HospitalInspections.org

Based on observation on facility tour, review of facility records and staff interviews, the facility failed to ensure that the hospital was constructed, arranged and maintained to ensure access to and safety of patients, and provide adequate space for the provision of direct services.

Cross refer to 0221 as it relates to failure of the facility to meet the Life Safety Code Requirements of the National Fire Protection Asscociation; and
Cross refer to 0222 as it relates to failure of the hospital to maintain all hospital systems and the physicial plant.

Based on observation and staff interview it was determined that the facility failed to ensure that all vertical openings are protected with at least one hour fire resistive construction in accordance with NFPA 101 19.3.1.1 This could place all Staff, Visitors, and Patients at risk in the event of a fire.
The findings were:
On 07/23/12 between 11:00 a.m. and 1:30 p.m. observations revealed that there were unprotected vertical openings in the elevator equipment room and in the file room.
These findings were confirmed by Staff M at the time of discovery.

Based on observation and staff interview it was determined that the facility failed to ensure that hazardous areas were separated with one hour fire rated construction as required in NFPA 101 19.3.2.1. This could place all Staff, Visitors, and Patients at risk in the event of a fire.
The findings were:
On 07/23/12 between 11:00 a.m. and 1:30 p.m. observation revealed that the mechanical storage room had holes in the sheet rock which voids the required one hour fire rating of the wall.
These findings were confirmed by Staff M at the time of discovery


Based on observation and staff interviews it was determined that the facility failed to ensure that emergency lighting of at least one and one half hour duration was provided for the exit discharge path to the public way as required by NFPA 101 19.2.9.1 and chapter 7.9. This could place all Staff, Visitors, and Patients at risk in the event of a failure of the normal power.
The findings were:
During a review of facility records with Staff M on 07/23/12 between 11:00 a.m. and 1:30 p.m., records revealed that there was no evidence that the outside lighting was powered by the generator to provide lighting in the event of failure of the normal power.
On 07/23/12 between 11:00 a.m. and 1:30 p.m., observation revealed that it could not be confirmed that the outside lighting was powered by the generator in the event of failure of the normal power.
An interview with Staff M at the time of discovery revealed that he/she could not confirm that the outside lights were or were not powered by the generator in the event of normal power failure.

Based on observations, review of facility records, and staff interview it was determined that the facility failed to ensure that the construction type was in accordance with requirements of 19.1.6.2, 19.1.6.3, 19.1.6.4, 19.1.5.1 of NFPA 101 2000, ed. This could place all Staff, Visitors, and Patients at risk in the event of a fire.
The findings include:
During a review of facility records with Staff M on 07/23/12 between 11:00 a.m. and 1:30 p.m., Preventive Maintenance records revealed that the facility had no sprinkler system that met the requirements of National Fire Protection Association (NFPA) 13 and therefore the Construction type of II(111) would not be allowed for a two story building with a basement.
On 07/23/12 between 11:00 a.m. and 1:30 p.m. observations revealed that there was no NFPA 13 sprinkler system installed in the building.
These findings were confirmed by Staff M at the time of discovery.

Based on observation and staff interview, it was determined that the facility failed to ensure that the sprinkler system protecting a part of the basement was in compliance with NFPA 13. This could place all Staff, Visitors, and Patients at risk in the event of a fire.
The findings include:
During a review of facility records with Staff M on 07/23/12 between 11:00 a.m. and 1:30 p.m., records revealed that there were no sprinkler inspection reports for the partial system.
On 07/23/12 between 11:00 a.m. and 1:30 p.m., observations revealed that the partial sprinkler system covering the basement area did not have a sprinkler riser valve and was supplied water by the domestic water. The domestic sprinkler system installed consists of fifty- five sprinkler heads, however, NFPA 13 limits a domestic water system to supply no more than six sprinkler heads.
Information received during an interview with staff member M between 11:00 a.m. and 1:30 p.m. revealed that the system had no sprinkler riser valve and that the system had not been inspected by a certified sprinkler company.