HospitalInspections.org

Observations revealed that the 20 minute fire rated doors in the 1-hour fire barrier between the clinic and the community center was not self-closing as required by NFPA 101 "The Life Safety Code" 2000 edition (LSC). This deficient practice could allow the products of combustion to travel from one building to another, which could negatively impact all the patients, staff and visitors of the facility.

Findings include:
Observations during the facility tour on September 21, 2010 between 3:30 pm and 03:45 pm, revealed that the door into the community wellness center was not self-closing.

The staff on site verified this deficient practice during the facility tour.

Observation revealed that the flame spread rating of insulation installed on the ceiling in the old boiler room was not documented and appeared to be combustible. This deficient practice could effect the staff in the boiler room and the patients and visitors if a fire involves the boiler room.

Findings include:
During the facility tour on September 21, 2010, between 1:00 PM and 2:30 PM, observations revealed that the sound proofing material installed on the basement boiler room ceiling appeared to be a sprayed on combustible material and it could not be documented as a class B interior finish with a flame spread of 75 or less.

This was verified by the Maintenance staff during the facility tour.

Observations revealed that two of twelve hazardous areas are not in accordance with NFPA 101 "The Life Safety Code 2000 edition (LSC) section 18.3.2 This deficient practice could allow the products of combustion to travel throughout the building if a fire occurs within these rooms, which could negatively impact all of the patients, staff and visitors.

Findings include:
During the facility tour on September 21, 2010, between 1:00 PM and 2:30 PM, observations revealed that :

1) The corridor doors from the basement soiled line storage room near the west stairway has doors that are not self-closing as required by LSC section 18.3.2, and

2) The mechanical room doors did not latch when allowed to be come self-closing.

This was verified by the Director of Maintenance and his staff during the facility tour.

A review of facility documentation revealed that the portable fire extinguishers have not been serviced in accordance with NFPA 10 Standard for Portable Fire Extinguishers 1998 sedition 9.7.4.1. This deficient practice could effect all patients, staff, and visitors.

Findings include:
Observations and a review of extinguisher tags during the facility tour on September 21, 2010 between 3:30 pm and 03:45 pm, revealed that the portable fire extinguisher did not have a service tag and could not be documented as being serviced with in the past year.

The staff on site verified this deficient practice during the facility tour.

Observations revealed that a light duty extension cord was in use as a substitute for permanent wiring and is not in accordance with NFPA 70 "The National Electrical Code" (NEC) 1999 edition. This deficient practice could cause over heating of the device causing a fire that will negatively impact the patients, visitors and staff.

Findings include:
Observations during the facility tour on September 21, 2010 between 3:30 pm and 03:45 pm, revealed that a light duty extension cord is in use in the office, which may allow the electrical circuits in the room to be overloaded.

The staff on site verified this deficient practice during the facility tour.

Observations revealed that the alcohol based hand sanitizer dispensers installed in the facility are not in accordance with CFR 483.70 Alcohol Based Hand Rubs and the Minnesota State Fire Code (2007 edition). This deficient practice could allow the ignition of the waterless flammable hand sanitizer causing a fire that would negatively impact the staff, residents and guests.

Findings include:
During the facility tour on September 21, 2010, between 1:00 PM and 2:30 PM, it was observed that alcohol based hand sanitizer dispenser installed in all patient sleeping rooms are mounted directly above light switches which could
allow the sanitizer to drip into these ignition sources.

This was verified by the Maintenance Man during the facility tour.