HospitalInspections.org

Based on observations and interview, the facility failed to ensure two sets of doors in fire walls and smoke barriers in remodeled areas of the facility remained in compliance with 18.3.7.8 (requirements for new construction). This deficient practice potentially affected all staff, visitors and patient census of three.

Findings included:

1. Observation on 03/11/13 at 1:45 PM showed gaps of one eighth inch width not covered or sealed with an astragal (a molding attached to one of two leafs of a double door that creates a smoke tight barrier) on a set of doors that separated the hospital from Administration offices that were located in an older portion of the hospital.

2. Observation on 03/11/13 at 2:00 PM showed gaps of one eighth inch width not covered or sealed with an astragal on a set of doors at the end of the outpatient clinic, in the vicinity of Exam Room 6.

During an interview on 03/11/13 at 2:00 PM, Staff RR, Maintenance, stated that the set of doors at the west end of the hospital, and the smoke doors separating the hospital from the outpatient area were replaced during a major renovation and face-lift in 2009.

Based on observation and interview, the facility failed to ensure hazardous areas are protected in accordance with 7.2.1.8 and 18.3.2.1 with doors that are either self closing or automatically close and latch in the event of a fire alarm activation. This deficient practice had the potential to affect all visitors, staff and patients treated at the facility. The facility census was three.

Findings included:

1. Observation on 03/11/13 at 1:50 PM showed a large storage room in the north central part of the hospital, across from the surgery suite that was being used as a maintenance shop. The two interior shop walls the shop shared with the hospital did not extend all the way to the roof deck. The wall's sheet-rocked surfaces inside of the maintenance shop ended 14 inches from the top of the wall, and exposed unprotected metal framing studs and insulation batting above the ceiling level. The non-rated entrance door to the maintenance shop was propped open and exposed the mixed hazard contents of the shop to the Pre/Post Procedure area and the rest of the hospital. Among the items in the shop were building materials, power tools, flammable solvents, oils and a few cans of spray paint.

During an interview on 03/11/13 at 1:50 PM, Staff RR, Maintenance, and Staff SS, Director of Facilities acknowledged that the room had never been completed above ceiling level and stated that they would tape and sealed sheet rock on up to the ceiling to ensure the room offered maximum protection. They also stated that they would either have the door equipped with a magnetic hold-open device or keep it closed when the room is unoccupied.

Based on observation, record review and interview, the facility failed to ensure that smoke detectors, including those activating door hold-open devices, are approved, maintained, inspected and tested in accordance 9.6.1.3 and manufacturer's specifications. This deficient practice had the potential to affect all patients treated at the facility. The facility census was three.

Findings included:

1. Observation on during tours on 03/11/13 at1:45 PM through 03/12/13 at 11:50 AM, showed the facility was adequately equipped with smoke detectors in all areas and wired to the facility's master notification panel and fire alarm system.

2. Record review on 03/12/13 at 11:00 AM showed no evidence that smoke detector inspection and testing had been done for several years. No documentation was available to show the last time a sensitivity test was conducted following the renovations in 2009.

During an interview on 03/12/13 at 11:00 AM, Staff RR, Maintenance, stated that he goes around annually and checks them with a can of "smoke" (aerosol product that replicates smoke particles and activates the ionizing beam of smoke detectors), but doesn't keep formal records of his preventive maintenance and testing.

Based on observation, document review and interview, the facility failed to maintain the sprinkler system in accordance with NFPA 25, 9.7.5, and have the system inspected and flow tested at least annually. This deficient practice had the potential to affect all patients treated at the facility. The facility census was three.

Findings included:

1. Observation during tours on 03/11/13 at1:45 PM through 03/12/13 at 11:50 AM, showed the facility was totally sprinklered with quick-response sprinklers.

2. Record review on 03/12/13 at 11:00 AM showed the last complete wet system and flow test was conducted on 09/28/10.

During an interview on 03/12/13, Staff RR, Maintenance, stated that the 2010 annual inspection was the only one he could find and that he was pretty sure that was the last inspection and test completed.

