HospitalInspections.org

Based on observation and interview, the facility was found to have failed to maintain corridor doors as required.

Findings include:

On 9/14/2010 at 11:05, a wedge was found holding corridor door open on room B269.

Findings were confirmed by the facility engineer.

Doors are allowed to be held open with devices that release when the door is pushed or pulled.
Ref: 2000 NFPA 101 Section 19.3.6.3.3

Based on observation and interview, the facility was found to have failed to maintain doors to vertical openings as required.

Findings on 9/14/2010 at 9:30 am include:

Two rolling fire doors servings as patient registration windows were blocked from closing by office materials on the counter below where the door would meet the counter. In addition the facility engineer and the staff at the windows reported that the rolling doors only closed manually or by a fusible link. The doors did not close automatically when the fire alarm was activated.

The top catch on one leaf of the double doors on the clinic hallway door protecting the vertical opening was found to be broken causing the door to not latch when closed.

Door B206 was found to not latch when release from open position.

Door B207 one of two leaves were found not to close and latch when released from open position. Staff made adjustments so that the door at the time of the survey to restore the required function.

These doors listed above protected openings to the main lobby atrium.

Findings were confirmed by the facility engineer.

The vertical opening is required to have a minimum 1 hour fire resistance rating.
Ref: 2000 NFPA 101Section 19.3.1.1, 8.2.5.5(4)

Door assemblies in fire barriers are required to be in accordance to NFPA 80.
Ref: 2000 NFPA 101 Section 8.2.3.2.1;

Openings in fire barriers shall be protected to limit the spread of fire and restrict the movement of smoke from one side of the barrier to the other.
Ref: 2000 NFPA 101 Section 8.2.3.2.3.1,

Rolling steel doors in vertical openings are required to close automatically upon activation or release of a fusible link or detector.
Ref: 1999 NFPA 80 Section 6-4.1.2

All swinging doors shall be closed and latched at the time at the time of a fire.
Ref: 1999 NFPA 80 Section 2-1.4

Based on observation and interview, the facility was found to have failed to maintain hazardous area doors as required.

Findings include:

On 9/14/2010 at 10:55 am, the door to soiled utility room number B266 did not have a closer.

On 9/14/2010 at 4:30 pm, the public health storage room, number A104 was found not to have a closer on the door. The room was used for storage and was approximately 100 square foot in area. Storage rooms over 50 sq feet in area are considered hazardous areas.

Door closers are required on doors protecting openings to hazardous locations.
Ref: NFPA 101 Section 19.3.2.1

Findings were confirmed by the facility engineer.

Based on observation and interview, the facility was found to have failed to maintain exits as required.

Findings include

On 9/15/2010 at 10:00, exit door known as 153 had a lock jammed so that it did not operate readily.

Doors complying with 7.2.1 shall be permitted
Ref: NFPA 101 Section 19.2.2.2.1

Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.
Ref: NFPA 101 Section 7.2.1.5.1

Based on observation and interview, the facility was found to have failed to protect the entire facility with the required sprinkler system.

Findings include:

On 9/14/2010 at 3:00 pm, C252 stairway from the 1st floor to the basement was found to not have a sprinkler at the top of the stairway.

In noncombustible stair shafts with noncombustible stairs, sprinklers shall be installed at the top of the shaft and under the first landing above the bottom of the shaft.
Ref: NFPA 13 Section 5-13.3.2

The findings were confirmed by the facility engineer.

Based on observation and interview, the facility was found to have failed to maintain the fire sprinkler system as required.

Findings include:

On 9/14/2010 at 9:50 am, the fume hood in inpatient pharmacy was found to be 14.5 inches from the sprinkler head. The fume hood was against a wall and the sprinkler was located above the top of the hood.

On 9/14/2010 at 9:50 am, a storage shelf in inpatient pharmacy was found to be 16 inches from the sprinkler head. The storage shelf was against a wall and the sprinkler was located above the top of the shelf.

