HospitalInspections.org

Based on observation and staff interview the facility failed to ensure corridor door walls were continuous from floor to ceiling on 3 of 3 floors. The findings were:

1. Observation of the building structure on 6/14/10 between 3 PM and 5 PM showed the corridor wall near the laboratory and near the operating room recovery area were not continuous from floor to ceiling above. Each location above had wall penetrations or portions of the walls were noted to have been removed above the ceiling tiles. The smoke compartments where these walls were located only had a partial sprinkler system. At 3:51 PM the director of plant operations reported he was not aware the corridor walls were required to be smoke resistant from floor to ceiling if the facility only had partial sprinkler coverage.

2. Observation of the sprinkler system on 6/14/10 between 3 PM and 5 PM showed the standard sidewall sprinklers installed in the business office were located more than 14 feet from the back wall. The sprinkler were actually installed 16 feet from the back wall. Further review showed the operating room suite did not have any sprinkler coverage.

Based on observation and staff interview the facility failed to ensure corridor doors were smoke resistant in 1 of 12 smoke compartments. The findings were:

Observation on 6/14/10 at 12:41 PM showed the corridor door for the kitchen condensers was not smoke resistant. The door was equipped with an 18 inch square vent. At the time of observation the director of plant operations reported he was aware of the smoke resistant requirement. He could not explain why the door had not been noticed and replaced.

Based on observation and staff interview the facility failed to ensure 1 of 8 smoke barriers was smoke resistant. The findings were:

Observation of the first floor east smoke barrier on 6/14/10 at 1:56 PM showed the one of two first floor double corridor doors did not latch, with three attempts. At the time of observation the director of plant operations reported the barrier doors were inspected each month. He could not explain why the door was not able to latch.

Based on observation and staff interview the facility failed to ensure hazardous areas were separated from use areas in 1 of 12 smoke compartments. The findings were:

Observation of the second floor mechanical room on 6/14/10 at 2:27 PM showed two unsealed pipe penetrations. The largest hole was 3 by 4 inches wide. At the time of observation the director of plant operations reported he was aware that walls to hazardous areas were required to be sealed. He could not explain why the holes had not been noticed and repaired.

Based on record review and staff interview the facility failed to ensure a fire drill was conducted on each shift during 1 of the past 4 quarters. The findings were:

Review of the fire drill records showed a drill had not been conducted on the second shift during the fourth quarter of 2009. On 6/14/10 at 5:30 PM the director of plant operations reported he was aware of the above mentioned requirement. He further reported the drill was missed because an in-service was held during November 2009 for all nursing staff.

Based on record review, observation and staff interview the facility failed to ensure the fire alarm receiving equipment was tested on 1 of the past 12 months and failed to ensure the system would reactivate with multiple activations. The findings were:

1. Review of the fire alarm system testing records showed the receiving equipment had not been tested during November 2009. On 6/14/10 at 5:30 PM the director of plant operations reported the system was not activated because a fire drill was not held during November 2009 because a nursing in-service was held.

2. Observation of the fire drill held on 6/14/10 at 6:10 PM showed the fire alarm system was activated on the third floor during the drill. The system was silenced after the drill and another pull station was activated on the second floor. The smoke barrier doors in the area closed, but the alarm horns and strobes did not reactivate. The main fire alarm panel did not show the pull station had been activated. After four minutes the system was cleared and immediately the horns and strobes reactivated. The sytem was cleared again and the sytem indicated "normal." At the time of observation the director of plant operations was aware the system was required to respond to multiple inputs. He could not explain why the system did not respond appropriately. He also reported the system was replaced in August 2009.

Based on observation and staff interview the facility failed to ensure 2 of 2 wet agent fire extinguishers where hydrostatically tested. The findings were:

Observation on 6/14/10 at 3:32 PM showed the wet agent fire extinguisher in the surgery suite was manufactured in 2004. The extinguisher had not received a five year hydrostatic test in 2009. At the time of observation the director of plant operations reported he was not aware of the above mentioned requirement. He further reported that the facility relied upon the testing company to test the extinguisher within the require time frames. Further review showed the surgery suite was equipped with two wet agent extinguishers and both were manufactured in 2004 and over due for the hydrostatic test

Based on observation and staff interview the facility failed to ensure curtains were flame retardant in 1 of 12 smoke compartments. The findings were:

Observation of the classroom on 6/14/10 at 11:45 AM showed the window curtain did not have flame retardant documentation attached to the curtain. At the time of observation the director of plant operations reported the flame retardant documentation was kept by the material management staff. Further review showed the facility did not have flame retardant documentation for the noted curtain.

Based on observation and staff interview the facility failed to ensure electrical outlets in wet locations had ground fault circuit interrupter (GFCI) protection and failed to ensure damaged electrical face plates were replaced in 4 of 12 smoke compartments. The findings were:

1. Observation of the electrical system between 12 PM and 4 PM showed the electrical outlets in the first floor west women's restroom, patient room #200, and the four plex at the surgery suite nurses' station were located within 6 feet of a water source. Further review showed the above mentioned outlets did not have GFCI protection. At 12:25 PM the director of plant operations reported he was aware of the above mentioned requirement. He could not explain why the outlets had not been noticed during the monthly rounds and replaced.

2. Observation of the electrical system on 6/14/10 at 1:47 PM showed the electrical outlet face plate in the radiology film viewing area was missing. At the time of observation the director of plant operations could not explain why the missing face plate had not been noticed during monthly rounds and replaced.

