HospitalInspections.org

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to provide 2-hour rated construction at building separation walls in accordance with 2000 - NFPA 101, sections 19.1.1.4.1 and 8.2.3.2.


Findings include:

On facility tour between 7:30 AM and 4:30 PM on 06/14 - 15/2011 , observation revealed, that the following was found:

1. The 2-hour rated building separation wall between hospital and on-site clinic does not have 90 minute doors, separating 3 out of 4 building separation openings. This was based on life safety drawing provided by the facility.

2. The 2-hour rated building separation wall between hospital (I-occupancy) and emergency room garage (S- Occupancy):
a. No 90 minute doors
b. No positive latching
c. Open penetrations


These deficient practices were confirmed by the Director of Plant Operations (TG) and Facilities Staff (JM) at the time of discovery.

This STANDARD is not met as evidenced by:

Based on observation and staff interview, this building does not meet the requirements for construction type and height in accordance with 2000 - NFPA 101, section 19.1.6.2.

Findings include:
On facility tour between 7:30 AM and 4:30 PM on 06/14 - 15/2011, observation revealed the following:

1. Basement - Medical storage room # 3, required fire-proofing was damaged or missing on the steel beams

The entire facility needs to be checked for this deficiency.


This deficient practice was confirmed by the Director of Plant Operations (TG) and Facilities Staff (JM) at the time of discovery.

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to properly separated the hazards room 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 4:30 PM on 06/14 - 15/2011, observation revealed, that the following was found:

1. Basement - Pharmacy area (storage over 50 square feet)
a. open penetrations in walls above the ceiling
b. walk up window - there is a door with no door closer
c. wall not to deck and smoke resistive

2. Basement - Health records room # 1 (storage over 50 square feet)
a. open penetrations above the ceiling

3. Basement - stock and receiving room (storage over 50 square feet)
a. open penetrations - check all walls

4. Basement - linen storage room (storage over 50 square feet)
a. no door closer

5. Basement - medical records room # 2 (storage over 50 square feet)
a. no door closer

6. Basement - medical records room # 3 (storage over 50 square feet)
a. walls not to deck on hazardous side of room

7. 2nd floor - soiled utility room # 2338
a. no door closer
b. the solid core bond door is damaged making the door non smoke resisting and non solid-bonded core door

8. 1st floor - Emergency room storage room by emergency room garage (storage over 50 square feet)
a. has no door
b. no door closer



These deficient practices were confirmed by the Director of Plant Operations (TG) and Facilities Staff (JM) 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 4:30 PM on 06/14 - 15/2011, observation revealed, that the following was found:

1. Basement - west exit stairwell, has an open penetrations

2. Basement - NW exit stairwell:
a. open penetrations (check all levels)
b. no automatic door closer
c. unknown stairwell wall construction on basement level



These deficient practices were confirmed by the Director of Plant Operations (TG) and Facilities Staff (JM) at the time of discovery.

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, 2-3.5.1 and 7-5.2 # 12.

Findings include:

On facility tour between 7:30 AM and 4:30 PM on 06/14 - 15/2011, observation and review of the available documentation, that the following was found:

1. Sleepy study room # 2, smoke detector with-in 3 feet of air supply / return vents

2. 1st floor in corridor by facility office, smoke detector (M1-10) with-in 3 feet of air supply / return vents

3. 2nd floor - doctors sleep room # 277, no smoke detector with sounder base

4. There is no documentation for the single station 110 volt smoke alarms in the patient rooms, being tested as required by manufacturers instruction



These deficient practices were confirmed by the Director of Plant Operations (TG) and Facilities Staff (JM) at the time of discovery.

This STANDARD is not met as evidenced by:

Based on observation, the facility failed to provide proper coverage of the fire sprinkler system as per
1999 NFPA 13 Chapters 3-10, 5-6.5.3, 7-4.1.7 exception (j) and 2000 NFPA 14 Chapter 3-6.1.


Findings include:

On facility tour between 7:30 AM and 4:30 PM on 06/14 - 15/2011, observation revealed, that the following was found:

1. Basement - medical records room # 3, 4 and 8 feet deep storage racks:
a. have solid shelving
b. are not properly protected by fire sprinklers

2. Basement - medical records room # 1, the fire sprinkler head is being blocked by shelving that does not have 18 inch clearance from the fire sprinkler deflector. This creates an obstruction for the fire sprinkler head.

3. Basement - medical records room # 2, is not properly protected by fire sprinklers

4. 2nd floor - NE exit stairwell, no pressure gauge at top of standpipe riser

5. No horn/strobe at exterior fire department connection



These deficient practices were confirmed by the Director of Plant Operations (TG) and Facilities Staff (JM) at the time of discovery.

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to maintain the fire sprinkler system in accordance with the requirements of 2000 NFPA 101, Sections 19.3.4.1 and 9.6, as well as 1998 NFPA 25, section 2-2.1.1.

