HospitalInspections.org

Based on observations and staff interview, it was revealed that 1 of 3 two hour fire separations that were found not in compliance with NFPA 101 "The Life Safety Code" (00) section 18.1.1.4.2. These deficient conditions could allow the products of combustion to travel from one building to another, which could negatively affect all of the patients, staff and visitors of the facility.

Findings include:

On facility tour between 9:30 AM to 2:30 PM on 04/15/2015, observations revealed that the 90 minute fire rated doors located in the 2 hour fire separation separating the ambulance garage from the emergency room had a 1/4 inch gap between the door leaves.


This deficient condition was verified by the Maintenance Supervisor (JR).

Based on observations and staff interview, it was revealed that the facility has failed to provide proper protection from 1 of several hazardous areas located throughout the facility in accordance with NFPA Life Safety Code 101 (00) section 18.3.2.1. This deficient conditions could in the event of a fire, allow smoke and flames to spread throughout the effected corridors and areas making them untenable, which could negatively affect the exiting capabilities for patients, staff and visitors.


Findings include:

On facility tour between 9:30 AM to 2:30 PM on 04/15/2015, observation revealed, that there was a missing ceiling tile in the central storage room.


This deficient condition was verified by the Maintenance Supervisor (JR).

Based on observations and staff interview, it was revealed that the facility has failed to provide proper protection from 2 of several hazardous areas located throughout the facility in accordance with NFPA Life Safety Code 101 (00) section 19.3.2.1. This deficient conditions could in the event of a fire, allow smoke and flames to spread throughout the effected corridors and areas making them untenable, which could negatively affect the exiting capabilities for patients, staff and visitors.


Findings include:

On facility tour between 9:30 AM to 2:30 PM on 04/15/2015, observation revealed, that there were two ceiling tiles missing in the electrical / mechanical room and the door to the corner storage room was not equipped with a door closer.


This deficient condition was verified by the Maintenance Staff member (AM).

Based on documentation review and staff interview, the facility failed to test the emergency generators in accordance with the requirements of 2000 NFPA 101 - 9.1.3 and 1999 NFPA 110 6-4.2 (a) & (b) and 6-4.2.2. The deficient practice could affect all patients, staff, and visitors.

Findings include:

On facility tour between 9:30 AM to 2:30 PM on 04/15/2015, documentation review of the emergency generator testing logs indicated that the facility could not locate or provide documentation for any of the weekly and 1 of 12 monthly testing of the emergency power generator.


This deficient condition was verified by the Maintenance Staff member (AM).

Based on observation and interview with the staff the facility was using unapproved electrical devices that are not in accordance with NFPA 70 (99), National Electrical Code. This deficient practice could negatively affect the safety of patients, staff and visitors.


Findings include:

On facility tour between 9:30 AM to 2:30 PM on 04/15/2015, observations revealed the following deficient practices affecting the facility's electrical system:

1. there was a refrigerator in staff personnel (LB) that was plugged into a power strip,
2. there was a multi-plug adaptor located at the nurses station that is located in the surgery unit, and
3. there were extension cords located in the provider room and in the corner storage room.


This deficient condition was verified by the Maintenance Staff member (AM).

Based on a record review and staff interview, the facility has failed to provide a complete and acceptable written policy containing procedures to be followed in the event that the automatic fire sprinkler system has to be placed out-of-service for four or more hours in a 24 hour period. This deficient practice could affect the facility's ability for early response and notification of a fire and would affect the safety of all patients, visitors and staff.


Findings include:

On facility tour between 9:30 AM to 2:30 PM on 04/15/2015, during record review and an interview with the Maintenance Supervisor (JR), the facility failed to update and provide a complete list of contact information on the automatic fire sprinkler system out of service policy.


This deficient condition was verified by the Maintenance Supervisor (JR).

Based on a record review and staff interview, the facility has failed to provide a complete and acceptable written policy containing procedures to be followed in the event that the fire alarm system has to be placed out-of-service for four or more hours in a 24 hour period. This deficient practice could affect the facility's ability for early response and notification of a fire and would affect the safety of all patients, visitors and staff.


Findings include:

On facility tour between 9:30 AM to 2:30 PM on 04/15/2015, during record review and an interview with the Maintenance Supervisor (JR), the facility failed to update and provide a complete list of contact information on the fire alarm system out of service policy.


This deficient condition was verified by the Maintenance Supervisor (JR).

