HospitalInspections.org

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Based on observation and staff interview, the facility failed to ensure that corridor doors latched properly.

Findings:

On 06/14/16 at 11:28AM, it was observed that door latching mechanisms on the doors to Patient Sleeping Rooms #105 and #127 in the Brunswick Hall Building failed to properly latch and keep the door closed when tested. This same deficiency was also observed on 06/15/16 at 9:20AM with the doors to Patient Rooms #118 and #120 in the Brunswick Hall Building.

As per an interview with Staff W (Director of Environmental Services) on 06/15/16 at 9:20AM, the staff member confirmed these findings and said he will inform the facility Administrator.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code 19.3.6.3
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Based on observation and staff interview, the facility failed to ensure that the smoke barrier wall on the Lower Level of the Brunswick Hall Building was constructed to have at least a one-half (1/2) hour fire resistance rating.

Findings:

On 06/13/16 at 12:55PM, an unsealed membrane penetration of the smoke barrier wall was observed above the fire double door on the Lower Level of the Brunswick Hall Building of the facility.

As per an interview with Staff W (Director of Environmental Services) on 06/14/16 at 12:55PM, the staff member confirmed this finding and said he will inform the facility Administrator.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code 19.3.7.3, 19.3.7.3, 8.3
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Based on observation and staff interview, the facility failed to ensure that hazardous areas were protected in accordance to NFPA 101-2000 Life Safety Code. Specifically, doors to Hazardous Storage Rooms lacked required self-closing or automatically closing devices to help prevent the spread of smoke and other products of combustion from the Storage Rooms.

Findings:

On 06/14/16 at 10:01AM, it was observed that Nursing Department Storage Room #252 in the Brunswick Hall Building lacked a required self-closing device on the door.

On 06/14/16 at 11:09AM, it was observed that the Admitting Unit Storage Room on the Ground Floor of the Brunswick Hall Building lacked a required self-closing device on the door.

As per interview with Staff W (Director of Environmental Services) on 06/14/16 at 11:09AM, the staff member confirmed these findings and said he will inform the facility Administrator.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code 19.3.2.1
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Based on observation and staff interview, the facility failed to ensure that the automatic sprinkler system was maintained in reliable operating condition and was inspected and tested periodically.

Findings:

On 06/14/16 at 2:00PM, it was observed that a sprinkler escutcheon cover plate was missing from a concealed sprinkler head in the closet of Room #201 in the Carlin Building of the facility.

On 06/14/16 at 2:45PM, it was observed that a sprinkler escutcheon cover plate was missing from a concealed sprinkler head in the closet of Room #105 in the Carlin Building of the facility.

As per interviews with Staff W (Director of Environmental Services) on 06/14/16 at 2:00PM and 06/14/16 at 2:45PM, the staff member confirmed these findings and said he will inform the facility Administrator.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code 19.7.6, 4.6.12, NFPA 13, NFPA 25

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Based on observations, record review and staff interview, the facility failed to ensure that electrical equipment was used in accordance with its listing.

Findings:

On 06/14/16 at 11:10AM, two (2) relocatable power taps were observed on the Admitting Unit of the Brunswick Hall Building to be improperly serially connected to each other. Relocatable power taps must be used in accordance with their listing which would require that they only be connected directly to a permanent receptacle (e.g., a wall mounted duplex receptacle) and not to another relocatable power tap.

As per concurrent interview with Staff W (Director of Environmental Services) on 06/14/16 at 11:10AM, as well subsequent review of the facility Policy and Procedure on the use of extension cords (dated 02/2016) with Staff W on 06/15/16 at 10:30AM, the staff member confirmed this finding and said he will inform the facility Administrator.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: 110-3

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Based on observation and staff interview, the facility failed to ensure that corridor doors latched properly.

Findings:

On 06/14/16 at 11:28AM, it was observed that door latching mechanisms on the doors to Patient Sleeping Rooms #105 and #127 in the Brunswick Hall Building failed to properly latch and keep the door closed when tested. This same deficiency was also observed on 06/15/16 at 9:20AM with the doors to Patient Rooms #118 and #120 in the Brunswick Hall Building.

As per an interview with Staff W (Director of Environmental Services) on 06/15/16 at 9:20AM, the staff member confirmed these findings and said he will inform the facility Administrator.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code 19.3.6.3
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Based on observation and staff interview, the facility failed to ensure that the smoke barrier wall on the Lower Level of the Brunswick Hall Building was constructed to have at least a one-half (1/2) hour fire resistance rating.

Findings:

On 06/13/16 at 12:55PM, an unsealed membrane penetration of the smoke barrier wall was observed above the fire double door on the Lower Level of the Brunswick Hall Building of the facility.

As per an interview with Staff W (Director of Environmental Services) on 06/14/16 at 12:55PM, the staff member confirmed this finding and said he will inform the facility Administrator.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code 19.3.7.3, 19.3.7.3, 8.3
.

.
Based on observation and staff interview, the facility failed to ensure that hazardous areas were protected in accordance to NFPA 101-2000 Life Safety Code. Specifically, doors to Hazardous Storage Rooms lacked required self-closing or automatically closing devices to help prevent the spread of smoke and other products of combustion from the Storage Rooms.

Findings:

On 06/14/16 at 10:01AM, it was observed that Nursing Department Storage Room #252 in the Brunswick Hall Building lacked a required self-closing device on the door.

On 06/14/16 at 11:09AM, it was observed that the Admitting Unit Storage Room on the Ground Floor of the Brunswick Hall Building lacked a required self-closing device on the door.

As per interview with Staff W (Director of Environmental Services) on 06/14/16 at 11:09AM, the staff member confirmed these findings and said he will inform the facility Administrator.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code 19.3.2.1
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Based on observation and staff interview, the facility failed to ensure that the automatic sprinkler system was maintained in reliable operating condition and was inspected and tested periodically.

Findings:

On 06/14/16 at 2:00PM, it was observed that a sprinkler escutcheon cover plate was missing from a concealed sprinkler head in the closet of Room #201 in the Carlin Building of the facility.

On 06/14/16 at 2:45PM, it was observed that a sprinkler escutcheon cover plate was missing from a concealed sprinkler head in the closet of Room #105 in the Carlin Building of the facility.

As per interviews with Staff W (Director of Environmental Services) on 06/14/16 at 2:00PM and 06/14/16 at 2:45PM, the staff member confirmed these findings and said he will inform the facility Administrator.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code 19.7.6, 4.6.12, NFPA 13, NFPA 25

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Based on observations, record review and staff interview, the facility failed to ensure that electrical equipment was used in accordance with its listing.

Findings:

On 06/14/16 at 11:10AM, two (2) relocatable power taps were observed on the Admitting Unit of the Brunswick Hall Building to be improperly serially connected to each other. Relocatable power taps must be used in accordance with their listing which would require that they only be connected directly to a permanent receptacle (e.g., a wall mounted duplex receptacle) and not to another relocatable power tap.

As per concurrent interview with Staff W (Director of Environmental Services) on 06/14/16 at 11:10AM, as well subsequent review of the facility Policy and Procedure on the use of extension cords (dated 02/2016) with Staff W on 06/15/16 at 10:30AM, the staff member confirmed this finding and said he will inform the facility Administrator.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: 110-3