HospitalInspections.org

Based on observation and staff interview, this facility is not ensuring that two hour rated firewalls are free of holes or penetrations. The deficient practice affects all occupants including staff, visitors and patients. The facility has a capacity of 25 with a census of 7 patients.

Findings include:

Observations and staff interview on 1/27/16, between 9:30 a.m. and 2:30 p.m., revealed the following deficiencies:

1. There was a penetration, (approximately ¼ inch), around communications lines extending through the 2 hour wall separating the Hospital from the Medical Clinic.
2. There was a penetration, (approximately ¼ inch), around a conduit extending through the 2 hour wall separating the Hospital from the Medical Clinic
3. There was a penetration, (approximately 3 inches by 12 inches), around a tray containing communications lines, extending through the 2 hour wall by the Same Day Surgery Lounge.
4. There was a penetration, (approximately 1 inch), around a conduit and junction box, extending through the 2 hour wall by the Chapel Room.
5. There was a penetration, (approximately ¼ inch), around communications lines extending through the 2 hour wall by the Nurse Manager Office.
6. There were 2 penetrations, around communications lines and conduit, extending through the two hour wall by the Nurse Manager Office that were sealed with a yellow colored foam material that was not identified.

Maintenance Staff A verified observations during the survey process.

Based on observations and staff interview, this facility failed to maintain three smoke barriers in accordance with National Fire Protection Association (NFPA) Standard 101, 2000 new edition, 18.3.7.3. Smoke barriers shall be continuous from outside wall to outside wall and from floor to a roof extending through all concealed spaces. Smoke barriers shall have a fire resistance rating of not less than 1 hour. The facility has a capacity of 25 with a census of 7 patients.

Findings include:

Observations and staff interview on 1/27/16, between 9:30 a.m. and 2:30 p.m., revealed the following deficiencies:

1. There was an open conduit, (approximately 1 inch), that was not properly sealed, extending through the smoke barrier wall by the Chapel Room.
2. There was a penetration, (approximately ¼ inch), around communications lines, extending through the smoke barrier wall by the Surgery Entrance.
3. There was a penetration, (approximately ¼ inch), around communications lines, extending through the smoke barrier wall in the West Hallway by the Nurse Manager Office.

Maintenance Staff A verified observations during the survey process.

Based on observation and staff interview, the facility failed to ensure that gift shops considered hazardous areas are properly separated from the corridor in accordance with National Fire Protection Association, Life Safety Code, 2000 new edition, 18.3.2.5. The facility has a capacity of 25 with a census of 7 patients.

Findings include:

Observation and staff interview on 1/27/16 at 11:30 a.m., revealed the fire door to the Gift Shop was being held open with a wedge. Maintenance Staff A verified observations during the survey process.

Based upon record review and staff interview, the facility failed to hold fire drills under varied conditions at different times of the day for one of four quarters reviewed. Fire drills shall be held at unexpected times under varying conditions, at least quarterly on each shift. This deficient practice has the potential of affecting staff preparation and experience in providing for the protection of all patients in the event of a fire. This facility has a capacity of 25 with a census of 7 patients.

Findings include:

Record review and staff interview on 1/27/16 at 10:27 a.m., revealed the following deficiencies:

1. There was no available documentation of fire drills conducted for all 3 shifts during the 2nd Quarter of 2015.
2. Fire drills were conducted on the same date for all three shifts on 3/16/15, 7/7/15, 9/22/15 and 12/22/15.

Maintenance Staff A verified record review during the survey process.

Based on observation and staff interview, the facility failed to a properly protect the primary power supply for the fire alarm system in accordance with the National Fire Protection Association (NFPA), Standard 72, 1999 edition, 1-5.2.5.2. This deficient practice affects all occupants of the building. The facility has a capacity of 25 with a census of 7 patients.

Findings include:

Observation and staff interview on 1/27/16 at 11:01 a.m., revealed the circuit breaker supplying power to the fire alarm system was not mechanically protected. Maintenance Staff A verified observations during the survey process.

Based on observations and staff interview, this facility is not assuring that the fire alarm system is installed and maintained in accordance with National Fire Protection Association (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 an air diffuser can impede the operation of the smoke detector. The facility has a capacity of 25 with a census of 7 patients.

Findings include:

Observations and staff interview on 1/27/16, between 9:30 a.m. and 2:30 p.m., revealed smoke detectors installed within 3 feet of air supply or return vents in the following locations: Basement Corridor by the Boiler Room. Emergency Room Nurses Station. Rehab Waiting Room. Corridor by Room 106.

Maintenance Staff A verified observations during the survey process.

Based on observation and staff interview, the facility failed to maintain a complete automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 25, 1998 edition. The facility has a capacity of 25 with a census of 7 patients.

Findings include:

Observation and staff interview on 1/27/16, revealed a dirty sprinkler head located at the Patient Care Wing Nurses' Station. Maintenance Staff A verified observations during the survey process.

Based on observation and staff interview, the facility failed to maintain the hood and fire-extinguishing equipment in accordance with National Fire Protection Association (NFPA) Standard 96, the standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 1998 edition, 7-6.2. Where a fire alarm signaling system is serving the occupancy where the extinguishing system is located, the activation of the automatic fire-extinguishing system shall activated the fire alarm signaling system. The facility has a capacity of 25 with a census of 7 patients.

Findings include:

Observation and staff interview on 1/27/16 at 11:08 a.m., revealed access to the pull station for the Kitchen Hood and Duct Extinguishment System was blocked by a large cart. Maintenance Staff A verified observations during the survey process.

(A)
Based on observation and staff interview, the facility failed to provide maintain a remote annunciator panel for the emergency generator in accordance with National Fire Protection Association (NFPA) Standards 99, 1999 edition. The facility has a capacity of 25 with a census of 7 patients.

Findings include:

Observation and staff interview on 1/27/16 at 1:41 p.m., revealed 4 bulbs did not illuminate during testing of the remote annunciator panel display. Maintenance Staff A verified observations during the survey process.


(B)
Based on observation and staff interview, the facility failed to provide a remote manual stop station for the emergency generator set as required by National Fire Protection Association, NFPA 110, 1999 edition 3-5.5.6. The deficient practice affects all occupants of the building. The facility has a capacity of 25 with a census of 7 patients.

Findings include,

Observation and staff interview on 1/27/16 at 11:15 a.m., revealed the facility failed to provide a remote manual stop station for the primary emergency generator set, located outside of the room containing the generator. Maintenance Staff A verified observations during the survey process.

NFPA 110, 1999 edition 3-5.5.6

3-5.5.6* All level 1 and level 2 installations shall have a remote manual stop station of a type similar to a break glass station located outside the room housing the prime mover, where so installed or located elsewhere on the premises where the prime mover is located outside the building

A3-5.5.6 For level 1 and level 2 systems located outdoors the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified.

Based on observations and staff interview, 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. The facility has a capacity of 25 with a census of 7 patients.

Findings include:

Observations and staff interview on 1/27/16, between 9:30 a.m. and 2:30 p.m., revealed the following deficiencies:

1. There was a surge protector supplying power to a microwave in the Kitchen.
2. There was an open electrical junction box by the 1 hour wall near the smoke barrier wall by the Surgery Entrance.

Maintenance Staff A verified observations during the survey process.