HospitalInspections.org

Based on observation the facility failed to provide an acceptable smoke barrier.

The inspector observed while accompanied by the Maintenance Supervisor and other maintenance support staff during the hours of the inspection from 2:30 pm to 6:15 pm that there were holes in the smoke barrier above the ceiling at the following locations: 1) the cross corridors doors at the PT department and 2) the cross corridor doors between sterile supply and the mail room.

Based on observation the facility failed to provide an acceptable enclosure for hazardous storage areas.

The inspector observed while accompanied by the Maintenance Supervisor and other maintenance support staff during the hours of the inspection from 2:30 pm to 6:15 pm that there were storage areas that did not have an acceptable enclosure. They were: 1) the film storage room had two doors that did not have closures on the doors, 2) the kitchen storage requires a 45 minute fire rated door, a closure, and a positive latch, and 3) the soiled linen room door did not have a positive latch.

Based on observation the facility failed to provide an acceptable power reference for the main fire alarm control panel.

The inspector observed while accompanied by the Maintenance Supervisor and other maintenance support staff during the hours of the inspection from 2:30 pm to 6:15 pm that the fire alarm control panel did not have a label on the panel which referenced the electrical panel and breaker that supplies power to the unit as required by code. Also, panel L.S. in the basement that supplies power to the fire alarm panel shall have the breaker that supplies power to the fire alarm control panel colored red.

Based on observation the facility failed to provide acceptable flame spread data for curtains.

The inspector observed while accompanied by the Maintenance Supervisor and other maintenance support staff during the hours of the inspection from 2:30 pm to 6:15 pm that there was a curtain behind the nurse station that did not have proper documentation, i.e. passing NFPA 701.

Based on observation the facility failed to provide acceptable storage of medical gases.

The inspector observed while accompanied by the Maintenance Supervisor and other maintenance support staff during the hours of the inspection from 2:30 pm to 6:15 pm that there were unsecured medical gas bottles in the storage area. Also the storage area was filled with combustible organic matter (leaves).

The inspector observed between 5:30 pm and 6:15 pm by review of the documentation that the disaster drills were not being held semi-annually, only annually.

Based on a review of the records with the C.E.O. and the Maintenance Supervisor between 5:30 pm and 6:15 pm there were only annual disaster drills being conducted. NFPA 99, 11-5.3.9 and hospital regulations requires one or more specific responses of the emergency preparedness plan at least semi-annually. At least one semi-annual drill shall rehearse mass casualty response for health care facilities with emergency services, disaster receiving stations, or both. This means that a second drill does not need to be a mass casualty drill, but can be a less involved exercise.

Based on observation of the facilities records the facility did not have a written agreement for fuel in the case of a power outage.

Based on a review of the records with the C.E.O. and the Maintenance Supervisor between 5:30 pm and 6:15 pm there was no documentation showing that a letter of preferred customer status in the case of emergency situation for fuel.

Based on observation the facility failed to provide an acceptable smoke barrier.

The inspector observed while accompanied by the Maintenance Supervisor and other maintenance support staff during the hours of the inspection from 2:30 pm to 6:15 pm that there were holes in the smoke barrier above the ceiling at the following locations: 1) the cross corridors doors at the PT department and 2) the cross corridor doors between sterile supply and the mail room.

Based on observation the facility failed to provide an acceptable enclosure for hazardous storage areas.

The inspector observed while accompanied by the Maintenance Supervisor and other maintenance support staff during the hours of the inspection from 2:30 pm to 6:15 pm that there were storage areas that did not have an acceptable enclosure. They were: 1) the film storage room had two doors that did not have closures on the doors, 2) the kitchen storage requires a 45 minute fire rated door, a closure, and a positive latch, and 3) the soiled linen room door did not have a positive latch.

Based on observation the facility failed to provide an acceptable power reference for the main fire alarm control panel.

The inspector observed while accompanied by the Maintenance Supervisor and other maintenance support staff during the hours of the inspection from 2:30 pm to 6:15 pm that the fire alarm control panel did not have a label on the panel which referenced the electrical panel and breaker that supplies power to the unit as required by code. Also, panel L.S. in the basement that supplies power to the fire alarm panel shall have the breaker that supplies power to the fire alarm control panel colored red.

Based on observation the facility failed to provide acceptable flame spread data for curtains.

The inspector observed while accompanied by the Maintenance Supervisor and other maintenance support staff during the hours of the inspection from 2:30 pm to 6:15 pm that there was a curtain behind the nurse station that did not have proper documentation, i.e. passing NFPA 701.

Based on observation the facility failed to provide acceptable storage of medical gases.

The inspector observed while accompanied by the Maintenance Supervisor and other maintenance support staff during the hours of the inspection from 2:30 pm to 6:15 pm that there were unsecured medical gas bottles in the storage area. Also the storage area was filled with combustible organic matter (leaves).

The inspector observed between 5:30 pm and 6:15 pm by review of the documentation that the disaster drills were not being held semi-annually, only annually.

Based on a review of the records with the C.E.O. and the Maintenance Supervisor between 5:30 pm and 6:15 pm there were only annual disaster drills being conducted. NFPA 99, 11-5.3.9 and hospital regulations requires one or more specific responses of the emergency preparedness plan at least semi-annually. At least one semi-annual drill shall rehearse mass casualty response for health care facilities with emergency services, disaster receiving stations, or both. This means that a second drill does not need to be a mass casualty drill, but can be a less involved exercise.

Based on observation of the facilities records the facility did not have a written agreement for fuel in the case of a power outage.

Based on a review of the records with the C.E.O. and the Maintenance Supervisor between 5:30 pm and 6:15 pm there was no documentation showing that a letter of preferred customer status in the case of emergency situation for fuel.