Findings include:

On facility tour between 7:30 AM and 4:30 PM on 06/14 - 15/2011, observation revealed, that the following was found at the sprinkler riser:

1. gauges are over 5 years old (check all gauges throughout the facility)

2. spare fire sprinkler head box - there is not two spare sprinkler heads for each type of head in the facility

3. no sprinkler head wrench(s) for the type of fire sprinkler heads in the facility

4. no documentation when the last 5 year inspection was done on all check valves in the fire sprinkler system



These deficient practices were confirmed by the Director of Plant Operations (TG) and Facilities Staff (JM) at the time of discovery.

This STANDARD is not met as evidenced by:

Based on observations and interview, the facility has compressed gas cylinders not properly stored in compliance with the requirements of 1999 NFPA 99, Sections 4-3.5.2.1 (B) 27 . This deficient practice could affect some patients.

Findings include:

On facility tour between 7:30 AM and 4:30 PM on 06/14 - 15/2011, observation revealed that the following was found:

1. Basement - In room 200, there are (2) H size oxygen cylinders and (2) H size Nitrogen cylinders that are stored upright but are not property secured to prevent the cylinders from falling,


2. Basement - In room 200, there are (3) H size carbon dioxide cylinders that are stored upright but are not property secured to prevent the cylinders from falling,

3. Sleep Study area - there is (1) E size cylinder that is stored upright but is not property secured to prevent the cylinder from falling,



These deficient practices were confirmed by the Director of Plant Operations (TG) and Facilities Staff (JM) at the time of discovery.

This STANDARD is not met as evidenced by:

Based on documentation review and staff interview, the facility failed to test the emergency generators in accordance with the requirements of 2000 NFPA 101 - 9.1.3 and 1999 NFPA 110 6-4.2 (a) & (b) and 6-4.2.2. The deficient practice could affect all 41 residents.

Findings include:

On facility tour between 7:30 AM and 4:30 PM on 06/14 - 15/2011, documentation review of the monthly emergency generator testing log (June 2010 to May 2011), it could not be determined that the diesel emergency generator was being tested by one of the following means:

1. Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer or

2. under load of 30 percent or more (90 kw) of the nameplate rating (300 kw) of generator or

3. 2 hour load bank test in past 12 months. The last documented test was by Ziegler on 03/10/2010. Ziegler at that time did not perform the proper load bank as required by 1999 NFPA 110 Chapter 6-4.2.2:
a. 25 percent of nameplate rating for 30 minutes, followed by
b. 50 percent of nameplate rating for 30 minutes, followed by
c. 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.



This deficient practice was confirmed by the Director of Plant Operations (TG) and Facilities Staff (JM) 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 failed to provide 2-hour rated construction at building separation walls in accordance with 2000 - NFPA 101, sections 19.1.1.4.1 and 8.2.3.2.


Findings include:

On facility tour between 7:30 AM and 4:30 PM on 06/14 - 15/2011 , observation revealed, that the following was found:

1. The 2-hour rated building separation wall between hospital and on-site clinic does not have 90 minute doors, separating 3 out of 4 building separation openings. This was based on life safety drawing provided by the facility.

2. The 2-hour rated building separation wall between hospital (I-occupancy) and emergency room garage (S- Occupancy):
a. No 90 minute doors
b. No positive latching
c. Open penetrations


These deficient practices were confirmed by the Director of Plant Operations (TG) and Facilities Staff (JM) at the time of discovery.

This STANDARD is not met as evidenced by:

Based on observation and staff interview, this building does not meet the requirements for construction type and height in accordance with 2000 - NFPA 101, section 19.1.6.2.

Findings include:
On facility tour between 7:30 AM and 4:30 PM on 06/14 - 15/2011, observation revealed the following:

1. Basement - Medical storage room # 3, required fire-proofing was damaged or missing on the steel beams

The entire facility needs to be checked for this deficiency.


This deficient practice was confirmed by the Director of Plant Operations (TG) and Facilities Staff (JM) at the time of discovery.

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to properly separated the hazards room 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 4:30 PM on 06/14 - 15/2011, observation revealed, that the following was found:

1. Basement - Pharmacy area (storage over 50 square feet)
a. open penetrations in walls above the ceiling
b. walk up window - there is a door with no door closer
c. wall not to deck and smoke resistive

2. Basement - Health records room # 1 (storage over 50 square feet)
a. open penetrations above the ceiling

3. Basement - stock and receiving room (storage over 50 square feet)
a. open penetrations - check all walls

4. Basement - linen storage room (storage over 50 square feet)
a. no door closer

5. Basement - medical records room # 2 (storage over 50 square feet)
a. no door closer

6. Basement - medical records room # 3 (storage over 50 square feet)
a. walls not to deck on hazardous side of room

7. 2nd floor - soiled utility room # 2338
a. no door closer
b. the solid core bond door is damaged making the door non smoke resisting and non solid-bonded core door

8. 1st floor - Emergency room storage room by emergency room garage (storage over 50 square feet)
a. has no door
b. no door closer



These deficient practices were confirmed by the Director of Plant Operations (TG) and Facilities Staff (JM) 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 4:30 PM on 06/14 - 15/2011, observation revealed, that the following was found:

1. Basement - west exit stairwell, has an open penetrations

2. Basement - NW exit stairwell:
a. open penetrations (check all levels)
b. no automatic door closer
c. unknown stairwell wall construction on basement level



These deficient practices were confirmed by the Director of Plant Operations (TG) and Facilities Staff (JM) at the time of discovery.

