HospitalInspections.org

This STANDARD is not met as evidenced by :

Based on observation and the staff interview, the facility failed to provide protection of hazardous areas from adjacent corridors and non-hazardous rooms. The findings were:

Observation of the Records Storage Room on 6/5/14 at 3:03 PM showed the door to this hazardous area did not have a closer. Interview with the Plant Operations Director at the time of the observation acknowledged that the door did not have a closer.

Observation and staff interview on 6/5/14 at 9:42 AM of the old waiting room that was converted to a storage room across from room #319 revealed that the arm assembly of the door closing devise was missing. The Executive Assistant acknowledged that the arm was missing from the door closing mechanism without any further explanation.

Observation and staff interview on 6/5/14 at 12:07 PM of the PT storage room revealed the door was not latching into the strike plate of the frame when closed from the open position. The Executive Assistant acknowledged the door was not latching without any further explanation.
Observation and staff interview on 6/5/14 at 3:30 PM of the maintenance office revealed the room contained items for building maintenance and a closing device was not installed on the corridor door. The Executive Assistant acknowledged the door did not have a losing device without any further explanation.

This STANDARD is not met as evidenced by :

Based on observation and staff interview, the facility failed to maintain vertical opening construction to provide protection against fire and smoke from other parts of the building. The findings were:

Observation of the rated door entering the stairwell from the ER Admitting lobby on 6/5/14 at 2:58 PM revealed that the door hinges had been damaged, and that the door was unable to close. Interview with the Plant Operations Director at the time of the observation acknowledged the damaged door. He went on to explain that the facility will be repairing the door in the future.

This STANDARD is not met as evidenced by :

Based on observation and staff interview, the facility failed to ensure that components of the means of egress are in compliance with Section 7.2 and 19.2.2 of the Life Safety Code. The findings were:

Observation of the exit door and magnetic door lock located at the stairwell in the OB Area on 6/5/14 at 11:02 AM revealed that the door was not readily opened without special knowledge for operation from the egress side of the door. The operation of the door knob on the egress side would not open the door for egress. Interview with the Executive Assistant at the time of the observation revealed that a push button labeled "PUSH TO EXIT" was located approximately 12" to the right of the door and would release the magnet and allow the knob to open the door. The interview further revealed the magnetic lock was to control access into the OB area from the stairwell for the infant abduction security system. Additional interview revealed unfamiliarity with the requirements of the locking provisions of Section 19.2.2 of the Life Safety Code.

This STANDARD is not met as evidenced by :

Based on document review and staff interview, the facility failed to provide documentation identifying a maintenance policy of the fire alarm system. The findings were:

Document review and staff interview of the testing and maintenance documentation on 6/5/14 from 8:45 AM to 9:45 AM confirmed the lack of a testing and maintenance policy of the following aspects of the fire alarm system:
1. Heat detectors - annual test (NFPA 72, Table 7-3.2, 15)
2. Smoke Dampers operation - annual test (NFPA 90A, 4-4.1)
3. Smoke Detectors (in place, smoke entry) - annual test (NFPA 72, Table 7-3.2, 15)
4. Smoke Detector Sensitivity - bi-annual tests (NFPA 72, Table 7-3.2, 15)
5. Supervisory Signal Devices - quarterly test (NFPA 72 Table 7-3.2, 15)
6. Water Flow Alarm Devices - quarterly test (NFPA 25, Section 9-2.7 and NFPA 72, Section 2-6.2)
7. Fire Alarm Activation - monthly (NFPA 672, Table 7-3.2, 23)
8. Annunciator Panel Testing - annual (NFPA 72, Table 7-3.2, 14)
9. Battery Inspection - annual (NFPA 72, Table 7-32, 6)
10. Battery Load Voltage Test - semi-annual (NFPA 72, Table 7-3.2,6,c,3)
11. Alarm Notification Appliances - annual (NFPA 72, Table 7-3.2, 19)
12. Manual Fire alarm Boxes - annual (NFPA 72, Table 7-3.2, 15)

Interview with the Plant Operations Director during review of the documentation revealed that he was not aware of the testing being performed for the previous year, and that no policy was available to establish responsibility for ensuring that the required testing is performed and documented.

This STANDARD is not met as evidenced by :

Based on observation and staff interview, the facility failed to provide an approved, supervised automatic sprinkler system. The findings were:

1. Observation of the X-Ray Room on 6/5/14 at 2:58 PM revealed that 1 of 4 sprinkler heads required for full coverage of the space was obstructed by the x-ray equipment when placed in the resting position. Additional observation revealed that the same sprinkler head was missing its escutcheon at the ceiling. Interview with the Plant Operations Director at the time of the observation acknowledged the obstruction.

2. Observation of the Pharmacy on 6/5/14 at 3:50 PM revealed that ceiling tiles had been notched to accommodate sprinkler heads, but that the openings were approximately 1" larger than the escutcheon in each direction. This occurrence was typical for (2) sprinkler heads. Interview with the Plant Operations Director at the time of the observation acknowledged the gap in the ceiling.

