HospitalInspections.org

Observations revealed that an area open to the corridor is not in accordance with NFPA 101 "The Life Safety Code" 2000 edition, section 19.3.6.1. This deficient practice could affect all patients, visitors and staff of the facility if a fire occurs with in the area open to the corridor and smoke is allowed to travel from the room of origin into the corridor without warning.

Findings include:
Observations during the facility tour on November 5, 2012, between 1:45 pm and 3:30 pm, by surveyor 22373 revealed that the Gowned Patient waiting area, H1503 is open to the corridor which was not equipped with automatic smoke detection and does not meet any of the exceptions to NFPA 101 section 19.3.6.1.

The Maintenance Technician (GC) verified this finding during the facility tour and with the President (BC) and Facility's Manager (DW) during the the exit conference.

Observations showed that the Bio-Med Area did not comply with NFPA 101 "The Life Safety Code" 2000 Edition Section 19.3.6.1. If rooms do not have corridor doors, a fire could spread beyond the room of origin and would negatively impact all the patients, visitors and staff of that floor.

Findings include:
Observations during the facility tour on November 6, 2012, between 8:15 am and 10:30 am, by surveyor 03006 revealed that the Bio-Med area corridor door has been removed, opening the room to the corridor system that does not meet NFPA 101 section 19.3.6.1.

The Facility's Manager (DW) verified these findings during the facility tour and with the President (BC) during the the exit conference.

Observations revealed that at least three hazardous areas are not in accordance with NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 19.3.2.1. This deficient practice could allow the products of combustion to travel from one area to another if a fire occurs within this hazardous area, which could negatively impact all patients, visitors and staff.

Findings include:
Observations during the facility tour on November 6, 2012, between 8:15 am and 10:30, by surveyor 03006 revealed that:

1) The basement central storage south corridor door H0111 is not 3/4 hour rated,

2) The 1-hour fire rated door into the the central storage office, in the 1-hour fire wall is no longer self-closing, and

3) The corridor door to storage H072 is not self-closing.

The Facility's Manager (DW) verified these findings during the facility tour and with the President (BC) during the the exit conference.

Observations revealed that four smoke detectors are not install in accordance with NFPA 72 "The National Fire Alarm Code" 2000 edition section 7-3.2. This deficient practice could allow a delay in the fire alarm system alarming in a fire, which will negatively effect all the patients, visitors and staff.

Findings include:
Observations during the facility tour on November 5, 2012, between 1:45 pm and 3:30 pm, and November 6, 2012, between 8:15 am and 10:30, by surveyors 22373 and 03006 revealed that the following smoke detectors are not at least 36 inches from HVAC system diffusers (they are all within 12 inches of a HVAC supply air diffuser):

1) The detector located in the corridor near storage room H1513,

2) The detector located in the Emergency Dept. admissions supply room,

3) The detector located in patient room H2217, and

4) The detector in Rehab Registration office.

The Maintenance Lead (RG) verified these findings during the facility tour and with the President (BC) and Facility's Manager (DW) during the the exit conference.

Observations revealed that the automatic fire sprinkler system is not installed in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems sections 5-1.1 nor is it been maintained in accordance with NFPA 25 Standard for Inspection, Testing and Maintenance of a Water-Based Fire protection System, 1998 edition section 6-3.6. These deficient practices may allow a fire to grow which will negatively impact all the patients, visitors and staff.

Findings include:
Observations during the facility tour on November 5, 2012, between 1:45 pm and 3:30 pm and November 6, 2012, between 8:15 am and 10:30 by surveyor 22373 and surveyor 03006 revealed that:

1) The equipment storage alcove near room H1513 was not protected by the automatic fire sprinkler system,

2) The electrical room H0113 was not protected by the automatic fire sprinkler system,

3) The closet in the main boiler room was not protected by the automatic fire sprinkler system, and

4) The sprinkler system gauges could not be documented as having been replaced, nor recalibrated, within the pass 5 years.

The Maintenance Lead (RG) and Facility's Manager (DW) verified these findings during the facility tour and with the President (BC) during the the exit conference.

Observations and an interview with staff revealed that the 5 operating rooms do not have isolation monitors on their electrical systems in accordance with NFPA 99 (1999 edition) section 3-3.2.1.2. This deficient practice could affect all patients and staff within the operating room if the floor is wet during normal use.

Findings include:
Observations and an interview with Maintenance Lead (RG) during the facility tour on November 5, 2012, between 1:45 pm and 3:30 pm, by surveyor 22373 revealed that the operating rooms are not equipped with line isolation monitors in accordance with NFPA 99 (1999 edition), Section 3-3.2.1.2(f)1, for Wet Locations.

The Maintenance Lead (RG) verified these findings during the facility tour and with the President (BC) and Facility's Manager (DW) during the the exit conference.

