HospitalInspections.org

Based on observation, it was determined two of two observed fire doors located at common wall building separation walls did not self-close due to obstruction on the latching mechanism and malfunctioning of the self closing devices. The failed practice had the potential to affect all patients admitted to the facility and four of four patients on census on 09/07/10. The findings follow:

A. On a tour of the facility on 09/08/10 at 0930 fire doors that were not self-closing were observed at the following locations:
1) The set of fire doors located at the building separation wall between the Hospital and the Nursing Home did not fully close when opened and were allowed to swing freely. One door closed partially and the other door did not move from the full open position when released.
2) The set of fire doors located at the fire wall separating the Patient Wing corridor from the Kitchen was unable to fully close due to a rubber material placed over the latching mechanism on the door frame, which prevented full closure of the fire doors.
B. The fire doors that did not fully close were verified by the Director of Housekeeping and Laundry, who was responsible for maintenance operations at the facility, at 1500 on 09/08/10.

Based on observation, it was determined the one hour fire resistance of smoke barrier walls was compromised at two of four locations observed due to unsealed penetrations of the smoke barrier walls and damage to the smoke barrier wall. The failed practice had the potential to affect four of four patients on census on 09/07/10 and all patients admitted to the facility. The findings follow:

A. On a tour of the facility on 09/08/10 at 1330 with the Maintenance Manager, unsealed penetrations of the smoke barrier walls were observed at the following locations:
1) Above the ceiling at the fire doors separating the Patient Wing corridor and Kitchen, an electrical conduit penetrating the wall was not sealed with a fire rated material.
2) Above the ceiling at the fire doors located at the main entrance lobby, one electrical conduit penetrating the wall was not sealed with a fire rated material. There were also two holes that were open to each side of the wall, allowing the passage of fire and smoke at the smoke barrier doors near the post operative area. At this same location, one layer of the gypsum board comprising the smoke barrier wall was damaged, exposing the cavity between behind the gypsum board, which compromised the integrity of the one hour fire resistance rating of the wall.

B. The Director of Housekeeping and Laundry, who was responsible for maintenance operations at the facility, verified the above observations on 09/08/10 at 1500.

Based on observation and interview, it was determined the facility failed to perform monthly inspections from May 2010 to September 2010 for 10 (Patient Room Wing, Boiler Room, Patient Wing near Nurses Station, corridor Kitchen entrance, Laboratory (Lab), corridor near Emergency Department, near ambulance entrance of Emergency Department, corridor near Respiratory Therapy and Central Supply and corridor near CT Scanner room) of 11 fire extinguishers observed and perform annual maintenance in 2009 on three out of eleven fire extinguishers observed. The failed practice had the potential to effect all patients in the facility and four out of four patients in the facility on census on 09/07/10. The findings follow:

A. On a tour of the facility on 09/08/10 at 0930, ten of eleven fire extinguishers observed were not current on monthly inspections. Eight of 10 fire extinguishers had monthly inspection tags with the most recent inspection date of 05/13/10. Three of 11 fire extinguishers had inspection tags that were blank with no inspection dates. Three of 11 fire extinguishers were marked with an annual maintenance date of September 2008 with an inspection due date of September 2009. The fire extinguishers overdue for inspection were observed at the following locations:
1) In the Patient Room Wing at the end of the corridor.
2) In the Boiler Room.
3) In the Patient Room Wing near the Nurse Station.
4) In the corridor at the Kitchen entrance.
5) In the Lab.
6) In the corridor near the Emergency Department.
7) Near the ambulance entrance in the Emergency Department.
8) In the corridor near Respiratory Therapy Room and Central Supply Room.
9) In the entrance alcove to the Respiratory Therapy Room and Central Supply Room.
10) In the corridor near the CT Scanner Room.
B. In an interview on 09/08/10 at 1430, the Director of Housekeeping and Laundry, whose role was the administrative director of maintenance operations in the facility, verified the fire extinguishers were overdue for monthly inspections and annual maintenance.