This STANDARD is not met as evidenced by :

Based on document review and staff interview, the facility failed to provide documentation identifying a maintenance policy of the sprinkler system. The findings were:

Document review and staff interview of the testing and maintenance documentation on 6/5/14 from 8:45 AM to 9:45 AM confirmed the lack of an annual testing and maintenance policy for backflow prevention per NFPA 25, Section 9.6.2.1. Interview with the Plant Operations Director during document review indicated that no policy was available to establish responsibility for ensuring that the required testing is performed and documented.

This STANDARD is not met as evidenced by :

Based on document review and staff interview, the facility failed to ensure that HVAC systems were tested per the requirements of NFPA 90A. The findings were:

Document review and staff interview on 6/5/14 between 8:45 AM and 9:45 AM revealed that no documentation was available to indicate that fire dampers were being tested on a 4-year basis in accordance with NFPA 90A, Section 3-4.7. Interview with the Plant Operations Director at the time of document review acknowledged that testing was not being performed.

This STANDARD is not met as evidenced by :

Based on document review and staff interview, the facility failed to ensure cooking facilities were protected in accordance with NFPA 96. The findings were:

Document review and staff interview of the cooking facility testing and maintenance documentation on 6/5/14 between 8:45 AM and 9:45 AM revealed that no documentation was available to indicate semi-annual inspections of the kitchen extinguishing system. Further observation revealed that an inspection tag was affixed to the kitchen extinguishing system to indicate that the required inspection had been performed. Interview with the Plant Operations Director during document review revealed that he was not aware of the inspection requirement, and could not identify who was responsible for ensuring that the testing is performed on a semi-annual basis.

This STANDARD is not met as evidenced by :

Based on observation and staffing interview, the facility failed to ensure that electrical systems were in compliance with NFPA 70. The findings were:

Observation of the Administrative Alcove in the X-Ray Suite on 6/5/14 at 3:02 PM revealed that a receptacle was missing its cover. Interview with the Plant Operations Director at the time of the observation acknowledged the missing receptacle cover.

This STANDARD is not met as evidenced by :

Based on observation and staff interview, the facility failed to provide the required firefighter's service requirements for elevators. The findings were:

Observation and staff interview on 6/5/14 at 3:05 PM of the elevator machine room revealed a smoke detector was not installed to detect smoke for the elevator recall system in accordance with Section 2.27.3.2 of the ASME A17.1, Safety Code for Elevators and Escalators and Section 3.9.3 of the NFPA 72, National Fire Alarm Code. The Executive Assistance Acknowledge that no smoke detector was provided and the fire detector in the room was a heat detector near the sprinkler head for the elevator shut down controls without any further explanation

This STANDARD is not met as evidenced by :

Based on observation and the staff interview, the facility failed to provide protection of hazardous areas from adjacent corridors and non-hazardous rooms. The findings were:

Observation of the Records Storage Room on 6/5/14 at 3:03 PM showed the door to this hazardous area did not have a closer. Interview with the Plant Operations Director at the time of the observation acknowledged that the door did not have a closer.

Observation and staff interview on 6/5/14 at 9:42 AM of the old waiting room that was converted to a storage room across from room #319 revealed that the arm assembly of the door closing devise was missing. The Executive Assistant acknowledged that the arm was missing from the door closing mechanism without any further explanation.

Observation and staff interview on 6/5/14 at 12:07 PM of the PT storage room revealed the door was not latching into the strike plate of the frame when closed from the open position. The Executive Assistant acknowledged the door was not latching without any further explanation.
Observation and staff interview on 6/5/14 at 3:30 PM of the maintenance office revealed the room contained items for building maintenance and a closing device was not installed on the corridor door. The Executive Assistant acknowledged the door did not have a losing device without any further explanation.

This STANDARD is not met as evidenced by :

Based on observation and staff interview, the facility failed to maintain vertical opening construction to provide protection against fire and smoke from other parts of the building. The findings were:

Observation of the rated door entering the stairwell from the ER Admitting lobby on 6/5/14 at 2:58 PM revealed that the door hinges had been damaged, and that the door was unable to close. Interview with the Plant Operations Director at the time of the observation acknowledged the damaged door. He went on to explain that the facility will be repairing the door in the future.

This STANDARD is not met as evidenced by :

Based on observation and staff interview, the facility failed to ensure that components of the means of egress are in compliance with Section 7.2 and 19.2.2 of the Life Safety Code. The findings were:

Observation of the exit door and magnetic door lock located at the stairwell in the OB Area on 6/5/14 at 11:02 AM revealed that the door was not readily opened without special knowledge for operation from the egress side of the door. The operation of the door knob on the egress side would not open the door for egress. Interview with the Executive Assistant at the time of the observation revealed that a push button labeled "PUSH TO EXIT" was located approximately 12" to the right of the door and would release the magnet and allow the knob to open the door. The interview further revealed the magnetic lock was to control access into the OB area from the stairwell for the infant abduction security system. Additional interview revealed unfamiliarity with the requirements of the locking provisions of Section 19.2.2 of the Life Safety Code.