Based on observations and interview, the facility failed to ensure two sets of doors in fire walls and smoke barriers in remodeled areas of the facility remained in compliance with 18.3.7.8 (requirements for new construction). This deficient practice potentially affected all staff, visitors and patient census of three.

Findings included:

1. Observation on 03/11/13 at 1:45 PM showed gaps of one eighth inch width not covered or sealed with an astragal (a molding attached to one of two leafs of a double door that creates a smoke tight barrier) on a set of doors that separated the hospital from Administration offices that were located in an older portion of the hospital.

2. Observation on 03/11/13 at 2:00 PM showed gaps of one eighth inch width not covered or sealed with an astragal on a set of doors at the end of the outpatient clinic, in the vicinity of Exam Room 6.

During an interview on 03/11/13 at 2:00 PM, Staff RR, Maintenance, stated that the set of doors at the west end of the hospital, and the smoke doors separating the hospital from the outpatient area were replaced during a major renovation and face-lift in 2009.

Based on observation and interview, the facility failed to ensure hazardous areas are protected in accordance with 7.2.1.8 and 18.3.2.1 with doors that are either self closing or automatically close and latch in the event of a fire alarm activation. This deficient practice had the potential to affect all visitors, staff and patients treated at the facility. The facility census was three.

Findings included:

1. Observation on 03/11/13 at 1:50 PM showed a large storage room in the north central part of the hospital, across from the surgery suite that was being used as a maintenance shop. The two interior shop walls the shop shared with the hospital did not extend all the way to the roof deck. The wall's sheet-rocked surfaces inside of the maintenance shop ended 14 inches from the top of the wall, and exposed unprotected metal framing studs and insulation batting above the ceiling level. The non-rated entrance door to the maintenance shop was propped open and exposed the mixed hazard contents of the shop to the Pre/Post Procedure area and the rest of the hospital. Among the items in the shop were building materials, power tools, flammable solvents, oils and a few cans of spray paint.

During an interview on 03/11/13 at 1:50 PM, Staff RR, Maintenance, and Staff SS, Director of Facilities acknowledged that the room had never been completed above ceiling level and stated that they would tape and sealed sheet rock on up to the ceiling to ensure the room offered maximum protection. They also stated that they would either have the door equipped with a magnetic hold-open device or keep it closed when the room is unoccupied.

Based on observation, record review and interview, the facility failed to ensure that smoke detectors, including those activating door hold-open devices, are approved, maintained, inspected and tested in accordance 9.6.1.3 and manufacturer's specifications. This deficient practice had the potential to affect all patients treated at the facility. The facility census was three.

Findings included:

1. Observation on during tours on 03/11/13 at1:45 PM through 03/12/13 at 11:50 AM, showed the facility was adequately equipped with smoke detectors in all areas and wired to the facility's master notification panel and fire alarm system.

2. Record review on 03/12/13 at 11:00 AM showed no evidence that smoke detector inspection and testing had been done for several years. No documentation was available to show the last time a sensitivity test was conducted following the renovations in 2009.

During an interview on 03/12/13 at 11:00 AM, Staff RR, Maintenance, stated that he goes around annually and checks them with a can of "smoke" (aerosol product that replicates smoke particles and activates the ionizing beam of smoke detectors), but doesn't keep formal records of his preventive maintenance and testing.

Based on observation, document review and interview, the facility failed to maintain the sprinkler system in accordance with NFPA 25, 9.7.5, and have the system inspected and flow tested at least annually. This deficient practice had the potential to affect all patients treated at the facility. The facility census was three.

Findings included:

1. Observation during tours on 03/11/13 at1:45 PM through 03/12/13 at 11:50 AM, showed the facility was totally sprinklered with quick-response sprinklers.

2. Record review on 03/12/13 at 11:00 AM showed the last complete wet system and flow test was conducted on 09/28/10.

During an interview on 03/12/13, Staff RR, Maintenance, stated that the 2010 annual inspection was the only one he could find and that he was pretty sure that was the last inspection and test completed.