HospitalInspections.org

Based on observation and interview, the facility failed to maintain the integrity and fire resistance rating for five of five (X-Ray Room, near Patient Room 6, 14 and 15 and GI (Gastrointestinal Lab) smoke barrier walls inspected because of unsealed penetrations of the smoke barrier wall. The failed practice had the potential to affect all patients, staff, and visitors due to the inability of the compromised smoke barrier walls to prevent the passage of smoke and fire from one side of the smoke barrier to the other. The facility had a census of three patients on 04/25/12. The findings follow:

A. Unsealed penetrations were observed in the following areas on a tour of the facility on 04/26/12 at 1335 with the Maintenance Supervisor:
1) One unsealed penetration was observed above the smoke barrier doors near the X-Ray Room.
2) Three unsealed penetrations were observed above the smoke barrier doors near the Patient Room 15.
3) Three unsealed penetrations were observed above the smoke barrier doors near the G.I. Lab.
4) Two unsealed penetrations were observed above the smoke barrier doors near Patient Room 14.
5) One unsealed penetration was observed above the smoke barrier doors near the Patient Room 6.
B. The Maintenance Supervisor verified the unsealed penetrations during the inspection at 1335 on 04/26/12.

Based on Generator Log review and interview, it could not be determined for each monthly load test that the generator was run for a total of 30 consecutive minutes due to a lack of documentation of total load run time on the generator log. Failure to run the generator a minimum of 30 minutes per month had the potential to affect the health and safety of all patients, staff, and visitors because the reliable functioning of the generator was not tested or verified. The facility had a census of three patients on 04/25/12. The findings follow:

A. Review of the Generator Logs dated 11/28/11 through 4/23/12 on 04/25/12 at 1330 revealed no data documenting the time duration of the monthly load test of the generator was recorded. Based on the data recorded, it could not be determined the generator was run for 30 consecutive minutes on the day of the test.
B. In an interview on 04/5/12 at 1400, the Maintenance Supervisor verified the generator log did not include data on the length of time the generator was run on a monthly basis and there was no further documentation available for review.

Based on observation and interview, the facility failed to maintain the integrity and fire resistance rating for five of five (X-Ray Room, near Patient Room 6, 14 and 15 and GI (Gastrointestinal Lab) smoke barrier walls inspected because of unsealed penetrations of the smoke barrier wall. The failed practice had the potential to affect all patients, staff, and visitors due to the inability of the compromised smoke barrier walls to prevent the passage of smoke and fire from one side of the smoke barrier to the other. The facility had a census of three patients on 04/25/12. The findings follow:

A. Unsealed penetrations were observed in the following areas on a tour of the facility on 04/26/12 at 1335 with the Maintenance Supervisor:
1) One unsealed penetration was observed above the smoke barrier doors near the X-Ray Room.
2) Three unsealed penetrations were observed above the smoke barrier doors near the Patient Room 15.
3) Three unsealed penetrations were observed above the smoke barrier doors near the G.I. Lab.
4) Two unsealed penetrations were observed above the smoke barrier doors near Patient Room 14.
5) One unsealed penetration was observed above the smoke barrier doors near the Patient Room 6.
B. The Maintenance Supervisor verified the unsealed penetrations during the inspection at 1335 on 04/26/12.

Based on Generator Log review and interview, it could not be determined for each monthly load test that the generator was run for a total of 30 consecutive minutes due to a lack of documentation of total load run time on the generator log. Failure to run the generator a minimum of 30 minutes per month had the potential to affect the health and safety of all patients, staff, and visitors because the reliable functioning of the generator was not tested or verified. The facility had a census of three patients on 04/25/12. The findings follow:

A. Review of the Generator Logs dated 11/28/11 through 4/23/12 on 04/25/12 at 1330 revealed no data documenting the time duration of the monthly load test of the generator was recorded. Based on the data recorded, it could not be determined the generator was run for 30 consecutive minutes on the day of the test.
B. In an interview on 04/5/12 at 1400, the Maintenance Supervisor verified the generator log did not include data on the length of time the generator was run on a monthly basis and there was no further documentation available for review.