HospitalInspections.org

Based on observations and staff interviews, the facility failed to provide 2-hour rated construction at building separation walls between the hospital building and the non-conforming building construction as required by NFPA 101" Life Safety Code " 2000 edition, sections 18.1.1.4.1. The deficient practice could negatively impact the residents of the facility by allowing a fire to spread from one building to another.

Findings include:

On facility tour between 11:15 AM and 4:30 PM on 05/07/2012, observation revealed the following:

1. 1st floor - the 2 hour fire rated building separation wall by the Laboratory from Hospital to the Clinic has open conduit ends above the lay in ceiling

2. 1st floor - the 2 hour fire rated building separation wall by Room # 730 from the Hospital to Clinic has open conduit ends above the lay in ceiling


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

Based on observation and staff interview, the facility failed to provide reliable lighting for all components of the means of egress as required by 2000 NFPA 101, Section 19.2.9.1, 7.8, and 7.9.

Findings include:

On facility tour between 11:15 AM and 4:30 PM on 05/07/2012, observation revealed that the southeast exit discharge does not have a two bulb fixture on exterior of building.


This deficient practice was confirmed by the Director of Facility Maintenance (DC) 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 19.7.1.2.

Findings include:

On facility tour between 11:15 AM and 4:30 PM on 05/07/2012, the review of the fire drill documentation for the past 12 months (May 2011 to April 2012) revealed the drill times for the following shifts were not not sufficiently varied:

a. Evening - 1534, 1600, 1550 and 1440 hours
b. Night - 0605, 0525, 0025 and 0542 hours


This deficient practice was confirmed by the Director of Facility Maintenance (DC) 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 19.7.1.2.

Findings include:

On facility tour between 11:15 AM and 4:30 PM on 05/07/2012, the review of the fire drill documentation for the past 12 months (May 2011 to April 2012) revealed the drills for the following shifts did not not sufficiently vary the times that the drills were conducted:

a. evening - 1534, 1600, 1550 and 1440 hours
b. night - 0605, 0525, 0025 and 0542 hours


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

Based on observation and staff interview, the facility failed to install and maintain the fire alarm system in accordance with the requirements of 2000 NFPA 101, Sections 19.3.4.1 and 9.6, as well as 1999 NFPA 72, 2-3.5.1 and 7-5.2 # 12.

Findings include:

On facility tour between 11:15 AM and 4:30 PM on 05/07/2012, observation and review of the available documentation, that the following was found:

1. Doctor's Sleep Rooms # 1 & 2:
a. Smoke alarms are not interconnected with the building fire alarm system and are mounted on the wall more than 12 inches from ceiling
b. No automatic smoke detector with sounder base that is interconnect to building fire alarm system

2. The following locations have smoke detectors that are located with-in 3 feet of air supply/return vents:
a. OR storage room
b. In hallway by by OR # 2
c. In patient sleep rooms # 121 & 122

NOTE: The entire facility needs to be checked for the smoke detector distances from air vents.


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

Based on documentation review and staff interview, the facility failed to provide proper maintenance of the fire sprinkler system as per 1999 NFPA 13 and 1998 NFPA 25, section 5-3.2.1.

Findings include:

On facility tour between 11:15 AM and 4:30 PM on 05/07/2012, The review of the weekly fire pump run log (November 2011 when installed to May 2012) revealed, that the weekly fire pump run/inspection test has not been done.


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

Based on observation and staff interview, the facility failed to assure the pipe medical gas system is labeled and tested as required by 1999 NFPA 99.


Findings include:

On facility tour between 11:15 AM and 4:30 PM on 05/07/2012, the review of the medical gas alarm system testing documentation revealed, that the testing of audible and visual alarm indicators has not been conducted in the past 12 months as required by the 1999 Edition of NFPA 99, Chapter 4-3.5.2.3 (i) .


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


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

Based on observation and staff interview, the facility failed to assure the pipe medical gas system is labeled and tested as required by 1999 NFPA 99.
.

Findings include:

On facility tour between 11:15 AM and 4:30 PM on 05/07/2012, a review of the medical gas alarm system testing documentation revealed, that the testing of audible and visual alarm indicators have not been conducted in the past 12 months as required by the 1999 Edition of NFPA 99, Chapter 4-3.5.2.3 (i)


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

Based on observation and staff interview, the facility failed to install isolated power systems per 2000 NFPA 101 -19.3.2.3, 1999 NFPA 99 3-3.2.1 and 1999 NFPA 70 - Article 517-20(a).

Findings include:

On facility tour between 11:15 AM and 4:30 PM on 05/07/2012, observation revealed that in Operating Room # 3, there is no isolated power system. Operating Room # 3 is considered a wet location and can not tolerate electrical circuit interruptions during surgeries.