On 9/14/2010 at 4:00 pm, a shelf in room A145, known as dental records was found to be 12 inches vertically from a sprinkler head.

Clearance to top of storage is required to a minimum of 18 inches.
Ref: NFPA 25 Section 5-6.6

On 9/14/2010 ceiling tiles were observed out of place or missing at the following locations:
9:40 am: Janitors closet #219, 1 each
11:10 am: Janitors closet #234, 1 ea, replaced at time of survey
3:00 pm: C226, 1 ea 2ft x 4ft
4:00 pm: Dental room #9, 1each - 4ft x 2ft tile out

On 9/14/2010 a ceiling hatch was found open in the maintenance area storage room.

Ceilings tiles must be in place and ceiling hatches must be closed to prevent heat from rising to spaces above. Opening in the ceiling allow heat to escape to spaces above the ceiling tile delaying the response of the sprinklers.
Ref: NFPA 101 Section 4.5.7 -Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be maintained unless the Code exempts such maintenance.

On 10/14/2010 sprinkler escutcheon rings were missing or out of place at the following locations
9:55 am: Room 215
9:55 am: Dr. Wilcox ' s office
2:00 pm: maintenance area storage room
3:15 pm: outpatient pharmacy over shelves

Manufacturer ' s instructions prescribe installation of an escutcheon ring.
Ref: NFPA 101 Section 4.5.7 -Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be maintained unless the Code exempts such maintenance.

On 9/14/2010 at 10:50 a sprinkler head was obstructed in room B277 by a light fixture. The operating room light fixture was 3 inches tall and right next to the fixture. The diffuser was above the level of the fixture.

Sprinklers must be position to avoid obstructions to discharge.
Ref: NFPA 13 Table 5-6.5.1.2

On 9/14/2010 at 4:00pm, a sprinkler head in room A2 known as med room outpatient pharmacy was found located approximately 1 inch horizontally from a wall mounted cabinet.

Standard pendant and upright sprinkler heads shall be mounted a minimum of 4 inches from a wall.
Ref: NFPA 13 Section 5-6.3.3

The findings were confirmed by the facility engineer.

Based on observation and interview, the facility was found to have failed to test and maintain the fire sprinkler system as required.

Findings include:

On 9/15/2010 at 3:00pm, rolling shelves in the med room were 6 inches vertically from rolling book shelves.

Clearance to top of storage is required to a minimum of 18 inches.
Ref: NFPA 25 Section 5-6.6

The facility did not have quarterly main alarm device or annual main drain testing.

Existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed.
Ref: NFPA 101 Section 4.6.12.2*

Sprinkler alarm devices required quarterly testing and main drains annual testing.
Ref: NFPA 25 Table 2-1

The findings were confirmed by the facility engineer.

Based on observation and interview, the facility was found to have failed to maintain fire extinguishers as required.

Findings include:

On 9/14/2010 at 9:15 fire extinguisher labeled as FE42 was missed its last monthly inspections. The last dated inspection was 7/10/2010.

The findings were confirmed by the facility engineer

Fire extinguishers are required to be inspected monthly.
Ref: NFPA 10, 4-3.1

Based on observation and interview, the facility was found to have failed to protect cooking facilities as required.

Findings include:

On 9/14/2010 at 2:00 pm, a filter element in the grease removal system was found to be out of place. The facility staff reported that they left the filter out of place as condensation formed when it was in place.

The finding was acknowledged by the facility engineer.

Protect cooking facilities according to 9.2.3
Ref NFPA 101 Section 19.3.2.6

Protect cooking facilities according to NFPA 96
Ref NFPA 101 Section 9.2.3

Filter elements must be tight fitting and firmly held in place.
Ref NFPA 96 Section 3-2.3

Based on observation and interview, the facility was found to have failed to meet NFPA 99 requirements for medical gas storage.

