HospitalInspections.org

Based on observation and interview, the provider failed to maintain the fire-resistive characteristics of the one randomly checked two hour fire-resistive wall between the hospital and the administration/physical therapy building. Findings include:

1. Observation at 3:30 p.m. on 11/5/13 revealed a 90 minute fire rated door located in the two hour fire rated barrier separating the hospital occupancy from the business occupancy. That door was held open by an automatic hold open device. Upon activation of the buildings fire alarm that door was released from the open position. That door did not close and latch into its frame under the power of the doors self-closing device. Interview with the plant operations manager at the time of the observation confirmed that condition.

Based on observation and interview, the provider failed to maintain proper separation of hazardous areas in one randomly observed location (basement storage room near exit stairs). Findings include:

1. Observation at 10:45 a.m. revealed a storage room over 50 square feet in the basement. Because of the room's floor area size and combustible materials being stored there, it was classified as a hazardous area. The room was provided with an automatic sprinkler and was provided with smoke tight construction. However the door to the room was not provided with a self-closing device. Interview with the plant operations supervisor at the time of the observation revealed he was unaware of that requirement.

Based on observation and interview, the provider failed to conduct the required annual inspection of the kitchen range exhaust ductwork in one of one location (dinning service kitchen hood). Findings include:

1. Observation at 11:00 a.m. on 11/5/13 revealed a kitchen hood in the basement dinning service area. That kitchen hood was exhausted to the outside through ductwork that traversed from the basement through the main level and up to the roof exhaust fan. That ductwork from the hood to the roof exhaust fan should have been inspected and cleaned annually or more frequently if inspection indicated such.
2. Interview with the plant observation supervisor at the time of the above observation revealed the kitchen hood was normally cleaned by staff personnel. Further interview revealed the duct work from the hood to the exhaust fan was not being cleaned and inspected. He was not aware of the annual inspection requirement.

Based on interview and observation, the provider failed to conduct weekly inspections for the generator. Findings include:

1. Interview with the plant operations supervisor at 1:30 p.m. on 11/5/13 while inspecting the generator revealed no weekly inspection of that generator was being performed. That generator including all equipment and components should have been inspected weekly at a minimum.

Based on observation and interview, the provider failed to maintain three feet of clear working space in front of the electrical panels in one randomly observed location (the janitor's closet). The provider must comply with the National Fire Protection Association (NFPA 70), National Electrical Code (NEC) article 110.26(A)(1) Depth of Working Space (see attachment). Findings include:

1. Observation at 2:15 p.m. revealed a janitors room that also housed electrical panels. Those electrical panels were blocked by a janitorial cart. There was not a minimum three feet of clear working space provided for the electrical panels in the room. Interview with the plant operations supervisor at the time of the observation confirmed that condition.

Based on observation and interview, the provider failed to maintain the fire-resistive characteristics of the one randomly checked two hour fire-resistive wall between the hospital and the administration/physical therapy building. Findings include:

1. Observation at 3:30 p.m. on 11/5/13 revealed a 90 minute fire rated door located in the two hour fire rated barrier separating the hospital occupancy from the business occupancy. That door was held open by an automatic hold open device. Upon activation of the buildings fire alarm that door was released from the open position. That door did not close and latch into its frame under the power of the doors self-closing device. Interview with the plant operations manager at the time of the observation confirmed that condition.

Based on observation and interview, the provider failed to maintain proper separation of hazardous areas in one randomly observed location (basement storage room near exit stairs). Findings include:

1. Observation at 10:45 a.m. revealed a storage room over 50 square feet in the basement. Because of the room's floor area size and combustible materials being stored there, it was classified as a hazardous area. The room was provided with an automatic sprinkler and was provided with smoke tight construction. However the door to the room was not provided with a self-closing device. Interview with the plant operations supervisor at the time of the observation revealed he was unaware of that requirement.

Based on record review, observation, and interview, the provider failed to develop a proper fire safety plan and ensure all staff were familiar with fire drill procedures. Findings include:

1. Review of the fire safety plan revealed it did not indicate the necessity to activate the fire alarm system using the nearest manual fire alarm pull station upon discovery of a fire. Interview with the plant operations supervisor at the time record review revealed that policy had recently been revised. He was not aware the policy was missing the proper information.

2. Observation at 3:30 p.m. on 11/5/13 during a fire drill revealed the charge nurse responding to the simulated patient distress call did not follow protocol. Upon receiving the distress call from the nurse call system the charge nurse announced code red over the hospitals intercom. She failed to initiate the buildings fire alarm system. Staff came to the aid of the patient and removed the patient from the room. Other staff arrived with fire extinguishers while also closing corridor doors as they came. The plant operations manager mentioned to the staff that the fire alarm needs to be activated and staff then found the nearest manual pull station to activate the fire alarm. Interview with plant operations supervisor at the time of observation revealed initiation of the fire alarm in other fire drills have not been an issue.

Based on observation and interview, the provider failed to conduct the required annual inspection of the kitchen range exhaust ductwork in one of one location (dinning service kitchen hood). Findings include:

1. Observation at 11:00 a.m. on 11/5/13 revealed a kitchen hood in the basement dinning service area. That kitchen hood was exhausted to the outside through ductwork that traversed from the basement through the main level and up to the roof exhaust fan. That ductwork from the hood to the roof exhaust fan should have been inspected and cleaned annually or more frequently if inspection indicated such.
2. Interview with the plant observation supervisor at the time of the above observation revealed the kitchen hood was normally cleaned by staff personnel. Further interview revealed the duct work from the hood to the exhaust fan was not being cleaned and inspected. He was not aware of the annual inspection requirement.

Based on interview and observation, the provider failed to conduct weekly inspections for the generator. Findings include:

1. Interview with the plant operations supervisor at 1:30 p.m. on 11/5/13 while inspecting the generator revealed no weekly inspection of that generator was being performed. That generator including all equipment and components should have been inspected weekly at a minimum.

Based on observation and interview, the provider failed to maintain three feet of clear working space in front of the electrical panels in one randomly observed location (the janitor's closet). The provider must comply with the National Fire Protection Association (NFPA 70), National Electrical Code (NEC) article 110.26(A)(1) Depth of Working Space (see attachment). Findings include:

1. Observation at 2:15 p.m. revealed a janitors room that also housed electrical panels. Those electrical panels were blocked by a janitorial cart. There was not a minimum three feet of clear working space provided for the electrical panels in the room. Interview with the plant operations supervisor at the time of the observation confirmed that condition.