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


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

Based on observations and staff interviews, the facility failed to provide 2-hour rated construction at building separation walls between the hospital building and the non-conforming building construction as required by NFPA 101" Life Safety Code " 2000 edition, sections 18.1.1.4.1. The deficient practice could negatively impact the residents of the facility by allowing a fire to spread from one building to another.

Findings include:

On facility tour between 11:15 AM and 4:30 PM on 05/07/2012, observation revealed the following:

1. 1st floor - the 2 hour fire rated building separation wall by the Laboratory from Hospital to the Clinic has open conduit ends above the lay in ceiling

2. 1st floor - the 2 hour fire rated building separation wall by Room # 730 from the Hospital to Clinic has open conduit ends above the lay in ceiling


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

Based on observation and staff interview, the facility failed to provide reliable lighting for all components of the means of egress as required by 2000 NFPA 101, Section 19.2.9.1, 7.8, and 7.9.

Findings include:

On facility tour between 11:15 AM and 4:30 PM on 05/07/2012, observation revealed that the southeast exit discharge does not have a two bulb fixture on exterior of building.


This deficient practice was confirmed by the Director of Facility Maintenance (DC) 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 19.7.1.2.

Findings include:

On facility tour between 11:15 AM and 4:30 PM on 05/07/2012, the review of the fire drill documentation for the past 12 months (May 2011 to April 2012) revealed the drill times for the following shifts were not not sufficiently varied:

a. Evening - 1534, 1600, 1550 and 1440 hours
b. Night - 0605, 0525, 0025 and 0542 hours


This deficient practice was confirmed by the Director of Facility Maintenance (DC) 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 19.7.1.2.

Findings include:

On facility tour between 11:15 AM and 4:30 PM on 05/07/2012, the review of the fire drill documentation for the past 12 months (May 2011 to April 2012) revealed the drills for the following shifts did not not sufficiently vary the times that the drills were conducted:

a. evening - 1534, 1600, 1550 and 1440 hours
b. night - 0605, 0525, 0025 and 0542 hours


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

Based on observation and staff interview, the facility failed to install and maintain the fire alarm system in accordance with the requirements of 2000 NFPA 101, Sections 19.3.4.1 and 9.6, as well as 1999 NFPA 72, 2-3.5.1 and 7-5.2 # 12.

Findings include:

On facility tour between 11:15 AM and 4:30 PM on 05/07/2012, observation and review of the available documentation, that the following was found:

1. Doctor's Sleep Rooms # 1 & 2:
a. Smoke alarms are not interconnected with the building fire alarm system and are mounted on the wall more than 12 inches from ceiling
b. No automatic smoke detector with sounder base that is interconnect to building fire alarm system

2. The following locations have smoke detectors that are located with-in 3 feet of air supply/return vents:
a. OR storage room
b. In hallway by by OR # 2
c. In patient sleep rooms # 121 & 122

NOTE: The entire facility needs to be checked for the smoke detector distances from air vents.


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

Based on documentation review and staff interview, the facility failed to provide proper maintenance of the fire sprinkler system as per 1999 NFPA 13 and 1998 NFPA 25, section 5-3.2.1.

Findings include:

On facility tour between 11:15 AM and 4:30 PM on 05/07/2012, The review of the weekly fire pump run log (November 2011 when installed to May 2012) revealed, that the weekly fire pump run/inspection test has not been done.


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

Based on observation and staff interview, the facility failed to assure the pipe medical gas system is labeled and tested as required by 1999 NFPA 99.


Findings include:

On facility tour between 11:15 AM and 4:30 PM on 05/07/2012, the review of the medical gas alarm system testing documentation revealed, that the testing of audible and visual alarm indicators has not been conducted in the past 12 months as required by the 1999 Edition of NFPA 99, Chapter 4-3.5.2.3 (i) .


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


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

Based on observation and staff interview, the facility failed to assure the pipe medical gas system is labeled and tested as required by 1999 NFPA 99.
.

Findings include:

On facility tour between 11:15 AM and 4:30 PM on 05/07/2012, a review of the medical gas alarm system testing documentation revealed, that the testing of audible and visual alarm indicators have not been conducted in the past 12 months as required by the 1999 Edition of NFPA 99, Chapter 4-3.5.2.3 (i)


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

Based on observation and staff interview, the facility failed to install isolated power systems per 2000 NFPA 101 -19.3.2.3, 1999 NFPA 99 3-3.2.1 and 1999 NFPA 70 - Article 517-20(a).

Findings include:

On facility tour between 11:15 AM and 4:30 PM on 05/07/2012, observation revealed that in Operating Room # 3, there is no isolated power system. Operating Room # 3 is considered a wet location and can not tolerate electrical circuit interruptions during surgeries.


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


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