HospitalInspections.org

Based on observation and staff interview, this facility is not providing a firewall with a two-hour fire rating separating the Maintenance Shop from the Maintenance Corridor. The facility has a capacity of 25 with a census of 8 patients.

Findings include:
Observation and staff interview on 7/30/14, revealed a gap, (approximately 2 inches by 10 inches) extending through the two hour wall separating the Maintenance Shop from the Maintenance Corridor. Maintenance Staff A verified observations during the survey process.

Based on observations and staff interview, the facility failed to provide separation of hazardous areas from other compartments in accordance with National Fire Protection Association (NFPA) Standard 101, The Life Safety Code, 2000 edition, 19.3.2.1. The facility is composed of protected non-combustible construction and is only equipped with a partial sprinkler system. The facility has a capacity of 25 with a census of 8 residents.

Findings include:

Observations and staff interview on 7/30/14, revealed the following deficiencies:

1. There were two penetrations, (both approximately 3/16 inch), around conduit extending through the ceiling above electrical panels in the Laundry Room.
2. There were 3 penetrations, (all approximately 3/16 inch), around conduit extending through the ceiling of the Surgery Medical Gas Storage Room.
3. There was an open pipe, (approximately 1 inch), that was not properly sealed extending through the ceiling of the Surgery Medical Gas Storage Room.
4. The fire door between the Maintenance Shop and the Maintenance Garage did not close and latch properly when tested.
5. The door to the Storage Closet by the Laundry Room did not close and latch properly when tested.

Maintenance Staff A verified observations during the survey process.

Based on observation and staff interview, the facility failed to maintain exits readily accessible at all times in accordance with National Fire Protection Association (NFPA) Standard 101, The Life Safety Code, 7.1. Doors shall be arranged to be opened readily from the egress side when ever the building is occupied. Locks, if provided shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side. The facility has a capacity of 25 with a census of 8 patients.

Findings include:

Observation and staff interview on 7/30/14, revealed the door from the Physical Therapy Room to the Emergency Room Exit Corridor was locked by a deadbolt. The door is signed as a required exit. Maintenance Staff A verified observations during the survey process.

Based on record review and staff interview, revealed that the facility failed to conduct and document fire drills as required 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. The facility has a capacity of 25 with a census of 8 patients.

Findings include:

Record review and staff interview on 7/30/14, revealed the following deficiencies:

1. Available documentation indicated no record of a fire drill conducted on the 2nd Shift for the 3rd Quarter of 2013. The time written on the 2013 fire drill log indicated that the drill was conducted at 1600 and counted as a 2nd Shift Drill. However the time on the actual fire drill sheet showed that the drill was conducted at 6 A.M., which would have been a 1st Shift drill.
2. Available documentation of a fire drill conducted on 7/26/13 indicated a drill time of 10:05, but did not indicate an A.M. or P.M. designation.

Maintenance Staff A verified record review during the survey process.

Based on observations, record review and staff interview, the facility failed to provide a properly maintained fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, the National Fire Alarm Code, 1999 edition. The facility has a capacity of 25 with a census of 8 residents.

Findings include:

Observation and staff interview on 7/30/14 and 7/31/14, revealed the following deficiencies:

1. The facility failed to mechanically protect the circuit breaker supplying power to the fire alarm system.
2. The Pleasantville Clinic is equipped with single station smoke detectors. The facility failed to test the detectors and maintain documentation of testing to ensure proper operation.
3. During testing of the fire alarm system the system failed to send a signal indicating a loss of phone communications to a location that is monitored by staff 24 hours a day.

Maintenance Staff A verified observations and record review during the survey process.

Based on observation and staff interview, the facility failed to provide proper storage of oxygen cylinders in accordance with the National Fire Protection Association (NFPA) Standard 99. The facility has a capacity of 25 with a census of 8 patients.

Findings include:

Observation and staff interview on 7/30/14, revealed an oxygen cylinder in the Emergency Room that was not properly secured. Maintenance Staff A verified observations during the survey process.

Based on record review and staff interview, the facility failed to maintain and test the emergency generator power supply as required. Emergency generators are required to be inspected weekly and exercised under load for 30 minutes per month and shall be in accordance with National Fire Protection Association (NFPA), Standard 99, 3.4.4.1, and NFPA 110, 8.4.2. The emergency generator would effect all smoke compartments and all facility staff and residents. The facility has a capacity of 25 with a census of 8 patients.

Findings include:

Record review and staff interview on 7/30/14, revealed the following deficiencies:

1. On the available documentation there were no dates on the weekly generator inspection forms between the following dates: 11/29/13 to 12/9/12, 12/13/13 to 12/23/13, 1/31/14 to 2/10/14, 2/28/14 to 3/11/14, 4/11/14 to 4/22/14, 7/3/14 to 7/21/14.
2. On the available documentation there was a gap in the weekly generator log between 4/25/14 and 5/5/14.

Maintenance Staff A verified record review during the survey process.

Based on observation 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 8 patients.

Findings include:

Observation and staff interview on 7/30/14, revealed 2 electrical outlets within 6 feet of a sink that were not ground fault circuit protected in the Maintenance Shop. Maintenance Staff A verified observations during the survey process.