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Based on observation the facility failed to properly maintain their fire sprinkler system. Water pressure gauges are required to be tested or replaced at a maximum of five year intervals. The normal life expectancy of a water pressure gauge is between 10 and 15 years. The gauge can be within 3% of maximum.

Findings include :

While on tour with staff on January 23, 2013, from 9:30 AM to 3:15 PM, with staff the following was observed :
1 On the 5th floor C wing stairway , a fire sprinkler gauge dated prior to 2007 was observed.
2. On the 5th floor A wing stairway, a fire sprinkler gauge dated prior to 2007 was observed.
3. On the 4th floor stairway by the nurse station, a fire sprinkler gauge dated prior to 2007 was observed.
NFPA 25 (1998 edition ) Chapter 5..2 requires test or replacement of gauges at intervals not to exceed 5 years.

Base on observation the facility failed to proper install fire extinguishers as required by NFPA 10 ( 1998 edition ) .Portable fire extinguishers are required to be located within 75 feet of any location in a facility measured along the path of travel to a fire extinguisher. A delay in travel or locating a portable fire extinguisher could allow a fire to rapidly develop.

Findings include :

While on tour on January 24, 2013 from 9:30 AM to 12:00 PM with staff, in the first floor main electrical room, accessible only from the exterior, no portable fire extinguisher was observed. NFPA 10 ( 1998 edition ) requires a potable fire extinguisher be located within 75 feet.

Based on observation, the facility failed to establish policy and procedures to insure compliance with NFPA 70 ( 1999 edition ) National Electric Code. Power strips are are use outside their UL listing, exposing patients, staff and visitors to shock and fire hazards.

Findings include :

While on tour January 23,2013, from 9:00 AM to 3:15 PM, with staff, the following observations were made :
1. Fourth floor equipment room, misuse of power strip
2. Third floor office, refrigerator plugged into power strip
3. Third floor Cath Lab 1, power strip not acceptable for use with equipment requiring hospital grade receptacles
4. Second floor case manager office, coffee pot plugged into power strip
5. First floor security office, improper use of power strip
6. First floor administration office, refrigerator plugged into power strip
NFPA 70 (1999 edition ) Chapter 9.1.2 requires power strips be used within their UL listing

Based on observation, the facility failed to properly in stall Alcohol-Based Hand-Rub Dispensers ( ABHRD ). ABHRD were observed installed less than one inch horizontal of an electrical ignition source and above an ignition source within a horizontal distance of one inch either side of an ignition source. The alcohol in the hand-rub could ignite, endangering patients, staff and guests.

Findings Include :

While on tour January 23, 2013, from 9:00 AM to 3:30 PM, with staff, improperly installed ABHRD were observed in the following :
1. On the fifth floor, in the conference room
2. On the fifth floor in the soiled linen room
3. On the fourth floor in the A wing Sun Room
4. On the third floor in Cath Lab 1 recovery
NFPA 101( 2009 edition ) Chapter 18.3.2.6 (7) requires AHBHR be located at least one inch horizontally from an ignition source.

Based on observation the facility failed to properly maintain their fire sprinkler system. Water pressure gauges are required to be tested or replaced at a maximum of five year intervals. The normal life expectancy of a water pressure gauge is between 10 and 15 years. The gauge can be within 3% of maximum.

Findings include :

While on tour with staff on January 23, 2013, from 9:30 AM to 3:15 PM, with staff the following was observed :
1 On the 5th floor C wing stairway , a fire sprinkler gauge dated prior to 2007 was observed.
2. On the 5th floor A wing stairway, a fire sprinkler gauge dated prior to 2007 was observed.
3. On the 4th floor stairway by the nurse station, a fire sprinkler gauge dated prior to 2007 was observed.
NFPA 25 (1998 edition ) Chapter 5..2 requires test or replacement of gauges at intervals not to exceed 5 years.

Base on observation the facility failed to proper install fire extinguishers as required by NFPA 10 ( 1998 edition ) .Portable fire extinguishers are required to be located within 75 feet of any location in a facility measured along the path of travel to a fire extinguisher. A delay in travel or locating a portable fire extinguisher could allow a fire to rapidly develop.

Findings include :

While on tour on January 24, 2013 from 9:30 AM to 12:00 PM with staff, in the first floor main electrical room, accessible only from the exterior, no portable fire extinguisher was observed. NFPA 10 ( 1998 edition ) requires a potable fire extinguisher be located within 75 feet.

Based on observation, the facility failed to establish policy and procedures to insure compliance with NFPA 70 ( 1999 edition ) National Electric Code. Power strips are are use outside their UL listing, exposing patients, staff and visitors to shock and fire hazards.

Findings include :

While on tour January 23,2013, from 9:00 AM to 3:15 PM, with staff, the following observations were made :
1. Fourth floor equipment room, misuse of power strip
2. Third floor office, refrigerator plugged into power strip
3. Third floor Cath Lab 1, power strip not acceptable for use with equipment requiring hospital grade receptacles
4. Second floor case manager office, coffee pot plugged into power strip
5. First floor security office, improper use of power strip
6. First floor administration office, refrigerator plugged into power strip
NFPA 70 (1999 edition ) Chapter 9.1.2 requires power strips be used within their UL listing