Findings include:

On 9/14/2010 at 9:20am, in the medical gas storage area in the dock area, 3 ea CO2 and 2 ea NO2 bottles were standing unsecured. The unsecured bottles were approximately 2 feet tall.

In storage locations, cylinders shall be properly secured in racks or adequately fastened.
NFPA 99 Section 4-3.5.2.2 (Level 1 systems)

Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.
NFPA 99 Section 4-3.1.1.2(a)3

On 9/14/2010 the main valves were found to be located in an area accessible to the public. Specifically they were located in the maintenance loading dock hallway.

Main line valves shall be located to permit aces by authorized personnel only.
Ref: NFPA 99 Section 4-3.1.2.3(b)

On 9/14/2010 at 3:15pm, 14 each E size oxygen cylinders were found in the ambulance bay directly adjacent to boxes of crutch parts, a combustible material. 14 E cylinders is less than 3000 cubic feet of oxygen.

Storage for nonflammable oxidizing gases such as oxygen and nitrous oxide less than 3000 ft3(85 m3).
shall be separated from combustibles or incompatible materials by either:
-A minimum distance of 20 ft (6.1 m), or
-A minimum distance of 5 ft (1.5 m) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems,
Ref: NFPA 99 Section 8-3.11.2

Based on observation and interview, the facility was found to have failed to maintain medical air system as required.

Findings include:

On 9/14/2010 at 11:45am, the medical gas compressor air intake was found to be unscreened.

Medical gas systems are required to be maintained according to NFPA 99.
Ref: NFPA 101 Section 19.3.2.4

Medical air intake is required to be screened to prevent entry of vermin.
Ref NFPA 99 Section 4-3.1.1.9

On 9/14/2010, the main valves were located in the maintenance loading dock hallway, an area accessible to the public.

Main line valves shall be located to permit access by authorized personnel only.
Ref: NFPA 99 Section 4-3.1.2.3(b)

On 9/14/2010 at 10:10am, the medical gas alarm panel in the med/ surg area indicated a malfunction with the air dryer. Staff stated that the light was always on.

Medical air compressors systems and their require dryers are required to be maintained.
Ref: NFPA 101 Section 4.5.7, NFPA 99 Section 4-3.1.1.9(g)

The findings were confirmed by the facility engineer.

Based on observation and interview, the facility was found to have failed to maintain electrical equipment as required.

Findings include:

On 9/15/2010 at 10:15, load panel B located in the soiled utility room had an open gap in the panel where a breaker could be installed.

Unused opening are required to be effectively closed.
Ref: NFPA 70 Article 373-4:

The findings were confirmed by the facility engineer.

Based on observation and interview, the facility was found to have failed to maintain the electrical system as required.

Findings include:

On 9/14/2010 the following was observed:

Panel 2N2L: med cart was stored in front of panel blocking access
Panel 2C1L: storage in front of panel
Panel 2N1L: rolling book cart in front of panel

Sufficient working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Area required is three feet deep in front of equipment and 30 inches wide or the width of the equipment from live parts is required to be maintained if exposed. Distances shall be measured from the live parts if such are exposed or from the enclosure front or opening if such are enclosed.
Ref: NFPA 70 Article 110-26

On 9/14/2010 at 11:05 am a surge protector was plugged into another surge protector.

Flexible cords are required to be plugged directly into an electrical outlet.
Ref: NFPA 70 Article 400-7(b)

On 9/14/2010 at 4:15pm, in the operating room area, in room B231, an electrical junction box was found without a cover.

All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the
box or conduit body construction and suitable for the conditions of use.
Ref: NFPA 70 Article 370-28(c)

On 9/14/2010 at 4:20, electrical panel 1N2H in room A127 was found to not to have a means to identify the circuit associated with each breaker.

Panel board breakers are required to be identified either on the panel door or on face
Ref: NFPA 70 Article 384-13


The findings were confirmed by the facility engineer.

