HospitalInspections.org

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility had corridor doors which were impeded from fully closing and latching into their frames in accordance with the requirements of 2000 NFPA 101, Sections 19.3.6.3.2.


FINDINGS INCLUDE:

On facility tour between 7:30 AM and 12:30 PM on 08/17/2011, observation revealed the following:

1. 1st floor - Cindy's office door that opens to the corridor does not have positive latching hardware

2. Basement - north dietary door that opens to the corridor does not have positive latching hardware

3. Basement - housekeeping door that opens to the corridor does not have positive latching hardware


These deficient practices were confirmed by the Facility Manager (JZ), at the time of discovery.

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to maintain 1 hour fire rated wall construction in accordance with the following requirements of 2000 NFPA 101, Section 19.3.2.1.


Findings include:

On facility tour between 7:30 AM and 12:30 PM on 08/17/2011, observation revealed, the following was found:

1. Basement - Central Supply Room (over 50 square feet),
a. no positive latching
b. open penetrations above the ceiling on south wall

2. Basement - storage room # 151 (over 50 square feet), does not have automatic door closer on the east and west doors



These deficient practices were confirmed by the Facility Manager (JZ), at the time of discovery.

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 one hour in the exit component accordance with the following requirements of 2000 NFPA 101, Section 19.3.1.1, 8.2.5.2.

Findings include:

On facility tour between 7:30 AM and 12:30 PM on 08/17/2011, observation revealed, that the 2nd floor - Stairwell "A" door does not have a 1 hour fire rating label.



This deficient practice was confirmed by the Facility Manager (JZ), at the time of discovery.

This STANDARD is not met as evidenced by:

Based on documentation review and staff interview, the facility failed to assure fire drills were conducted once per shift per quarter as required by 2000 NFPA 101, Section 19.7.1.2..

Findings include:

On facility tour between 7:30 AM and 12:30 PM on 08/17/2011, the review of the fire drill documentation for the past 12 months (August 2010 to July 2011) revealed, that the facility failed to vary time/conditions on the falling shifts:

1. Days - 0800, 1452, 0810 and 0826 hours

2. Evenings - 1853, 1620, 1700 and 1609 hours

3. Nights - 0736, 0700, 0740 and 0720 hours



This deficient practice was confirmed by the Facility Manager (JZ), at the time of discovery.

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to provide proper fire sprinkler system as per 1999 NFPA 13 Chapter 5-15.2.3.5, 1998 NFPA 25 Chapter 2-2.1.1 and 2-2.3 and 2000 NFPA 101 Chapter 19.3.5 and 9.7.


Findings include:

On facility tour between 7:30 AM and 12:30 PM on 08/17/2011, observation revealed, that the following was found


1. 1st floor - Emergency room - janitor closet, the ceiling was removed and has a pendant sprinkler head


2. Outside Fire Department Connection, has a name plate that states "Wall Hydrant" inside of Fire Department Connection

3. 1st floor - Inside clean linen room across from room #107, the sprinkler head and pipe are dropping down from ceiling. Need to check for proper hanger.

4. Basement - conference room "C", closet does not have fire sprinkler protection



These deficient practices were confirmed by the Facility Manager (JZ), at the time of discovery.

This STANDARD is not met as evidenced by:

Based on documentation review and staff interview, that the facility's general ventilating and air conditioning system (HVAC) was not maintained in accordance with the LSC, Section 19.5.2.1 and NFPA 90A, Section 3-4.7.

Findings include:

On facility tour between 7:30 AM and 12:30 PM on 08/17/2011, documentation review of the fire/smoke damper testing log for the past 4 or 6 years revealed, that the fire/smoke dampers have not been visual inspected and documented.


This deficient practice was confirmed by the Facility Manager (JZ), at the time of discovery.




*TEAM COMPOSITION*
Gary Schroeder, Life Safety Code Spc.

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility had corridor doors which were impeded from fully closing and latching into their frames in accordance with the requirements of 2000 NFPA 101, Sections 19.3.6.3.2.


FINDINGS INCLUDE:

On facility tour between 7:30 AM and 12:30 PM on 08/17/2011, observation revealed the following:

1. 1st floor - Cindy's office door that opens to the corridor does not have positive latching hardware

2. Basement - north dietary door that opens to the corridor does not have positive latching hardware

3. Basement - housekeeping door that opens to the corridor does not have positive latching hardware


These deficient practices were confirmed by the Facility Manager (JZ), at the time of discovery.

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to maintain 1 hour fire rated wall construction in accordance with the following requirements of 2000 NFPA 101, Section 19.3.2.1.


Findings include:

On facility tour between 7:30 AM and 12:30 PM on 08/17/2011, observation revealed, the following was found:

1. Basement - Central Supply Room (over 50 square feet),
a. no positive latching
b. open penetrations above the ceiling on south wall

2. Basement - storage room # 151 (over 50 square feet), does not have automatic door closer on the east and west doors



These deficient practices were confirmed by the Facility Manager (JZ), at the time of discovery.

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 one hour in the exit component accordance with the following requirements of 2000 NFPA 101, Section 19.3.1.1, 8.2.5.2.

Findings include:

On facility tour between 7:30 AM and 12:30 PM on 08/17/2011, observation revealed, that the 2nd floor - Stairwell "A" door does not have a 1 hour fire rating label.



This deficient practice was confirmed by the Facility Manager (JZ), at the time of discovery.

This STANDARD is not met as evidenced by:

Based on documentation review and staff interview, the facility failed to assure fire drills were conducted once per shift per quarter as required by 2000 NFPA 101, Section 19.7.1.2..

Findings include:

On facility tour between 7:30 AM and 12:30 PM on 08/17/2011, the review of the fire drill documentation for the past 12 months (August 2010 to July 2011) revealed, that the facility failed to vary time/conditions on the falling shifts:

1. Days - 0800, 1452, 0810 and 0826 hours

2. Evenings - 1853, 1620, 1700 and 1609 hours

3. Nights - 0736, 0700, 0740 and 0720 hours



This deficient practice was confirmed by the Facility Manager (JZ), at the time of discovery.

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to provide proper fire sprinkler system as per 1999 NFPA 13 Chapter 5-15.2.3.5, 1998 NFPA 25 Chapter 2-2.1.1 and 2-2.3 and 2000 NFPA 101 Chapter 19.3.5 and 9.7.


Findings include:

On facility tour between 7:30 AM and 12:30 PM on 08/17/2011, observation revealed, that the following was found


1. 1st floor - Emergency room - janitor closet, the ceiling was removed and has a pendant sprinkler head


2. Outside Fire Department Connection, has a name plate that states "Wall Hydrant" inside of Fire Department Connection

3. 1st floor - Inside clean linen room across from room #107, the sprinkler head and pipe are dropping down from ceiling. Need to check for proper hanger.

4. Basement - conference room "C", closet does not have fire sprinkler protection



These deficient practices were confirmed by the Facility Manager (JZ), at the time of discovery.

This STANDARD is not met as evidenced by:

Based on documentation review and staff interview, that the facility's general ventilating and air conditioning system (HVAC) was not maintained in accordance with the LSC, Section 19.5.2.1 and NFPA 90A, Section 3-4.7.

Findings include:

On facility tour between 7:30 AM and 12:30 PM on 08/17/2011, documentation review of the fire/smoke damper testing log for the past 4 or 6 years revealed, that the fire/smoke dampers have not been visual inspected and documented.


This deficient practice was confirmed by the Facility Manager (JZ), at the time of discovery.




*TEAM COMPOSITION*
Gary Schroeder, Life Safety Code Spc.