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, 2-3.5.1 and 7-5.2 # 12.

Findings include:

On facility tour between 7:30 AM and 4:30 PM on 06/14 - 15/2011, observation and review of the available documentation, that the following was found:

1. Sleepy study room # 2, smoke detector with-in 3 feet of air supply / return vents

2. 1st floor in corridor by facility office, smoke detector (M1-10) with-in 3 feet of air supply / return vents

3. 2nd floor - doctors sleep room # 277, no smoke detector with sounder base

4. There is no documentation for the single station 110 volt smoke alarms in the patient rooms, being tested as required by manufacturers instruction



These deficient practices were confirmed by the Director of Plant Operations (TG) and Facilities Staff (JM) at the time of discovery.

This STANDARD is not met as evidenced by:

Based on observation, the facility failed to provide proper coverage of the fire sprinkler system as per
1999 NFPA 13 Chapters 3-10, 5-6.5.3, 7-4.1.7 exception (j) and 2000 NFPA 14 Chapter 3-6.1.


Findings include:

On facility tour between 7:30 AM and 4:30 PM on 06/14 - 15/2011, observation revealed, that the following was found:

1. Basement - medical records room # 3, 4 and 8 feet deep storage racks:
a. have solid shelving
b. are not properly protected by fire sprinklers

2. Basement - medical records room # 1, the fire sprinkler head is being blocked by shelving that does not have 18 inch clearance from the fire sprinkler deflector. This creates an obstruction for the fire sprinkler head.

3. Basement - medical records room # 2, is not properly protected by fire sprinklers

4. 2nd floor - NE exit stairwell, no pressure gauge at top of standpipe riser

5. No horn/strobe at exterior fire department connection



These deficient practices were confirmed by the Director of Plant Operations (TG) and Facilities Staff (JM) at the time of discovery.

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to maintain the fire sprinkler system in accordance with the requirements of 2000 NFPA 101, Sections 19.3.4.1 and 9.6, as well as 1998 NFPA 25, section 2-2.1.1.

Findings include:

On facility tour between 7:30 AM and 4:30 PM on 06/14 - 15/2011, observation revealed, that the following was found at the sprinkler riser:

1. gauges are over 5 years old (check all gauges throughout the facility)

2. spare fire sprinkler head box - there is not two spare sprinkler heads for each type of head in the facility

3. no sprinkler head wrench(s) for the type of fire sprinkler heads in the facility

4. no documentation when the last 5 year inspection was done on all check valves in the fire sprinkler system



These deficient practices were confirmed by the Director of Plant Operations (TG) and Facilities Staff (JM) at the time of discovery.

This STANDARD is not met as evidenced by:

Based on observations and interview, the facility has compressed gas cylinders not properly stored in compliance with the requirements of 1999 NFPA 99, Sections 4-3.5.2.1 (B) 27 . This deficient practice could affect some patients.

Findings include:

On facility tour between 7:30 AM and 4:30 PM on 06/14 - 15/2011, observation revealed that the following was found:

1. Basement - In room 200, there are (2) H size oxygen cylinders and (2) H size Nitrogen cylinders that are stored upright but are not property secured to prevent the cylinders from falling,


2. Basement - In room 200, there are (3) H size carbon dioxide cylinders that are stored upright but are not property secured to prevent the cylinders from falling,

3. Sleep Study area - there is (1) E size cylinder that is stored upright but is not property secured to prevent the cylinder from falling,



These deficient practices were confirmed by the Director of Plant Operations (TG) and Facilities Staff (JM) at the time of discovery.

This STANDARD is not met as evidenced by:

Based on documentation review and staff interview, the facility failed to test the emergency generators in accordance with the requirements of 2000 NFPA 101 - 9.1.3 and 1999 NFPA 110 6-4.2 (a) & (b) and 6-4.2.2. The deficient practice could affect all 41 residents.

Findings include:

On facility tour between 7:30 AM and 4:30 PM on 06/14 - 15/2011, documentation review of the monthly emergency generator testing log (June 2010 to May 2011), it could not be determined that the diesel emergency generator was being tested by one of the following means:

1. Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer or

2. under load of 30 percent or more (90 kw) of the nameplate rating (300 kw) of generator or

3. 2 hour load bank test in past 12 months. The last documented test was by Ziegler on 03/10/2010. Ziegler at that time did not perform the proper load bank as required by 1999 NFPA 110 Chapter 6-4.2.2:
a. 25 percent of nameplate rating for 30 minutes, followed by
b. 50 percent of nameplate rating for 30 minutes, followed by
c. 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.



This deficient practice was confirmed by the Director of Plant Operations (TG) and Facilities Staff (JM) at the time of discovery.





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