Based on observation and interview, the facility was found to have failed to maintain corridor doors as required.

Findings include:

On 9/14/2010 at 11:05, a wedge was found holding corridor door open on room B269.

Findings were confirmed by the facility engineer.

Doors are allowed to be held open with devices that release when the door is pushed or pulled.
Ref: 2000 NFPA 101 Section 19.3.6.3.3

Based on observation and interview, the facility was found to have failed to maintain doors to vertical openings as required.

Findings on 9/14/2010 at 9:30 am include:

Two rolling fire doors servings as patient registration windows were blocked from closing by office materials on the counter below where the door would meet the counter. In addition the facility engineer and the staff at the windows reported that the rolling doors only closed manually or by a fusible link. The doors did not close automatically when the fire alarm was activated.

The top catch on one leaf of the double doors on the clinic hallway door protecting the vertical opening was found to be broken causing the door to not latch when closed.

Door B206 was found to not latch when release from open position.

Door B207 one of two leaves were found not to close and latch when released from open position. Staff made adjustments so that the door at the time of the survey to restore the required function.

These doors listed above protected openings to the main lobby atrium.

Findings were confirmed by the facility engineer.

The vertical opening is required to have a minimum 1 hour fire resistance rating.
Ref: 2000 NFPA 101Section 19.3.1.1, 8.2.5.5(4)

Door assemblies in fire barriers are required to be in accordance to NFPA 80.
Ref: 2000 NFPA 101 Section 8.2.3.2.1;

Openings in fire barriers shall be protected to limit the spread of fire and restrict the movement of smoke from one side of the barrier to the other.
Ref: 2000 NFPA 101 Section 8.2.3.2.3.1,

Rolling steel doors in vertical openings are required to close automatically upon activation or release of a fusible link or detector.
Ref: 1999 NFPA 80 Section 6-4.1.2

All swinging doors shall be closed and latched at the time at the time of a fire.
Ref: 1999 NFPA 80 Section 2-1.4

Based on observation and interview, the facility was found to have failed to maintain hazardous area doors as required.

Findings include:

On 9/14/2010 at 10:55 am, the door to soiled utility room number B266 did not have a closer.

On 9/14/2010 at 4:30 pm, the public health storage room, number A104 was found not to have a closer on the door. The room was used for storage and was approximately 100 square foot in area. Storage rooms over 50 sq feet in area are considered hazardous areas.

Door closers are required on doors protecting openings to hazardous locations.
Ref: NFPA 101 Section 19.3.2.1

Findings were confirmed by the facility engineer.

Based on observation and interview, the facility was found to have failed to maintain exits as required.

Findings include

On 9/15/2010 at 10:00, exit door known as 153 had a lock jammed so that it did not operate readily.

Doors complying with 7.2.1 shall be permitted
Ref: NFPA 101 Section 19.2.2.2.1

Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.
Ref: NFPA 101 Section 7.2.1.5.1

Based on observation and interview, the facility was found to have failed to protect the entire facility with the required sprinkler system.

Findings include:

On 9/14/2010 at 3:00 pm, C252 stairway from the 1st floor to the basement was found to not have a sprinkler at the top of the stairway.

In noncombustible stair shafts with noncombustible stairs, sprinklers shall be installed at the top of the shaft and under the first landing above the bottom of the shaft.
Ref: NFPA 13 Section 5-13.3.2

The findings were confirmed by the facility engineer.

Based on observation and interview, the facility was found to have failed to maintain the fire sprinkler system as required.

Findings include:

On 9/14/2010 at 9:50 am, the fume hood in inpatient pharmacy was found to be 14.5 inches from the sprinkler head. The fume hood was against a wall and the sprinkler was located above the top of the hood.

On 9/14/2010 at 9:50 am, a storage shelf in inpatient pharmacy was found to be 16 inches from the sprinkler head. The storage shelf was against a wall and the sprinkler was located above the top of the shelf.

