HospitalInspections.org

Based on observation and staff interview, this facility failed to provide a firewall with a two-hour fire rating between the Clinic and the Hospital portion of the facility. The wall is penetrated above the lay-in ceiling tile with building services (pipes, ductwork) and should only have a penetration in the corridor passageway. This deficient practice affects all occupants including staff, visitors and residents. This facility has a capacity of 25 and a census of 5 residents.

Findings include:

Observations and staff interview on 08/03/10, at 11:43 a.m., revealed the the two-hour firewall located between the Osage Clinic and the Emergency Room Registration area of the facility. Above the lay in tile there was a 1/2 inch electrical conduit and a yellow electrical wire (construction lighting) with a 1/2 inch to 3/4 inch gap in the fire wall. According to Maintenance Staff A, this was the two-hour firewall intended to separate the occupancies.

Maintenance Staff A and B verified this observation.

Based on observation, the facility failed to maintain a smoke tight ceiling. The building is composed of Type II protected construction and is required by the Life Safety Code 19.1.6.2, to maintain smoke tight ceilings if used for healthcare occupancy. This deficient practice affects all occupants of the five smoke zones, This facility has a capacity of 25 and a census of 5 residents.
Findings include:
Observations on 08/03/10, at 11:37 a.m., revealed the sprinkler head in the Emergency Room entrance foyer had a 1/4 inch to 1/2 inch gap at the ceiling.

Maintenance Staff A & B verified this observation.

Based on observation, the facility failed to provide separation of hazardous areas from other compartments. The area of deficient practice affected four (4) of eight (8) smoke compartments in the facility. This could affect staff, visitors and 25 residents. This facility has a capacity of 25 and a census of 5 residents.

Findings include:

1.) Observations on 08/03/10, at 10:02 a.m., revealed the following penetrations in the Main Electrical Room (basement).
A.) Along the South wall above the double doors there was a 3 inch pipe with a 1/2 inch gap at the wall, a 1/2 inch hole in the wall.
B.) Above panel NEHD1 there was a 2 inch electrical conduit with a 1/4 inch to 1/2 inch gap.
C.) Along the East wall there were two (2) 3/4 inch electrical conduits with a 1/4 inch gap. A 1/2 inch conduit with a 1/4 inch gap and a 2 inch conduit with a 1/2 inch gap.
2.) Observations on 08/03/10, at 10:11 a.m., revealed the following penetrations in Air Handler Room #1 (basement).
A.) Along the South wall a 8 inch circular hole in the drywall next to the circulating pumps.
B.) There were four (4) condenser lines with a 1/4 inch to 1/2 inch gap.
C.) There was a two (2) inch gas line with a 1/2 inch to 3/4 inch gap.
D.) Along the ceiling in the corner there was a concrete support beam that went through the wall and had a 3/4 inch to 1 inch gap in the wall.
3.) Observations on 08/03/10, at 10:19 a.m., revealed the following penetrations in along the South wall of room #LL68 above the doors.
A.) There was a communication wire and 2-1/2 inch electrical conduits with a 3/4 inch gap in the wall.
B.) There was a 1 inch conduit with a 1/2 inch to 3/4 inch gap.
C.) There was a six (6) inch hole in the wall in the Southeast corner above the door.
4.) Observations on 08/03/10, at 10:22, revealed the the East wall of Storage Room #LL62 above the ceiling tile (one hour rated room) the drywall seams needed to be sealed.
5.) Observations on 08/03/10, at 10:34 a.m., revealed that six (6) electrical conduits in the Pump room penetrated the concrete ceiling with a 1/4 inch to 1/2 inch gap and was open to the lobby above.
6.) Observations on 08/03/10, at 10:39 a.m., revealed a communication wire bundle penetrated the 2 hour wall and had a 1 inch gap.
7.) Observations on 08/03/10, at 10:42 a.m., revealed that the wall separating Electrical Room # LL15 and the corridor was penetrated by 2 chiller lines with 1/2 inch to 3/4 inch gaps.
8.) Observations on 08/03/10, at 11:17 a.m., revealed that the wall separating Electrical Room #1113 and the corridor was penetrated by a 1/2 inch electrical conduit and a black communication wire with a 1/2 inch gap.
9.) Observations on 08/03/10, at 11:20 a.m., revealed the door to the Soiled Utility room #1114, which is over 50 sqft failed to positively close and latch.
10.) Observations on 08/03/10, at 11:25 a.m., revealed the Medical/Surgical Linin Room which was over 50 sqft did not have a closure installed on the door. The door would also not close in the door frame, it was binding on the bottom of the frame.

