HospitalInspections.org

K345


Based on observation, and staff interviews it was determined the facility failed to maintain fire alarm system.

This could place all patients and staff at risk in the event of fire.

The findings include:

During a tour of the facility with Staff M on 02/01/2017 between 09:00 am and 11:00 observation revealed that the fire alarm was showing a smoke detector trouble on the panel. System still operating.

These findings were confirmed by Staff M at the time of discovery.

Reference:

NFPA 101, 2012 ED. Chapter 19, section 19.3.4.1 NFPA 101, 2012 ED. Chapter 9, Section 9.6.2.10.1.1; NFPA 72 2010 ED. Chapter 14, Section 14.4.5.3.1 & 14.4.5.3.2 & 14.4.5.3.3..1

K-Tag 353

Based on observation, and staff interviews it was determined the facility failed to maintain sprinkler system in proper working order.

This could place all patients at risk in the event of fire.


The findings include:

During a tour of the facility with Staff M on 02/01/2017 between 09:00 am and 11:00 observation revealed that sprinkler system had numerous violations.

The findings were:

Sprinkler Gages on riser system out of date
FDC sign not posted above fire department connections
Painted sprinkler head in Bio Hazard room across from dining room
Escutcheon ring from sprinkler head missing in X-Ray #1
Sprinkler head painted in room 202
Sprinkler head corroded in kitchen cooler



These findings were confirmed by Staff M at the time of discovery.

Reference: NFPA 101 2012 ED. CHAPTER 19 sections 19.1.6.1 & 19.3.5.3 & 19.3.5.4 and CHAPTER 9 SECTION 9.7.5, 9.7.7, & 9.7.8

Gauges: NFPA 101 2012: Chapter 19 Section 19.1.1.1.3, NFPA 101 2012 ED. CHAPTER 19 sections 19.1.6.1 & 19.3.5.3 & 19.3.5.4, NFPA 101 2012 ED. CHAPTER 9, section: 9.7.1.(1) NFPA 25, 2011 ED. Chapter 5, section: 5.3.2.1


Painted Heads: NFPA 101 2012: Chapter 19 Section 19.1.1.1.3, NFPA 101 2012 ED. CHAPTER 19 sections 19.1.6.1 & 19.3.5.3 & 19.3.5.4, NFPA 101 2012 ED. CHAPTER 9, section: 9.7.1.(1) Chapter 4 Section 4.6.12.1 , NFPA 25 2011 edition: Chapter 5, Section 5.2.1.1.2 (5), & (6), & Chapter 5 Section 5.2.1.1.4

FDC Sign;
NFPA 101, 2012 ED. section: 9.7.1.1, NFPA 13, 2010 ED. Chapter 8 section 8.17.2.4.7.1

Escutcheon & Corroded Heads: NFPA 101 2012 ED. CHAPTER 19 sections 19.1.6.1 & 19.3.5.3 & 19.3.5.4, NFPA 101 2012 ED. CHAPTER 9, section: 9.7.1.(1) NFPA 25, 2011 ED. Chapter 5, section; 5.2.1.1.2

K-355

Based on observation, and staff interviews it was determined the facility failed to properly check and maintain portable fire extinguishers.

This could place all patients at risk in the event of fire.

The findings include:

During a tour of the facility with Staff M on 02/01/2017 between 09:00 am and 11:00 observation revealed that the fire extinguisher located at room 232 was found discharged in the fire extinguisher cabinet.

These findings were confirmed by Staff M at the time of discovery.

Reference:

NFPA 101, 2012 ED, Chapter 19, section 19.3.5.12, & Chapter 7 section 9.7.4.1, NFPA 10, 2010 ED, Chapter 7, section 7.2.3.2.

K-Tag 372

Based on observation, and staff interviews it was determined the facility failed to maintain fire wall penetrations.

This could place all patients at risk in the event of fire.

The findings include:

During a tour of the facility with Staff M on 02/01/2017 between 09:00 am and 11:00 observation revealed that penetrations in fire walls were not maintained in the following locations.

Open penetration above D hall fire doors in ceiling at room 208
Open penetrations above fire doors in ER
Fire Wall penetration in "Same Day Hallway"


These findings were confirmed by Staff M at the time of discovery.

Reference:

NFPA 101 2012 ED. Chapter 19, Section: 19.3.7.3, Chapter 8, Sections 8.5.6.3 & 8.3.5 & 8.5.6.4

K-Tag 511


Based on observation, and staff interviews it was determined the facility failed to secure exposed wiring.

This could place all patients at risk in the event of electrical malfunction and or resulting fire.

The findings include:

During a tour of the facility with Staff M on 02/01/2017 between 09:00 am and 11:00 observation revealed that open wiring was protruding from the wall above the desk in the Purchasing Office.

These findings were confirmed by Staff M at the time of discovery.

Reference:
NFPA 101, 2012 ED. Chapter 19, section 19.5.1.1, NFPA 101, 2012 ED. Chapter 9, section 9.1.2 NFPA 101, 2012 ED. Chapter 4 section 4.3.1. NFPA 70 2011 ED. Chapter, 3, section 398.15 (C)

K-781

Based on observation, and staff interviews it was determined the facility failed to remove electrical space heaters from service within the facility.

This could place all patients at risk in the event of fire.


The findings include:

During a tour of the facility with Staff M on 02/01/2017 between 09:00 am and 11:00 observation revealed that electrical space heaters were not removed from service in the following locations within the facility.

Electric portable space heater in room 12,
Doctors On Call Room
Room 201


These findings were confirmed by Staff M at the time of discovery.

Reference:

NFPA 101 2012 ED. Chapter 19, section 19.7.8

K-920

Based on observation, and staff interviews it was determined the facility failed to maintain power strips from floor and remove extension cords from service.

This could place all patients at risk in the event of fire.


The findings include:

During a tour of the facility with Staff M on 02/01/2017 between 09:00 am and 11:00 observation revealed that power strips were not being maintained off of flooring and that extension cords were being used as permanent wiring in the following locations.

Power strips on floor: Purchasing Office, rooms 229, 230, 238, 239, ER admissions, dining room, Medical records file room #2,

Extension cords in use in: Dietary Office, Morgue, ceiling of maintenance shop,


These findings were confirmed by Staff M at the time of discovery.

Reference:

Multi tap on floor:

NFPA 101 2012 edition Chapter 19 Section 19.5.1.1, Chapter 9 Section 9.1.1, NFPA 70 2011 ed Article 380.12 (2)


Extension cords:

NFPA 99, 2012 ED. Chapter 10, section 10.2.4. 10.2.3.6 NFPA 70, 2011 ED. Chapter 400 section 400-8. 590.3(D)