On 9/14/2010 at 4:00 pm, a shelf in room A145, known as dental records was found to be 12 inches vertically from a sprinkler head.

Clearance to top of storage is required to a minimum of 18 inches.
Ref: NFPA 25 Section 5-6.6

On 9/14/2010 ceiling tiles were observed out of place or missing at the following locations:
9:40 am: Janitors closet #219, 1 each
11:10 am: Janitors closet #234, 1 ea, replaced at time of survey
3:00 pm: C226, 1 ea 2ft x 4ft
4:00 pm: Dental room #9, 1each - 4ft x 2ft tile out

On 9/14/2010 a ceiling hatch was found open in the maintenance area storage room.

Ceilings tiles must be in place and ceiling hatches must be closed to prevent heat from rising to spaces above. Opening in the ceiling allow heat to escape to spaces above the ceiling tile delaying the response of the sprinklers.
Ref: NFPA 101 Section 4.5.7 -Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be maintained unless the Code exempts such maintenance.

On 10/14/2010 sprinkler escutcheon rings were missing or out of place at the following locations
9:55 am: Room 215
9:55 am: Dr. Wilcox ' s office
2:00 pm: maintenance area storage room
3:15 pm: outpatient pharmacy over shelves

Manufacturer ' s instructions prescribe installation of an escutcheon ring.
Ref: NFPA 101 Section 4.5.7 -Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be maintained unless the Code exempts such maintenance.

On 9/14/2010 at 10:50 a sprinkler head was obstructed in room B277 by a light fixture. The operating room light fixture was 3 inches tall and right next to the fixture. The diffuser was above the level of the fixture.

Sprinklers must be position to avoid obstructions to discharge.
Ref: NFPA 13 Table 5-6.5.1.2

On 9/14/2010 at 4:00pm, a sprinkler head in room A2 known as med room outpatient pharmacy was found located approximately 1 inch horizontally from a wall mounted cabinet.

Standard pendant and upright sprinkler heads shall be mounted a minimum of 4 inches from a wall.
Ref: NFPA 13 Section 5-6.3.3

The findings were confirmed by the facility engineer.

Based on observation and interview, the facility was found to have failed to test and maintain the fire sprinkler system as required.

Findings include:

On 9/15/2010 at 3:00pm, rolling shelves in the med room were 6 inches vertically from rolling book shelves.

Clearance to top of storage is required to a minimum of 18 inches.
Ref: NFPA 25 Section 5-6.6

The facility did not have quarterly main alarm device or annual main drain testing.

Existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed.
Ref: NFPA 101 Section 4.6.12.2*

Sprinkler alarm devices required quarterly testing and main drains annual testing.
Ref: NFPA 25 Table 2-1

The findings were confirmed by the facility engineer.

Based on observation and interview, the facility was found to have failed to maintain fire extinguishers as required.

Findings include:

On 9/14/2010 at 9:15 fire extinguisher labeled as FE42 was missed its last monthly inspections. The last dated inspection was 7/10/2010.

The findings were confirmed by the facility engineer

Fire extinguishers are required to be inspected monthly.
Ref: NFPA 10, 4-3.1

Based on observation and interview, the facility was found to have failed to protect cooking facilities as required.

Findings include:

On 9/14/2010 at 2:00 pm, a filter element in the grease removal system was found to be out of place. The facility staff reported that they left the filter out of place as condensation formed when it was in place.

The finding was acknowledged by the facility engineer.

Protect cooking facilities according to 9.2.3
Ref NFPA 101 Section 19.3.2.6

Protect cooking facilities according to NFPA 96
Ref NFPA 101 Section 9.2.3

Filter elements must be tight fitting and firmly held in place.
Ref NFPA 96 Section 3-2.3

Based on observation and interview, the facility was found to have failed to meet NFPA 99 requirements for medical gas storage.

