HospitalInspections.org

Facility failed to maintain corridors in accordance with the 2000 edition of the Life Safety Code, NFPA 101. Findings included the following:

Surveyor observed between 12:30 and 1:30 pm on 7/21/15 that IT room ( former surgery lounge) had air transfer grilles in corridor. This does not meet NFPA 101, 2003: 19.3.6.4 Transfer Grilles. Transfer grilles, regardless of whether they are protected by fusible-link dampers, shall not be used in these walls or doors. In addition the door was chocked open with waste basket due to heat build up.

Facility to maintain 4 doors to egress corridor in accordance with the 2000 edition of the Life Safety Code NFPA (National Fire Protection Association) 101. Findings included the following:

Surveyor observed between 12:30 and 1:30 pm on 7/21/15 that doors to IT, dining, pharmacy, and central supply were chocked open which is an impediment to closing the doors.

Facility failed to maintain sprinkler piping in accordance with NFPA 13, Standard for installation of Fire Sprinklers. Findings included the following:

Surveyor observed between 11:00 and 11:30 am on 7/21/15 that one fire sprinkler below ceiling in alcove leading to Maintenance Room and one in the kitchen near stove appeared to be bent.

Facility failed to maintain ventilation in accordance with ventilation table cross-referenced in
NFPA 90A, Findings included the following:

Surveyor observed between 1:00 and 1:30 pm that storage room had been coverted to use as janitor closet and exhaust required for this room was present.

Facility failed to maintain disaster policy in accordance with the Standard for Health Care Facilities, NFPA
99. Findings included the following:

Surveyor observed between 1:00 and 1:30 pm on 7/21/15 that disaster policy did not specifically require after-action reports of disaster drills.

Facililty failed to maintain electrical panels in accordance with the National Electrical Code, NFPA 70. Findings included the following:

Surveyor observed between 12:30 and 1:30 pm on 7/21/15 that 2 electrical panels in corridor including emergency panel near central supply were unlocked and not secure from unauthorized individuals.