HospitalInspections.org

Based upon observations and staff interviews on 7/29/14 the facility has failed to maintain doors capable of resisting fire for at least 20 minutes. This could result in toxic products of combustion getting into the room and into the exit corridor which would endanger the residents, staff and/or visitors within the smoke compartment. The above was discussed and acknowledged by the Facility Maintenance Director.

The findings include, but are not limited to:
The basement elevator lobby door had an inoperative door closing coordinator.

The basement physical therapy HVAC equipment room door into the corridor was equipped with a louver.

The kitchen door into the corridor was blocked open with a door wedge, preventing it from fully closing and latching.

Based upon observations and staff interviews on 7/29/14 between approximately 0900 and 1500 hours the facility has failed to maintain smoke barrier walls to the required one hour fire resistive rating. This could result in the passage of smoke from one smoke compartment into another smoke compartment thereby exposing residents, staff and/or visitors to the toxic products of combustion.

The findings include, but are not limited to:
There was an uncovered penetration in the ceiling of the Emergency Room entrance.
There was an uncovered penetration in the smoke barrier above the corridor smoke doors at the North and South Acute Care suite entrances.

The above was discussed and acknowledged by the Maintenance Director.

Based upon observations and staff interviews on 7/19/14 between approximately 0900 and 1500 hours the facility has failed to have the emergency generator meet the requirements of the Fire Safety Code. This could result in a failure to shutdown the emergency generator in the event of a fire at the generator.
The findings include, but are not limited to:

The facility does not have an emergency stop button installed outside of the room housing the generator or separate of the generator when the generator is located outside of the building in accordance with NFPA 110 3-5.5.6.

The above was discussed and acknowledged by the Maintenance Director.

Based upon observations and staff interviews on 7/29/14 between approximately 0900 and 1500 hours the facility has failed to restrict the use of multi-plug outlets (power strips) to providing power to permitted electrical equipment. This could result in a fire from overheating of the plug strip due to the heavy power draw endangering the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
There was a powerstrip in use with IV pump battery chargers in the Emergency Room.

Based upon observations and staff interviews on 7/29/14 between approximately 0900 and 1500 hours the facility has failed to maintain the use of multi-plug outlets (power strips) as permitted by code This could result in a fire from overheating of the plug strip due to the heavy power draw endangering the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
There was a powerstrip plugged into another powerstrip in the Acute Care Nurses Station.
There was an unapproved cube style multi-plug adaptor in the Doctor's sleeping quarters.


The above was discussed and acknowledged by the Maintenance Director.

Based upon observations and staff interviews on 7/29/14 the facility has failed to maintain doors capable of resisting fire for at least 20 minutes. This could result in toxic products of combustion getting into the room and into the exit corridor which would endanger the residents, staff and/or visitors within the smoke compartment. The above was discussed and acknowledged by the Facility Maintenance Director.

The findings include, but are not limited to:
The basement elevator lobby door had an inoperative door closing coordinator.

The basement physical therapy HVAC equipment room door into the corridor was equipped with a louver.

The kitchen door into the corridor was blocked open with a door wedge, preventing it from fully closing and latching.

Based upon observations and staff interviews on 7/29/14 between approximately 0900 and 1500 hours the facility has failed to maintain smoke barrier walls to the required one hour fire resistive rating. This could result in the passage of smoke from one smoke compartment into another smoke compartment thereby exposing residents, staff and/or visitors to the toxic products of combustion.

The findings include, but are not limited to:
There was an uncovered penetration in the ceiling of the Emergency Room entrance.
There was an uncovered penetration in the smoke barrier above the corridor smoke doors at the North and South Acute Care suite entrances.

The above was discussed and acknowledged by the Maintenance Director.

Based upon observations and staff interviews on 7/19/14 between approximately 0900 and 1500 hours the facility has failed to have the emergency generator meet the requirements of the Fire Safety Code. This could result in a failure to shutdown the emergency generator in the event of a fire at the generator.
The findings include, but are not limited to:

The facility does not have an emergency stop button installed outside of the room housing the generator or separate of the generator when the generator is located outside of the building in accordance with NFPA 110 3-5.5.6.

The above was discussed and acknowledged by the Maintenance Director.

Based upon observations and staff interviews on 7/29/14 between approximately 0900 and 1500 hours the facility has failed to restrict the use of multi-plug outlets (power strips) to providing power to permitted electrical equipment. This could result in a fire from overheating of the plug strip due to the heavy power draw endangering the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
There was a powerstrip in use with IV pump battery chargers in the Emergency Room.

Based upon observations and staff interviews on 7/29/14 between approximately 0900 and 1500 hours the facility has failed to maintain the use of multi-plug outlets (power strips) as permitted by code This could result in a fire from overheating of the plug strip due to the heavy power draw endangering the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
There was a powerstrip plugged into another powerstrip in the Acute Care Nurses Station.
There was an unapproved cube style multi-plug adaptor in the Doctor's sleeping quarters.


The above was discussed and acknowledged by the Maintenance Director.