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 18.1.1.4.3,. 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 9:00 AM to 5:00 PM on 09/08/11, observation revealed, that the 2-hour rated building separation wall on the 1st floor between the hospital (I-occupancy) and the emergency room's garage (S- Occupancy) 90 minute fire doors had a 1/4 inch gap between the door leaves.


This deficient practice was confirmed by the Maintenance Supervisor (DL).

This STANDARD is not met as evidenced by:

Based on observations, the facility has failed to provide proper protection for several hazardous areas located throughout the facility in accordance with NFPA Life Safety Code 101 (2000 edition) section 18.3.2.1. The following deficient practices could affect all patients, staff and visitors as smoke and fire in this rooms could enter the corridor making it untenable.

Findings include:

On facility tour between 9:00 AM to 5:00 PM on 09/08/11, observation revealed, that the following deficient conditions were identified:

1. The Emergency Room Equipment Storage Room door did not positively close and latch in the frame.

2. A penetration was found above the door in the same day surgery unit's Electrical Room.


This deficient practice was confirmed by the Maintenance Supervisor (DL).

This STANDARD is not met as evidenced by:

Based on an interview with staff, the facility has failed to ensure that emergency lighting has been tested in accordance with NFPA LSC (00) Section 7.9, 18.2.9.1. This deficient practice could affect all patients, staff and visitors in the event of an emergency evacuation during a power outage.

Findings include:

On facility tour between 9:00 AM and 5:00 PM on 9/8/11, during a documentation review and interview with the Maintenance Supervisor (DL), it was revealed that there was no documentation of monthly 30 second testing, and the annual 1 1/2 hour testing for all of the battery powered emergency lights throughout the facility per NFPA 101, 2000 Edition Chapter 18, sec 18.2.9.1.


This deficient practice was confirmed by the Maintenance Supervisor (DL).

This STANDARD is not met as evidenced by:

Based on review of reports, records and interview, it was determined that the facility failed to vary the times on numerous fire drills in the last 12-month period. 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, staff and visitors.
.

Findings include:

On facility tour between 9:00 AM and 5:00 PM on 9/8/11, during a documentation review of the available fire drill reports and interview with the Facility Maintenance Supervisor (DL), it was revealed that the facility failed to conduct the required number of fire drills as follows,

1. The Facility failed to conduct 2 of 4 fire drills for the 2nd shift,
2. The Facility failed to conduct 4 of 4 fire drills for the 3rd shift.


This deficient practice was confirmed by the Maintenance Supervisor (DL).

This STANDARD is not met as evidenced by:

Based on observations, the automatic sprinkler system is not installed and maintained in accordance with NFPA 13 the Standard for the Installation of Sprinkler Systems (99). This failure to maintain the sprinkler system in compliance with NFPA 13 (99) could allow fire development that would reduce the egress conditions affecting all patients, staff and visitors of the facility.

Findings include:

On facility tour between 9:00 AM and 5:00 PM on 9/8/11, it was observed that the Post Indicator Valve located outside in the rear of the facility that is open to the public was not electronically monitored.


This deficient practice was confirmed by the Maintenance Supervisor (DL).

This STANDARD is not met as evidenced by:

Based on documentation review and interview with staff, the facility has failed to properly inspect and maintain the automatic sprinkler system in accordance with NFPA 101 LSC (00) section 18.7.6, 4.6.12. This deficient practice does not ensure that the fire sprinkler system is functioning properly and is fully operational in the event of a fire and could negatively affect all patients, staff and visitors.

Findings include:

On facility tour between 9:00 AM and 5:00 PM on 9/8/11, during a review of the available fire sprinkler test and inspection documentation, observations revealed and were confirmed by interview with the Maintenance Supervisor (DL), that the facility failed to provide documentation for 1 of 4 fire sprinkler flow tests of the facility's fire sprinkler system.

This deficient practice was confirmed by the Maintenance Supervisor (DL).

Based on observations, it was determined that the facility failed to install and maintain portable fire extinguishers in accordance with NFPA 101-2000 edition, Section 9.7.4.1 and NFPA 10. This deficient practice could affect all patients, staff and visitors.

Findings include:

On facility tour between 9:00 AM and 5:00 PM on 9/8/11, observations Revealed that the facility failed to provide the minimum required Fire extinguisher protection for the facility's Heli-pad.


This deficient practice was confirmed by the Maintenance Supervisor (DL).

