HospitalInspections.org

Observations and an interview with staff revealed that the flame spread rating of the some wall finishes could not be determined. Failure of the interior wall finishes to be at least a Class B interior finish (flame spread of 75 or less) in accordance with the NFPA 101 "The Life Safety Code" 2000 edition section 19.3.3 could negatively impact the patients, visitors and staff in the area if a fire occurs.

Findings include:
During the facility tour on August 25, 2011, between 1:00 pm and 3:15 pm, observations and a interview with the Director of Maintenance (CG) revealed that the hanging plastic used to cover the opening into the old x-ray film storage area, to prevent people for stumbling into the depressions in the floor, could not be documented as being fire resistive nor flame retardant nor document as having a flame spread rating.

This finding was verified by the Director of Maintenance (CG) during the facility tour and at the exit conference.

Observations showed that two of one hundred-plus corridor doors tested did not comply with NFPA 101 "The Life Safety Code" 2000 Edition Section 19.2.2.2. If corridor doors do not positively latch a fire could spread beyond the room of origin and would negatively impact all the patients, visitors and staff.

Findings include:
During the facility tour on August 25 and 26, 2011, between 1:00 pm and 3:00 pm and 10:15 am and 12:15 pm, observations revealed that:

1) The OR 3 corridor door did not latch properly and the coordinator failed, and
2) The latching on room B232 did not work properly.

These findings were verified by the Director of Maintenance (CG) during the facility tour and at the exit conference.

Observations revealed that eight of thirty hazardous areas observed are not in accordance with NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 19.3.2.1. These deficient practices could allow the products of combustion to travel from the hazardous area listed which could negatively impact all the patients, staff and visitors.

Findings include:
During the facility tour on August 25 and 26, 2011, between 1:00 pm and 3:00 pm and 10:15 am and 12:15 pm, observations revealed that:

1) The Laboratory door was not positive latching,
2) The Central Storage room (old PT) has over an 1/8 inch gap between the meeting edges of the north doors,
3) The Central Storage room (old PT) does not have 3/4 hour fire rated doors on the south end of the room nor are they self-closing,
4) The 1st floor elevator equipment room west is not self-closing,
5) The new Medical Records room door is not self-closing,
6) The dry food storage room is not self-closing,
7) the kitchen corridor doors are not self-closing, and
8) The door to storage room 2104 did not have a latch.

These findings were verified by the Director of Maintenance (CG) during the facility tour and at the exit conference.

Observations revealed that one of ten hazardous areas is not in accordance with NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 19.3.2.1. This deficient practice could allow the products of combustion to travel from this hazardous area which could negatively impact all the patients, staff and visitors of this wing of the facility.

Findings include:
During the facility tour on August 26, 2011, between 9:30 am and 10:15 am, observations revealed that the boiler room door did not latch as required by NFPA 101 section 19.3.2.1.

These findings were verified by the Director of Maintenance (CG) during the facility tour and at the exit conference.

Observations revealed that not all exits are in accordance with the Minnesota State Fire Code 2007 edition. This deficiency could effect all patient, staff and visitors using these exits.

Findings include:
During the facility tour on August 25, between 1:00 pm and 3:00 pm, observations revealed that the locked exit and exit access doors in surgery do not comply with the requirement for a remote release device at the nurse's station within the unit as required by the Minnesota State Fire Code, 2007 Edition, Section 1008.1.11 and the release devices near the doors are not labeled as to how to release the doors from within the unit.

These findings were verified by the Director of Maintenance (CG) during the facility tour and at the exit conference.

Observations and an interview with staff revealed that the automatic sprinkler system does not extend into the MRI trailer nor does the trailer have another suppression system installed. Failing to provide complete automatic fire sprinkler system through out the facility could affect all patients, staff and visitors, of this area if fire emergency occurs within the trailer.

Findings include:
During the facility tour on August 26, 2011, between 9:30 am and 10:15 am, observations and an interview with facility maintenance staff and the Director of Maintenance (CG) revealed that the MRI trailer that had been replaced in 2009 may not have any fire suppression systems installed in it and does not meet NFPA 101 "The Life Safety Code" 1999 edition section 19.7.6 as it is attached to fully sprinkler protected building.

This finding was verified by the Director of Maintenance (CG) during the facility tour and at the exit conference.

Observations and an interview with staff, revealed that the not all air handling units have smoke detection as required by NFPA 90A Standard for the Installation of Air-Conditioning and Ventilating Systems 1998 edition. The deficient practice could allow the products of combustion to travel far from the room of fire origin and negatively affect the patients, visitors and staff by restricting their means of egress in a fire situation.

Findings include:
During the facility tour on August 26, 2011, 10:15 am and 12:15 pm, observations and an interview with the Director of Maintenance revealed that not all of the air handling units in the facility have duct smoke detection to insure shut down of the units when a fire occurs.:

This finding was verified by the Director of Maintenance (CG) during the facility tour and at the exit conference.

