HospitalInspections.org

Based on observation and interview, the facility failed to provide a minimum one half hour fire resistance rating in accordance with 19.3.6.1, between a storage closet and in the north end of the building constructed in 1938. This deficient practice has the potential to affect patients, staff and visitors. The facility census was 18.

Findings included:

1. Observation on 03/20/13 at 2:00 PM showed four electric wiring conduits penetrated a corridor wall between a storage room and first floor corridor of a soiled utility room at the north end of the 1938 building. The exposed annular spaces around the unsealed penetrations were up to one half-inch wide.

During an interview on 03/20/13 at 2:00 PM, Staff J, Director of Facility Services confirmed that he had missed the penetrations during his regular PM rounds.

Based on observations and interview, the facility failed to ensure a set of newly installed doors in a fire wall of a remodeled portion of the facility was in compliance with 18.3.7.8 (requirements for new construction that the doors meeting edge have a rabbet, bevel, or astragal to resist the passage of smoke though the gap in between the doors.). The facility is partially sprinklered, 2000 (existing) Life Safety Code construction. This deficient practice has the potential to affect patients, staff and visitors. The facility census was 18.

Findings included:

1. Observation on 03/20/13 at 1:45 PM showed a gap one quarter-inch width not covered or sealed with an astragal (a molding attached to one of two leafs of a double door that creates a smoke tight barrier) on a set of doors in a fire wall on the second floor that separated a section of the building constructed in 1961 from the original 1938 building.

During an interview on 03/11/13 at 2:00 PM, Staff J, Director of Facility Services, confirmed that the doors were in a fire wall that separated two dissimilar portions of the building. He stated that the original doors had sustained numerous damages over years and they had just replaced them recently.

Based on observation and interview the facility failed to provide a NO EXIT sign in accordance with 7.10.8.1 and 19.2.10.1, on a gate to notify pedestrians that the set of stairs that continued to the ground level did not lead directly to an exit at the ground level. This deficient practice potentially affects all staff, visitors and patients in a facility with a census of 18.

Findings included:

1. Observation on 03/20/13 at 1:30 PM showed a stairway off of second floor that descended to first floor level. A gate on the last flight of stairs discouraged traffic from continuing on down the stairs, but was not marked to avoid being mistaken for an egress to an exit off of the ground level.

During an interview on 03/20/13 at 1:40 PM, Staff J, Director of Facility Services stated that the door at the bottom of the stairs was always locked. He stated that it did not lead directly to an exit, but was a back door into the Medical Records storage room.

Based on observation and interview, the facility failed to provide a minimum one half hour fire resistance rating in accordance with 19.3.6.1, between a storage closet and in the north end of the building constructed in 1938. This deficient practice has the potential to affect patients, staff and visitors. The facility census was 18.

Findings included:

1. Observation on 03/20/13 at 2:00 PM showed four electric wiring conduits penetrated a corridor wall between a storage room and first floor corridor of a soiled utility room at the north end of the 1938 building. The exposed annular spaces around the unsealed penetrations were up to one half-inch wide.

During an interview on 03/20/13 at 2:00 PM, Staff J, Director of Facility Services confirmed that he had missed the penetrations during his regular PM rounds.

Based on observations and interview, the facility failed to ensure a set of newly installed doors in a fire wall of a remodeled portion of the facility was in compliance with 18.3.7.8 (requirements for new construction that the doors meeting edge have a rabbet, bevel, or astragal to resist the passage of smoke though the gap in between the doors.). The facility is partially sprinklered, 2000 (existing) Life Safety Code construction. This deficient practice has the potential to affect patients, staff and visitors. The facility census was 18.

Findings included:

1. Observation on 03/20/13 at 1:45 PM showed a gap one quarter-inch width not covered or sealed with an astragal (a molding attached to one of two leafs of a double door that creates a smoke tight barrier) on a set of doors in a fire wall on the second floor that separated a section of the building constructed in 1961 from the original 1938 building.

During an interview on 03/11/13 at 2:00 PM, Staff J, Director of Facility Services, confirmed that the doors were in a fire wall that separated two dissimilar portions of the building. He stated that the original doors had sustained numerous damages over years and they had just replaced them recently.

Based on observation and interview the facility failed to provide a NO EXIT sign in accordance with 7.10.8.1 and 19.2.10.1, on a gate to notify pedestrians that the set of stairs that continued to the ground level did not lead directly to an exit at the ground level. This deficient practice potentially affects all staff, visitors and patients in a facility with a census of 18.

Findings included:

1. Observation on 03/20/13 at 1:30 PM showed a stairway off of second floor that descended to first floor level. A gate on the last flight of stairs discouraged traffic from continuing on down the stairs, but was not marked to avoid being mistaken for an egress to an exit off of the ground level.

During an interview on 03/20/13 at 1:40 PM, Staff J, Director of Facility Services stated that the door at the bottom of the stairs was always locked. He stated that it did not lead directly to an exit, but was a back door into the Medical Records storage room.