HospitalInspections.org

Based on observation and interview, the facility had corridor doors that did not meet the requirements of NFPA 101 LSC (00) Section 19.3.6.3.2. This deficient practice could affect the safety of all patients, staff and visitors.

Findings include:

During the facility tour on 1-5-10 at 2:00PM it was observed that the latching devices on the double corridor doors into the Emergency Department were disabled causing the doors to not positively latch when closed in accordance with LSC (00), Section 19.3.6.3.2.

This deficient practice was verified by the Facilities Services Manager.

Based on observations and interview, the facility had three hazardous areas that were not properly separated in accordance with 8.4.1 and/or 19.3.5.4 when an approved automatic fire extinguishing system option is used. This deficient practice could effect all patients, staff, and visitors.

Findings include:

During the facility tour on 1-5-10, between 9:00AM and 5:00PM, based on observation, the roll down doors in the following corridor walls have fusible links that are not connected to automatic smoke detection:

1) First floor materials supply room.
2) First floor mail room.
3) First floor lab northwest.

This deficient practice was verified by the Facilities Service Manager.

1. Based on observation, a hard surface is not provided from all exits to the public way in conformance with NFPA 101-2000 Edition, Sections 7.1, 7.1.10 and 7.5.4. This deficient practice could affect all occupants including patients staff and visitors.

Findings include:

During the facility tour on 1-5-10 between approximately 1:00 and 2:00 PM, it was observed that two exits, one from the first floor exit stairwell near the Pharmacy and the other from the first floor Operating Room, do not have a hard surface path of travel to the public way. All other exits are in compliance at this time.

This deficient practice was confirmed by the Facilities Services Manager.

2. Based on observation the facility has the capability to secure all exits from the Emergency Department with electric locking devices, however the area is not in compliance with Minnesota State Fire Code(MSFC), Section 1008.1.11 (3) because the space does not have a complete automatic smoke detection system throughout.

Findings include:

During the facility tour on 1-5-10 at 3:30 PM, it was observed that the exit doors of the Emergency Department are equipped with electric locks that would permit the area to be secured to prevent un-wanted persons from both entering and exiting the area. The area is protected by a complete automatic fire sprinkler system but does not have a complete automatic smoke detection system that isinter-connected to the building fire alarm system as required by the MSFC.

This deficient practice was confirmed be the Facilities Service Manager.

Based on observation the facility has not properly maintained the complete automatic fire sprinkler system in accordance with LSC(00) Section 19.7.6, NFPA 13, and NFPA 25.9.7.5. This deficient practice could affect all occupants, including, patients, staff, and visitor.

Findings include:

During the facility tour on 1-5-10 between 9:00AM-5:00PM it was observed that fire sprinkler heads of dis-similar temperature ratings are located within the same smoke compartment in the following areas:

1). Third floor ICU nurses station.
2). Third floor lounge.
3). Third floor elevator lobby.
4). First floor PACU.

This deficient practice was confirmed by the Facilities Service Manager.

Based on observations, the facility existing emergency generator for this building,i not installed per NFPA 99 and NFPA 110. This deficient practice could affect all residents, staff and visitors in the event of a loss of power and generator failure.

Findings include:

On facility tour between on 1-5-09 at 1:30PM it was observed that the emergency generator, which was installed in 1968, does not comply with NFPA 110 (99) Section 3-4-1-15 because there are no remote monitoring signals at a location where they could be heard and observed 24 hours a day.

This deficient practice was confirmed by the Facilities Services Manager.

Based on observation and interview, the facility had corridor doors that did not meet the requirements of NFPA 101 LSC (00) Section 19.3.6.3.2. This deficient practice could affect the safety of all patients, staff and visitors.

Findings include:

During the facility tour on 1-5-10 at 2:00PM it was observed that the latching devices on the double corridor doors into the Emergency Department were disabled causing the doors to not positively latch when closed in accordance with LSC (00), Section 19.3.6.3.2.

This deficient practice was verified by the Facilities Services Manager.

Based on observations and interview, the facility had three hazardous areas that were not properly separated in accordance with 8.4.1 and/or 19.3.5.4 when an approved automatic fire extinguishing system option is used. This deficient practice could effect all patients, staff, and visitors.

Findings include:

During the facility tour on 1-5-10, between 9:00AM and 5:00PM, based on observation, the roll down doors in the following corridor walls have fusible links that are not connected to automatic smoke detection:

1) First floor materials supply room.
2) First floor mail room.
3) First floor lab northwest.

This deficient practice was verified by the Facilities Service Manager.

1. Based on observation, a hard surface is not provided from all exits to the public way in conformance with NFPA 101-2000 Edition, Sections 7.1, 7.1.10 and 7.5.4. This deficient practice could affect all occupants including patients staff and visitors.

Findings include:

During the facility tour on 1-5-10 between approximately 1:00 and 2:00 PM, it was observed that two exits, one from the first floor exit stairwell near the Pharmacy and the other from the first floor Operating Room, do not have a hard surface path of travel to the public way. All other exits are in compliance at this time.

This deficient practice was confirmed by the Facilities Services Manager.

2. Based on observation the facility has the capability to secure all exits from the Emergency Department with electric locking devices, however the area is not in compliance with Minnesota State Fire Code(MSFC), Section 1008.1.11 (3) because the space does not have a complete automatic smoke detection system throughout.

Findings include:

During the facility tour on 1-5-10 at 3:30 PM, it was observed that the exit doors of the Emergency Department are equipped with electric locks that would permit the area to be secured to prevent un-wanted persons from both entering and exiting the area. The area is protected by a complete automatic fire sprinkler system but does not have a complete automatic smoke detection system that isinter-connected to the building fire alarm system as required by the MSFC.

This deficient practice was confirmed be the Facilities Service Manager.

Based on observation the facility has not properly maintained the complete automatic fire sprinkler system in accordance with LSC(00) Section 19.7.6, NFPA 13, and NFPA 25.9.7.5. This deficient practice could affect all occupants, including, patients, staff, and visitor.

Findings include:

During the facility tour on 1-5-10 between 9:00AM-5:00PM it was observed that fire sprinkler heads of dis-similar temperature ratings are located within the same smoke compartment in the following areas:

1). Third floor ICU nurses station.
2). Third floor lounge.
3). Third floor elevator lobby.
4). First floor PACU.

This deficient practice was confirmed by the Facilities Service Manager.

Based on observations, the facility existing emergency generator for this building,i not installed per NFPA 99 and NFPA 110. This deficient practice could affect all residents, staff and visitors in the event of a loss of power and generator failure.

Findings include:

On facility tour between on 1-5-09 at 1:30PM it was observed that the emergency generator, which was installed in 1968, does not comply with NFPA 110 (99) Section 3-4-1-15 because there are no remote monitoring signals at a location where they could be heard and observed 24 hours a day.

This deficient practice was confirmed by the Facilities Services Manager.