Maintenance Staff A & B verified these observations.

Based on observation, the facility failed to provide an unobstructed corridors that provides a clear path of egress for one (1) of eight (8)seven smoke zones. This deficient practice could affect up to 25 patents, visitors and staff. This facility is licensed for 25 and a census of 5.

Findings include:

Observations on 08/03/10, at 1:25 p.m., revealed the History corridor smoke doors and the Surgery Hall smoke doors were not equipped with panic hardware. These sets of doors had a round knob on the right hand door to use for egress. These doors closed and latched when the Fire Alarm system was tested. This knob would make it difficult to open these doors in a limited visibility situation.

Maintenance Staff A verified these observations. According to the facility layout, this was a required exit.

Based on observation, the facility failed to maintain the emergency egress lighting. This deficient practice affects all patients, staff and visitors of one (1) smoke zone. This facility has a capacity of 25 and a census of 5 residents.

Findings include:

Observation on 08/03/10, at 11:10 a.m., revealed the Emergency light located in the Modular Conference Room #1116 did not illuminate.

Maintenance Staff A & B verified this documentation.

Based on observation, the facility failed to provide a directional exit sign at the end of a corridor for two (2) of eight (8) exits. This deficient practice could effect residents, staff and visitors in the facility. This facility is licensed for 25 and a census of 5 residents.

1.) Observations on 08/03/10, at 10:55 a.m., revealed the Main Lower Level corridor to the main stairway was missing an Exit sign. There was a set of smoke doors installed to allow the open stairway at the en of the corridor. When the doors were int he open position an Exit sign was visible from the corridor. When the smoke doors were closed there was only one exit sign noted in the corridor.

2.) Observations on 08/03/10, at 11:21 a.m., revealed the the Southwest Medical/Surgical smoke doors was missing an exit sign. When exiting the area leading towards the Nurses Station there was not exit sign visible when the smoke doors were in the closed position. This only gave one Exit sign in the corridor.

Maintenance staff A & B verified these observations.

Based on record review, the facility failed to conduct fire drills at least quarterly on each shift. This deficient practice effects all occupants including staff, visitors and residents, as the lack of drills can affect the abilities of the staff to respond in the event of an actual emergency. This facility has a capacity of 25 and a census of 5 residents.

Findings include:

Review of the facility's fire drill records on 08/03/10, revealed that fire drills on the night shift were not documented correctly. For the period reviewed the Night Shift (10:45p.m-6:45a.m.) was missing the the time and location of the drill conducted on 12/31/09.

Maintenance Staff A & B verified this observation.

(A)
Based on observation, interview and record review, the facility failed to provided a properly tested and maintained fire alarm system. All of the facility including all residents, staff and visitors could be directly affected by the deficient practice. The facility has 25 certified beds and a census was 5.

Findings include:

1.) Record review on 08/03/10, revealed that the last Fire Inspection report was from 12/30/09. Maintenance Staff verified that this system was only inspected annually by the Fire Alarm Company.

2.) Observation 08/03/10, at 1:35 p.m., revealed during the inspection and testing of the fire alarm system revealed that when the automatic dialer panel was placed in trouble from phone line failure, a trouble signal was not sent to the main fire alarm control panel or the annunciator panel located at the nurse ' s station. The annunciator panel showed that all systems were normal when part of the system was in trouble. The alarm company received the trouble and the dialer which was in a isolated area showed a trouble.