Based on observations and staff interview, it was revealed that 1 of 3 two hour fire separations that were found not in compliance with NFPA 101 "The Life Safety Code" (00) section 18.1.1.4.2. These deficient conditions could allow the products of combustion to travel from one building to another, which could negatively affect all of the patients, staff and visitors of the facility.

Findings include:

On facility tour between 9:30 AM to 2:30 PM on 04/15/2015, observations revealed that the 90 minute fire rated doors located in the 2 hour fire separation separating the ambulance garage from the emergency room had a 1/4 inch gap between the door leaves.


This deficient condition was verified by the Maintenance Supervisor (JR).

Based on observations and staff interview, it was revealed that the facility has failed to provide proper protection from 1 of several hazardous areas located throughout the facility in accordance with NFPA Life Safety Code 101 (00) section 18.3.2.1. This deficient conditions could in the event of a fire, allow smoke and flames to spread throughout the effected corridors and areas making them untenable, which could negatively affect the exiting capabilities for patients, staff and visitors.


Findings include:

On facility tour between 9:30 AM to 2:30 PM on 04/15/2015, observation revealed, that there was a missing ceiling tile in the central storage room.


This deficient condition was verified by the Maintenance Supervisor (JR).

Based on observations and staff interview, it was revealed that the facility has failed to provide proper protection from 2 of several hazardous areas located throughout the facility in accordance with NFPA Life Safety Code 101 (00) section 19.3.2.1. This deficient conditions could in the event of a fire, allow smoke and flames to spread throughout the effected corridors and areas making them untenable, which could negatively affect the exiting capabilities for patients, staff and visitors.


Findings include:

On facility tour between 9:30 AM to 2:30 PM on 04/15/2015, observation revealed, that there were two ceiling tiles missing in the electrical / mechanical room and the door to the corner storage room was not equipped with a door closer.


This deficient condition was verified by the Maintenance Staff member (AM).

Based on documentation review and staff interview, the facility failed to test the emergency generators in accordance with the requirements of 2000 NFPA 101 - 9.1.3 and 1999 NFPA 110 6-4.2 (a) & (b) and 6-4.2.2. The deficient practice could affect all patients, staff, and visitors.

Findings include:

On facility tour between 9:30 AM to 2:30 PM on 04/15/2015, documentation review of the emergency generator testing logs indicated that the facility could not locate or provide documentation for any of the weekly and 1 of 12 monthly testing of the emergency power generator.


This deficient condition was verified by the Maintenance Staff member (AM).

Based on observation and interview with the staff the facility was using unapproved electrical devices that are not in accordance with NFPA 70 (99), National Electrical Code. This deficient practice could negatively affect the safety of patients, staff and visitors.


Findings include:

On facility tour between 9:30 AM to 2:30 PM on 04/15/2015, observations revealed the following deficient practices affecting the facility's electrical system:

1. there was a refrigerator in staff personnel (LB) that was plugged into a power strip,
2. there was a multi-plug adaptor located at the nurses station that is located in the surgery unit, and
3. there were extension cords located in the provider room and in the corner storage room.


This deficient condition was verified by the Maintenance Staff member (AM).

Based on a record review and staff interview, the facility has failed to provide a complete and acceptable written policy containing procedures to be followed in the event that the automatic fire sprinkler system has to be placed out-of-service for four or more hours in a 24 hour period. This deficient practice could affect the facility's ability for early response and notification of a fire and would affect the safety of all patients, visitors and staff.


Findings include:

On facility tour between 9:30 AM to 2:30 PM on 04/15/2015, during record review and an interview with the Maintenance Supervisor (JR), the facility failed to update and provide a complete list of contact information on the automatic fire sprinkler system out of service policy.


This deficient condition was verified by the Maintenance Supervisor (JR).

Based on a record review and staff interview, the facility has failed to provide a complete and acceptable written policy containing procedures to be followed in the event that the fire alarm system has to be placed out-of-service for four or more hours in a 24 hour period. This deficient practice could affect the facility's ability for early response and notification of a fire and would affect the safety of all patients, visitors and staff.


Findings include:

On facility tour between 9:30 AM to 2:30 PM on 04/15/2015, during record review and an interview with the Maintenance Supervisor (JR), the facility failed to update and provide a complete list of contact information on the fire alarm system out of service policy.


This deficient condition was verified by the Maintenance Supervisor (JR).