HospitalInspections.org

Based on observation, building plan review, and interview it was determined the medical records room was not protected as a hazardous room by fire rated construction or a sprinkler system as required by NFPA 101 Section 19.3.2.1. Storing the combustible materials in a unprotected room had the potential to affect all patients, staff and visitors due to the spread of fire and smoke from the room in the event of a fire. The facility had a census of 15 patients on 12/03/12. The findings follow:

A. On a tour of the facility on 12/05/12 at 1055 with the System Maintenance/Plant Operations Director, the room used for storage of medical records was observed without a sprinkler system or smoke detection system. The 1 hour fire rated barrier enclosing the room was incomplete because the rated wall did not extend to the roof deck at one section. The door to the room had a 20 minute fire rating (45 minute rating was required.) The room contained shelves of medical records in quantities conducive to the rapid propagation of fire.
B. Review of the building plans on 12/06/12 at 1110 revealed the 1 hour rated barrier enclosing the medical records room consisted of the 1 hour rated corridor wall. The barrier wall did not extend to the exterior wall in the southeast corner to fully separate the room from the remainder of the building.
C. An interview with the System Maintenance/Plant Operations Director on 12/05/12 at 1125 revealed the room used for medical records storage had been converted from a Critical Care Unit approximately eight years ago. He also verified the room was not protected as a hazardous area by a complete fire rated wall, 45 minute fire rated door, or sprinkler system.

Based on Safety Policy and Procedure Manual review, Generator Log review and interview, it was determined the generator was not inspected weekly from January to December 2012. Failure to perform weekly generator inspections had the potential to affect the health and safety of all patients because the reliability of the generator to provide power to the facility in the event of the loss of normal power was not assured. The facility had a census of 15 patients on 12/03/12. The findings follow:

A. Review of the Generator Log on 12/04/12 at 0920 revealed there was no documentation of weekly generator inspections from January to December 2012.
B. Review of the Safety Policy and Procedure Manual on 12/04/12 at 0930 revealed the facility had a "Policy for Emergency Power Systems", which required the following "Weekly Preventative Maintenance Items:"
1) General physical condition and condition of area
2) Exhaust system condition
3) Starting battery electrolyte level
4) Water jacket heater
5) Radiator hoses and belt good condition
6) Radiator air path clear
7) Adequate cooling water to heat exchanger; coolant level
8) Lube oil heater
9) Engine lubrication oil level
10) Fuel flex hoses and connectors
11) Water in fuel oil
12) Main fuel tank level, day tank level and condition
13) Fuel pump/transfer pump operation, solenoid valve operation
14) Fuel supply
C. In an interview on 12/05/12 at 0900, the System Maintenance/Plant Operations Director verified there was no documentation of weekly generator inspections available for review.

Based on observation, building plan review, and interview it was determined the medical records room was not protected as a hazardous room by fire rated construction or a sprinkler system as required by NFPA 101 Section 19.3.2.1. Storing the combustible materials in a unprotected room had the potential to affect all patients, staff and visitors due to the spread of fire and smoke from the room in the event of a fire. The facility had a census of 15 patients on 12/03/12. The findings follow:

A. On a tour of the facility on 12/05/12 at 1055 with the System Maintenance/Plant Operations Director, the room used for storage of medical records was observed without a sprinkler system or smoke detection system. The 1 hour fire rated barrier enclosing the room was incomplete because the rated wall did not extend to the roof deck at one section. The door to the room had a 20 minute fire rating (45 minute rating was required.) The room contained shelves of medical records in quantities conducive to the rapid propagation of fire.
B. Review of the building plans on 12/06/12 at 1110 revealed the 1 hour rated barrier enclosing the medical records room consisted of the 1 hour rated corridor wall. The barrier wall did not extend to the exterior wall in the southeast corner to fully separate the room from the remainder of the building.
C. An interview with the System Maintenance/Plant Operations Director on 12/05/12 at 1125 revealed the room used for medical records storage had been converted from a Critical Care Unit approximately eight years ago. He also verified the room was not protected as a hazardous area by a complete fire rated wall, 45 minute fire rated door, or sprinkler system.

Based on Safety Policy and Procedure Manual review, Generator Log review and interview, it was determined the generator was not inspected weekly from January to December 2012. Failure to perform weekly generator inspections had the potential to affect the health and safety of all patients because the reliability of the generator to provide power to the facility in the event of the loss of normal power was not assured. The facility had a census of 15 patients on 12/03/12. The findings follow:

A. Review of the Generator Log on 12/04/12 at 0920 revealed there was no documentation of weekly generator inspections from January to December 2012.
B. Review of the Safety Policy and Procedure Manual on 12/04/12 at 0930 revealed the facility had a "Policy for Emergency Power Systems", which required the following "Weekly Preventative Maintenance Items:"
1) General physical condition and condition of area
2) Exhaust system condition
3) Starting battery electrolyte level
4) Water jacket heater
5) Radiator hoses and belt good condition
6) Radiator air path clear
7) Adequate cooling water to heat exchanger; coolant level
8) Lube oil heater
9) Engine lubrication oil level
10) Fuel flex hoses and connectors
11) Water in fuel oil
12) Main fuel tank level, day tank level and condition
13) Fuel pump/transfer pump operation, solenoid valve operation
14) Fuel supply
C. In an interview on 12/05/12 at 0900, the System Maintenance/Plant Operations Director verified there was no documentation of weekly generator inspections available for review.