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Based on the observation and staff interview, the facility failed to maintain the fire door assembly in the Emergency Department (ED).

Failure to maintain a fire door could negatively impact the closing of a fire door in case of a fire.

Findings Include:

During the tour of the facility's ED on 11/02/2021 at 11:25 AM, the 1.5 hour rated two (2) leaf fire doors between the ED and the ED waiting area did not positively latch upon manual release from the electromagnetic lock.

This observation was identified in the presence of Staff D, Director of Support Services and upon interview at that time of observation, Staff D acknowledged the finding.

Based on observations, document review and staff interview, it was determined the facility did not provide required clearance between the storage and sprinkler deflector.

Failure to maintain adequate clearance could negatively impact the function of the sprinkler system in case of a fire.

Findings Include:

During the tour of the facility on 11/02/2021 at 1:30 PM, in the MRI storage room the clearance between the sprinkler deflector and the top of storage was approximately 16 inches.

According to NFPA 13, 2010- 8.5.6.1 the clearance between the sprinkler deflector and the top of storage shall be 18 inches (457 mm) or greater.

This observation was identified in the presence of Staff D, Director of Support Services who acknowledged the finding.

Based on document review and staff interview, it was determined the facility did not inspect and test fire door assembles annually according to NFPA 80, 2010 edition.

Failure to maintain fire doors could negatively impact the closing of all fire doors in case of a fire.

Findings Include:

During document review on 11/03/2021 at 11:30 AM, there was no written records available for inspection and testing of the fire door assembly.

During an interview conducted with Staff D, Director of Support Services on 11/3/2021 at 11:30 AM, he acknowledged the finding and he stated he was not aware of this requirement.

Based on observations, document review and staff interview, it was determined the facility's critical care rooms did not have a Type 1 Essential Electric System (EES). In accordance with NFPA 99 2000, 6.3.2.2.10.1, Critical care rooms (Category 1) in which electrical system failure is likely to cause major injury or death of patients, including all rooms where electric life support equipment is required, are served by a Type 1 EES.

Findings Include:

During the tour of the facility on 11/03/2021 between 2:00 PM - 3:00 PM, the review of labels on panels LP1155 B, LF1036A and LF1036 B, revealed that the facility did not have three (3) branches (Life Safety, Critical, and Equipment) of EES.

During the tour, it was also observed that the electrical receptacles or cover plates supplied from the life safety and critical branches does not have a distinctive color or marking according to NFPA 99, 6.2.2.3.2.

The facility did not have Type I EES, and it did not provide adequate emergency power to the facility for safe cessation of procedures and evacuation of all occupants in the event of an interruption in normal power supply.

During interview of Staff D, Director of Support Services on 11/03/2021 at 11:00 AM, the staff reported that the facility has only Type 2 EES (Life Safety and Critical branches) in the operating rooms (ORs) and other critical areas that were served by the generator. Staff D also stated that the Type 1 EES branching is only in the newly renovated Emergency Department.