HospitalInspections.org

Based on observation and interview with the Director of Maintenance at 1:40 PM on December 14 , the facility failed to maintain Corridors that are separated from use areas by walls constructed with at least ? hour fire resistance rating. 19.3.6.1, 19.3.6.2.1, Findings:

Rated walls throughout the facility had penetrations that were not sealed. The penetrations were found in several locations above the ceilings; including above the duct work and in hard to reach places.

This deficiency was previously cited in the April 13, 2005 Life Safety Code Survey.

Based on observation and interview with the Director of Maintenance at 1:30 PM on December 14 , the facility failed to maintain Smoke barriers that are constructed to provide at least a one half hour fire resistance rating. Findings::

Walls separating the facility at all smoke compartment locations had penetrations that were not sealed; including where new cabling was recently installed, above duct work in areas that are hard to access and around conduit and fire sprinkler lines.

This deficiency was previously cited in the April 13, 2005 Life Safety Code Survey.

Based on observation and interview with the Director of Maintenance at 1:55 PM on December 14 , the facility failed to maintain exit and directional signs that are continuously illuminated. Findings::

Eight (8) exit signs, located in various areas of the building. were not illuminated.

Based on review of records and interview with the Director of Maintenance , the facility failed to conduct drills held at unexpected times under varying conditions, at least quarterly on each shift. The facility failed to ensure the staff is familiar with procedures and that drills are part of an established routine. Findings: :

The drill records did not provide evidence of a drill for the staff on the night shift or documentation to demonstrate they were familiar with procedures and policy.

Based on observation, a request of third party verification test forms and interview with the Director of Maintenance, the facility failed to provide a fire alarm system that is maintained in accordance with NFPA 72 and records of maintenance are kept readily available. Findings:

The facility did not have records of a third party inspection and did not have a placard (green tag) to show that the fire alarm system had been inspected or approved in accordance with NFPA 72. Also, the facility failed to require an outside vendor to provide re-acceptance testing for repairs made to the system in accordance with 7-1.6.2.

Based on observation and interview with the Director of Maintenance at 1:50 PM on December 14 , the facility failed to maintain means of egress that are continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. 7.1.10, Findings:

Dirty linen carts were parked in the corridors adjacent to occupied rooms.

This deficiency was previously cited in the April 13, 2005 Life Safety Code Survey.

Based on interview with the Director of Maintenance, Operating Room Director, and staff that works in the surgery suite at 3 PM December 13, 2010, the facility failed to provide evidence that the OR Room has a smoke evacuation system in accordance with NFPA 101, 2000, 19.3.2.3 , NFPA 99, 1999, 5-4.1.2 and 5-4.1.3, Findings:

A Smoke detector was not installed at the ceiling and staff did not know if a detector was installed in the return duct.

1. Based on observation and interview with staff the facility failed to protect parts of the building by separating or protecting the boiler room in accordance with NFPA 101, 6.2.1.3/ 8.4, Findings:

A gas powered mower, gasoline powered weed eaters and blowers were stored in the Boiler, Medical Gas & Vacuum Pump Room.

2. Based upon observation and interview with staff, the facility failed to provide records of the required test for the Line Isolation Monitor located in the old Labor/Delivery Room and in the Operating Rooms in accordance with NFPA 99, 1999, The Line Isolation Monitor is not tested every month by activating the actuating switch.

The Line Isolation Monitor was last tested April of 1995. The audible alarm is not functioning on the Monitor in the Operating Room.

Based on observation and interview with the Director of Maintenance at 1:45 PM on December 14 , the facility failed to maintain Master alarm panels that are in two separate locations and have audible and visible signals. NFPA 99, 4.3.1.2.2, Findings:

The wires to the annunciating switch for the master alarm panel were not connected to the switch at the O2 Liquid Tank, leaving the alarm non-functional.

Based on observation and interview with the Director of Maintenance at 1:40 PM on December 14 , the facility failed to maintain Corridors that are separated from use areas by walls constructed with at least ? hour fire resistance rating. 19.3.6.1, 19.3.6.2.1, Findings:

Rated walls throughout the facility had penetrations that were not sealed. The penetrations were found in several locations above the ceilings; including above the duct work and in hard to reach places.

This deficiency was previously cited in the April 13, 2005 Life Safety Code Survey.

Based on observation and interview with the Director of Maintenance at 1:30 PM on December 14 , the facility failed to maintain Smoke barriers that are constructed to provide at least a one half hour fire resistance rating. Findings::

Walls separating the facility at all smoke compartment locations had penetrations that were not sealed; including where new cabling was recently installed, above duct work in areas that are hard to access and around conduit and fire sprinkler lines.

This deficiency was previously cited in the April 13, 2005 Life Safety Code Survey.

Based on observation and interview with the Director of Maintenance at 1:55 PM on December 14 , the facility failed to maintain exit and directional signs that are continuously illuminated. Findings::

Eight (8) exit signs, located in various areas of the building. were not illuminated.

Based on review of records and interview with the Director of Maintenance , the facility failed to conduct drills held at unexpected times under varying conditions, at least quarterly on each shift. The facility failed to ensure the staff is familiar with procedures and that drills are part of an established routine. Findings: :

The drill records did not provide evidence of a drill for the staff on the night shift or documentation to demonstrate they were familiar with procedures and policy.

Based on observation, a request of third party verification test forms and interview with the Director of Maintenance, the facility failed to provide a fire alarm system that is maintained in accordance with NFPA 72 and records of maintenance are kept readily available. Findings:

The facility did not have records of a third party inspection and did not have a placard (green tag) to show that the fire alarm system had been inspected or approved in accordance with NFPA 72. Also, the facility failed to require an outside vendor to provide re-acceptance testing for repairs made to the system in accordance with 7-1.6.2.

Based on observation and interview with the Director of Maintenance at 1:50 PM on December 14 , the facility failed to maintain means of egress that are continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. 7.1.10, Findings:

Dirty linen carts were parked in the corridors adjacent to occupied rooms.

This deficiency was previously cited in the April 13, 2005 Life Safety Code Survey.

Based on interview with the Director of Maintenance, Operating Room Director, and staff that works in the surgery suite at 3 PM December 13, 2010, the facility failed to provide evidence that the OR Room has a smoke evacuation system in accordance with NFPA 101, 2000, 19.3.2.3 , NFPA 99, 1999, 5-4.1.2 and 5-4.1.3, Findings:

A Smoke detector was not installed at the ceiling and staff did not know if a detector was installed in the return duct.

1. Based on observation and interview with staff the facility failed to protect parts of the building by separating or protecting the boiler room in accordance with NFPA 101, 6.2.1.3/ 8.4, Findings:

A gas powered mower, gasoline powered weed eaters and blowers were stored in the Boiler, Medical Gas & Vacuum Pump Room.

2. Based upon observation and interview with staff, the facility failed to provide records of the required test for the Line Isolation Monitor located in the old Labor/Delivery Room and in the Operating Rooms in accordance with NFPA 99, 1999, The Line Isolation Monitor is not tested every month by activating the actuating switch.

The Line Isolation Monitor was last tested April of 1995. The audible alarm is not functioning on the Monitor in the Operating Room.

Based on observation and interview with the Director of Maintenance at 1:45 PM on December 14 , the facility failed to maintain Master alarm panels that are in two separate locations and have audible and visible signals. NFPA 99, 4.3.1.2.2, Findings:

The wires to the annunciating switch for the master alarm panel were not connected to the switch at the O2 Liquid Tank, leaving the alarm non-functional.