HospitalInspections.org

Multiple Occupancies - Construction Type
Where separated occupancies are in accordance with 18/19.1.3.2 or 18/19.1.3.4, the most stringent construction type is provided throughout the building, unless a 2-hour separation is provided in accordance with 8.2.1.3, in which case the construction type is determined as follows:
* The construction type and supporting construction of the health care occupancy is based on the story in which it is located in the building in accordance with 18/19.1.6 and Tables 18/19.1.6.1
* The construction type of the areas of the building enclosing the other occupancies shall be based on the applicable occupancy chapters.
18.1.3.5, 19.1.3.5, 8.2.1.3
Findings Include:

On facility tour between 08:30 AM and 04:00 PM on 12/13/16, based on observation and interview revealed or based on documentation review and interview that the following include:
The 3rd floor 2hour fire separation between 1976 and 2006 Buildings needs to be re-evaluated. Separation is not defined in the correct location on current floor diagrams.

This deficient practice could affect the safety of all the paients, staff and visitors within the smoke compartment.

This deficient practice was confirmed by the Facility Maintenance Director at the time of discovery.

Interior Wall and Ceiling Finish
2012 EXISTING
Interior wall and ceiling finishes, including exposed interior surfaces of buildings such as fixed or movable walls, partitions, columns, and have a flame spread rating of Class A or Class B. The reduction in class of interior finish for a sprinkler system as prescribed in 10.2.8.1 is permitted.
10.2, 19.3.3.1, 19.3.3.2
Indicate flame spread rating(s). _____________________
Findings Include:

On facility tour between 09:00 AM and 04:00 PM on 12/13/16, based on observation and interview revealed or based on documentation review and interview that the following include:
A 10'W x 12' H Piece of cardboard was observed taped on the interior wall in Buidling 12 lower level.

This deficient practice could affect the safety of all the patient, staff and visitors within the smoke compartment.

This deficient practice was confirmed by the Facility Maintenance Director at the time of discovery.

Fire Alarm System - Installation
A fire alarm system is installed with systems and components approved for the purpose in accordance with NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm Code to provide effective warning of fire in any part of the building. In areas not continuously occupied, detection is installed at each fire alarm control unit. In new occupancy, detection is also installed at notification appliance circuit power extenders, and supervising station transmitting equipment. Fire alarm system wiring or other transmission paths are monitored for integrity.
18.3.4.1, 19.3.4.1, 9.6, 9.6.1.8

On facility tour between 10:00 AM and 04:00 PM on 12/12/2016, based on observation and interview revealed the following include:

1. RT Sleepover Room (326) does not have a fire alarm/smoke detector with sounder bar.
2. OB Physician Room (328) does not have a fire alarm/smoke detector with sounder bar.

This deficient practice could affect the safety of all the residents, staff and visitors within the compartment.

This deficient practice was confirmed by the Facility Maintenance Director at the time of discovery.

Spinkler System - Installation
2012 EXISTING
Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.
In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers.
In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems.
19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1)

Findings Include:

On facility tour between 09:00 AM and 04:00 PM on 12/13/16, based on observation and interview revealed or based on documentation review and interview that the following include:
Fire Sprinklers were not observed in the following locations:
Ambulance Garage (attached to Hospital)
Radiology Tech Area
Radiology Electrical Room
Room1-236
Room 1-236

This deficient practice could affect the safety of all the patients, staff and visitors within the smoke compartment.

This deficient practice was confirmed by the Facility Maintenance Director at the time of discovery.

Corridor - Doors
2012 EXISTING
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 1-3/4 inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Doors shall be provided with a means suitable for keeping the door closed.
There is no impediment to the closing of the doors. Clearance between bottom of door and floor covering is not exceeding 1 inch. Roller latches are prohibited by CMS regulations on corridor doors and rooms containing flammable or combustible materials. Powered doors complying with 7.2.1.9 are permissible. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted.
Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies.
19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.

On facility tour between 10:00 AM and 04:00 PM on 12/12/2016, based on observation and interview revealed the following include:

The following patient rooms were observed with a non-functioning door latch:
2-254 and 2-232

This deficient practice could affect the safety of all the residents, staff and visitors within the smoke compartment.

This deficient practice was confirmed by the Facility Maintenance Director at the time of discovery.

Utilities - Gas and Electric
Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life.
18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2

On facility tour between 10:00 AM and 04:00 PM on 12/12/2016, based on observation and interview revealed the following include:
A microwave oven was observed plugged into a power strip in the Hospitist Sleepover room (384).

This deficient practice could affect the safety of all the residents, staff and visitors within the smoke compartment.

This deficient practice was confirmed by the Facility Maintenance Director at the time of discovery.

Utilities - Gas and Electric
Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life.
18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2
Findings Include:

On facility tour between 09:00 AM and 04:00 PM on 12/13/16, based on observation and interview revealed or based on documentation review and interview that the following include:
A therapy oven was observed in the Patient Re-Hab Area without a power lock-out switch/on-off indicator light and automatic shut off timer.

This deficient practice could affect the safety of all the patients, staff and visitors within the smoke compartment.

This deficient practice was confirmed by the Facility Maintenance Director at the time of discovery.