HospitalInspections.org

Based on observation and interview with staff, the facility failed to provide smoke barriers that are at least a one half hour fire resistance rating in accordance with Section 8.3. Findings:

1) In the Medical Units, open penetrations were found in the smoke barriers, including around wiring, conduit, ductwork, fire sprinkler piping, and water lines passing through the smoke barriers.

Based on observation and interview with staff, the facility failed to provide a fire alarm system tested and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72. Findings:

1) The last annual inspection and testing of the fire alarm system on 3-13-12, conducted by Firetrol Protection Systems, found the damper in Room 201 failed the test, noting "bad motor". There is no documentation that this damper has been repaired.

Based on observation and interview with staff, the facility failed to provide a piped in medical gas system complying with NFPA 99, Chapter 4. Findings:

1) In Hospital Unit # 4, the medical gas room was found to have the light switch located less than 60" above the floor, the exhaust vent is clogged, open joints in the gypsum board was found where the wall has been patched, and the room is being used for storage of combustibles.

Based on observation and interview with staff, the facility failed to provide generator recordkeeping. Findings:

1) There is no documentation of monthly load testing for the generators. Refer to NFPA 110 Section 8.4

Based on observation and interview with staff, the facility failed to provide electrical wiring in accordance with NFPA 70 National Electrical Code. Findings:

1) Open junction boxes (electrical boxes with no cover plate) were found in Hospital Unit # 4 and in the main building.