HospitalInspections.org

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Based on observation on 3/1/2017, the facility failed to maintain means of egress. Findings include:

A chair was observed blocking the exit door by Patient Room 111, preventing the exit door from fully opening.

The deficiencies impacted 1 of 3 smoke compartments.
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Review of 2012 NFPA 101, 19.2.1
Review of 2012 NFPA 101, 7.5.1.1
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Based on interviews and documentation for the dietary hood system on 03/01/2017, the facility failed to maintain the cooking facilities. Findings include:

The facility failed to provide documentation for the 6 month fire-extinguishing system that was due January 2017. The last documented inspection was July 2016.

The deficiencies impacted 1 of 3 smoke compartments.
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Review of 2012 NFPA 101, 19.3.2.5.1
Review of 2012 NFPA 101, 9.2.3
Review of 2011 NFPA 96, 11.2.1
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Based on review of the documentation on 3/1/2017, the facility failed to maintain the smoke detectors. Findings include:

Documentation was not provided for the sensitivity testing of the smoke detectors within the past two years.

The deficiencies impacted 3 of 3 smoke compartments.
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Review of 2012 NFPA 101, 19.3.4.5
Review of 2012 NFPA 101, 9.6.1.3
Review of 2010 NFPA 72, 14.4.5.3.2
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Based on observation on 3/1/2017, the facility failed to maintain the automatic sprinkler system. Findings include:

1. The facility failed to provide documentation of testing or replacement of automatic sprinkler riser gauges within the past five years.

2. Last quarterly inspection of sprinkler system was conducted on 10/11/2016.

The deficiencies impacted 3 of 3 smoke compartments.
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Review of 2012 NFPA 101, 19.3.5.1
Review of 2012 NFPA 101, 9.7.5
Review of 2011 NFPA 25, 5.3.2.1, and 5.1.1.2
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Based on the observation during the survey on 03/01/2017, the facility failed to maintain the fire extinguishers. Findings include:

Several fire extinguishers throughout the facility were observed with the operating instructions located on the front of the fire extinguishers covered with the 6-year maintenance labels.

The deficiency impacted 3 of 3 smoke compartments.
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Review of 2012 NFPA 101, 19.3.5.12
Review of 2012 NFPA 101, 9.7.4.1
Review of 2010 NFPA 10, 6.1.3.9.1
Review of 2010 NFPA 10, 6.1.3.9.2
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Based on observation on 3/1/2017, the facility failed to maintain corridor doors. Findings include:

1. The kitchen corridor door failed to positive latch in the frame, this area is not sprinklered.

2. The Dining Room corridor door failed to positive latch in the frame, this area is not sprinklered.

3. The Lab corridor door failed to positive latch in the frame, this area is not sprinklered.

The deficiencies impacted 3 of 3 smoke compartments.
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Review of 2012 NFPA 101, 19.3.6.3.5
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Based on the observation of the smoke barriers on 03/01/2017 the facility failed to maintain smoke barriers that would provide at least a half hour fire resistance rating and were protected by a system or material capable of restricting the transfer of smoke. Findings include:

The surveyor observed unsealed penetrations around electrical conduit (flex and hard pipe), in the smoke barrier by the copy machine room.

The deficiency impacts 1 of 3 smoke compartments.
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Review of 2012 NFPA 101, 19.3.7.3, 8.5.1, and 8.5.6.2
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Based on observation on 03/01/2017, the facility failed to maintain the electrical wiring and equipment in accordance with the National Electrical Code (NFPA 70). Findings include:

1. Above the ceiling in the hall near the Receptionist's Office an electrical junction box was observed missing its cover.
2. The Medical Records Office was observed with the faceplate missing on a receptacle behind the desk.
3. The Dietary Kitchen was observed with the faceplate missing on a receptacle behind the stove.

The deficiencies impacted 2 of 3 smoke compartments.
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Review of 2012 NFPA 101, 19.5.1.1
Review of 2012 NFPA 101, 9.1.2
Review of 2011 NFPA 70, 314.28 (C)
Review of 2011 NFPA 70, 406.6
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Based on observation on 3/01/2017, the facility failed to maintain the HVAC smoke dampers. Findings include:

An HVAC smoke damper, in the smoke barrier by the Accounting Department was observed to be in the closed position, when it should have been in the open position.

The deficiency impacted 2 of 3 smoke compartments.
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Review of 2012 NFPA 101, 19.5.2.1

Review of 2012 NFPA 101, 9.2.1

Review of 2012 NFPA 90A, 5.4.8.2

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Based on document review and staff interview, the facility failed to exercise the diesel generator once monthly for a minimum of 30 minutes under loading that maintains the minimum exhaust gas temperature or under operating temperature conditions at not less than 30% of the nameplate kW rating. The facility did not document the load transfers of the generator per the requirements of:

2012 NFPA 99, 6.5.4.1.1.2, 6.4.4.1.1.3, and 6.5.4.2
2010 NFPA 110, 1.3, 8.3.2.1, 8.4.1, 8.4.2, and 8.4.2.3

The deficiency affected the monthly 30 minute exercise and yearly 90 minute exercise of the diesel generator.

The deficiency impacted 1 of 3 smoke compartments.

Findings include:

On 3/1/2017 the facility failed to provide documentation that the diesel generator was exercised once monthly for a minimum of 30 minutes and of the annual 1 ½ hour load bank test for the previous 12 months. A load bank test is required if the facility does not document that not less than 30% of the diesel generator nameplate kW rating load is pulled during the monthly 30 minute exercise/load transfer or the minimum manufacturer recommended exhaust temperature is meet during the monthly 30 minute exercise/load transfer.

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Based on observation of the oxygen storage on 03/01/2017, the facility failed to provide proper storage for the oxygen cylinders . Findings include:

In the corridor alcove near the Pharmacy Supply Closet two H-Type O2 cylinders (500 cubic ft.) were observed being stored in a patient care location. "The piped in medical gas had been disconnected" according to the maintance director.

The deficiency impacted 1 of 3 smoke compartments.
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Review of: S&C-07-10 January 12, 2007
Review of 2012 NFPA 99, 11.3.2
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Based on interviews and documentation provided on 03/01/2017, the facility failed to provide documentation on the training and continuous education of the risk for personnel applying, maintaining, and handling oxygen cylinders. Findings include:

The facility failed to provide documentation for personnel on the training and continuous education, including safety guidelines and usage requirements on oxygen cylinders.


The deficiency impacted 3 of 3 smoke compartments.
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Review of 2012 NFPA 99, 11.5.2.1
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