HospitalInspections.org

Based upon observations and staff interviews on 10/23/15 during the physical tour of the facility between 0930 and 1200 hours the facility has failed to maintain doors capable of resisting smoke. This could result in toxic products of combustion getting into the room and into the exit corridor which would endanger the residents, staff and/or visitors within the smoke compartment.

The findings include, but are not limited to:
Multiple room doors that open to the exit corridor in the Administration wing had louvers installed.

The above was discussed and acknowledged by the Maintenance Director who said he thought the door louvers would be allowed as the hospital has a zoned smoke control system.

Based upon observations and staff interviews on 10/23/15 during the physical tour of the facility between 0930 and 1200 hours the facility has failed to maintain doors to hazardous areas as self or automatic closing. This could result in the spreading of the toxic products of combustion into the corridor in the event of a fire which would endanger residents, staff and/or visitors.

The findings include, but are not limited to:
Room # 123 is over 50 square feet and being used for storage without a self-closer device on the room door to the corridor.

TCU storage room is over 50 square feet and being used for storage without a self-closer device on the room door to the corridor.

The above was discussed and acknowledged by the Maintenance Director who said he did not realize the storage room doors needed self-closers.

Based upon observations and staff interviews on 10/23/2015 during the physical tour between approximately 0930 and 1200 hours, the facility has failed to provide fire sprinkler protection to all required areas of the facility. This could result in a fire not being contained to the area of origin and could endanger residents, staff and/or visitors.

The findings include, but are not limited to:
1 out of 1 sprinkler heads in the Basement Transfer switch room is obstructed by a permanently installed electrical conduit.

The above was discussed and acknowledged by the Maintenance Director who said he had not previously observed the obstruction.

Based upon observations and staff interviews on 10/23/15 during the physical tour of the facility between approximately 0930 and 1200 hours the facility has failed to have the emergency generator meet the requirements of the Fire Safety Code. This could result in a failure to shut off the emergency generator in the event of a fire at the generator which would endanger the residents, staff and/or visitors within the facility.


The findings include, but are not limited to:
There is no remote emergency stop button installed separate of the facility's automatic generator in accordance with NFPA 110 3-5.5.6.

The above was discussed and acknowledged by the Maintenance Director who said he was unaware of the stop switch requirements.

Based upon observations and staff interviews on 10/23/15 during the physical tour of the facility between approximately 0930 and 1200 hours the facility has failed to properly maintain the Type 1 EES in the facility. This could result in electrical malfunction which could potentially endanger residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
The facility's Type I electrical system's labeled Critical Branch electrical panel CRD 208/120 indicates that the Fire Alarm system is on the critical branch circuit #17 instead of the Life Safety Branch as required by NFPA 99 3-4.2.2.2.

The above was discussed and acknowledged by the Facility Maintenance Director who said he believes that circuit was relocated to the Life Safety Branch but was unable to verify at the time of the inspection.

Based upon observations and staff interviews on 10/23/15 during the physical tour of the facility between approximately 0930 and 1200 hours the facility has failed to properly install alcohol based hand rub dispensers. Dispensers installed improperly could result in hand rub coming in contact with an electrical source resulting in a fire causing potential endanger to residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
There was an ABHR installed over a light switch in the IV Prep room.
There was an ABHR installed over an electrical outlet in the Admitting Reception desk behind the printer.

The above was discussed and acknowledged by the Maintenance Director who said he had not noticed the dispensers.

Based upon observations and staff interviews on 10/23/15 during the physical tour of the facility between 0930 and 1200 hours the facility has failed to maintain doors capable of resisting smoke. This could result in toxic products of combustion getting into the room and into the exit corridor which would endanger the residents, staff and/or visitors within the smoke compartment.

The findings include, but are not limited to:
Multiple room doors that open to the exit corridor in the Administration wing had louvers installed.

The above was discussed and acknowledged by the Maintenance Director who said he thought the door louvers would be allowed as the hospital has a zoned smoke control system.

Based upon observations and staff interviews on 10/23/15 during the physical tour of the facility between 0930 and 1200 hours the facility has failed to maintain doors to hazardous areas as self or automatic closing. This could result in the spreading of the toxic products of combustion into the corridor in the event of a fire which would endanger residents, staff and/or visitors.

The findings include, but are not limited to:
Room # 123 is over 50 square feet and being used for storage without a self-closer device on the room door to the corridor.

TCU storage room is over 50 square feet and being used for storage without a self-closer device on the room door to the corridor.

The above was discussed and acknowledged by the Maintenance Director who said he did not realize the storage room doors needed self-closers.

Based upon observations and staff interviews on 10/23/2015 during the physical tour between approximately 0930 and 1200 hours, the facility has failed to provide fire sprinkler protection to all required areas of the facility. This could result in a fire not being contained to the area of origin and could endanger residents, staff and/or visitors.

The findings include, but are not limited to:
1 out of 1 sprinkler heads in the Basement Transfer switch room is obstructed by a permanently installed electrical conduit.

The above was discussed and acknowledged by the Maintenance Director who said he had not previously observed the obstruction.

Based upon observations and staff interviews on 10/23/15 during the physical tour of the facility between approximately 0930 and 1200 hours the facility has failed to have the emergency generator meet the requirements of the Fire Safety Code. This could result in a failure to shut off the emergency generator in the event of a fire at the generator which would endanger the residents, staff and/or visitors within the facility.


The findings include, but are not limited to:
There is no remote emergency stop button installed separate of the facility's automatic generator in accordance with NFPA 110 3-5.5.6.

The above was discussed and acknowledged by the Maintenance Director who said he was unaware of the stop switch requirements.

Based upon observations and staff interviews on 10/23/15 during the physical tour of the facility between approximately 0930 and 1200 hours the facility has failed to properly maintain the Type 1 EES in the facility. This could result in electrical malfunction which could potentially endanger residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
The facility's Type I electrical system's labeled Critical Branch electrical panel CRD 208/120 indicates that the Fire Alarm system is on the critical branch circuit #17 instead of the Life Safety Branch as required by NFPA 99 3-4.2.2.2.

The above was discussed and acknowledged by the Facility Maintenance Director who said he believes that circuit was relocated to the Life Safety Branch but was unable to verify at the time of the inspection.