HospitalInspections.org

This STANDARD is not met as evidenced by:

Observations revealed that there were several fire barriers located throughout the facility that did not meet the rated requirements for two hour fire separation and are not in accordance with NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 19.1.1.4.3,. These deficient practices could allow the products of combustion to travel from one building to another, which could negatively impact all the patients, staff and visitors of the facility.

Findings include:

On facility tour between 1:00 PM on 05/14/2012 to 1:00 PM on 05/15/2012, observation revealed, that the following deficient conditions were identified:

1. The 2-hour fire rated building separation wall on the 1st floor between the hospital (I-occupancy) and the emergency room's garage (S- Occupancy) was not equipped with the required 90 minute doors, nor did the existing doors positively latch when closed,

2. The 2 hour fire separation wall separating the garage from the emergency room was found to have multiple penetrations passing through it that were not sealed with an approved through penetration fire rated intumescent fire caulking.

3. The door leading to the Ambulance Garage did not become positively latch upon closing during the activation of the facility's fire alarm system.


These deficient practices were confirmed by the Director of Facilities (ML).

This STANDARD is not met as evidenced by:

Based on observations, the facility has failed to provide proper protection for 1 of several hazardous areas located throughout the facility in accordance with NFPA Life Safety Code 101 (2000 edition) section 19.3.2.1. The following deficient practices could affect patients, staff and visitors as smoke and fire in this rooms could enter the corridor making it untenable.

Findings include:

On facility tour between 1:00 PM on 05/14/2012 to 1:00 PM on 05/15/2012, observation revealed that the Main Floor Emergency department's soiled utility room had a door that is not equipped with a self closing device.


This deficient practice was verified by the Facility Administrator (TL).

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to maintain a fire resistance rating of at least two hour in the exit component accordance with the following requirements of 2000 NFPA 101, Section 19.3.1.2, 8.2.5.2 and 7.1.3.2.1 (e). These deficient practices could allow the products of combustion to travel from the affected building and into the exiting component making it untenable, which could negatively impact all the patients, staff and visitors of the facility.


Findings include:

On facility tour between 1:00 PM on 05/14/2012 to 1:00 PM on 05/15/2012, observation revealed, that the Main Floor stairwell by the Ambulance Garage had open penetrations on the corridor side above the ceiling tile around the heating lines.


These deficient practices were confirmed by the Director of Facilities (ML).

This STANDARD is not met as evidenced by:

Based on observations and interviews the facility failed to ensure 100 percent employee participation during the required fire drills per the requirements of 2000 NFPA 101, Section 19.7.1.2. This deficient practice could affect how staff react in the event of a fire. Improper reaction by staff would affect the safety of all patients, visitors and staff.

Findings include:

On facility tour between 1:00 PM on 05/14/2012 to 1:00 PM on 05/15/2012, during the fire drill that was conducted in the operating suite, DSFM (GS) observed 2 staff members in the Emergency Department that did not participate in the fire drill. He approached the two staff members (DR & PA) and asked if they normally participated in fire drills and they stated "nope". In an interview with the Director of Facilities (ML) it was stated that hospital policy states that all staff participate in any fire drill conducted on site. This deficient practice reduces the knowledge and awareness of fire safety during a fire drill and will also reduce the man power needed during a fire emergency.


These deficient practices were confirmed by the Director of Facilities (ML).

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to install and maintain the fire alarm system in accordance with the requirements of 2000 NFPA 101, Sections 19.3.4.1 and 9.6, as well as 1999 NFPA 72, Sections 2-3.4.5.1.2, 2-3.5.1. These deficient practices could adversely affect the functioning of the fire alarm system that could delay the timely notification and emergency actions for the facility thus negatively affecting all patients, staff, and visitors of the facility.


Findings include:


On facility tour between 1:00 PM on 05/14/2012 to 1:00 PM on 05/15/2012, observation revealed, that the following deficient conditions were identified:

1. On the Main Floor, the fire alarm FCPS 1 & 2 located in the panel room across from Cat Scan room is not protected by automatic smoke detection,

2. On the 2nd floor in the Doctor's On-Call sleeping room there were no audible fire alram sounding devices in conjunction with the fire alarm smoke detection head to notify sleeping staff in the room of an alarm activation, and

3. There were smoke detectors that are located with-in 3 feet of air supply and/or return vents at the following locations:
a. Main floor - in hallway by ER room #14
b. Main floor -in hallway by electrical panel "P"
c. 2nd floor - ICU store room


These deficient practices were confirmed by the Director of Facilities (ML).



These deficient practices were confirmed by the Director of Maintenance (AA) at the time of discovery.

This STANDARD is not met as evidenced by:

Observations revealed that the oxygen and medical gas systems are not properly labeled in accordance with NFPA 99 Standards for Health Care Facilities (1999 edition). This deficient practice could create confusion in identifying medical gas piping located in the interstitial spaces and could negatively impact all patients and staff in an emergency.

Findings include:

On facility tour between 1:00 PM on 05/14/2012 to 1:00 PM on 05/15/2012, the following deficient practices were observed involving the oxygen and medical gas systems and storage:

1. On the main floor, the Emergency Room medical gas zone control valve lines boxes (3 valve locations) are not identified with proper labels,

2. On the main floor in the Ambulance storage room and in the Respiratory Therapy storage room the facility is storing oxygen cylinders, and the entrance doors to these rooms are not properly labeled with Oxygen Storage signd, and

3. On the main floor in the EMS/Respiratory Director's office area the medical gas lines above the ceiling are not identified with the proper labels.

These deficient practices were confirmed by the Director of Facilities (ML).

