HospitalInspections.org

Based on observation the facility failed to provide continuity of smoke barriers in the facility and to maintain the building's interior fire resistance rating .

Failure to provide smoke barrier continuity and maintaining the interior fire resistance rating puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Findings include:

1. On 1/19/2011 the surveyor noted penetrations at the double doors to the Kitchen area above the ceiling tile.
2. On 1/19/2011 the surveyor noted a penetration into the tool shed from the adjoining shop area. Said penetration was made to accomodate the improper use of an extension cord.
3. On 1/19/2011 the surveyor noted a penetration of the wall opposite the shop garage doorst.
4. On 1/19/2011 the surveyor noted penetrations above the drop ceiling in the IT Room to the corridor.
5. On 1/19/2011 the surveyor noted penetrations of the wall in the IT Server Room (Off Admin hallway, across from Respiratory Therapy) created by the running of cable.
6. On 1/19/2011 the surveyor noted penetrations of the wall in Respiratory Therapy created by the running of cable.
7. On 1/19/2011 the surveyor noted penetrations of the wall of the basement fire alarm control panel room (ventilation and cables).
8. On 1/19/2011 the surveyor noted penetrations in the wall of the basement electrical room/vacuum rooms.
9. On 1/19/2011 the surveyor noted penetrations in the wall of the Nursing Administrative office created by the running of cable.

Based on observation the facility failed to provide doors that would resist the passage of smoke.

Failure on the part of the facility to provide doors that have the ability to resist the passage of smoke puts patients, staff and visitors of the facility at risk of injury in the event of a fire.

Reference: NFPA 101 Life Safety Code, 2000 Edition, Chapter 8.3.4.1 and related Appendix.

Findings include:

1. On 1/19/2011 the surveyor noted that the fire door entering the shop has held in the open position by a stop that would not allow it to automatically close upon activation of the fire alarm system.
2. On 1/19/2011 the surveyor noted that the doors leading into the adjoining Long Term Care unit would not properly latch.
3. On 1/19/2011 the surveyor noted that the doors to conference rooms A/B did not have positive latching as the crash bar system had been set in the open position.
4. On 1/19/2011 the surveyor noted that the door to the Support Services/IS Coordinator office had been fitted with a louver that would permit the passage of smoke.
5. On 1/19/2011 the surveyor noted that the door to the corridor from the "old business office" and a second door to the "new linen room") would not properly latch.
6. On 1/19/2011 the surveyor noted that the corridor door to the "staff dining room" lacked a self closing device.
7. On 1/19/2011 the surveyor noted that door to the risk managers office was held in the open position by a stop that would not allow it to close upon activation of the fire alarm system.
8. On 1/19/2011 the surveyor noted the the self closing device on the door to the basement mechanical room was not attached.
9. On 1/19/2011 the surveyor noted the the door to the vacuum room (back of mechanical room) had been propped open.
10. On 1/19/2011 the surveyor noted the the basement double doors near the exit would not latch properly.
11. On 1/19/2011 the surveyor noted that the double doors leading to the Specialty Clinic had excessive gaps that would allow for the passage of smoke.
12. On 1/19/2011 the surveyor noted that the double doors into the Physical Therapy unit had been propped open with an unapproved device (door wedge).

Based on observation, the hospital failed to maintain the automatic sprinkler system in accordance with NFPA 13 and NFPA 25.

Failure to maintain the automatic sprinkler system as required puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Findings include:

1. On 1/19/2011 the surveyor noted that sprinkler heads in both the materials management storeroom and the purchasing corridor had been subjected to paint overspray.

2. On 1/19/2011 the surveyor noted that a light fixture was hanging from a sprinkler line in the tool shed.

Based on observation the facility failed to keep unacceptable portable space heating devices out of non-patient care areas of the facility.

Failure on the part of the facility to assure that unacceptable portable heating devices are kept out of the facility puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Findings include:

1. On 1/19/2011 the surveyor noted in the purchasing office a space heater that was of a kind that is not approved for use in health care facilities (heating elements obtain temperatures >212 degrees F).

Based on observation the facility failed to maintain walking surfaces in the means of egress, more specifically the "exit discharge" in a state or condition that would not serve to impede travel to the public way. And, the facility failed to keep the means of egress free of impediments.

Failure on the part of the facility to maintain the exit discharge and the means of exit clear of impediments puts patients, staff and visitors of the facility at risk should emergency egress be required.

Findings include:

1. On 1/19/2011 the surveyor noted that the exit door emptying into the courtyard (from long term care corridor) is not provided with an exit discharge having an all weather surface. Users of that exit would be required to traverse a lawn surface to reach the public way.