Maintenance Staff A & B verified these observations.

(B)
Based on observation and staff interview, the facility did not assure that the fire alarm system is in accordance with NFPA 72, and chapter 9.6.4 of NFPA 101 by ensuring that the fire alarm breaker is mechanically protected. This deficient practice affects all occupants of the building, including staff, visitors and residents. This facility has a capacity of 25 with a census of 5.

Findings include:

Observations on 08/03/10, at 10:17 a.m., revealed the facility failed to provide a properly maintained fire alarm system. The fire alarm breaker not secured with a mechanical lock to assure that the breaker is not inadvertently shut off. All occupants would be directly affected by the deficient practice.

Maintenance Staff A & B verified this observation.

Based on observation, this facility failed to maintain that the fire alarm system is installed and maintained in accordance with NFPA 72, 2-3.5, which requires that smoke detectors are not placed within direct airflow, nor closer that three feet to air supply or air return. Installation of a smoke detector close to a ceiling fan can impede the operation of the smoke detector and can affect all occupants of the building. This facility has a capacity of 25 and a census of 5 residents.

Findings include:

Observations on 08/03/10, at 11:10 a.m., revealed the smoke detector(#D42) located in the corridor outside of room #1112 was located within three (3) feet of the air diffuser.

Maintenance Staff A & B verified this observation.

(A)
Based on record review, the facility failed to maintain the sprinkler system in accordance with the 1998 edition of NFPA 25 by failing to inspect and test the sprinkler system. These items could effect the operation of the heads by obstructing spray patterns, delaying the response time, and causing the heads or the entire sprinkler system to be inoperable. This deficient practice affects all occupants in this facility with a capacity of 25 and a census of 5.

Findings include:

Record review on 8-3-10, revealed that only an annual inspection was being completed on the sprinkler system. No quarterly inspections had been completed or documented

(B)
Based on observation, the facility failed to maintain the sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 13. Standard for the installation of Sprinkler Systems, 1999 edition. The facility is licensed for 25 and a census of 5.

Findings include:

Observations on 08/03/10, at 11:03 a.m., revealed the Ambulance garage which is attached to the building (Emergency Room) was not equipped with sprinklers. This area is a single stall ambulance garage with storage and has access to the Emergency Room through sliding doors.

Maintenance staff A & B verified these observations.

Based on staff interview and record review, the facility failed to maintain and test the emergency generator power supply as required. The deficient practice would affect all smoke compartments of the facility along with all of the residents, visitors and staff. The facility is licensed for 25 beds and a census of 5.

Findings include:

Documentation review and staff interview on 08/03/10, at 9:45 a.m., revealed that proper documentation of the generator weekly inspections and run times had not been maintained. The Documentation for the weekly visual inspection was only once during the month of January (01/21/10). For the month of April it was conducted on 04/22/10 and 04/26/10. There was no documentation for the weekly checks for the month of May 2010. Documentation did show monthly 30-minute load tests for the period reviewed.

Maintenance Staff A & B verified these observations.

Based on observation, it was determined the facility failed to maintain the buildings electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition, placing the Staff and Residents of the facility at risk in the event of a fire. The facility had a capacity of 25 and a census of 5 at the time of the survey.

Findings Include:

1.) Observations on 08/03/10, at 10:14 a.m., revealed the facility failed to maintain the Electrical System in the Air Handler Room #1. Along the North Exterior wall there was an electrical pull box with an open cover and exposed wires.

2.) Observations on 08/03/10, at 10:26 a.m., revealed the facility failed to maintain the electrical system in the Boiler Room. Along the west wall there was a 4 inch x 4 inch electrical junction box and a single gang junction box missing covers and had exposed wires.

Maintenance Staff A & b verified these observations.

