HospitalInspections.org

Based on observation and staff interview, this facility is not providing a firewall with a two-hour fire rating between the Hospital and the Ambulance Garage. The deficient practice affects all occupants including staff, visitors and residents. The facility has a capacity of 11 with a census of 2 patients.

Findings include:

Observation and staff interview on 4/2/13, revealed that the fire doors in the two hour wall separating the Hospital from the Ambulance Garage did not close and latch properly. Maintenance Staff A verified observations during the survey process.

Based on observation and staff interview, the facility failed to separate the corridors from other areas by partitions complying with 18.3.6.2 through 18.3.6.5 of the 2000 Life Safety Code, new edition. In fully sprinklered smoke compartments, partitions are only required to resist the passage of smoke. The facility has a capacity of 11 with a census of 2 patients.

Findings include:

Observation and staff interview on 4/2/13, revealed an open pipe that was not sealed extending through the corridor wall by Doors C117. Maintenance Staff A verified observations during the survey process.

Based on observation and staff interview, the facility is not ensuring that doors to rooms are provided with suitable hardware that keep the doors shut tightly into their frames. This deficient practice affects occupants in 1 of 3 smoke zones as the doors would not prevent the spread of fire and smoke. The facility has a capacity of 11 with a census of 2 patients.

Findings include:

Observation and staff interview on 4/2/13, revealed the Door to Room 119 did not close and latch properly. The door frame was not equipped with a latch plate. Maintenance Staff A verified observations during the survey process.

Based on observation and staff interview, this facility failed to maintain one smoke barrier in accordance with National Fire Protection Association (NFPA) Life Safety Code, 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 one hour. This deficient practice affects 2 of 3 smoke zones. The facility has a capacity of 11 with a census of 2 patients.

Findings include:

Observation and staff interview on 4/2/13, revealed a hole, (approximately 1 inch), in the C113 Smoke Barrier Wall. Maintenance Staff A verified observations during the survey process.

Based on observation and staff interview, the facility failed to maintain smoke doors to close and resist the passage of smoke. The deficient practice affects 2 out of 3 smoke zones in the facility. The facility has a capacity of 11 with a census of 2 residents.

Findings include:

Observation and staff interview on 4/2/13, revealed that Smoke Barrier Doors #C113 did not close and latch properly. Maintenance Staff A verified observations during the survey process.

Based on observation and staff interview, the facility failed to provide separation of hazardous areas from other compartments in accordance with National Fire Protection Association (NFPA) Life Safety Code, new edition 18.3.2.1. The facility is composed of unprotected noncombustible construction equipped with a sprinkler system. Where a sprinkler system option is used to provide separation, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. The facility has a capacity of 11 with a census of 2 patients.

Findings include:

Observation and staff interview on 4/2/13, revealed a penetration, (approximately 1/4 inch), around a ventilation duct extending through the corridor wall of the Maintenance Room. 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 two 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 11 with a census of 2 patients.

Findings include:

Record review and staff interview on 4/2/13, revealed no documentation of a fire drill conducted for the 2nd Shift in the 3rd Quarter of 2012 and no documentation of a fire drill conducted for the 3rd Shift in the 4th Quarter of 2012. Maintenance Staff A verified record review during the survey process.

Based on observation 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 deficient practice affects all occupants of the Medical Clinic. The facility has a capacity of 11 with a census of 2 patients.

Findings include:

Observation and staff interview on 4/2/13 revealed that the two fire partitions in the Medical Clinic did not close during testing of the fire alarm system. Maintenance Staff A indicated that they were aware of the issue and is working on a solution.

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. This facility has a capacity of 11 with a census of 2 residents.

Findings include:

Observations and staff interview on 4/2/13, revealed the following deficiencies:

1. There was a smoke detector installed within three feet of an air diffuser in the Clean Linen Room.
2. There was a smoke detector installed within three feet of an air diffuser in the Cardio Gym.

Maintenance Staff A verified observations during the survey process.

Based on record review and staff interview, the facility failed to maintain and test a complete automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 25, 1998 edition. All smoke compartments in the building and all residents and staff could be affected by the deficient practice. The facility has a capacity of 11 with a census of 2 patients.

Findings include:

Record review and staff interview on 4/2/13, revealed no documentation of an inspection of the sprinkler system for the first quarter of 2013. 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. This facility has a capacity of 11 with a census of 2 residents.

Findings include:

Observation and staff interview on 4/2/13, revealed cracked insulation on the power cord to the grinder in the Maintenance Room. The cracked insulation left the electrical wiring exposed. Maintenance Staff A verified observations during the survey process.

Based on record review and staff interview, this facility failed to ensure that the policy in place regarding the procedures to be taken in the event that the sprinkler system is out of service for more than four hours in any twenty-four hour period contained all applicable information. This deficient practice affects all occupants of the building, including staff, visitors and residents. The facility has a capacity of 11 with a census of 2 patients.

Findings include:

Record review and staff interview on 4/2/13, revealed that the sprinkler system outage policy did not contain notifying the State Fire Marshal as the authority having jurisdiction. Maintenance Staff A verified record review during the survey process.

Based on record review and staff interview, this facility failed to ensure that the policy in place regarding the procedures to be taken in the event that the fire alarm system is out of service for more than four hours in any twenty-four hour period contained all applicable information. This deficient practice affects all occupants of the building, including staff, visitors and residents. The facility has a capacity of 11 with a census of 2 patients.

Findings include:

Record review and staff interview on 4/2/13, revealed that the fire alarm system outage policy did not contain notifying the State Fire Marshal as the authority having jurisdiction. Maintenance Staff A verified record review during the survey process.