (BJ) verified these findings during the inspection and at the exit conference.

Observations revealed that three of six exit discharges are not illuminated in accordance with NFPA 101 "The Life Safety Code" (LSC) 2000 edition, section 19.2.8. Lack of proper lighting for exit discharges could cause the slowing of evacuation of the facility, negatively impacting all residents as well as staff and visitors using these exits.

Findings include:
During the facility tour on March 14, 2012, between 1:45 pm and 4:15 pm, observations revealed that the exit discharge lighting could not be verified as being on the emergency generator for the south east exit, the boiler room exit and the west south exit.

The Director of Maintenance (BJ) verified these findings during the inspection and at the exit conference.

Observations revealed that three of six exit discharges are not illuminated in accordance with NFPA 101 "The Life Safety Code" (LSC) 2000 edition, section 19.2.8. Lack of proper lighting for exit discharges could cause the slowing of evacuation of the facility, negatively impacting all residents as well as staff and visitors using these exits.

Findings include:
During the facility tour on March 14, 2012, between 1:45 pm and 4:15 pm, observations revealed that the south east, the boiler room and the west south exit discharges do not have 2 lighting fixtures that cover the exit discharges to insure a single bulb failure does not allow the area to be in total darkness.

The Director of Maintenance (BJ) verified these findings during the inspection and at the exit conference.

Observations revealed that the bulk oxygen storage is not in accordance with the Minnesota State Fire Code section 312.1 Vehicle Impact Protection. This deficient practice could allow a the oxygen tank do be impacted, causing a release of oxygen and allowing a fire to grow and become more intense which could negatively impact the safety of any patients, staff or visitor if they are near the area of the tank.

Findings include:
During the facility tour on March 14, 2012, between 1:45 pm and 4:15 pm, observations revealed that the outside bulk liquid oxygen storage tank is not protected against vehicle impact with the required guard posts of steel that are 4 inches in diameter, filled with concrete, spaced not more than 4 feet on center, not less than 3 feet deep in a concrete footing of not less than a 15-inch diameter, with the top of the posts not less than 3 feet above the ground and not less than 3 feet from the tank as required by MSFC section 312.1.

The Director of Maintenance (BJ) verified these findings during the inspection and at the exit conference.

An interview with staff and a review of facility documentation revealed that the emergency generator may not maintained in accordance with NFPA 110 The Standard for Emergency and Standby Power Systems 1999 edition. This deficient practice could allow the generator to fail with the loss of power to the facility which could negatively impact the all the patients, staff and visitors.

Findings include:
During the facility tour on March 14, 2012, between 1:45 pm and 4:15 pm, a review of facility generator testing documentation and an interview with the Director of Maintenance (BJ) revealed the documentation is incomplete and does not indicate the weekly inspections of the fuel, oil level, cooling system, exhaust system, the battery, and the electrical circuits. Nor does the monthly testing indicate the time it is run, the coolant temperature, the load, for a minimum of 30 minutes, at not less than 30 percent of the generator ' s nameplate rating as list in NFPA 110.

The Director of Maintenance (BJ) verified these findings during the inspection and at the exit conference.