HospitalInspections.org

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to maintain the fire rated doors in accordance with the following requirements of 2000 NFPA 101, Section 19.3.2.1.


Findings include:

On facility tour between 9:15 and 1:00 PM on 04/15/2010, observation revealed, that the following was found:

1. Laundry room:
a. NW door was blocked opened by two bricks and
b. south door will not positively latch

2. Soiled utility room # 7, will not positively latch



These deficient practices were confirmed by the Facility Maintenance Director (RL) and Chief Executive Officer (TT), at the time of discovery.

This STANDARD is not met as evidenced by:

Based on documentation review, the facility failed to assure fire drills were conducted once per shift per quarter for all staff under varied conditions as required by 2000 NFPA 101, Section 19.7.1.2.

Findings include:

On facility tour between 9:15 and 1:00 PM on 04/15/2010, the review of the fire drill documentation for the past 12 months (April 2009 to March 2010) revealed, that the fire drill was missed on the 3rd quarter - 2009, day shift.


This deficient practice was confirmed by the Facility Maintenance Director (RL) at the time of discovery.

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to assure the oxygen manifold room is a 1 hour fire rate room as required by 1999 NFPA 99, Chapter 4-3.1.1.2 (2).
.

Findings include:

On facility tour between 9:15 and 1:00 PM on 04/15/2010, observation revealed and that the oxygen storage room has open penetrations in NW corner of room.


This deficient practice was confirmed by the Facility Maintenance Director (RL) and Chief Executive Officer (TT), at the time of discovery.

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to assure the pipe medical gas system is labeled and tested as required by 1999 NFPA 99.
.

Findings include:

On facility tour between 9:15 and 1:00 PM on 04/15/2010, that the following was found:

1. The review of the medical gas alarm system testing documentation revealed, that the testing of audible and visual alarm indicators have not been tested in the past 12 months as required by 1999 NFPA 99, Chapter 4-3.5.2.3 (i)

2. Observation revealed that the shut off valve by room # 146 was not labeled to reflect the rooms that are controlled by such valve as required by 1999 NFPA 99, Chapter 4-3.5.4.2


This deficient practice was confirmed by the Facility Maintenance Director (RL) and Chief Executive Officer (TT), at the time of discovery.




*TEAM COMPOSITION*
Gary Schroeder, Life Safety Code Spc.