HospitalInspections.org

Based on observation, it was determined the facility failed to maintain the ability of the double fire rated door to self-latch in one (Behavioral Health Unit) of four areas observed. Failure to maintain the ability for the doors to fully self-close had the potential to affect the health and safety of patients, visitors, and staff because the doors' inability to fully close would allow the passage of fire and smoke through the doors in the event of a smoke and fire event. Findings follow:

A. On a tour of the facility with the Director of Maintenance on 03/23/2016 at 1300, it was observed the double fire rated doors to the Behavioral Health Unit did not self-latch.
B. The Director of Maintenance verified the doors were unable to self-latch.

Based on observation and interview, it was observed the facility failed to seal five of eleven penetrations in two of five fire and smoke rated barriers (between the mechanical room and the corridor near the nurses' station; the barrier between the Nutrition Room and Cardio Rehab room). The failed practice had the potential to affect all patients, visitors, and staff because failure to maintain the fire/smoke resistance rating would allow smoke and fire to pass from one side of the barrier to the other in the event of a smoke and fire event. Findings follow:

A. While on tour with the Director of Maintenance on 03/23/2016 at 1000, it was observed:
1) Four of ten electrical conduits penetrating the 2-hour fire rated wall which separated the mechanical room from the corridor near the nurses' station were not sealed with a fire-rated material.
2) One of one copper pipe penetrating the 1-hour fire rated wall which separated the Nutrition Room from the Cardio Rehab Room was not sealed with a fire rated material.
B. During the tour, the Director of Maintenance verified the penetrations were not sealed with a fire rated material.

Based on the Fire Drill Log review and interview, it was determined that the facility failed to perform four of eight fire drills during the second shift for the first, second, third, and fourth quarters of 2015. The failed practice had the potential to affect patients, visitors, and staff because the effectiveness of the fire plan and staff training in the event of a fire event could not be evaluated. Findings follow:

A. During review of the Fire Drill Log on 03/22/2016 at 0940, it was determined that four of eight required fire drills had not been performed for the year 2015:
1. The facility failed to perform one fire drill during the second shift for the quarter from January 2015 through March 2015.
2. The facility failed to perform one fire drill during the second shift for the quarter from April 2015 through June 2015.
3. The facility failed to perform one fire drill during the second shift for the quarter from July 2015 through September 2015.
4. The facility failed to perform one fire drill during the second shift for the quarter from October 2015 through December 2015.
B. During an interview on 03/22/2016 at 0940 with the Director of Maintenance, it was verified four of eight required fire drills had not been performed.