Based on observation and staff interview, this facility failed to provide a firewall with a two-hour fire rating between the Clinic and the Hospital portion of the facility. The wall is penetrated above the lay-in ceiling tile with building services (pipes, ductwork) and should only have a penetration in the corridor passageway. This deficient practice affects all occupants including staff, visitors and residents. This facility has a capacity of 25 and a census of 5 residents.

Findings include:

Observations and staff interview on 08/03/10, at 11:43 a.m., revealed the the two-hour firewall located between the Osage Clinic and the Emergency Room Registration area of the facility. Above the lay in tile there was a 1/2 inch electrical conduit and a yellow electrical wire (construction lighting) with a 1/2 inch to 3/4 inch gap in the fire wall. According to Maintenance Staff A, this was the two-hour firewall intended to separate the occupancies.

Maintenance Staff A and B verified this observation.

Based on observation, the facility failed to maintain a smoke tight ceiling. The building is composed of Type II protected construction and is required by the Life Safety Code 19.1.6.2, to maintain smoke tight ceilings if used for healthcare occupancy. This deficient practice affects all occupants of the five smoke zones, This facility has a capacity of 25 and a census of 5 residents.
Findings include:
Observations on 08/03/10, at 11:37 a.m., revealed the sprinkler head in the Emergency Room entrance foyer had a 1/4 inch to 1/2 inch gap at the ceiling.

Maintenance Staff A & B verified this observation.

Based on observation, the facility failed to provide separation of hazardous areas from other compartments. The area of deficient practice affected four (4) of eight (8) smoke compartments in the facility. This could affect staff, visitors and 25 residents. This facility has a capacity of 25 and a census of 5 residents.

Findings include:

1.) Observations on 08/03/10, at 10:02 a.m., revealed the following penetrations in the Main Electrical Room (basement).
A.) Along the South wall above the double doors there was a 3 inch pipe with a 1/2 inch gap at the wall, a 1/2 inch hole in the wall.
B.) Above panel NEHD1 there was a 2 inch electrical conduit with a 1/4 inch to 1/2 inch gap.
C.) Along the East wall there were two (2) 3/4 inch electrical conduits with a 1/4 inch gap. A 1/2 inch conduit with a 1/4 inch gap and a 2 inch conduit with a 1/2 inch gap.
2.) Observations on 08/03/10, at 10:11 a.m., revealed the following penetrations in Air Handler Room #1 (basement).
A.) Along the South wall a 8 inch circular hole in the drywall next to the circulating pumps.
B.) There were four (4) condenser lines with a 1/4 inch to 1/2 inch gap.
C.) There was a two (2) inch gas line with a 1/2 inch to 3/4 inch gap.
D.) Along the ceiling in the corner there was a concrete support beam that went through the wall and had a 3/4 inch to 1 inch gap in the wall.
3.) Observations on 08/03/10, at 10:19 a.m., revealed the following penetrations in along the South wall of room #LL68 above the doors.
A.) There was a communication wire and 2-1/2 inch electrical conduits with a 3/4 inch gap in the wall.
B.) There was a 1 inch conduit with a 1/2 inch to 3/4 inch gap.
C.) There was a six (6) inch hole in the wall in the Southeast corner above the door.
4.) Observations on 08/03/10, at 10:22, revealed the the East wall of Storage Room #LL62 above the ceiling tile (one hour rated room) the drywall seams needed to be sealed.
5.) Observations on 08/03/10, at 10:34 a.m., revealed that six (6) electrical conduits in the Pump room penetrated the concrete ceiling with a 1/4 inch to 1/2 inch gap and was open to the lobby above.
6.) Observations on 08/03/10, at 10:39 a.m., revealed a communication wire bundle penetrated the 2 hour wall and had a 1 inch gap.
7.) Observations on 08/03/10, at 10:42 a.m., revealed that the wall separating Electrical Room # LL15 and the corridor was penetrated by 2 chiller lines with 1/2 inch to 3/4 inch gaps.
8.) Observations on 08/03/10, at 11:17 a.m., revealed that the wall separating Electrical Room #1113 and the corridor was penetrated by a 1/2 inch electrical conduit and a black communication wire with a 1/2 inch gap.
9.) Observations on 08/03/10, at 11:20 a.m., revealed the door to the Soiled Utility room #1114, which is over 50 sqft failed to positively close and latch.
10.) Observations on 08/03/10, at 11:25 a.m., revealed the Medical/Surgical Linin Room which was over 50 sqft did not have a closure installed on the door. The door would also not close in the door frame, it was binding on the bottom of the frame.

