HospitalInspections.org

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to provide 2-hour rated construction at the building separation walls in accordance with 2000 - NFPA 101, sections 18.1.1.4, 18.1.2.3 and 8.2.3.2.


Findings include:

On facility tour between 12:30 PM and 6:30 PM on 06/14/2012, observation revealed the following in the 2-hour fire rated building separation wall between the Hospital and the Clinic:

1. 1st floor - the entire 2 hour fire rated wall had numerous penetrations, open conduit ends and open cable trays above the drop in ceiling and;

2. 2nd floor - open penetrations around the electrical conduit and open conduit ends above the drop in ceiling



These deficient practices were confirmed by the Facility Maintenance Director (TP) at the time of discovery.

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to provide 2-hour rated construction at the building separation walls in accordance with 2000 - NFPA 101, sections 19.1.1.4, 19.1.2.3 and 8.2.3.2.


Findings include:

On facility tour between 12:30 PM and 6:30 PM on 06/14/2012, observation revealed the following in the 2-hour fire rated building separation wall between the Hospital and the Ambulance Garage:

1. There are no 90 minute fire rated doors in the following locations:
a. The Staff Mothers Nursing Room
b. The single and double doors going to the new CT room

2. There is an open penetration above the ceiling panels going to the Emergency Room


These deficient practices were confirmed by the Facility Maintenance Director (TP) at the time of discovery.

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility has corridor doors that do not latch into their frames in accordance with the requirements of 2000 NFPA 101, Sections 19.3.6.3.2.

FINDINGS INCLUDE:

On facility tour between 12:30 PM and 6:30 PM on 06/14/2012, observation revealed that in the Emergency Department (that is open to the corridor) there are 4 sliding doors that do not have positive latching hardware.

This deficient practice was confirmed by the Facility Maintenance Director (TP) at the time of discovery.

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to maintain smoke barrier wall in accordance with the following requirements of 2000 NFPA 101, Section 19.3.7.3, and 8.3.4.1.

Findings include:

On facility tour between 12:30 PM and 6:30 PM on 06/14/2012, observation revealed the following in the smoke barrier walls by: 1. Room # 1137 - has open penetrations around a bundle of 15 cables, and the 1/2 inch electrical conduit above the drop in ceiling, and

2. In patient room # 217 - there are open penetrations above the drop in ceiling


NOTE: All smoke barrier walls shall be checked for this deficiency.


This deficient practice was confirmed by the Facility Maintenance Director (TP) at the time of discovery.

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to maintain 1 hour fire rated wall construction in accordance with the following requirements of 2000 NFPA 101, Section 19.3.2.1.

Findings include:

On facility tour between 9:00 AM and 4:30 PM on 06/12/2012, observation revealed the following:

1. 3rd floor - Auxiliary Storage Room (which is more than 50 sq ft), doors # 3007 A and B, do not have automatic door closers

2. 3rd floor - Storage Room # 3001A (over 50 square feet):
a. has a hallow core door
b. no automatic door closer
c. has a wall not sealed to deck
d. has a mailbox cut into wall and which is not sealed around it

3. 2nd floor - Storage Room # N2089 (over 50 square feet), the door does not positively latch


These deficient practices were confirmed by the Facility Technical Maintenance Supervisor (RF) at the time of discovery.

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to maintain a storage fee stairwell in the exit component accordance with the following requirements of 2000 NFPA 101, 7.2.2.5.

Findings include:

On facility tour between 9:00 AM and 4:30 PM on 06/12/2012, observation revealed, that the required west stairwell exit has storage at the bottom of stairwell.


This deficient practice was confirmed by the Facility Technical Maintenance Supervisor (RF) at the time of discovery.

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to maintain the unlocking requirements in accordance with the requirements of 2000 NFPA 101, Chapter 19.2.2.2.2.

Findings include:

On facility tour between 9:00 AM and 4:30 PM on 06/12/2012, observation revealed that the main and rear doors to the 2nd floor locked Mental Health area do not have a manual unlocking /locking device at the Nursing Station in accordance with the 2007 Minnesota State Fire Code, Section 1008.1.11.


This deficient practice was confirmed by the Facility Technical Maintenance Supervisor (RF) at the time of discovery.

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to provide proper coverage of the fire sprinkler system as per 2000 NFPA 101 Chapter 19.3.5 and 9.7 and 1999 NFPA 13, 5-13.6.

FINDINGS INCLUDE:

On facility tour between 9:00 AM and 4:30 PM on 06/12/2012, observation revealed that the penthouse elevator machine room for elevators 1 and 2, located in Building 1, was not equipped with automatic fire sprinkler protection.


This deficient practice was confirmed by the Facility Technical Maintenance Supervisor (RF) at the time of discovery.

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to maintain the fire sprinkler system in accordance with the requirements of 2000 NFPA 101, Sections 19.3.4.1 and 9.6, as well as 1998 NFPA 25, section 2-2.1.1.

Findings include:

On facility tour between 9:00 AM and 4:30 PM on 06/12/2012, observation revealed the following:

1. In the Penthouse in building 1, the fire sprinkler heads above the parts storage area had paint over-spray on them

2. 2nd Floor - Room N2088, the escutcheon plate for the fire sprinkler head was missing.

