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CLAIBORNE MEMORIAL MEDICAL CENTER
Sprinkler System - Maintenance and Testing
Tag No.: K0353
Based on visual observation the facility failed to assure that the complete, supervised, automatic sprinkler system was inspected and tested in accordance with the requirements of NFPA 13. Activation of the sprinkler system shall trigger notification of the emergency to the fire alarm system within 90 seconds, which results in protection of life and property. This deficiency has the potential to affect 23 of 23 residents.
Findings:
During the facility tour, on 6/6/2018, observation revealed sprinkler system last annual inspection was 04/13/2018, this exceed the 12 month standard.
Interview with maintenance manger it was stated that the hospital is in the process of changing vendors and the new vendor have not made to do the inspection at this time.
Corridor - Doors
Tag No.: K0363
Based on visual observation the facility failed to provide corridor doors that were not closing and latching in the frame. When the doors latch a smoke resistive seal is formed to protect the rooms' occupants. The deficient practice had the potential to affect no residents.
1 Of 3 corridors had doors that were deficient.
Findings:
During the facility tour, on 6/6/2018 observation revealed a kick down door stop on the mail / copy room door in the corridor by dietary.
Interview with maintenance manger stated that this will be removed, was not aware this was not incompetence.
Subdivision of Building Spaces - Smoke Barrie
Tag No.: K0372
Based on visual observation the facility failed to assure the construction of the smoke barriers walls. The walls are required to be continuous and properly protected from penetrations and gaps. Unprotected penetrations would permit the movement of smoke from one compartment to the other in the facility. The deficient practice had the potential to affect 8 of 8 residents.
4 Of 4 smoke barriers were deficient.
Findings:
During the facility tour, on 6/6/2018 observation revealed unsealed penetration and unapproved form in barrier walls. at these locations, (1) Hallway II ICU to OR unsealed wires and unapproved form, (2) Barrier wall that separate the kitchen unsealed conduit and open whole corridor wall to dinning hall, (3) Unsealed penetration teens hall barrier wall of black wire, (4) Twenties hall have unsealed penetration and unapproved form in barrier wall.
Interview with maintenance manager stated that contractors ran wires did not sealed them all and used unapproved form in areas.