Maintenance Staff A & B verified these observations.

Based on observation, the facility failed to provide an unobstructed corridors that provides a clear path of egress for one (1) of eight (8)seven smoke zones. This deficient practice could affect up to 25 patents, visitors and staff. This facility is licensed for 25 and a census of 5.

Findings include:

Observations on 08/03/10, at 1:25 p.m., revealed the History corridor smoke doors and the Surgery Hall smoke doors were not equipped with panic hardware. These sets of doors had a round knob on the right hand door to use for egress. These doors closed and latched when the Fire Alarm system was tested. This knob would make it difficult to open these doors in a limited visibility situation.

Maintenance Staff A verified these observations. According to the facility layout, this was a required exit.

Based on observation, the facility failed to maintain the emergency egress lighting. This deficient practice affects all patients, staff and visitors of one (1) smoke zone. This facility has a capacity of 25 and a census of 5 residents.

Findings include:

Observation on 08/03/10, at 11:10 a.m., revealed the Emergency light located in the Modular Conference Room #1116 did not illuminate.

Maintenance Staff A & B verified this documentation.

Based on observation, the facility failed to provide a directional exit sign at the end of a corridor for two (2) of eight (8) exits. This deficient practice could effect residents, staff and visitors in the facility. This facility is licensed for 25 and a census of 5 residents.

1.) Observations on 08/03/10, at 10:55 a.m., revealed the Main Lower Level corridor to the main stairway was missing an Exit sign. There was a set of smoke doors installed to allow the open stairway at the en of the corridor. When the doors were int he open position an Exit sign was visible from the corridor. When the smoke doors were closed there was only one exit sign noted in the corridor.

2.) Observations on 08/03/10, at 11:21 a.m., revealed the the Southwest Medical/Surgical smoke doors was missing an exit sign. When exiting the area leading towards the Nurses Station there was not exit sign visible when the smoke doors were in the closed position. This only gave one Exit sign in the corridor.

Maintenance staff A & B verified these observations.

Based on record review, the facility failed to conduct fire drills at least quarterly on each shift. This deficient practice effects all occupants including staff, visitors and residents, as the lack of drills can affect the abilities of the staff to respond in the event of an actual emergency. This facility has a capacity of 25 and a census of 5 residents.

Findings include:

Review of the facility's fire drill records on 08/03/10, revealed that fire drills on the night shift were not documented correctly. For the period reviewed the Night Shift (10:45p.m-6:45a.m.) was missing the the time and location of the drill conducted on 12/31/09.

Maintenance Staff A & B verified this observation.

(A)
Based on observation, interview and record review, the facility failed to provided a properly tested and maintained fire alarm system. All of the facility including all residents, staff and visitors could be directly affected by the deficient practice. The facility has 25 certified beds and a census was 5.

Findings include:

1.) Record review on 08/03/10, revealed that the last Fire Inspection report was from 12/30/09. Maintenance Staff verified that this system was only inspected annually by the Fire Alarm Company.

2.) Observation 08/03/10, at 1:35 p.m., revealed during the inspection and testing of the fire alarm system revealed that when the automatic dialer panel was placed in trouble from phone line failure, a trouble signal was not sent to the main fire alarm control panel or the annunciator panel located at the nurse ' s station. The annunciator panel showed that all systems were normal when part of the system was in trouble. The alarm company received the trouble and the dialer which was in a isolated area showed a trouble.