3. The check valves have not had a 5 year inspection per NFPA 25 (98), Chapter 9-4.2.1

4. Standpipes have not had their 5 year flow test per NFPA 25 (98), Chapter 3-3.1

5. The dry type fire sprinkler heads in the 1st Floor Kitchen are over 10 years old



These deficient practices were confirmed by the Facility Maintenance Director (TP) at the time of discovery.

Based on observations and interview, the facility has compressed gas cylinders not properly stored in compliance with the requirements of NFPA 99.

Findings include:

On facility tour between 9:00 AM and 4:30 PM on 06/12/2012, observation revealed the following:

1. In the following locations, there are "E" size oxygen tanks stored with-in rooms without proper signage on the door:
a. 2nd floor - Respitory Care Supply
b. Rooms 2036, 2039 and 2043

2. 1st floor - Medical Gas Room, the medical gas lines going though walls and ceiling deck are not properly labeled


These deficient practices were confirmed by the Facility Maintenance Director (TP) at the time of discovery.

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to maintain electrical supply in accordance with the requirements of 2000 NFPA 101 - 9.1.2, 1999 NFPA 70, and 2007 Minnesota State Fire Code 605.4 and 605.5 .

Findings include:

On facility tour between 9:00 AM and 4:30 PM on 06/12/2012, observation revealed the following:

1. Room # 2109 - extension cord plugged into power strip

2. Room # 3007A - microwave and refrigerator plugged into power strip

3. 1st floor - Radiology Break Room - microwave and refrigerator plugged into power strip

4. 1st floor - Physicians Lounge - microwave and refrigerator plugged into power strip

5. 1st floor - Cafeteria serving area - 3 extension cords in use


These deficient practices were confirmed by the Facility Technical Maintenance Supervisor (RF) at the time of discovery.



*TEAM COMPOSITION*
Gary Schroeder, Life Safety Code Spc.

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to maintain electrical supply in accordance with the requirements of 2000 NFPA 101 - 9.1.2, 1999 NFPA 70, and 2007 Minnesota State Fire Code 605.4 and 605.5 .

Findings include:

On facility tour between 9:00 AM and 4:30 PM on 06/12/2012, observation revealed, that the Physical Therapy staff cubicles area have several power strips that were connected with each other.


These deficient practices were confirmed by the Facility Technical Maintenance Supervisor (RF) at the time of discovery.



*TEAM COMPOSITION*
Gary Schroeder, Life Safety Code Spc.

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to provide 2-hour rated construction at the building separation walls in accordance with 2000 - NFPA 101, sections 18.1.1.4, 18.1.2.3 and 8.2.3.2.


Findings include:

On facility tour between 12:30 PM and 6:30 PM on 06/14/2012, observation revealed the following in the 2-hour fire rated building separation wall between the Hospital and the Clinic:

1. 1st floor - the entire 2 hour fire rated wall had numerous penetrations, open conduit ends and open cable trays above the drop in ceiling and;

2. 2nd floor - open penetrations around the electrical conduit and open conduit ends above the drop in ceiling



These deficient practices were confirmed by the Facility Maintenance Director (TP) at the time of discovery.

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to provide 2-hour rated construction at the building separation walls in accordance with 2000 - NFPA 101, sections 19.1.1.4, 19.1.2.3 and 8.2.3.2.


Findings include:

On facility tour between 12:30 PM and 6:30 PM on 06/14/2012, observation revealed the following in the 2-hour fire rated building separation wall between the Hospital and the Ambulance Garage:

1. There are no 90 minute fire rated doors in the following locations:
a. The Staff Mothers Nursing Room
b. The single and double doors going to the new CT room

2. There is an open penetration above the ceiling panels going to the Emergency Room


These deficient practices were confirmed by the Facility Maintenance Director (TP) at the time of discovery.

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility has corridor doors that do not latch into their frames in accordance with the requirements of 2000 NFPA 101, Sections 19.3.6.3.2.

FINDINGS INCLUDE:

On facility tour between 12:30 PM and 6:30 PM on 06/14/2012, observation revealed that in the Emergency Department (that is open to the corridor) there are 4 sliding doors that do not have positive latching hardware.

This deficient practice was confirmed by the Facility Maintenance Director (TP) at the time of discovery.

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to maintain smoke barrier wall in accordance with the following requirements of 2000 NFPA 101, Section 19.3.7.3, and 8.3.4.1.

Findings include:

On facility tour between 12:30 PM and 6:30 PM on 06/14/2012, observation revealed the following in the smoke barrier walls by: 1. Room # 1137 - has open penetrations around a bundle of 15 cables, and the 1/2 inch electrical conduit above the drop in ceiling, and

2. In patient room # 217 - there are open penetrations above the drop in ceiling


NOTE: All smoke barrier walls shall be checked for this deficiency.


This deficient practice was confirmed by the Facility Maintenance Director (TP) at the time of discovery.

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to maintain 1 hour fire rated wall construction in accordance with the following requirements of 2000 NFPA 101, Section 19.3.2.1.

