HospitalInspections.org

Based on observation and staff interview it was determined the facility failed to ensure the building is properly constructed to meet minimum requirements.
The findings were:
During the tour of the facility with Staff A on 04/05/13 from 9:30 a.m. to 11:30 a.m. it was observed that the attic area wood framed did not have the required draft stopping to prevent smoke and fire travel across the facility.
During the tour of the facility with Staff A on 04/05/13 from 9:30 a.m. to 11:30 a.m. it was observed that paper backed insulation was improperly installed in the attic space.
During the tour of the facility with Staff A on 04/05/13 from 9:30 a.m. to 11:30 a.m. it was observed that the required one hour tenant separation is not provided.
This finding was confirmed by Staff A at the time of discovery.

Based on observation, testing, and staff interviews it was determined the facility failed to maintain doors in corridors capable of resisting fire for at least 20 minutes and having no impediment to closing the doors.
The findings were:
During a tour of the facility with Staff M on 04/04/13 from 11:00 a.m. to 4:15 p.m. it was observed by testing corridor smoke doors that the doors did not close fully creating a smoke resistance barrier. Lab, Laundry Corridor, and Rented Medical Office space.
During a tour of the facility with Staff M on 04/04/13 from 11:00 a.m. to 4:15 p.m. it was observed that the door leading from the Laundry Room and X-ray storage did not have a self closing device to protect the corridor from smoke or fire transfer.
These findings were confirmed by Staff M at the time of discovery.

Based on observation and staff interview it was determined the facility failed to maintain the smoke and fire barrier walls to provide at least a one hour fire resistance rating.

The findings were:

During a tour of the facility with Staff M on 04/04/13 from 11:00 a.m. to 4:15 p.m. it was observed that rated walls were not sealed to the roof deck as required.

During a tour of the facility with Staff M on 04/04/13 from 11:00 a.m. to 4:15 p.m. it was observed that rated walls around the lab had to large hole cut through the wall approximately 2 ft. by 2 ft.

These finding were confirmed by Staff M at the time of discovery.

Based on observation, review of facility records, and staff interviews it was determined the facility failed to maintain emergency lighting of at least one and one half hours duration.
The findings were:
During a review of facility records with Staff A on 04/05/13 at approximately 9:00 a.m. it was observed that the emergency lights were not tested for 30 second each month and 90 minutes annually.
During the tour of the facility with Staff A on 04/05/13 from 9:30 a.m. to 11:30 a.m. it was observed that no emergency lights are installed at all exits from the facility to the public way.
These findings were confirmed by Staff A at the time of discovery.

Based on observation and staff interview it was determined the facility failed to provide a exit sign with continuous illumination.

The findings were:

During a tour of the facility with Staff M on 04/04/13 from 11:00 a.m. to 4:15 p.m. it was observed the facility had failed to provide an illuminated sign in the Lab hallway and waiting area.

This finding was confirmed by Staff M at the time of discovery.

Based on observation, review of facility records, and staff interviews it was determined the facility failed to ensure that all staff members take part in quarterly fire drills.
The findings were:
During a review of facility records on 04/04/13 at approximately 10:30 a.m. it was determined the facility failed to conduct fire drills for weekend Staff members. It was also discovered that fire drills are not being conducted at varying times. All third shift drill for the past 12 months were conducted at 6:00, all second shift drill were held at 4:00, first shift drill were conducted at varying times.
These findings were confirmed by Staff A at the time of discovery.

Based on observation and staff interviews it was determined the facility updated the fire alarm system in February 2011 but failed to bring the facility up to current code requirements.
The findings were:
During a tour of the facility with Staff M on 04/04/13 from 11:00 a.m. to 4:15 p.m. it was observed that there is no type of visual notification devices in the following areas: Conference Room, Employee Break Area, Lab Waiting, Meditation Room, ER Restroom, Main Entrance accessible restrooms, Medical and Surgical Staff Lounges, OR Waiting Room, and Doctors and Nurses Locker Rooms.
This finding was confirmed by Staff M at the time of discovery.

Based on observation and staff interview it was determined the facility fire sprinkler system was not installed in accordance to NFPA 13 to provide complete coverage for all portions of the building.

The findings were:

During a tour of the facility with Staff M on 04/04/13 from 11:00 a.m. to 4:15 p.m. it was observed that the following areas are not covered by the fire sprinkler system: Main covered drive, Emergency Entrance, covered areas outside exits, and electrical room next to Patient Room 111.

During a tour of the facility with Staff M on 04/04/13 from 11:00 a.m. to 4:15 p.m. it was discovered that fire sprinkler heads are obstructed in closets near the ER and that one head is obstructed in X-Ray 1.

These findings were confirmed by Staff M at the time of discovery.

Based on observation and staff interview it was determined the facility failed to install fire extinguishers at proper locations.
The findings were:
During the tour of the facility with Staff A on 04/05/13 from 9:30 a.m. to 11:30 a.m. it was observed that the fire extinguisher in the Kitchen break area is not installed in the proper location.
During the tour of the facility with Staff A on 04/05/13 from 9:30 a.m. to 11:30 a.m. it was observed that the fire extinguisher in the hallway 6 year inspection collar does not meet code requirements.
This finding was confirmed by Staff A at the time of discovery.

Based on observation and staff interview it was determined the facility failed to ensure that the requirements for accessibility are met.
The finding were:

During a tour of the facility with Staff A on 04/05/13 from 9:30 a.m. to 11:30 a.m. it was observed that the Handicap parking signs are not correctly installed to proper height and did not contain all required information Permit Parking with $500 Fine.
During a tour of the facility with Staff A on 04/05/13 from 9:30 a.m. to 11:30 a.m. it was observed that the threshold at the rear door exceeded ? inch rise.
These findings were confirmed by Staff A at the time of discovery.

Based on observation and staff interview it was determined the facility failed to maintain the electrical wiring in accordance with NFPA 70, The National Electrical Code.

The finding were:

During a tour of the facility with Staff A on 04/05/13 from 9:30 a.m. to 11:30 a.m. it was observed that an electrical receptacle cover is missing in the Kitchen Storage room.

These findings were confirmed by Staff A at the time of discovery.