Based on observation, it was determined two of two observed fire doors located at common wall building separation walls did not self-close due to obstruction on the latching mechanism and malfunctioning of the self closing devices. The failed practice had the potential to affect all patients admitted to the facility and four of four patients on census on 09/07/10. The findings follow:

A. On a tour of the facility on 09/08/10 at 0930 fire doors that were not self-closing were observed at the following locations:
1) The set of fire doors located at the building separation wall between the Hospital and the Nursing Home did not fully close when opened and were allowed to swing freely. One door closed partially and the other door did not move from the full open position when released.
2) The set of fire doors located at the fire wall separating the Patient Wing corridor from the Kitchen was unable to fully close due to a rubber material placed over the latching mechanism on the door frame, which prevented full closure of the fire doors.
B. The fire doors that did not fully close were verified by the Director of Housekeeping and Laundry, who was responsible for maintenance operations at the facility, at 1500 on 09/08/10.

Based on observation, it was determined the one hour fire resistance of smoke barrier walls was compromised at two of four locations observed due to unsealed penetrations of the smoke barrier walls and damage to the smoke barrier wall. The failed practice had the potential to affect four of four patients on census on 09/07/10 and all patients admitted to the facility. The findings follow:

A. On a tour of the facility on 09/08/10 at 1330 with the Maintenance Manager, unsealed penetrations of the smoke barrier walls were observed at the following locations:
1) Above the ceiling at the fire doors separating the Patient Wing corridor and Kitchen, an electrical conduit penetrating the wall was not sealed with a fire rated material.
2) Above the ceiling at the fire doors located at the main entrance lobby, one electrical conduit penetrating the wall was not sealed with a fire rated material. There were also two holes that were open to each side of the wall, allowing the passage of fire and smoke at the smoke barrier doors near the post operative area. At this same location, one layer of the gypsum board comprising the smoke barrier wall was damaged, exposing the cavity between behind the gypsum board, which compromised the integrity of the one hour fire resistance rating of the wall.

B. The Director of Housekeeping and Laundry, who was responsible for maintenance operations at the facility, verified the above observations on 09/08/10 at 1500.

Based on observation and interview, it was determined the facility failed to perform monthly inspections from May 2010 to September 2010 for 10 (Patient Room Wing, Boiler Room, Patient Wing near Nurses Station, corridor Kitchen entrance, Laboratory (Lab), corridor near Emergency Department, near ambulance entrance of Emergency Department, corridor near Respiratory Therapy and Central Supply and corridor near CT Scanner room) of 11 fire extinguishers observed and perform annual maintenance in 2009 on three out of eleven fire extinguishers observed. The failed practice had the potential to effect all patients in the facility and four out of four patients in the facility on census on 09/07/10. The findings follow:

A. On a tour of the facility on 09/08/10 at 0930, ten of eleven fire extinguishers observed were not current on monthly inspections. Eight of 10 fire extinguishers had monthly inspection tags with the most recent inspection date of 05/13/10. Three of 11 fire extinguishers had inspection tags that were blank with no inspection dates. Three of 11 fire extinguishers were marked with an annual maintenance date of September 2008 with an inspection due date of September 2009. The fire extinguishers overdue for inspection were observed at the following locations:
1) In the Patient Room Wing at the end of the corridor.
2) In the Boiler Room.
3) In the Patient Room Wing near the Nurse Station.
4) In the corridor at the Kitchen entrance.
5) In the Lab.
6) In the corridor near the Emergency Department.
7) Near the ambulance entrance in the Emergency Department.
8) In the corridor near Respiratory Therapy Room and Central Supply Room.
9) In the entrance alcove to the Respiratory Therapy Room and Central Supply Room.
10) In the corridor near the CT Scanner Room.
B. In an interview on 09/08/10 at 1430, the Director of Housekeeping and Laundry, whose role was the administrative director of maintenance operations in the facility, verified the fire extinguishers were overdue for monthly inspections and annual maintenance.