Based on observation and staff interview the facility failed to ensure corridor door walls were continuous from floor to ceiling on 3 of 3 floors. The findings were:

1. Observation of the building structure on 6/14/10 between 3 PM and 5 PM showed the corridor wall near the laboratory and near the operating room recovery area were not continuous from floor to ceiling above. Each location above had wall penetrations or portions of the walls were noted to have been removed above the ceiling tiles. The smoke compartments where these walls were located only had a partial sprinkler system. At 3:51 PM the director of plant operations reported he was not aware the corridor walls were required to be smoke resistant from floor to ceiling if the facility only had partial sprinkler coverage.

2. Observation of the sprinkler system on 6/14/10 between 3 PM and 5 PM showed the standard sidewall sprinklers installed in the business office were located more than 14 feet from the back wall. The sprinkler were actually installed 16 feet from the back wall. Further review showed the operating room suite did not have any sprinkler coverage.

Based on observation and staff interview the facility failed to ensure corridor doors were smoke resistant in 1 of 12 smoke compartments. The findings were:

Observation on 6/14/10 at 12:41 PM showed the corridor door for the kitchen condensers was not smoke resistant. The door was equipped with an 18 inch square vent. At the time of observation the director of plant operations reported he was aware of the smoke resistant requirement. He could not explain why the door had not been noticed and replaced.

Based on observation and staff interview the facility failed to ensure 1 of 8 smoke barriers was smoke resistant. The findings were:

Observation of the first floor east smoke barrier on 6/14/10 at 1:56 PM showed the one of two first floor double corridor doors did not latch, with three attempts. At the time of observation the director of plant operations reported the barrier doors were inspected each month. He could not explain why the door was not able to latch.

Based on observation and staff interview the facility failed to ensure hazardous areas were separated from use areas in 1 of 12 smoke compartments. The findings were:

Observation of the second floor mechanical room on 6/14/10 at 2:27 PM showed two unsealed pipe penetrations. The largest hole was 3 by 4 inches wide. At the time of observation the director of plant operations reported he was aware that walls to hazardous areas were required to be sealed. He could not explain why the holes had not been noticed and repaired.

Based on record review and staff interview the facility failed to ensure a fire drill was conducted on each shift during 1 of the past 4 quarters. The findings were:

Review of the fire drill records showed a drill had not been conducted on the second shift during the fourth quarter of 2009. On 6/14/10 at 5:30 PM the director of plant operations reported he was aware of the above mentioned requirement. He further reported the drill was missed because an in-service was held during November 2009 for all nursing staff.

Based on record review, observation and staff interview the facility failed to ensure the fire alarm receiving equipment was tested on 1 of the past 12 months and failed to ensure the system would reactivate with multiple activations. The findings were:

1. Review of the fire alarm system testing records showed the receiving equipment had not been tested during November 2009. On 6/14/10 at 5:30 PM the director of plant operations reported the system was not activated because a fire drill was not held during November 2009 because a nursing in-service was held.

2. Observation of the fire drill held on 6/14/10 at 6:10 PM showed the fire alarm system was activated on the third floor during the drill. The system was silenced after the drill and another pull station was activated on the second floor. The smoke barrier doors in the area closed, but the alarm horns and strobes did not reactivate. The main fire alarm panel did not show the pull station had been activated. After four minutes the system was cleared and immediately the horns and strobes reactivated. The sytem was cleared again and the sytem indicated "normal." At the time of observation the director of plant operations was aware the system was required to respond to multiple inputs. He could not explain why the system did not respond appropriately. He also reported the system was replaced in August 2009.

Based on observation and staff interview the facility failed to ensure 2 of 2 wet agent fire extinguishers where hydrostatically tested. The findings were:

Observation on 6/14/10 at 3:32 PM showed the wet agent fire extinguisher in the surgery suite was manufactured in 2004. The extinguisher had not received a five year hydrostatic test in 2009. At the time of observation the director of plant operations reported he was not aware of the above mentioned requirement. He further reported that the facility relied upon the testing company to test the extinguisher within the require time frames. Further review showed the surgery suite was equipped with two wet agent extinguishers and both were manufactured in 2004 and over due for the hydrostatic test

Based on observation and staff interview the facility failed to ensure curtains were flame retardant in 1 of 12 smoke compartments. The findings were:

Observation of the classroom on 6/14/10 at 11:45 AM showed the window curtain did not have flame retardant documentation attached to the curtain. At the time of observation the director of plant operations reported the flame retardant documentation was kept by the material management staff. Further review showed the facility did not have flame retardant documentation for the noted curtain.

Based on observation and staff interview the facility failed to ensure electrical outlets in wet locations had ground fault circuit interrupter (GFCI) protection and failed to ensure damaged electrical face plates were replaced in 4 of 12 smoke compartments. The findings were:

1. Observation of the electrical system between 12 PM and 4 PM showed the electrical outlets in the first floor west women's restroom, patient room #200, and the four plex at the surgery suite nurses' station were located within 6 feet of a water source. Further review showed the above mentioned outlets did not have GFCI protection. At 12:25 PM the director of plant operations reported he was aware of the above mentioned requirement. He could not explain why the outlets had not been noticed during the monthly rounds and replaced.

2. Observation of the electrical system on 6/14/10 at 1:47 PM showed the electrical outlet face plate in the radiology film viewing area was missing. At the time of observation the director of plant operations could not explain why the missing face plate had not been noticed during monthly rounds and replaced.