Findings include:

On facility tour between 9:00 AM and 4:30 PM on 06/12/2012, observation revealed the following:

1. 3rd floor - Auxiliary Storage Room (which is more than 50 sq ft), doors # 3007 A and B, do not have automatic door closers

2. 3rd floor - Storage Room # 3001A (over 50 square feet):
a. has a hallow core door
b. no automatic door closer
c. has a wall not sealed to deck
d. has a mailbox cut into wall and which is not sealed around it

3. 2nd floor - Storage Room # N2089 (over 50 square feet), the door does not positively latch


These deficient practices were confirmed by the Facility Technical Maintenance Supervisor (RF) at the time of discovery.

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to maintain a storage fee stairwell in the exit component accordance with the following requirements of 2000 NFPA 101, 7.2.2.5.

Findings include:

On facility tour between 9:00 AM and 4:30 PM on 06/12/2012, observation revealed, that the required west stairwell exit has storage at the bottom of stairwell.


This deficient practice was confirmed by the Facility Technical Maintenance Supervisor (RF) at the time of discovery.

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to maintain the unlocking requirements in accordance with the requirements of 2000 NFPA 101, Chapter 19.2.2.2.2.

Findings include:

On facility tour between 9:00 AM and 4:30 PM on 06/12/2012, observation revealed that the main and rear doors to the 2nd floor locked Mental Health area do not have a manual unlocking /locking device at the Nursing Station in accordance with the 2007 Minnesota State Fire Code, Section 1008.1.11.


This deficient practice was confirmed by the Facility Technical Maintenance Supervisor (RF) at the time of discovery.

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to provide proper coverage of the fire sprinkler system as per 2000 NFPA 101 Chapter 19.3.5 and 9.7 and 1999 NFPA 13, 5-13.6.

FINDINGS INCLUDE:

On facility tour between 9:00 AM and 4:30 PM on 06/12/2012, observation revealed that the penthouse elevator machine room for elevators 1 and 2, located in Building 1, was not equipped with automatic fire sprinkler protection.


This deficient practice was confirmed by the Facility Technical Maintenance Supervisor (RF) at the time of discovery.

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to maintain the fire sprinkler system in accordance with the requirements of 2000 NFPA 101, Sections 19.3.4.1 and 9.6, as well as 1998 NFPA 25, section 2-2.1.1.

Findings include:

On facility tour between 9:00 AM and 4:30 PM on 06/12/2012, observation revealed the following:

1. In the Penthouse in building 1, the fire sprinkler heads above the parts storage area had paint over-spray on them

2. 2nd Floor - Room N2088, the escutcheon plate for the fire sprinkler head was missing.

3. The check valves have not had a 5 year inspection per NFPA 25 (98), Chapter 9-4.2.1

4. Standpipes have not had their 5 year flow test per NFPA 25 (98), Chapter 3-3.1

5. The dry type fire sprinkler heads in the 1st Floor Kitchen are over 10 years old



These deficient practices were confirmed by the Facility Maintenance Director (TP) at the time of discovery.

Based on observations and interview, the facility has compressed gas cylinders not properly stored in compliance with the requirements of NFPA 99.

Findings include:

On facility tour between 9:00 AM and 4:30 PM on 06/12/2012, observation revealed the following:

1. In the following locations, there are "E" size oxygen tanks stored with-in rooms without proper signage on the door:
a. 2nd floor - Respitory Care Supply
b. Rooms 2036, 2039 and 2043

2. 1st floor - Medical Gas Room, the medical gas lines going though walls and ceiling deck are not properly labeled


These deficient practices were confirmed by the Facility Maintenance Director (TP) at the time of discovery.

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to maintain electrical supply in accordance with the requirements of 2000 NFPA 101 - 9.1.2, 1999 NFPA 70, and 2007 Minnesota State Fire Code 605.4 and 605.5 .

Findings include:

On facility tour between 9:00 AM and 4:30 PM on 06/12/2012, observation revealed the following:

1. Room # 2109 - extension cord plugged into power strip

2. Room # 3007A - microwave and refrigerator plugged into power strip

3. 1st floor - Radiology Break Room - microwave and refrigerator plugged into power strip

4. 1st floor - Physicians Lounge - microwave and refrigerator plugged into power strip

5. 1st floor - Cafeteria serving area - 3 extension cords in use


These deficient practices were confirmed by the Facility Technical Maintenance Supervisor (RF) at the time of discovery.



*TEAM COMPOSITION*
Gary Schroeder, Life Safety Code Spc.

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to maintain electrical supply in accordance with the requirements of 2000 NFPA 101 - 9.1.2, 1999 NFPA 70, and 2007 Minnesota State Fire Code 605.4 and 605.5 .

Findings include:

On facility tour between 9:00 AM and 4:30 PM on 06/12/2012, observation revealed, that the Physical Therapy staff cubicles area have several power strips that were connected with each other.


These deficient practices were confirmed by the Facility Technical Maintenance Supervisor (RF) at the time of discovery.



*TEAM COMPOSITION*
Gary Schroeder, Life Safety Code Spc.