2. On 1/19/2011 the surveyor noted that a book case was encroaching upon the exit access (partially blocking exit) and the door to the courtyard.

Based on observation the facility failed to ensure that the Type I emergency electrical system was being maintained in accordance with NFPA 99. More specifically, Chapter 3-4.2.2.2(b)(5) which calls for "task illumination" at the generator set location.

Failure on the part of the facility to provide task illumination in the generator set location puts patients, staff and visitors of the facility at risk should there be a need for emergency power and the generator was not working in a time of need.

Findings include:

1. On 1/19/2011 the surveyor noted that battery powered emergency lighting (task illumination) was not available in the generator room.

Based on observation the facility failed provide wiring solutions in accordance with NFPA 70, National Electrical Code. More specifically, the facility improperly used extension cords to certain equipment and exposed electrical wiring.

Failure on the part of the facility to provide wiring as required puts patients, staff and visitors of the facility at risk of electrical shock or fire.

Findings include:

1. On 1/19/2011 the surveyor noted in the tool shed that an extension cord was connected to a power strip that was providing power to a light fixture hanging on a sprinkler line.
2. On 1/19/2011 the surveyor noted that an extension had been run from a power source in the shop through the wall separating the shop from the tool shed.
3. On 1/19/2011 the surveyor noted that a power cord connected to a junction box in the tool shed was connected to an extension cord.
4. On 1/19/2011 the surveyor noted in the shop office that a power strip was plugged into an extension cord.
5. On 1/19/2011 the surveyor noted in the purchasing office an extension cord being used as a source of power.
6. On 1/19/2011 the surveyor noted in the IT room a junction box that did not have a cover leaving wires exposed.
7. On 1/19/2011 the surveyor noted in the boiler room that an extension cord was being used to power a time clock in the adjoining corridor.
8. On 1/19/2011 the surveyor noted in the housekeeping manager's office that an extension cord was connected to a power strip.
9. On 1/19/2011 the surveyor noted in the doctor's lounge that an extension cord was connected to a microwave oven.

Based on observation the facility failed to install an alcohol based hand rub (ABHR) dispenser in an appropriate manner.

Failure to install ABHR dispensers appropriately puts patients, staff and visitors of the facility at risk from the effects of fire and smoke.

Findings include:

1. On 1/19/2011 the surveyor noted in the corridor outside of the shop an ABHR dispenser that was installed above a light switch

Based on observation the facility failed to provide continuity of smoke barriers in the facility and to maintain the building's interior fire resistance rating .

Failure to provide smoke barrier continuity and maintaining the interior fire resistance rating puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Findings include:

1. On 1/19/2011 the surveyor noted penetrations at the double doors to the Kitchen area above the ceiling tile.
2. On 1/19/2011 the surveyor noted a penetration into the tool shed from the adjoining shop area. Said penetration was made to accomodate the improper use of an extension cord.
3. On 1/19/2011 the surveyor noted a penetration of the wall opposite the shop garage doorst.
4. On 1/19/2011 the surveyor noted penetrations above the drop ceiling in the IT Room to the corridor.
5. On 1/19/2011 the surveyor noted penetrations of the wall in the IT Server Room (Off Admin hallway, across from Respiratory Therapy) created by the running of cable.
6. On 1/19/2011 the surveyor noted penetrations of the wall in Respiratory Therapy created by the running of cable.
7. On 1/19/2011 the surveyor noted penetrations of the wall of the basement fire alarm control panel room (ventilation and cables).
8. On 1/19/2011 the surveyor noted penetrations in the wall of the basement electrical room/vacuum rooms.
9. On 1/19/2011 the surveyor noted penetrations in the wall of the Nursing Administrative office created by the running of cable.

Based on observation the facility failed to provide doors that would resist the passage of smoke.

Failure on the part of the facility to provide doors that have the ability to resist the passage of smoke puts patients, staff and visitors of the facility at risk of injury in the event of a fire.

Reference: NFPA 101 Life Safety Code, 2000 Edition, Chapter 8.3.4.1 and related Appendix.