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 18.1.1.4.3,. 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 9:00 AM to 5:00 PM on 09/08/11, observation revealed, that the 2-hour rated building separation wall on the 1st floor between the hospital (I-occupancy) and the emergency room's garage (S- Occupancy) 90 minute fire doors had a 1/4 inch gap between the door leaves.


This deficient practice was confirmed by the Maintenance Supervisor (DL).

This STANDARD is not met as evidenced by:

Based on observations, the facility has failed to provide proper protection for several hazardous areas located throughout the facility in accordance with NFPA Life Safety Code 101 (2000 edition) section 18.3.2.1. The following deficient practices could affect all patients, staff and visitors as smoke and fire in this rooms could enter the corridor making it untenable.

Findings include:

On facility tour between 9:00 AM to 5:00 PM on 09/08/11, observation revealed, that the following deficient conditions were identified:

1. The Emergency Room Equipment Storage Room door did not positively close and latch in the frame.

2. A penetration was found above the door in the same day surgery unit's Electrical Room.


This deficient practice was confirmed by the Maintenance Supervisor (DL).

This STANDARD is not met as evidenced by:

Based on an interview with staff, the facility has failed to ensure that emergency lighting has been tested in accordance with NFPA LSC (00) Section 7.9, 18.2.9.1. This deficient practice could affect all patients, staff and visitors in the event of an emergency evacuation during a power outage.

Findings include:

On facility tour between 9:00 AM and 5:00 PM on 9/8/11, during a documentation review and interview with the Maintenance Supervisor (DL), it was revealed that there was no documentation of monthly 30 second testing, and the annual 1 1/2 hour testing for all of the battery powered emergency lights throughout the facility per NFPA 101, 2000 Edition Chapter 18, sec 18.2.9.1.


This deficient practice was confirmed by the Maintenance Supervisor (DL).

This STANDARD is not met as evidenced by:

Based on review of reports, records and interview, it was determined that the facility failed to vary the times on numerous fire drills in the last 12-month period. 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, staff and visitors.
.

Findings include:

On facility tour between 9:00 AM and 5:00 PM on 9/8/11, during a documentation review of the available fire drill reports and interview with the Facility Maintenance Supervisor (DL), it was revealed that the facility failed to conduct the required number of fire drills as follows,

1. The Facility failed to conduct 2 of 4 fire drills for the 2nd shift,
2. The Facility failed to conduct 4 of 4 fire drills for the 3rd shift.


This deficient practice was confirmed by the Maintenance Supervisor (DL).

This STANDARD is not met as evidenced by:

Based on observations, the automatic sprinkler system is not installed and maintained in accordance with NFPA 13 the Standard for the Installation of Sprinkler Systems (99). This failure to maintain the sprinkler system in compliance with NFPA 13 (99) could allow fire development that would reduce the egress conditions affecting all patients, staff and visitors of the facility.

Findings include:

On facility tour between 9:00 AM and 5:00 PM on 9/8/11, it was observed that the Post Indicator Valve located outside in the rear of the facility that is open to the public was not electronically monitored.


This deficient practice was confirmed by the Maintenance Supervisor (DL).

This STANDARD is not met as evidenced by:

Based on documentation review and interview with staff, the facility has failed to properly inspect and maintain the automatic sprinkler system in accordance with NFPA 101 LSC (00) section 18.7.6, 4.6.12. This deficient practice does not ensure that the fire sprinkler system is functioning properly and is fully operational in the event of a fire and could negatively affect all patients, staff and visitors.

Findings include:

On facility tour between 9:00 AM and 5:00 PM on 9/8/11, during a review of the available fire sprinkler test and inspection documentation, observations revealed and were confirmed by interview with the Maintenance Supervisor (DL), that the facility failed to provide documentation for 1 of 4 fire sprinkler flow tests of the facility's fire sprinkler system.

This deficient practice was confirmed by the Maintenance Supervisor (DL).

Based on observations, it was determined that the facility failed to install and maintain portable fire extinguishers in accordance with NFPA 101-2000 edition, Section 9.7.4.1 and NFPA 10. This deficient practice could affect all patients, staff and visitors.

Findings include:

On facility tour between 9:00 AM and 5:00 PM on 9/8/11, observations Revealed that the facility failed to provide the minimum required Fire extinguisher protection for the facility's Heli-pad.


This deficient practice was confirmed by the Maintenance Supervisor (DL).