Observations revealed that the chute termination room on the basement level does not comply with NFPA 101 "The Life Safety Code" (2000 edition) Sections 19.5.4 and 9.5. This deficient practice could allow the products of combustion to travel from the chute room into the basement corridor which would negatively impact the safety of patients, visitors and staff on that floor.

Findings include:
During the facility tour on August 25, 2011, between 1:00 pm and 3:00 pm, observations revealed that a block was missing in the chute termination room wall between the room and an office, above the suspended ceiling.

This finding was verified by the Director of Maintenance (CG) during the facility tour and at the exit conference.

Observations revealed that the facility staff have items that obstruct the full and instant use of the stairways in an emergency which is required by NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 7.1.10.2.1. This deficient practice can slow or even prevent exiting from the floor that is obstructed, effecting all the patients, staff and visitors of those floors

Findings include:
During the facility tour on August 25, between 1:00 PM and 3:00 PM, observations revealed that equipment is stored in:

1) The lower level of the north east stairway near the fitness center, and
2) The north east stairway from the OR suite.

These findings were verified by the Director of Maintenance (CG) during the facility tour and at the exit conference.

Observation revealed that the a written policy for the use of the secured rooms in the mental health unit was not available for review. This could affect all the patients and staff occupying these rooms by slowing their response to a fire and preventing their escape..

Findings include:
During the facility tour on August 26, 2011, between 10:15 am and 12:15 pm, observations and an interview with staff on the unit revealed that a written policy on how the secured rooms in the mental health unit are to be used and how often staff observe the patients in these rooms.

This finding was verified by the Director of Maintenance (CG) during the facility tour and at the exit conference.

Observations revealed that the emergency generator is not installed in accordance with NFPA 110 The Standard for Emergency and Standby Power Systems 1999 edition. This deficient practice could allow the generator to have a problem that would go unnoticed by staff which could negatively impact the all patients, visitors and staff.

Findings include:
During the facility tour on August 25, between 1:00 PM and 3:00 PM, observations revealed that the emergency generator does not have a remote alarm annunciator in a constantly attended location. The remote panel that provides individual displays indicating the generator is operating and when the battery charger is malfunctioning and individual displays with a common audible alarm that indicate low oil pressure, low coolant temp, excessive coolant temp, less than a 3 hour fuel supply, failure to start and overspeed required by NFPA 110 section 3-5.5.2 is not in a constantly attend location.

These findings were verified by the Director of Maintenance (CG) during the facility tour and at the exit conference.

Observations and an interview with staff revealed that the flame spread rating of the some wall finishes could not be determined. Failure of the interior wall finishes to be at least a Class B interior finish (flame spread of 75 or less) in accordance with the NFPA 101 "The Life Safety Code" 2000 edition section 19.3.3 could negatively impact the patients, visitors and staff in the area if a fire occurs.

Findings include:
During the facility tour on August 25, 2011, between 1:00 pm and 3:15 pm, observations and a interview with the Director of Maintenance (CG) revealed that the hanging plastic used to cover the opening into the old x-ray film storage area, to prevent people for stumbling into the depressions in the floor, could not be documented as being fire resistive nor flame retardant nor document as having a flame spread rating.

This finding was verified by the Director of Maintenance (CG) during the facility tour and at the exit conference.

Observations showed that two of one hundred-plus corridor doors tested did not comply with NFPA 101 "The Life Safety Code" 2000 Edition Section 19.2.2.2. If corridor doors do not positively latch a fire could spread beyond the room of origin and would negatively impact all the patients, visitors and staff.

Findings include:
During the facility tour on August 25 and 26, 2011, between 1:00 pm and 3:00 pm and 10:15 am and 12:15 pm, observations revealed that:

1) The OR 3 corridor door did not latch properly and the coordinator failed, and
2) The latching on room B232 did not work properly.

These findings were verified by the Director of Maintenance (CG) during the facility tour and at the exit conference.

Observations revealed that eight of thirty hazardous areas observed are not in accordance with NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 19.3.2.1. These deficient practices could allow the products of combustion to travel from the hazardous area listed which could negatively impact all the patients, staff and visitors.

Findings include:
During the facility tour on August 25 and 26, 2011, between 1:00 pm and 3:00 pm and 10:15 am and 12:15 pm, observations revealed that:

1) The Laboratory door was not positive latching,
2) The Central Storage room (old PT) has over an 1/8 inch gap between the meeting edges of the north doors,
3) The Central Storage room (old PT) does not have 3/4 hour fire rated doors on the south end of the room nor are they self-closing,
4) The 1st floor elevator equipment room west is not self-closing,
5) The new Medical Records room door is not self-closing,
6) The dry food storage room is not self-closing,
7) the kitchen corridor doors are not self-closing, and
8) The door to storage room 2104 did not have a latch.

These findings were verified by the Director of Maintenance (CG) during the facility tour and at the exit conference.

