HospitalInspections.org

One story Existing Health Care Occupancy buildings of Type II (000) construction are required to be protected throughout with an automatic fire sprinkler system.

The facility failed to provide a structure that meets the requirements of the Life Safety Code.

Observation determined the construction type of Cavalier County Memorial Hospital is Type II (000). Unprotected metal structural members above the non-rated suspended ceiling assemblies were observed throughout the first floor. The building is not protected throughout with an automatic sprinkler system.

The facility failed to provide corridors separated from use areas by walls with at least 1/2 hour fire resistance rating.

Observation determined:

1) The exit corridor walls throughout the Main Floor were not constructed with 30 minute fire rated material.

2) The exit corridor walls were not fire resistive construction from the floor to the roof deck.

3) The exit corridor walls were not plastered on both sides of the metal studs.

Approximately 12 - 18 inches of the exit corridor walls (above the suspended ceilings) throughout the main floor had exposed metal studs on the corridor side.

The facility failed to separate hazardous areas from other spaces with self-closing doors.

Observation determined the door to the Record Storage Room, one of two hazardous areas, was not equipped with a self-closing device.

The facility failed to ensure exit access was readily accessible at all times.

1) Observation determined two (2) of three (3) exit stairs had obstructions that reduced the clear width of the stairs to less than 44 inches.

a) A fixed heater was located in the south exit stair that reduced the width of the stairs to 40 inches.

b) A fixed heater was located in the east exit stair that reduced the width of the stairs to 36 inches.

2) Exits must terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge must be of required width and size to provide all occupants with safe access to a public way. 7.7.1

To ensure adequate exit capability, CMS requires asphalt or concrete surfaces from exterior exits to public ways.

Observation determined the two (2) east exterior exits transversed the lawn to get to a public way.

The facility failed to ensure the exit signs were displayed with continuous illumination.

Observation determined the exit signs above the exterior door to the Emergency Entrance and the Emergency Room were not illuminated.

The owner or occupant of a property in which fire extinguishers are provided for the protection of the structure and the hazardous combustible contents, must give proper attention to the inspection, maintenance and recharging of the fire protection equipment. NFPA 10, Standard for Portable Fire Extinguishers.

The facility failed to inspect the portable fire extinguishers located in the facility on a monthly basis. Observation showed the inspection tag on all of the extinguishers had not been initialed to indicate a monthly inspection during May 2011.

The facility failed to provide emergency procedures for when the automatic sprinkler system is out of service for more than 4 hours.

The emergency procedures manual for the facility did not include any information detailing when and how the facility would contact the State Survey Agency in the event that the automatic sprinkler system is out of service for 4 hours or more.

The facility failed to provide emergency procedures for when the fire alarm system is out of service for more than 4 hours.

The emergency procedures manual for the facility did not include any information detailing when and how the facility would contact the State Survey Agency in the event that the fire alarm system is out of service for 4 hours or more.

One story Existing Health Care Occupancy buildings of Type II (000) construction are required to be protected throughout with an automatic fire sprinkler system.

The facility failed to provide a structure that meets the requirements of the Life Safety Code.

Observation determined the construction type of Cavalier County Memorial Hospital is Type II (000). Unprotected metal structural members above the non-rated suspended ceiling assemblies were observed throughout the first floor. The building is not protected throughout with an automatic sprinkler system.

The facility failed to provide corridors separated from use areas by walls with at least 1/2 hour fire resistance rating.

Observation determined:

1) The exit corridor walls throughout the Main Floor were not constructed with 30 minute fire rated material.

2) The exit corridor walls were not fire resistive construction from the floor to the roof deck.

3) The exit corridor walls were not plastered on both sides of the metal studs.

Approximately 12 - 18 inches of the exit corridor walls (above the suspended ceilings) throughout the main floor had exposed metal studs on the corridor side.

The facility failed to separate hazardous areas from other spaces with self-closing doors.

Observation determined the door to the Record Storage Room, one of two hazardous areas, was not equipped with a self-closing device.

The facility failed to ensure exit access was readily accessible at all times.

1) Observation determined two (2) of three (3) exit stairs had obstructions that reduced the clear width of the stairs to less than 44 inches.

a) A fixed heater was located in the south exit stair that reduced the width of the stairs to 40 inches.

b) A fixed heater was located in the east exit stair that reduced the width of the stairs to 36 inches.

2) Exits must terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge must be of required width and size to provide all occupants with safe access to a public way. 7.7.1

To ensure adequate exit capability, CMS requires asphalt or concrete surfaces from exterior exits to public ways.

Observation determined the two (2) east exterior exits transversed the lawn to get to a public way.

The facility failed to ensure the exit signs were displayed with continuous illumination.

Observation determined the exit signs above the exterior door to the Emergency Entrance and the Emergency Room were not illuminated.

The owner or occupant of a property in which fire extinguishers are provided for the protection of the structure and the hazardous combustible contents, must give proper attention to the inspection, maintenance and recharging of the fire protection equipment. NFPA 10, Standard for Portable Fire Extinguishers.

The facility failed to inspect the portable fire extinguishers located in the facility on a monthly basis. Observation showed the inspection tag on all of the extinguishers had not been initialed to indicate a monthly inspection during May 2011.

The facility failed to provide emergency procedures for when the automatic sprinkler system is out of service for more than 4 hours.

The emergency procedures manual for the facility did not include any information detailing when and how the facility would contact the State Survey Agency in the event that the automatic sprinkler system is out of service for 4 hours or more.

The facility failed to provide emergency procedures for when the fire alarm system is out of service for more than 4 hours.

The emergency procedures manual for the facility did not include any information detailing when and how the facility would contact the State Survey Agency in the event that the fire alarm system is out of service for 4 hours or more.