HospitalInspections.org

Based on observation and staff interview, the facility failed to provide two hour fire resistant construction between healthcare and a contiguous non-healthcare occupancy. This deficient practice would allow fire, smoke and gases to migrate beyond the room of fire origin. Census was 3 patients at time of survey.

Finding are:
Observation and staff interview on 8-26-2020 at 10:45 AM revealed the following:

90 minute fire rated door located between the Hospital Kitchen and the LTC Dining room (2-hour fire rated occupancy separation wall) failed to latch into the frame when closed under its own force.

During an interview on 8-26-2020 at 10:45 AM, Maintenance Staff A confirmed the door failed to latch.

Based on observation and staff interview, the facility failed to ensure all hazardous areas were separated by smoke resistant partitions. This deficient practice could cause smoke and gases to migrate into the corridor. Census was 3 patients at time of survey.

Finding are:
Observations on 8-26-2020 at 10:05 AM revealed the following:

The Dark Room located in the Imaging Clinic was being used as a storage room and no door closing device was equipped on the door.

During an interview on 8-26-2020 at 10:05 AM Maintenance Staff A confirmed that a closer was not provided on the door.

Based on observation and staff interview, the facility failed to ensure all components of the fire sprinkler system were correctly installed and maintained. This deficient practice would delay activation of the sprinkler system allowing fire, smoke and gases to spread. Census was 3 patients at time of survey.

Findings are:
Observation on 8-26-2020 at 10:25 and 10:45 AM revealed the following:

1) Excessive lint build up on the fire sprinkler located in ER room 406.
2) Fire sprinkler was missing an escutcheon in the Dining room above the soda dispenser.

During an interview on 8-26-2020 at 10:05 AM Maintenance Staff A confirmed the fire sprinkler conditions.

Based on record review and staff interview, the facility failed to ensure that fire rated doors are inspected and tested annually. This deficient practice would allow fire smoke and gases to migrate outside of the effected space. Census was 3 patients at time of survey.

Finding are:
Observation, record review and staff interview on 8-26-2020 at 9:20 AM revealed the following:

Fire rated doors were not being inspected or tested annually.

During interview on 8-26-2020 at 9:20 AM, Maintenance Staff A confirmed fire door inspections were not being performed.