Findings include:

On 9/14/2010 at 9:20am, in the medical gas storage area in the dock area, 3 ea CO2 and 2 ea NO2 bottles were standing unsecured. The unsecured bottles were approximately 2 feet tall.

In storage locations, cylinders shall be properly secured in racks or adequately fastened.
NFPA 99 Section 4-3.5.2.2 (Level 1 systems)

Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.
NFPA 99 Section 4-3.1.1.2(a)3

On 9/14/2010 the main valves were found to be located in an area accessible to the public. Specifically they were located in the maintenance loading dock hallway.

Main line valves shall be located to permit aces by authorized personnel only.
Ref: NFPA 99 Section 4-3.1.2.3(b)

On 9/14/2010 at 3:15pm, 14 each E size oxygen cylinders were found in the ambulance bay directly adjacent to boxes of crutch parts, a combustible material. 14 E cylinders is less than 3000 cubic feet of oxygen.

Storage for nonflammable oxidizing gases such as oxygen and nitrous oxide less than 3000 ft3(85 m3).
shall be separated from combustibles or incompatible materials by either:
-A minimum distance of 20 ft (6.1 m), or
-A minimum distance of 5 ft (1.5 m) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems,
Ref: NFPA 99 Section 8-3.11.2

Based on observation and interview, the facility was found to have failed to maintain medical air system as required.

Findings include:

On 9/14/2010 at 11:45am, the medical gas compressor air intake was found to be unscreened.

Medical gas systems are required to be maintained according to NFPA 99.
Ref: NFPA 101 Section 19.3.2.4

Medical air intake is required to be screened to prevent entry of vermin.
Ref NFPA 99 Section 4-3.1.1.9

On 9/14/2010, the main valves were located in the maintenance loading dock hallway, an area accessible to the public.

Main line valves shall be located to permit access by authorized personnel only.
Ref: NFPA 99 Section 4-3.1.2.3(b)

On 9/14/2010 at 10:10am, the medical gas alarm panel in the med/ surg area indicated a malfunction with the air dryer. Staff stated that the light was always on.

Medical air compressors systems and their require dryers are required to be maintained.
Ref: NFPA 101 Section 4.5.7, NFPA 99 Section 4-3.1.1.9(g)

The findings were confirmed by the facility engineer.

Based on observation and interview, the facility was found to have failed to maintain electrical equipment as required.

Findings include:

On 9/15/2010 at 10:15, load panel B located in the soiled utility room had an open gap in the panel where a breaker could be installed.

Unused opening are required to be effectively closed.
Ref: NFPA 70 Article 373-4:

The findings were confirmed by the facility engineer.

Based on observation and interview, the facility was found to have failed to maintain the electrical system as required.

Findings include:

On 9/14/2010 the following was observed:

Panel 2N2L: med cart was stored in front of panel blocking access
Panel 2C1L: storage in front of panel
Panel 2N1L: rolling book cart in front of panel

Sufficient working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Area required is three feet deep in front of equipment and 30 inches wide or the width of the equipment from live parts is required to be maintained if exposed. Distances shall be measured from the live parts if such are exposed or from the enclosure front or opening if such are enclosed.
Ref: NFPA 70 Article 110-26

On 9/14/2010 at 11:05 am a surge protector was plugged into another surge protector.

Flexible cords are required to be plugged directly into an electrical outlet.
Ref: NFPA 70 Article 400-7(b)

On 9/14/2010 at 4:15pm, in the operating room area, in room B231, an electrical junction box was found without a cover.

All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the
box or conduit body construction and suitable for the conditions of use.
Ref: NFPA 70 Article 370-28(c)

On 9/14/2010 at 4:20, electrical panel 1N2H in room A127 was found to not to have a means to identify the circuit associated with each breaker.

Panel board breakers are required to be identified either on the panel door or on face
Ref: NFPA 70 Article 384-13


The findings were confirmed by the facility engineer.