HospitalInspections.org

K-11

Based on observation and interviews, this facility is not ensuring the two hour fire separation between the Hospital and the nursing home portion of the facility. The rated door in the opening did not positively latch when closed. This deficient practice affects all occupants including staff, visitors and residents. This facility has a capacity of 20 and a census of 4 residents. Findings include:


Observation on 7-13-10 at 10:41 a.m. reveal the door in the two hour separation between the hospital and nursing home did not positively latch when closed. Observation confirmed by maintenance staff at the time of the observation and during the exit interview.

NFPA Standard: Health care occupancies in buildings housing other occupancies shall be completely separated from them by construction having a fire resistance rating of not less than 2 hours as provided for additions in 18/19.1.1.4. 2000 NFPA 101, 18/19.1.2.3

K-29

Based on observation and interview the facility failed to maintain the separation of hazardous areas by not having rated doors and doors that are self-closing. This deficient practice has the potential to affect all residents, staff, and visitors of the facility. The facility capacity is 20 and the census was 4.
Findings Include:

Observation on 7-13-10 at 10:35 a.m. revealed the supply storage room door was being held open with a wedge and the area was unoccupied. Observation confirmed by maintenance staff at the time of the observation and during the exit interview.

Observation on 7-13-10 at 11:06 a.m. revealed storage room 108 in the patient care area the door is not equipped with self closing device. Observation confirmed by maintenance staff at the time of the observation and during the exit interview.

NFPA Standard: Hazardous areas shall be safeguarded by a fire barrier of one-
hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1

K-38

Based on observation, staff interview and record review this facility is not providing unobstructed corridors that provides a clear path of egress. This facility has a capacity of 20 with a census of 4. Findings include:

Observation on 7-13-10 at 11:10 a.m. revealed the facility is storing and charging blood pressure machines in the corridor near the reception area. Observation confirmed by maintenance staff at the time of the observation and during the exit interview.

NFPA Standard: Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. 2000 NFPA 101, 7.1.10.1

K-46

The facility failed to provide a means of illumination at each exit discharge so that failure of normal lighting would not leave the area to a public way in darkness. This has the potential of affecting all occupants of the building in the event of a power failure. This facility has a census of 20 with a capacity of 4. Findings are:


Observation on 7-13-10 at 11:15 a.m. of the east exit of the patient care wing the facility did not have egress lighting to the public way on the sidewalk on the south side of the building. Observation confirmed by maintenance staff at the time of the observation and during the exit interview.

NFPA Standard: Emergency illumination shall be provided for not less than 11/2 hours in the event of failure of normal lighting. Emergency lighting facilities shall be arranged to provide initial illumination that is not less than an average of 1 foot-candle. 2000 NFPA 101, 7.9.2.1

NFPA Standard: The emergency lighting system shall be arranged to provide the required illumination automatically in the event of the interruption of normal lighting, opening of a circuit breaker, or a manual act, including accidental opening of a switch controlling normal lighting facilities. 2000 NFPA 101, 7.9.2.2

K147

Based on observation and interview the facility failed to maintain the electrical system of the facility in accordance with NFPA 70, National Electrical Code 1999ed. by having emergency lighting units installed with cords and not connected to the circuit supplying. This deficient practice affects all patients, visitors and staff. The facility capacity is 20 and the census was 4.

Observation on 7-13-10 at 10:45 a.m. revealed the battery-powered emergency light in the generator room was plugged into an electrical receptacle and was not connected to the circuit that supplies the normal lighting for the area. Observation confirmed by maintenance staff at the time of the observation and during the exit interview.

K-11

Based on observation and interviews, this facility is not ensuring the two hour fire separation between the Hospital and the nursing home portion of the facility. The rated door in the opening did not positively latch when closed. This deficient practice affects all occupants including staff, visitors and residents. This facility has a capacity of 20 and a census of 4 residents. Findings include:


Observation on 7-13-10 at 10:41 a.m. reveal the door in the two hour separation between the hospital and nursing home did not positively latch when closed. Observation confirmed by maintenance staff at the time of the observation and during the exit interview.

NFPA Standard: Health care occupancies in buildings housing other occupancies shall be completely separated from them by construction having a fire resistance rating of not less than 2 hours as provided for additions in 18/19.1.1.4. 2000 NFPA 101, 18/19.1.2.3

K-29

Based on observation and interview the facility failed to maintain the separation of hazardous areas by not having rated doors and doors that are self-closing. This deficient practice has the potential to affect all residents, staff, and visitors of the facility. The facility capacity is 20 and the census was 4.
Findings Include:

Observation on 7-13-10 at 10:35 a.m. revealed the supply storage room door was being held open with a wedge and the area was unoccupied. Observation confirmed by maintenance staff at the time of the observation and during the exit interview.

Observation on 7-13-10 at 11:06 a.m. revealed storage room 108 in the patient care area the door is not equipped with self closing device. Observation confirmed by maintenance staff at the time of the observation and during the exit interview.

NFPA Standard: Hazardous areas shall be safeguarded by a fire barrier of one-
hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1

K-38

Based on observation, staff interview and record review this facility is not providing unobstructed corridors that provides a clear path of egress. This facility has a capacity of 20 with a census of 4. Findings include:

Observation on 7-13-10 at 11:10 a.m. revealed the facility is storing and charging blood pressure machines in the corridor near the reception area. Observation confirmed by maintenance staff at the time of the observation and during the exit interview.

NFPA Standard: Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. 2000 NFPA 101, 7.1.10.1

K-46

The facility failed to provide a means of illumination at each exit discharge so that failure of normal lighting would not leave the area to a public way in darkness. This has the potential of affecting all occupants of the building in the event of a power failure. This facility has a census of 20 with a capacity of 4. Findings are:


Observation on 7-13-10 at 11:15 a.m. of the east exit of the patient care wing the facility did not have egress lighting to the public way on the sidewalk on the south side of the building. Observation confirmed by maintenance staff at the time of the observation and during the exit interview.

NFPA Standard: Emergency illumination shall be provided for not less than 11/2 hours in the event of failure of normal lighting. Emergency lighting facilities shall be arranged to provide initial illumination that is not less than an average of 1 foot-candle. 2000 NFPA 101, 7.9.2.1

NFPA Standard: The emergency lighting system shall be arranged to provide the required illumination automatically in the event of the interruption of normal lighting, opening of a circuit breaker, or a manual act, including accidental opening of a switch controlling normal lighting facilities. 2000 NFPA 101, 7.9.2.2

K147

Based on observation and interview the facility failed to maintain the electrical system of the facility in accordance with NFPA 70, National Electrical Code 1999ed. by having emergency lighting units installed with cords and not connected to the circuit supplying. This deficient practice affects all patients, visitors and staff. The facility capacity is 20 and the census was 4.

Observation on 7-13-10 at 10:45 a.m. revealed the battery-powered emergency light in the generator room was plugged into an electrical receptacle and was not connected to the circuit that supplies the normal lighting for the area. Observation confirmed by maintenance staff at the time of the observation and during the exit interview.