Observations revealed that one of ten hazardous areas is not in accordance with NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 19.3.2.1. This deficient practice could allow the products of combustion to travel from this hazardous area which could negatively impact all the patients, staff and visitors of this wing of the facility.

Findings include:
During the facility tour on August 26, 2011, between 9:30 am and 10:15 am, observations revealed that the boiler room door did not latch as required by NFPA 101 section 19.3.2.1.

These findings were verified by the Director of Maintenance (CG) during the facility tour and at the exit conference.

Observations revealed that not all exits are in accordance with the Minnesota State Fire Code 2007 edition. This deficiency could effect all patient, staff and visitors using these exits.

Findings include:
During the facility tour on August 25, between 1:00 pm and 3:00 pm, observations revealed that the locked exit and exit access doors in surgery do not comply with the requirement for a remote release device at the nurse's station within the unit as required by the Minnesota State Fire Code, 2007 Edition, Section 1008.1.11 and the release devices near the doors are not labeled as to how to release the doors from within the unit.

These findings were verified by the Director of Maintenance (CG) during the facility tour and at the exit conference.

Observations and an interview with staff revealed that the automatic sprinkler system does not extend into the MRI trailer nor does the trailer have another suppression system installed. Failing to provide complete automatic fire sprinkler system through out the facility could affect all patients, staff and visitors, of this area if fire emergency occurs within the trailer.

Findings include:
During the facility tour on August 26, 2011, between 9:30 am and 10:15 am, observations and an interview with facility maintenance staff and the Director of Maintenance (CG) revealed that the MRI trailer that had been replaced in 2009 may not have any fire suppression systems installed in it and does not meet NFPA 101 "The Life Safety Code" 1999 edition section 19.7.6 as it is attached to fully sprinkler protected building.

This finding was verified by the Director of Maintenance (CG) during the facility tour and at the exit conference.

Observations and an interview with staff, revealed that the not all air handling units have smoke detection as required by NFPA 90A Standard for the Installation of Air-Conditioning and Ventilating Systems 1998 edition. The deficient practice could allow the products of combustion to travel far from the room of fire origin and negatively affect the patients, visitors and staff by restricting their means of egress in a fire situation.

Findings include:
During the facility tour on August 26, 2011, 10:15 am and 12:15 pm, observations and an interview with the Director of Maintenance revealed that not all of the air handling units in the facility have duct smoke detection to insure shut down of the units when a fire occurs.:

This finding was verified by the Director of Maintenance (CG) during the facility tour and at the exit conference.

Observations revealed that the chute termination room on the basement level does not comply with NFPA 101 "The Life Safety Code" (2000 edition) Sections 19.5.4 and 9.5. This deficient practice could allow the products of combustion to travel from the chute room into the basement corridor which would negatively impact the safety of patients, visitors and staff on that floor.

Findings include:
During the facility tour on August 25, 2011, between 1:00 pm and 3:00 pm, observations revealed that a block was missing in the chute termination room wall between the room and an office, above the suspended ceiling.

This finding was verified by the Director of Maintenance (CG) during the facility tour and at the exit conference.

Observations revealed that the facility staff have items that obstruct the full and instant use of the stairways in an emergency which is required by NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 7.1.10.2.1. This deficient practice can slow or even prevent exiting from the floor that is obstructed, effecting all the patients, staff and visitors of those floors

Findings include:
During the facility tour on August 25, between 1:00 PM and 3:00 PM, observations revealed that equipment is stored in:

1) The lower level of the north east stairway near the fitness center, and
2) The north east stairway from the OR suite.

These findings were verified by the Director of Maintenance (CG) during the facility tour and at the exit conference.

Observation revealed that the a written policy for the use of the secured rooms in the mental health unit was not available for review. This could affect all the patients and staff occupying these rooms by slowing their response to a fire and preventing their escape..

Findings include:
During the facility tour on August 26, 2011, between 10:15 am and 12:15 pm, observations and an interview with staff on the unit revealed that a written policy on how the secured rooms in the mental health unit are to be used and how often staff observe the patients in these rooms.

This finding was verified by the Director of Maintenance (CG) during the facility tour and at the exit conference.

Observations revealed that the emergency generator is not installed in accordance with NFPA 110 The Standard for Emergency and Standby Power Systems 1999 edition. This deficient practice could allow the generator to have a problem that would go unnoticed by staff which could negatively impact the all patients, visitors and staff.

Findings include:
During the facility tour on August 25, between 1:00 PM and 3:00 PM, observations revealed that the emergency generator does not have a remote alarm annunciator in a constantly attended location. The remote panel that provides individual displays indicating the generator is operating and when the battery charger is malfunctioning and individual displays with a common audible alarm that indicate low oil pressure, low coolant temp, excessive coolant temp, less than a 3 hour fuel supply, failure to start and overspeed required by NFPA 110 section 3-5.5.2 is not in a constantly attend location.

These findings were verified by the Director of Maintenance (CG) during the facility tour and at the exit conference.