HospitalInspections.org

Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas are substantial doors, such as those conducted of 1 3/4 inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in sprinklered buildings are only required to resist the passage of smoke. There is no impediment to the closing of the doors. Doors are provided with a means suitable for keeping the door closed. Dutch doors meeting 19.3.6.3.6 are permitted. 19.3.6.3

Roller latches are prohibited by CMS regulations in all health care facilities.

This STANDARD is not met as evidenced by: This tag not met as observed by the Director of Facilities Services, Facility Safety Officer and this surveyor. It was observed that the fire doors located outside PAT area and the Emergency Department (outside room 1242) did not close and latch properly when tested.

One hour fire rated construction (with 3/4 hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protects hazardous areas. When the approved automatic fire extinguishing system option is used, the areas are separated from other spaces by smoke resisting partitions and doors. Doors are self-closing and non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door are permitted. 19.3.2.1

This STANDARD is not met as evidenced by: This tag not met as observed by the Director of Facilities Services, Facility Safety Officer and this surveyor. It was observed that the door leading into the Meg Surg South conference/break room/storage room requires a closure device. This door is to be self-closing and positive latching.

Exit access is arranged so that exits are readily accessible at all times in accordance with section 7.1 19.2.1

This STANDARD is not met as evidenced by: This tag not met as observed by the Director of Facilities Services, Facility Safety Officer and this surveyor. It was observed that one of the double exit doors leading to the loading dock was lock and one of the double exit doors leading to the rear patio of the cafeteria was blocked by a table and chairs. Exit doors are to remain unlocked and accessible at all times.

A fire alarm system required for life safety is installed, tested, and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72. The system has an approved maintenance and testing program complying with applicable requirements of NFPA 70 and 72. 9.6.1.4.

This STANDARD is not met as evidenced by: This tag not met as observed by the Director of Facilities Services, Facility Safety Officer and this surveyor. It was observed the the Fire Alarm System inspection/test records for 6/2011 indicated that two device were not functioning. To date no action had been taken to find or correct the deficiencies. It is the responsibility of the facilities personnel to review inspection/test reports and take action to resolve discrepancies on the report.

Medical gas storage and administration areas are protected in accordance with NFPA 99, Standards for Health Care Facilities.

(a) Oxygen storage locations of greater than 3,000 cu.ft. are enclosed by a one-hour separation.

(b) Locations for supply systems of greater than 3,000 cu.ft. are vented to the outside. NFPA 99 4.3.1.1.2, 19.3.2.4

This STANDARD is not met as evidenced by: This tag not met as observed by the Director of Facilities Services, Facility Safety Officer and this surveyor. It was observed O2 cylinders were improperly stored in the Materials Storage area and in the storage room located in the corridor of Minor Surgery. In the Materials Storage area O2 cylinders were stored to close to combustibles. In the Minor Surgery storage room the room did not meet the requirements for storage of >300CF but <3000CF of O2 in that the door leading into the area was not the proper 45 min rated fire door assembly.

Piped in medical gas systems comply with NFPA 99, Chapter 4.

This STANDARD is not met as evidenced by: This tag not met as observed by the Director of Facilities Services, Facility Safety Officer and this surveyor. It was observed that in the Maternity Wing of the hospital the corridor door was blocking the Medical Gas Zone Valves. It was also observed that this medical Gas Zone Valves were improperly located outside of the wing that it serves. It serves the Cardiovascular Wing and is located in the Maternity Wing. In accordance with NFPA 99, section 5.1.4.8.7 a zone valve shall be located immediately outside each vital life-support, critical care, and anesthetizing location in each medical gas and/or vacuum line, and located so as to be readily accessible in an emergency.

OTHER LSC DEFICIENCY NOT ON 2786

This STANDARD is not met as evidenced by: This tag not met as observed by the Director of Facilities Services, Facility Safety Officer and this surveyor. It was observed that the following additional deficiencies were found;

1) The elevator machine room #075 located outside the Psychiatric Wing of the hospital had improper storage of combustible materials within. Machine rooms are not to be used for the storage of combustibles.

2) Combustible storage box located in the exit corridor discharge area of the operating rooms.

3) Several fire extinguishers located in the Maintenance Building office area and in the Generator Fuel storage building were not properly secured to prevent accidental damage to the head of the extinguisher and causing possible injury to personnel.

4) Fire extinguisher was blocked in the Emergency Department. Extinguishers are to remain accessible at all times.

5) The following offsite facilities were inspected as business occupancies and the deficiencies are listed with the facility;
Dr. Laurence, MS, 760 Commercial Street, Rockport.
Records Storage in the basement requires protection/separation in accordance with Life Safety Code 101, section 8.7. The area shall be separated from other parts of the building by fire barriers having a fire resistance rating of not less than 1 hour, with all openings therein protected by 3/4-hour, fire protection-rated, self-closing fire door assemblies. (2)The area shall be protected by an automatic extinguishing system in accordance with 9.7.1.1(1) or 9.7.1.2.

Rockport Family Medicine, 731 Commercial Street, Rockport.
The exit outside the sleep med section of the facility was blocked by construction materials. Also found was that the two records storage rooms being used are not completed. The walls and ceilings in both rooms are not covered exposing the structural members of the room and leaving little protection for the rooms located above.

The Charles F. Kava Offices, 68 Ben Paul Lane, Rockport.
Fire Alarm pull stations to be installed at each exit in accordance with Life Safety Code 101, section 9.6.2.3. The handicap ramp located outside of the building requires rounded handrails in accordance with section 39.2.2.6.

Waldoboro Family Medicine, 27 Mill Street, Waldoboro.
Fire Alarm pull stations are required at all exits of the facility in accordance with Life Safety Code 101, section 9.6.2.3. The rear steps of the facility are to be in accordance with section 7.2 and have guards and handrails. The fire alarm system must include all areas of the building. Two areas in the new section did not have detectors.

Penobscot Bay Physicians Building, 4 Glen Cove Drive, Rockport.
Additional illuminated exit sign required outside room 207 and on the inside of the east exit corridor on lower level. Remove the exit sign coming out of records storage and the exit sign leading to the central stairwell.

6) Fire Alarm records for the business occupancies surveyed were not available for review during survey.