Maintenance Staff A & B verified these observations.

(B)
Based on observation and staff interview, the facility did not assure that the fire alarm system is in accordance with NFPA 72, and chapter 9.6.4 of NFPA 101 by ensuring that the fire alarm breaker is mechanically protected. This deficient practice affects all occupants of the building, including staff, visitors and residents. This facility has a capacity of 25 with a census of 5.

Findings include:

Observations on 08/03/10, at 10:17 a.m., revealed the facility failed to provide a properly maintained fire alarm system. The fire alarm breaker not secured with a mechanical lock to assure that the breaker is not inadvertently shut off. All occupants would be directly affected by the deficient practice.

Maintenance Staff A & B verified this observation.

Based on observation, this facility failed to maintain that the fire alarm system is installed and maintained in accordance with NFPA 72, 2-3.5, which requires that smoke detectors are not placed within direct airflow, nor closer that three feet to air supply or air return. Installation of a smoke detector close to a ceiling fan can impede the operation of the smoke detector and can affect all occupants of the building. This facility has a capacity of 25 and a census of 5 residents.

Findings include:

Observations on 08/03/10, at 11:10 a.m., revealed the smoke detector(#D42) located in the corridor outside of room #1112 was located within three (3) feet of the air diffuser.

Maintenance Staff A & B verified this observation.

(A)
Based on record review, the facility failed to maintain the sprinkler system in accordance with the 1998 edition of NFPA 25 by failing to inspect and test the sprinkler system. These items could effect the operation of the heads by obstructing spray patterns, delaying the response time, and causing the heads or the entire sprinkler system to be inoperable. This deficient practice affects all occupants in this facility with a capacity of 25 and a census of 5.

Findings include:

Record review on 8-3-10, revealed that only an annual inspection was being completed on the sprinkler system. No quarterly inspections had been completed or documented

(B)
Based on observation, the facility failed to maintain the sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 13. Standard for the installation of Sprinkler Systems, 1999 edition. The facility is licensed for 25 and a census of 5.

Findings include:

Observations on 08/03/10, at 11:03 a.m., revealed the Ambulance garage which is attached to the building (Emergency Room) was not equipped with sprinklers. This area is a single stall ambulance garage with storage and has access to the Emergency Room through sliding doors.

Maintenance staff A & B verified these observations.

Based on staff interview and record review, the facility failed to maintain and test the emergency generator power supply as required. The deficient practice would affect all smoke compartments of the facility along with all of the residents, visitors and staff. The facility is licensed for 25 beds and a census of 5.

Findings include:

Documentation review and staff interview on 08/03/10, at 9:45 a.m., revealed that proper documentation of the generator weekly inspections and run times had not been maintained. The Documentation for the weekly visual inspection was only once during the month of January (01/21/10). For the month of April it was conducted on 04/22/10 and 04/26/10. There was no documentation for the weekly checks for the month of May 2010. Documentation did show monthly 30-minute load tests for the period reviewed.

Maintenance Staff A & B verified these observations.

Based on observation, it was determined the facility failed to maintain the buildings electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition, placing the Staff and Residents of the facility at risk in the event of a fire. The facility had a capacity of 25 and a census of 5 at the time of the survey.

Findings Include:

1.) Observations on 08/03/10, at 10:14 a.m., revealed the facility failed to maintain the Electrical System in the Air Handler Room #1. Along the North Exterior wall there was an electrical pull box with an open cover and exposed wires.

2.) Observations on 08/03/10, at 10:26 a.m., revealed the facility failed to maintain the electrical system in the Boiler Room. Along the west wall there was a 4 inch x 4 inch electrical junction box and a single gang junction box missing covers and had exposed wires.

Maintenance Staff A & b verified these observations.