HospitalInspections.org

Based on observation and document review, the provider failed to meet the minimum construction standards of the 2000 Life Safety Code (LSC). Findings include:

1. Observation on 6/3/14 revealed the building was a four story, protected, noncombustible, Type II (111) structure without a complete automatic sprinkler system. The patient rooms were not sprinklered. Review of the 2008 survey report confirmed that observation.

The building meets the FSES. Please mark an "F" in the completion date column to indicate the provider's intent to correct the deficiencies identified at K000.

Based on observation and interview, the provider failed to maintain fire protection rating in two of two exit stair enclosures. Findings include:

1. Observation at 8:45 a.m. on 6/4/14 revealed a stair enclosure near the main entrance. Further observation on the second floor of that stair enclousure revealed a 1 hour fire rated door that was held open by a magnetic hold open device and equipped with self-closing device. Testing of that door reveled that door would not latch into its frame under power of the doors self-closing device. Interview with the facility services supervisor at the time of observation confirmed that condition.

2. Observation at 9:40 a.m. on 6/4/14 revealed a stair enclosure near the back of the facility. Further observation on the first floor of that stair enclousure revealed a 1 hour fire rated door with self closing device. Testing of that door reveled that door would not latch into its frame under power of the doors self-closing device. Interview with the facility services supervisor at the time of observation confirmed that condition and indicated the air balacing in that portion of the building made it difficult for that door to operate properly.

Based on observation and interview, the provider failed to maintain proper separation of hazardous areas (laundry room). Findings include:

1. Observation at 10:30 a.m. on 6/4/14 revealed a laundry room in the ground level separated by a minimum of 1 hour fire rated construction. Further observation revealed both doors to that room were fire rated doors and equipped with self-closing hardware. Testing of those doors reveled both self-closing devices installed on those doors were incapable of closing and latching the doors into their frames. Interview with the plant operations supervisor at the time of the observations confirmed those findings.

Based on observation and interview, the provider failed to ensure the fire alarm system and its components were installed in accordance with NFPA 72, National Fire Alarm Code. Findings include:

1. Observation at 9:30 a.m. on 6/4/14 revealed a master fire alarm panel in the first floor vestibule. That fire alarm panel was indicating a trouble signal at the time of survey. Interview with the facility service supervisor at the time of observation reveled he was aware of the trouble signal. He indicated the trouble signal was from a bad backup battery in the remote alarm panel on the second floor. Further interview revealed the trouble signal was discovered by a nurse and reported to the facility maintenance supervisor. That trouble signal should have also been received at the fire alarm monitoring company. Further interview revealed that trouble signal was not received at the monitoring agency.

Based on observation and document review, the provider failed to meet the minimum construction standards of the 2000 Life Safety Code (LSC). Findings include:

1. Observation on 6/4/14 revealed the building was a four story, protected, noncombustible, Type II (111) structure without a complete automatic sprinkler system. The patient rooms were not sprinklered. Review of the 2008 survey report confirmed that observation.

The building meets the FSES. Please mark an "F" in the completion date column to indicate the provider's intent to correct the deficiencies identified at K000.

Based on record review and interview, the provider failed to ensure the automatic sprinkler system was continuously maintained in reliable operating condition and inspected and tested periodically in accordance with NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. Findings include:

1. Review of the provider's automatic sprinkler system inspection reports at 9:00 a.m. on 6/3/14 revealed no documentation for when the last 5 year internal obstruction investigation had been conducted. Interview with the plant operations supervisor at the time of the record review confirmed that condition and indicated a 5 year internal obstruction investigation was planned in the next few months.

Based on record review and interview, the provider failed to ensure the automatic sprinkler system was continuously maintained in reliable operating condition and inspected and tested periodically in accordance with NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. Findings include:

1. Review of the provider's automatic sprinkler system inspection reports revealed no documentation for when the last 5 year internal obstruction investigation had been conducted. Interview with the facility services supervisor at the time of the record review indicated he was unaware of the 5 year internal obstruction investigation testing requirements.

Based on document review and interview, the provider failed to conduct weekly inspections on the emergency generator. Findings include:

1. Review of maintenance documents revealed the generator was serviced annually by a qualified service company and exercised monthly by in-house staff. Interview with the facility service supervisor revealed no weekly maintenance and inspection was being performed for the generator. He further stated he was not aware of the generator weekly inspection requirement.