HospitalInspections.org

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The facility failed to maintain separation of hazardous areas. Findings include: During the survey, the following are examples of what was observed:


1. Unsealed penetrations around a water line in the wall of the soiled biohazard Room 254.

2. Unsealed penetrations at the end of a sleeve in the wall of the equipment Room 249.

3. Unsealed penetrations around a group of wiring, in the wall of storage room 121.

* All were sealed during the survey by maintenance.
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NFPA 101, 19.3.2.1 Hazardous areas with sprinkler coverage shall be provided with smokeresisting partitions and doors.
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The facility failed to maintain stairways with at least 1 hour fire resistance rating.Findings Include: During the survey, the following is an example of what was observed:

Unsealed penetrations at the deck of the Stairwell, by the Pharmacy Second Floor.
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NFPA 101 2000 Edition, 18.3.1.1 Any vertical opening shall be enclosed or protected in accordance with 8.2.5.

8.2.5.4 The fire resistance rating for the enclosure of floor openings shall be not less than as follows, provide a 1-hour fire barriers.
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The facility failed to provide complete documentation for fire drills. Findings include: During the survey, the following is an example of what was observed:


Upon review of the documentation for the fire drills, the facility was not able to provide sign in sheets for staff participation.
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NFPA 101, 19.7.1.2 and 19.7.1.3 Drills shall include proper procedures, making sure all staff members participate.
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Sprinkler coverage was observed during the survey not adequately provided. Findings include: During the survey, the following is an example of what was observed:


Build up of foreign material on a sprinkler in the boiler room.

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1999 NFPA 25, 2-2.1.1 and 2-4.1.2 Sprinklers that are painted, corroded or damaged shall be replaced with new listed sprinklers of the same characteristics, including orifice size, thermal response, and water distribution.
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The facility failed to maintain separation of hazardous areas. Findings include: During the survey, the following are examples of what was observed:


1. Unsealed penetrations around a water line in the wall of the soiled biohazard Room 254.

2. Unsealed penetrations at the end of a sleeve in the wall of the equipment Room 249.

3. Unsealed penetrations around a group of wiring, in the wall of storage room 121.

* All were sealed during the survey by maintenance.
---------------------------------

NFPA 101, 19.3.2.1 Hazardous areas with sprinkler coverage shall be provided with smokeresisting partitions and doors.
.

.
The facility failed to maintain stairways with at least 1 hour fire resistance rating.Findings Include: During the survey, the following is an example of what was observed:

Unsealed penetrations at the deck of the Stairwell, by the Pharmacy Second Floor.
----------------------------------------

NFPA 101 2000 Edition, 18.3.1.1 Any vertical opening shall be enclosed or protected in accordance with 8.2.5.

8.2.5.4 The fire resistance rating for the enclosure of floor openings shall be not less than as follows, provide a 1-hour fire barriers.
.

.
The facility failed to provide complete documentation for fire drills. Findings include: During the survey, the following is an example of what was observed:


Upon review of the documentation for the fire drills, the facility was not able to provide sign in sheets for staff participation.
------------------------------------------
NFPA 101, 19.7.1.2 and 19.7.1.3 Drills shall include proper procedures, making sure all staff members participate.
.

.
Sprinkler coverage was observed during the survey not adequately provided. Findings include: During the survey, the following is an example of what was observed:


Build up of foreign material on a sprinkler in the boiler room.

------------------------------------
1999 NFPA 25, 2-2.1.1 and 2-4.1.2 Sprinklers that are painted, corroded or damaged shall be replaced with new listed sprinklers of the same characteristics, including orifice size, thermal response, and water distribution.
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