HospitalInspections.org

Based on interview, record review, and observation, the facility failed to meet the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association, specifically, to ensure 30 minute smoke barriers are maintained, door openings in smoke barriers had at least 20 minute fire protection, exit doors were functional, operating room humidity temperatures were equal to or greater than 35 percent, sprinkler heads were cleaned, and smoke detectors were at least 36 inches from sources of air ventilation.
Findings:
Please refer to 482.42 (b) (1) (2) (3); A710 - Life Safety from Fire regarding the hospital's failure to meet the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association. This has the potential to affect all patients in the facility. The patient census was 18.
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Based on interview, record review, and observations, the hospital failed to meet the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association. This has the potential to affect all patients in the facility. The patient census was 18.
Findings include:
Refer to K20 - Failed to ensure door in stairwell-a vertical opening-was functional
Refer to K22 - Failed to ensure exit directional signs were in place.
Refer to K25 - Failed to maintain 30 minute smoke barrier
Refer to K27 - Failed to ensure door opening in the smoke barriers had at least a 20 minute fire protection rating
Refer to K29 - Failed to ensure door to hazard area had a self-closure
Refer to K38 - Failed to ensure exit access doors are functional
Refer to K46 - Failed to conduct proper emergency lighting test
Refer to K61 - Failed to ensure the main water valve is supervised
Refer to K62 - Failed to ensure sprinkler heads are clean
Refer to K78 - Failed to maintain humidity in operating rooms at equal to or greater than 35 percent
Refer to K130 - Failed to ensure smoke detectors were at least 36 inches from a source of ventilation