HospitalInspections.org

The facility failed to maintain self closing doors in a smoke barrier.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than I hour. (1/2 hour for existing) Section 8.3.4.1, " Doors in smoke barriers shall close the opening leaving only the minimum clearance necessary for proper operation and shall be without undercuts, louvers, or grilles.

On February 10, 2010, the surveyors, accompanied by the Director of Maintenance, observed the following corridor smoke/fire doors. When closed the smoke seals between the doors had worn and exposed a gap greater than 1/4 inch.

1. The smoke doors at room 202 has a gap greater than 1/4 inch.
2. The smoke doors at the entrance to intensive care has a gap greater than 1/4 inch.

This installation will allow smoke to contaminate smoke zones not directly effected by the fire, which will cause harm to patients.

The facility failed to provide a self-closing door hardware in hazardous area rooms.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.2.1, "Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.

On February 10, 2010, the surveyors accompanied by the Director of Maintenance, observed that the following rooms did not have self closing hardware on the corridor doors.

1. Kitchen dry good storage room, which is over 100 sq. ft. in area, no self closing hardware on the door.
2. Clean linen closet no self closing hardware on the door.
3. Janitor supply storage room no self closing hardware on the door.
4. The Lab Histology room no self closing hardware on the door.
5. Transformer room no self closing hardware on the door.
6. Dirty utility at the Nursing Station do self closing hardware on the door.
7. The corridor door/entrance door to the pre-op room would not close tightly when tested.

Failing to install self-closing hardware on a smoke/fire resistance door will cause harm to residents in time of a fire.

The facility did not keep exits readily accessible at all times.

NFPA 101 Life Safety Code, 2000, Chapter 19 Section 19.2.1, and Section 19.2.3.3. Section 19.2.1 "Every aisle, passageway, corridor, exit discharge, exit location and access shall be in accordance with Chapter 7. Section 18.2.3.3 "Aisles, corridors and ramps required for exit access in a hospital or nursing home shall be not less than 8 ft (Existing built to 8 feet must be maintained 8 feet clear) in clear and unobstructed width". Chapter 7 Section 7.5.1.1" Exits shall be so located and exit access shall be arranged so that exits are readily accessible at all times." Section 7.5.1.2 "Where exits are not immediately accessible from an open floor area, continuous passageways, aisles, or corridors leading directly to every exit and shall be maintained and shall be arranged to provide access for each occupant to not less than two exits by separate ways of travel."

On February 10, 2010, the surveyors, accompanied by the Director of Maintenance, observed storage of, equipment, chairs, and a portable X-ray machine, in the exit corridor to the entrance to surgery.

Failure to keep the exit corridors and exit access clear could hinder the evacuation during an emergency and will cause harm to patients.

The facility failed to document the monthly and annual testing of battery back up emergency lighting.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.2.9.1, "Emergency lighting shall be provided in accordance with Section 7.9". Section 7.9.3 " Periodic Testing of Emergency Lighting Equipment" " A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction."

On February 10, 2010, the surveyors accompanied by the Director of Maintenance, no documentation of monthly or annual testing of existing battery back-up emergency lighting was provided to the surveyors.

Failing to test and maintain emergency lighting units will cause harm to the patients.

The facility failed to provide battery operated emergency lighting in the operating rooms, anesthetizing locations.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.5.1 "Utilities shall comply with the provisions of Section 9.1. Section 9.1.2 "Electric wiring and equipment shall be in accordance with NFPA 70 National Electrical Code... Article 517 Health Care Facilities, Section 517-63 Grounded Power systems in Anesthetizing Locations. 517-63(a), 'Battery-Powered Emergency Lighting Units." "One or more battery-powered emergency lighting units shall be provided in accordance with Section 700-12(e)." NFPA 99, Health Care Facilities, Chapter 3, Section 3-3.2.1.2, (5) Wiring in Anesthetizing Locations. (e) Battery-Powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, Section 700-12 (e).

On February 10, 2010, the surveyors accompanied by the Director of Maintenance, observed the Operating Rooms in the Hospital. None of the Operating rooms were protected with battery powered emergency lighting.

Failing to provide battery-powered emergency lighting in the operating rooms will harm patients during a power outage and failure of the emergency generator.