Findings include:

1. On 1/19/2011 the surveyor noted that the fire door entering the shop has held in the open position by a stop that would not allow it to automatically close upon activation of the fire alarm system.
2. On 1/19/2011 the surveyor noted that the doors leading into the adjoining Long Term Care unit would not properly latch.
3. On 1/19/2011 the surveyor noted that the doors to conference rooms A/B did not have positive latching as the crash bar system had been set in the open position.
4. On 1/19/2011 the surveyor noted that the door to the Support Services/IS Coordinator office had been fitted with a louver that would permit the passage of smoke.
5. On 1/19/2011 the surveyor noted that the door to the corridor from the "old business office" and a second door to the "new linen room") would not properly latch.
6. On 1/19/2011 the surveyor noted that the corridor door to the "staff dining room" lacked a self closing device.
7. On 1/19/2011 the surveyor noted that door to the risk managers office was held in the open position by a stop that would not allow it to close upon activation of the fire alarm system.
8. On 1/19/2011 the surveyor noted the the self closing device on the door to the basement mechanical room was not attached.
9. On 1/19/2011 the surveyor noted the the door to the vacuum room (back of mechanical room) had been propped open.
10. On 1/19/2011 the surveyor noted the the basement double doors near the exit would not latch properly.
11. On 1/19/2011 the surveyor noted that the double doors leading to the Specialty Clinic had excessive gaps that would allow for the passage of smoke.
12. On 1/19/2011 the surveyor noted that the double doors into the Physical Therapy unit had been propped open with an unapproved device (door wedge).

Based on observation, the hospital failed to maintain the automatic sprinkler system in accordance with NFPA 13 and NFPA 25.

Failure to maintain the automatic sprinkler system as required puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Findings include:

1. On 1/19/2011 the surveyor noted that sprinkler heads in both the materials management storeroom and the purchasing corridor had been subjected to paint overspray.

2. On 1/19/2011 the surveyor noted that a light fixture was hanging from a sprinkler line in the tool shed.

Based on observation the facility failed to keep unacceptable portable space heating devices out of non-patient care areas of the facility.

Failure on the part of the facility to assure that unacceptable portable heating devices are kept out of the facility puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Findings include:

1. On 1/19/2011 the surveyor noted in the purchasing office a space heater that was of a kind that is not approved for use in health care facilities (heating elements obtain temperatures >212 degrees F).

Based on observation the facility failed to maintain walking surfaces in the means of egress, more specifically the "exit discharge" in a state or condition that would not serve to impede travel to the public way. And, the facility failed to keep the means of egress free of impediments.

Failure on the part of the facility to maintain the exit discharge and the means of exit clear of impediments puts patients, staff and visitors of the facility at risk should emergency egress be required.

Findings include:

1. On 1/19/2011 the surveyor noted that the exit door emptying into the courtyard (from long term care corridor) is not provided with an exit discharge having an all weather surface. Users of that exit would be required to traverse a lawn surface to reach the public way.

2. On 1/19/2011 the surveyor noted that a book case was encroaching upon the exit access (partially blocking exit) and the door to the courtyard.

Based on observation the facility failed to ensure that the Type I emergency electrical system was being maintained in accordance with NFPA 99. More specifically, Chapter 3-4.2.2.2(b)(5) which calls for "task illumination" at the generator set location.

Failure on the part of the facility to provide task illumination in the generator set location puts patients, staff and visitors of the facility at risk should there be a need for emergency power and the generator was not working in a time of need.

Findings include:

1. On 1/19/2011 the surveyor noted that battery powered emergency lighting (task illumination) was not available in the generator room.

Based on observation the facility failed provide wiring solutions in accordance with NFPA 70, National Electrical Code. More specifically, the facility improperly used extension cords to certain equipment and exposed electrical wiring.

Failure on the part of the facility to provide wiring as required puts patients, staff and visitors of the facility at risk of electrical shock or fire.

Findings include:

1. On 1/19/2011 the surveyor noted in the tool shed that an extension cord was connected to a power strip that was providing power to a light fixture hanging on a sprinkler line.
2. On 1/19/2011 the surveyor noted that an extension had been run from a power source in the shop through the wall separating the shop from the tool shed.
3. On 1/19/2011 the surveyor noted that a power cord connected to a junction box in the tool shed was connected to an extension cord.
4. On 1/19/2011 the surveyor noted in the shop office that a power strip was plugged into an extension cord.
5. On 1/19/2011 the surveyor noted in the purchasing office an extension cord being used as a source of power.
6. On 1/19/2011 the surveyor noted in the IT room a junction box that did not have a cover leaving wires exposed.
7. On 1/19/2011 the surveyor noted in the boiler room that an extension cord was being used to power a time clock in the adjoining corridor.
8. On 1/19/2011 the surveyor noted in the housekeeping manager's office that an extension cord was connected to a power strip.
9. On 1/19/2011 the surveyor noted in the doctor's lounge that an extension cord was connected to a microwave oven.