This STANDARD is not met as evidenced by:

Observations revealed that there were several fire barriers located throughout the facility that did not meet the rated requirements for two hour fire separation and are not in accordance with NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 19.1.1.4.3,. These deficient practices could allow the products of combustion to travel from one building to another, which could negatively impact all the patients, staff and visitors of the facility.

Findings include:

On facility tour between 1:00 PM on 05/14/2012 to 1:00 PM on 05/15/2012, observation revealed, that the following deficient conditions were identified:

1. The 2-hour fire rated building separation wall on the 1st floor between the hospital (I-occupancy) and the emergency room's garage (S- Occupancy) was not equipped with the required 90 minute doors, nor did the existing doors positively latch when closed,

2. The 2 hour fire separation wall separating the garage from the emergency room was found to have multiple penetrations passing through it that were not sealed with an approved through penetration fire rated intumescent fire caulking.

3. The door leading to the Ambulance Garage did not become positively latch upon closing during the activation of the facility's fire alarm system.


These deficient practices were confirmed by the Director of Facilities (ML).

This STANDARD is not met as evidenced by:

Based on observations, the facility has failed to provide proper protection for 1 of several hazardous areas located throughout the facility in accordance with NFPA Life Safety Code 101 (2000 edition) section 19.3.2.1. The following deficient practices could affect patients, staff and visitors as smoke and fire in this rooms could enter the corridor making it untenable.

Findings include:

On facility tour between 1:00 PM on 05/14/2012 to 1:00 PM on 05/15/2012, observation revealed that the Main Floor Emergency department's soiled utility room had a door that is not equipped with a self closing device.


This deficient practice was verified by the Facility Administrator (TL).

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to maintain a fire resistance rating of at least two hour in the exit component accordance with the following requirements of 2000 NFPA 101, Section 19.3.1.2, 8.2.5.2 and 7.1.3.2.1 (e). These deficient practices could allow the products of combustion to travel from the affected building and into the exiting component making it untenable, which could negatively impact all the patients, staff and visitors of the facility.


Findings include:

On facility tour between 1:00 PM on 05/14/2012 to 1:00 PM on 05/15/2012, observation revealed, that the Main Floor stairwell by the Ambulance Garage had open penetrations on the corridor side above the ceiling tile around the heating lines.


These deficient practices were confirmed by the Director of Facilities (ML).

This STANDARD is not met as evidenced by:

Based on observations and interviews the facility failed to ensure 100 percent employee participation during the required fire drills per the requirements of 2000 NFPA 101, Section 19.7.1.2. This deficient practice could affect how staff react in the event of a fire. Improper reaction by staff would affect the safety of all patients, visitors and staff.

Findings include:

On facility tour between 1:00 PM on 05/14/2012 to 1:00 PM on 05/15/2012, during the fire drill that was conducted in the operating suite, DSFM (GS) observed 2 staff members in the Emergency Department that did not participate in the fire drill. He approached the two staff members (DR & PA) and asked if they normally participated in fire drills and they stated "nope". In an interview with the Director of Facilities (ML) it was stated that hospital policy states that all staff participate in any fire drill conducted on site. This deficient practice reduces the knowledge and awareness of fire safety during a fire drill and will also reduce the man power needed during a fire emergency.


These deficient practices were confirmed by the Director of Facilities (ML).

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to install and maintain the fire alarm system in accordance with the requirements of 2000 NFPA 101, Sections 19.3.4.1 and 9.6, as well as 1999 NFPA 72, Sections 2-3.4.5.1.2, 2-3.5.1. These deficient practices could adversely affect the functioning of the fire alarm system that could delay the timely notification and emergency actions for the facility thus negatively affecting all patients, staff, and visitors of the facility.


Findings include:


On facility tour between 1:00 PM on 05/14/2012 to 1:00 PM on 05/15/2012, observation revealed, that the following deficient conditions were identified:

1. On the Main Floor, the fire alarm FCPS 1 & 2 located in the panel room across from Cat Scan room is not protected by automatic smoke detection,

2. On the 2nd floor in the Doctor's On-Call sleeping room there were no audible fire alram sounding devices in conjunction with the fire alarm smoke detection head to notify sleeping staff in the room of an alarm activation, and

3. There were smoke detectors that are located with-in 3 feet of air supply and/or return vents at the following locations:
a. Main floor - in hallway by ER room #14
b. Main floor -in hallway by electrical panel "P"
c. 2nd floor - ICU store room


These deficient practices were confirmed by the Director of Facilities (ML).



These deficient practices were confirmed by the Director of Maintenance (AA) at the time of discovery.

This STANDARD is not met as evidenced by:

Observations revealed that the oxygen and medical gas systems are not properly labeled in accordance with NFPA 99 Standards for Health Care Facilities (1999 edition). This deficient practice could create confusion in identifying medical gas piping located in the interstitial spaces and could negatively impact all patients and staff in an emergency.

Findings include:

On facility tour between 1:00 PM on 05/14/2012 to 1:00 PM on 05/15/2012, the following deficient practices were observed involving the oxygen and medical gas systems and storage:

1. On the main floor, the Emergency Room medical gas zone control valve lines boxes (3 valve locations) are not identified with proper labels,

2. On the main floor in the Ambulance storage room and in the Respiratory Therapy storage room the facility is storing oxygen cylinders, and the entrance doors to these rooms are not properly labeled with Oxygen Storage signd, and

3. On the main floor in the EMS/Respiratory Director's office area the medical gas lines above the ceiling are not identified with the proper labels.

These deficient practices were confirmed by the Director of Facilities (ML).