The facility failed to maintain self closing doors in a smoke barrier.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than I hour. (1/2 hour for existing) Section 8.3.4.1, " Doors in smoke barriers shall close the opening leaving only the minimum clearance necessary for proper operation and shall be without undercuts, louvers, or grilles.

On February 10, 2010, the surveyors, accompanied by the Director of Maintenance, observed the following corridor smoke/fire doors. When closed the smoke seals between the doors had worn and exposed a gap greater than 1/4 inch.

1. The smoke doors at room 202 has a gap greater than 1/4 inch.
2. The smoke doors at the entrance to intensive care has a gap greater than 1/4 inch.

This installation will allow smoke to contaminate smoke zones not directly effected by the fire, which will cause harm to patients.

The facility failed to provide a self-closing door hardware in hazardous area rooms.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.2.1, "Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.

On February 10, 2010, the surveyors accompanied by the Director of Maintenance, observed that the following rooms did not have self closing hardware on the corridor doors.

1. Kitchen dry good storage room, which is over 100 sq. ft. in area, no self closing hardware on the door.
2. Clean linen closet no self closing hardware on the door.
3. Janitor supply storage room no self closing hardware on the door.
4. The Lab Histology room no self closing hardware on the door.
5. Transformer room no self closing hardware on the door.
6. Dirty utility at the Nursing Station do self closing hardware on the door.
7. The corridor door/entrance door to the pre-op room would not close tightly when tested.

Failing to install self-closing hardware on a smoke/fire resistance door will cause harm to residents in time of a fire.

The facility did not keep exits readily accessible at all times.

NFPA 101 Life Safety Code, 2000, Chapter 19 Section 19.2.1, and Section 19.2.3.3. Section 19.2.1 "Every aisle, passageway, corridor, exit discharge, exit location and access shall be in accordance with Chapter 7. Section 18.2.3.3 "Aisles, corridors and ramps required for exit access in a hospital or nursing home shall be not less than 8 ft (Existing built to 8 feet must be maintained 8 feet clear) in clear and unobstructed width". Chapter 7 Section 7.5.1.1" Exits shall be so located and exit access shall be arranged so that exits are readily accessible at all times." Section 7.5.1.2 "Where exits are not immediately accessible from an open floor area, continuous passageways, aisles, or corridors leading directly to every exit and shall be maintained and shall be arranged to provide access for each occupant to not less than two exits by separate ways of travel."

On February 10, 2010, the surveyors, accompanied by the Director of Maintenance, observed storage of, equipment, chairs, and a portable X-ray machine, in the exit corridor to the entrance to surgery.

Failure to keep the exit corridors and exit access clear could hinder the evacuation during an emergency and will cause harm to patients.

The facility failed to document the monthly and annual testing of battery back up emergency lighting.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.2.9.1, "Emergency lighting shall be provided in accordance with Section 7.9". Section 7.9.3 " Periodic Testing of Emergency Lighting Equipment" " A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction."

On February 10, 2010, the surveyors accompanied by the Director of Maintenance, no documentation of monthly or annual testing of existing battery back-up emergency lighting was provided to the surveyors.

Failing to test and maintain emergency lighting units will cause harm to the patients.

The facility failed to provide battery operated emergency lighting in the operating rooms, anesthetizing locations.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.5.1 "Utilities shall comply with the provisions of Section 9.1. Section 9.1.2 "Electric wiring and equipment shall be in accordance with NFPA 70 National Electrical Code... Article 517 Health Care Facilities, Section 517-63 Grounded Power systems in Anesthetizing Locations. 517-63(a), 'Battery-Powered Emergency Lighting Units." "One or more battery-powered emergency lighting units shall be provided in accordance with Section 700-12(e)." NFPA 99, Health Care Facilities, Chapter 3, Section 3-3.2.1.2, (5) Wiring in Anesthetizing Locations. (e) Battery-Powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, Section 700-12 (e).

On February 10, 2010, the surveyors accompanied by the Director of Maintenance, observed the Operating Rooms in the Hospital. None of the Operating rooms were protected with battery powered emergency lighting.

Failing to provide battery-powered emergency lighting in the operating rooms will harm patients during a power outage and failure of the emergency generator.