Observations revealed that an area open to the corridor is not in accordance with NFPA 101 "The Life Safety Code" 2000 edition, section 19.3.6.1. This deficient practice could affect all patients, visitors and staff of the facility if a fire occurs with in the area open to the corridor and smoke is allowed to travel from the room of origin into the corridor without warning.

Findings include:
Observations during the facility tour on November 5, 2012, between 1:45 pm and 3:30 pm, by surveyor 22373 revealed that the Gowned Patient waiting area, H1503 is open to the corridor which was not equipped with automatic smoke detection and does not meet any of the exceptions to NFPA 101 section 19.3.6.1.

The Maintenance Technician (GC) verified this finding during the facility tour and with the President (BC) and Facility's Manager (DW) during the the exit conference.

Observations showed that the Bio-Med Area did not comply with NFPA 101 "The Life Safety Code" 2000 Edition Section 19.3.6.1. If rooms do not have corridor doors, a fire could spread beyond the room of origin and would negatively impact all the patients, visitors and staff of that floor.

Findings include:
Observations during the facility tour on November 6, 2012, between 8:15 am and 10:30 am, by surveyor 03006 revealed that the Bio-Med area corridor door has been removed, opening the room to the corridor system that does not meet NFPA 101 section 19.3.6.1.

The Facility's Manager (DW) verified these findings during the facility tour and with the President (BC) during the the exit conference.

Observations revealed that at least three hazardous areas are not in accordance with NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 19.3.2.1. This deficient practice could allow the products of combustion to travel from one area to another if a fire occurs within this hazardous area, which could negatively impact all patients, visitors and staff.

Findings include:
Observations during the facility tour on November 6, 2012, between 8:15 am and 10:30, by surveyor 03006 revealed that:

1) The basement central storage south corridor door H0111 is not 3/4 hour rated,

2) The 1-hour fire rated door into the the central storage office, in the 1-hour fire wall is no longer self-closing, and

3) The corridor door to storage H072 is not self-closing.

The Facility's Manager (DW) verified these findings during the facility tour and with the President (BC) during the the exit conference.

Observations revealed that four smoke detectors are not install in accordance with NFPA 72 "The National Fire Alarm Code" 2000 edition section 7-3.2. This deficient practice could allow a delay in the fire alarm system alarming in a fire, which will negatively effect all the patients, visitors and staff.

Findings include:
Observations during the facility tour on November 5, 2012, between 1:45 pm and 3:30 pm, and November 6, 2012, between 8:15 am and 10:30, by surveyors 22373 and 03006 revealed that the following smoke detectors are not at least 36 inches from HVAC system diffusers (they are all within 12 inches of a HVAC supply air diffuser):

1) The detector located in the corridor near storage room H1513,

2) The detector located in the Emergency Dept. admissions supply room,

3) The detector located in patient room H2217, and

4) The detector in Rehab Registration office.

The Maintenance Lead (RG) verified these findings during the facility tour and with the President (BC) and Facility's Manager (DW) during the the exit conference.

Observations revealed that the automatic fire sprinkler system is not installed in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems sections 5-1.1 nor is it been maintained in accordance with NFPA 25 Standard for Inspection, Testing and Maintenance of a Water-Based Fire protection System, 1998 edition section 6-3.6. These deficient practices may allow a fire to grow which will negatively impact all the patients, visitors and staff.

Findings include:
Observations during the facility tour on November 5, 2012, between 1:45 pm and 3:30 pm and November 6, 2012, between 8:15 am and 10:30 by surveyor 22373 and surveyor 03006 revealed that:

1) The equipment storage alcove near room H1513 was not protected by the automatic fire sprinkler system,

2) The electrical room H0113 was not protected by the automatic fire sprinkler system,

3) The closet in the main boiler room was not protected by the automatic fire sprinkler system, and

4) The sprinkler system gauges could not be documented as having been replaced, nor recalibrated, within the pass 5 years.

The Maintenance Lead (RG) and Facility's Manager (DW) verified these findings during the facility tour and with the President (BC) during the the exit conference.

Observations and an interview with staff revealed that the 5 operating rooms do not have isolation monitors on their electrical systems in accordance with NFPA 99 (1999 edition) section 3-3.2.1.2. This deficient practice could affect all patients and staff within the operating room if the floor is wet during normal use.

Findings include:
Observations and an interview with Maintenance Lead (RG) during the facility tour on November 5, 2012, between 1:45 pm and 3:30 pm, by surveyor 22373 revealed that the operating rooms are not equipped with line isolation monitors in accordance with NFPA 99 (1999 edition), Section 3-3.2.1.2(f)1, for Wet Locations.

The Maintenance Lead (RG) verified these findings during the facility tour and with the President (BC) and Facility's Manager (DW) during the the exit conference.