HospitalInspections.org

Based on observation, review of facility records, and staff interviews 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 National Fire Protection Assocaition (NFPA) 101 2000, ed. This could place all Staff, Visitors, and Patients at risk in the event of a fire.
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 the facility had no sprinkler system that met the requirements of 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., observation 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, review of facility records, and staff interviews it was determined 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 AM and 1:30 PM records revealed that the facility had no sprinkler system that met the requirements of 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., observation 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 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. observation 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 interviews it was determined 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 include:
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 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 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 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 he could not confirm that the outside lights were or were not powered by the generator in the event of normal power failure.

Based on observation and staff interviews it was determined 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., observation 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. NFPA 13 limits a domestic water system to supply no more than six sprinkler heads.
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.

Based on observation and staff interview it was determined the facility failed to ensure that all requirements of NFPA 96 were met.
This could place all Staff, Visitors, and Patients at risk in the event of a fire.
The findings include:
On 07/23/12 between 11:00 a.m. and 1:30 p.m., observation revealed that a required separation distance between the deep fryer and an open flame cooking device was not provided and that an acceptable steel baffle was not provided.
These findings were confirmed by Staff M at the time of discovery.

Based on observation, review of facility records, and staff interviews it was determined the facility failed to that all curtains were fire retardant treated or manufactured to be inherently flame retardant as required in NFPA 101 2000 ed. 10.3.1.
This could place two staff members 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. no records were available to show that the curtains in use in the transcription room were manufactured or treated to be flame retardant as required.
On 07/23/12 between 11:00 a.m. and 1:30 p.m., observation revealed that there was no label on the curtains in the transcription room to document that the curtains were manufactured to be inherently flame retardant.
Interview with Staff M at the time of discovery revealed that no documentation that the curtains were manufactured or had been treated to be flame retardant was available and that he had no knowledge of the curtains having been treated as required.

Based on observation and staff interviews it was determined the facility failed to ensure that the requirements of NFPA 70 were met.
This could place staff, visitors, and patients who come into contact with exposed energized wiring at risk of harm.
The findings include:
On 07/23/12 between 11:00 a.m. and 1:30 p.m., observation revealed that there was an electrical box cover missing in the Mechanical storage room, the Janitors closet has a missing light fixture cover, and an electrical cover plate was missing in the Lab supply room.
These findings were confirmed by Staff M at the time of discovery.

Based on observation, review of facility records, and staff interviews 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 National Fire Protection Assocaition (NFPA) 101 2000, ed. This could place all Staff, Visitors, and Patients at risk in the event of a fire.
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 the facility had no sprinkler system that met the requirements of 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., observation 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, review of facility records, and staff interviews it was determined 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 AM and 1:30 PM records revealed that the facility had no sprinkler system that met the requirements of 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., observation 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 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. observation 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 interviews it was determined 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 include:
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 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 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 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 he could not confirm that the outside lights were or were not powered by the generator in the event of normal power failure.

Based on observation and staff interviews it was determined 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., observation 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. NFPA 13 limits a domestic water system to supply no more than six sprinkler heads.
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.

Based on observation and staff interview it was determined the facility failed to ensure that all requirements of NFPA 96 were met.
This could place all Staff, Visitors, and Patients at risk in the event of a fire.
The findings include:
On 07/23/12 between 11:00 a.m. and 1:30 p.m., observation revealed that a required separation distance between the deep fryer and an open flame cooking device was not provided and that an acceptable steel baffle was not provided.
These findings were confirmed by Staff M at the time of discovery.

Based on observation, review of facility records, and staff interviews it was determined the facility failed to that all curtains were fire retardant treated or manufactured to be inherently flame retardant as required in NFPA 101 2000 ed. 10.3.1.
This could place two staff members 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. no records were available to show that the curtains in use in the transcription room were manufactured or treated to be flame retardant as required.
On 07/23/12 between 11:00 a.m. and 1:30 p.m., observation revealed that there was no label on the curtains in the transcription room to document that the curtains were manufactured to be inherently flame retardant.
Interview with Staff M at the time of discovery revealed that no documentation that the curtains were manufactured or had been treated to be flame retardant was available and that he had no knowledge of the curtains having been treated as required.

Based on observation and staff interviews it was determined the facility failed to ensure that the requirements of NFPA 70 were met.
This could place staff, visitors, and patients who come into contact with exposed energized wiring at risk of harm.
The findings include:
On 07/23/12 between 11:00 a.m. and 1:30 p.m., observation revealed that there was an electrical box cover missing in the Mechanical storage room, the Janitors closet has a missing light fixture cover, and an electrical cover plate was missing in the Lab supply room.
These findings were confirmed by Staff M at the time of discovery.