HospitalInspections.org

Based on observation and staff interview, the facility failed to ensure all smoke barriers were maintained as a continuous membrane in 1 of 3 smoke compartments. The findings were:

Observation on 9/14/10 at 9:48 AM revealed a 3 inch diameter hole in the wall in the oxygen storage room. The hole was approximately one foot from the floor. The maintenance manager verified this finding at the time of the observation.

Based on observation and staff interview, the facility failed to ensure 3 corridor doors were resistant to the passage of smoke in 2 of 3 smoke compartments. The findings were:

Observation on 9/14/10 revealed the following concerns:
1. An 8-inch long, white, wooden block was observed at 11:23 AM wedged between the door and the door frame leading into the therapeutic swimming pool room (# 616). The wooden block prevented the door from closing. The door had a self closure device (SCD) attached to it. In addition, a computer on wheels was observed in the swimming pool room. The computer's electrical cord ran through the blocked open door and was plugged into an electrical outlet in the adjacent room. The electrical cord also prevented the door from being closed.

2. Observation at 10: 48 AM revealed room # 602A (door into receptionist area) had a SCD attached but the device had been disabled.

3. During a fire drill on 9/13/10 at 8:00 PM, a wad of paper was observed jammed into the door latch mechnism on the door frame leading into the staff break room opposite the nurses station. The paper prevented the door from latching into the frame when closed. Interview with the plant operations manager at the times noted above confirmed the observations.

Based on observation, review of construction plans and staff interview, the facility failed to install an emergency exit sign in 1 of 3 smoke compartments. The findings were:

Observation on 9/14/10 at 12:48 PM revealed the cross corridor smoke barrier doors in the hallway leading south from the large therapeutic exercise room did not have an overhead, lighted directional exit sign over the doors. Review of the original 2006 construction plans revealed an exit sign was supposed to have been installed over the doors. Interview with the maintenance manager at the time of the observation confirmed the exit sign was missed during construction.

Based on observation and staff interview the facility failed to ensure 1 of 4 smoke barrier doors was resistant to the passage of smoke. The findings were:

Observation on 9/14/10 at 1:15 PM revealed the cross corridor, smoke barrier double doors near resident room # 301 did not completely close, creating a 1/2-inch gap. The maintenance manager confirmed the observation and stated the doors needed to be adjusted.

Based on observation, review of facility records and staff interview, the facility failed to ensure the fire suppression (sprinkler) system was properly maintained. The findings were:

Observation on 9/14/10 at 10:44 AM and at 12:33 PM revealed a gap greater than 1/2-inch existed between the sprinkler head escutcheons and the ceiling in the closet in the 200 hall and in the dry storage room in the kitchen. Interview with the plant operations manager confirmed the escutcheons needed to be adjusted.

Based on record review and staff interview the facility failed to conduct an annual inspection of the emergency generator. The findings were:

Review of facility emergency generator testing records on 9/13/10 at 3:48 PM revealed the most recent annual inspection of the generator was conducted 3/2/10. However, the previous inspection was conducted 12/10/08. Interview with the facility maintenance manager at the time confirmed more than a year had elapsed between inspections.

Based on observation and staff interview the facility failed to ensure the electrical system was maintained as required in 1 of 3 smoke compartments. The findings were:

Observation on 9/13/10 at 4:44 PM and again on 9/14/10 at 11:30 AM revealed three side by side electrical panels in the kitchen were blocked by three food containers. Interview with the plant operations manager at the time of the observations confirmed the electrical panels were blocked.