HospitalInspections.org

Through observation and staff interview, during the survey, July 8, 2014, it was determined that the facility failed to maintain the two hour fire resistance rating of the common wall between the entrance lobby and the hospital as per NFPA 101, 2000 edition, 19.1.2.2.

During the survey, the two hour roll up door between the entrance lobby and the hospital failed a drop test.

This deficiency effects two of five smoke compartments.

Through observation during the survey, July 8, 2014, it was determined the facility failed to maintain the doors to the cooridor per NFPA 101, 2000 edition, 19.3.6.3.

During the walk through of the facility with the Director of Support Services, the swing path for doors to the patient rooms were blocked by trash cans and IV poles. This was corrected during the survey.

This deficiency effects one of five smoke compartments.

Through observation during the survey,July 8, 2014, it was determined that the facility failed to maintain smoke barriers to provide at least a smoke resistance rating per NFPA 101, 2000 edition, 19.3.7.3 and 8.3.2.

During the walk through of the facility, with the facility's staff:
A) An unsealed pipe penetration in the one hour wall abaove the ceiling above the kitchen door.
B) Unsealed penetrations in the two hour wall above the ceiling in the lobby on the south side of the roll up door.
C) Unsealed ceiling penetrations in various IT rooms.

This deficiency effected four of five smoke comprtments.

Through observation, during the survey conducted July 8, 2014, it was determined that the facility failed to maintain the corridors free of obstructions per NFPA 101, 2000 edition, 19.2.1.

During the walk through of the facility with the Support Services Director, multiple cooridors were used for storage.
1. Patient care area corridor.
2. Pre- and Post-op corridor.
3. The corridor behind the kitchen.

This deficiency effected three of five smoke compartments.

Through record review and discussions with the staff during the survey, July 8, 2014, it was determined that the facility failed to conduct fire drills at least quarterly on each shift and under varied conditions.

During the review of facility records, with maintenance staff, documentation was not available to verify a fire drill was conducted on the second shift for the first quarter of 2014. Third shift drills conducted through out the year were conducted at roughly the same times. The times for conducting fire drills needs to be varied.

This deficiency effects the entire facility.

Through observation during the survey, July 8, 2014, the facility failed to maintain storage areas free of storage items ieghteen inches frrom ceiling to provide sprinkler coverage in accordance with NFPA 13.

During the walk through of the facility with the Director of Support Services, there were multiple storage areas with storage higher than eighteen inches from the ceiling obstructing the fire sprinkler path.
1. The med-surge storage area.
2. The kitchen storage area.

This deficiency effected two of five smoke compartments.

Through observation and staff interview, during the survey, July 8, 2014, it was determined that the facility failed to maintain the two hour fire resistance rating of the common wall between the entrance lobby and the hospital as per NFPA 101, 2000 edition, 19.1.2.2.

During the survey, the two hour roll up door between the entrance lobby and the hospital failed a drop test.

This deficiency effects two of five smoke compartments.

Through observation during the survey, July 8, 2014, it was determined the facility failed to maintain the doors to the cooridor per NFPA 101, 2000 edition, 19.3.6.3.

During the walk through of the facility with the Director of Support Services, the swing path for doors to the patient rooms were blocked by trash cans and IV poles. This was corrected during the survey.

This deficiency effects one of five smoke compartments.

Through observation during the survey,July 8, 2014, it was determined that the facility failed to maintain smoke barriers to provide at least a smoke resistance rating per NFPA 101, 2000 edition, 19.3.7.3 and 8.3.2.

During the walk through of the facility, with the facility's staff:
A) An unsealed pipe penetration in the one hour wall abaove the ceiling above the kitchen door.
B) Unsealed penetrations in the two hour wall above the ceiling in the lobby on the south side of the roll up door.
C) Unsealed ceiling penetrations in various IT rooms.

This deficiency effected four of five smoke comprtments.

Through observation, during the survey conducted July 8, 2014, it was determined that the facility failed to maintain the corridors free of obstructions per NFPA 101, 2000 edition, 19.2.1.

During the walk through of the facility with the Support Services Director, multiple cooridors were used for storage.
1. Patient care area corridor.
2. Pre- and Post-op corridor.
3. The corridor behind the kitchen.

This deficiency effected three of five smoke compartments.

Through record review and discussions with the staff during the survey, July 8, 2014, it was determined that the facility failed to conduct fire drills at least quarterly on each shift and under varied conditions.

During the review of facility records, with maintenance staff, documentation was not available to verify a fire drill was conducted on the second shift for the first quarter of 2014. Third shift drills conducted through out the year were conducted at roughly the same times. The times for conducting fire drills needs to be varied.

This deficiency effects the entire facility.

Through observation during the survey, July 8, 2014, the facility failed to maintain storage areas free of storage items ieghteen inches frrom ceiling to provide sprinkler coverage in accordance with NFPA 13.

During the walk through of the facility with the Director of Support Services, there were multiple storage areas with storage higher than eighteen inches from the ceiling obstructing the fire sprinkler path.
1. The med-surge storage area.
2. The kitchen storage area.

This deficiency effected two of five smoke compartments.