This STANDARD is not met as evidenced by :

Based on document review and staff interview, the facility failed to provide documentation identifying a maintenance policy of the fire alarm system. The findings were:

Document review and staff interview of the testing and maintenance documentation on 6/5/14 from 8:45 AM to 9:45 AM confirmed the lack of a testing and maintenance policy of the following aspects of the fire alarm system:
1. Heat detectors - annual test (NFPA 72, Table 7-3.2, 15)
2. Smoke Dampers operation - annual test (NFPA 90A, 4-4.1)
3. Smoke Detectors (in place, smoke entry) - annual test (NFPA 72, Table 7-3.2, 15)
4. Smoke Detector Sensitivity - bi-annual tests (NFPA 72, Table 7-3.2, 15)
5. Supervisory Signal Devices - quarterly test (NFPA 72 Table 7-3.2, 15)
6. Water Flow Alarm Devices - quarterly test (NFPA 25, Section 9-2.7 and NFPA 72, Section 2-6.2)
7. Fire Alarm Activation - monthly (NFPA 672, Table 7-3.2, 23)
8. Annunciator Panel Testing - annual (NFPA 72, Table 7-3.2, 14)
9. Battery Inspection - annual (NFPA 72, Table 7-32, 6)
10. Battery Load Voltage Test - semi-annual (NFPA 72, Table 7-3.2,6,c,3)
11. Alarm Notification Appliances - annual (NFPA 72, Table 7-3.2, 19)
12. Manual Fire alarm Boxes - annual (NFPA 72, Table 7-3.2, 15)

Interview with the Plant Operations Director during review of the documentation revealed that he was not aware of the testing being performed for the previous year, and that no policy was available to establish responsibility for ensuring that the required testing is performed and documented.

This STANDARD is not met as evidenced by :

Based on observation and staff interview, the facility failed to provide an approved, supervised automatic sprinkler system. The findings were:

1. Observation of the X-Ray Room on 6/5/14 at 2:58 PM revealed that 1 of 4 sprinkler heads required for full coverage of the space was obstructed by the x-ray equipment when placed in the resting position. Additional observation revealed that the same sprinkler head was missing its escutcheon at the ceiling. Interview with the Plant Operations Director at the time of the observation acknowledged the obstruction.

2. Observation of the Pharmacy on 6/5/14 at 3:50 PM revealed that ceiling tiles had been notched to accommodate sprinkler heads, but that the openings were approximately 1" larger than the escutcheon in each direction. This occurrence was typical for (2) sprinkler heads. Interview with the Plant Operations Director at the time of the observation acknowledged the gap in the ceiling.

This STANDARD is not met as evidenced by :

Based on document review and staff interview, the facility failed to provide documentation identifying a maintenance policy of the sprinkler system. The findings were:

Document review and staff interview of the testing and maintenance documentation on 6/5/14 from 8:45 AM to 9:45 AM confirmed the lack of an annual testing and maintenance policy for backflow prevention per NFPA 25, Section 9.6.2.1. Interview with the Plant Operations Director during document review indicated that no policy was available to establish responsibility for ensuring that the required testing is performed and documented.

This STANDARD is not met as evidenced by :

Based on document review and staff interview, the facility failed to ensure that HVAC systems were tested per the requirements of NFPA 90A. The findings were:

Document review and staff interview on 6/5/14 between 8:45 AM and 9:45 AM revealed that no documentation was available to indicate that fire dampers were being tested on a 4-year basis in accordance with NFPA 90A, Section 3-4.7. Interview with the Plant Operations Director at the time of document review acknowledged that testing was not being performed.

This STANDARD is not met as evidenced by :

Based on document review and staff interview, the facility failed to ensure cooking facilities were protected in accordance with NFPA 96. The findings were:

Document review and staff interview of the cooking facility testing and maintenance documentation on 6/5/14 between 8:45 AM and 9:45 AM revealed that no documentation was available to indicate semi-annual inspections of the kitchen extinguishing system. Further observation revealed that an inspection tag was affixed to the kitchen extinguishing system to indicate that the required inspection had been performed. Interview with the Plant Operations Director during document review revealed that he was not aware of the inspection requirement, and could not identify who was responsible for ensuring that the testing is performed on a semi-annual basis.

This STANDARD is not met as evidenced by :

Based on observation and staffing interview, the facility failed to ensure that electrical systems were in compliance with NFPA 70. The findings were:

Observation of the Administrative Alcove in the X-Ray Suite on 6/5/14 at 3:02 PM revealed that a receptacle was missing its cover. Interview with the Plant Operations Director at the time of the observation acknowledged the missing receptacle cover.

This STANDARD is not met as evidenced by :

Based on observation and staff interview, the facility failed to provide the required firefighter's service requirements for elevators. The findings were:

Observation and staff interview on 6/5/14 at 3:05 PM of the elevator machine room revealed a smoke detector was not installed to detect smoke for the elevator recall system in accordance with Section 2.27.3.2 of the ASME A17.1, Safety Code for Elevators and Escalators and Section 3.9.3 of the NFPA 72, National Fire Alarm Code. The Executive Assistance Acknowledge that no smoke detector was provided and the fire detector in the room was a heat detector near the sprinkler head for the elevator shut down controls without any further explanation