HospitalInspections.org

Based on observations during the tour of the facility on the morning of 7/21/2011, with the Senior Administrator and Administrator and Maintenance Operator, the facility failed to provide an acceptable means to protect the corridor. The corridor door into the emergency suite, where patients would be located, did not latch when closed.

Based on observations during the tour of the facility on the morning of 7/21/2011, with the Senior Administrator and Administrator and Maintenance Operator, the facility failed to assure that the smoke barriers were constructed to resist the movement of smoke. Walls did not go from floor to deck and outside wall to outside wall. The facility shall determine the location of the smoke compartments without exceeding 22,500 square feet per smoke compartment and with no more than 30 patients per smoke compartment. Additionally the travel distance to and from any point to reach a door in the required smoke barrier shall not exceed 200 feet. All smoke compartment walls are to be constructed smoke tight. Door openings shall have 20 minute fire protection rating and self-closing or automatic-closing

Based on observations during the tour of the facility on the morning of 7/21/2011, with the Senior Administrator and Administrator and Maintenance Operator, the facility failed to maintain a rated barrier. Hot Lab ' s door and X-ray film storage ' s door were missing closures to keep the doors in a closed position.

Based on observations during the tour of the facility on the morning of 7/21/2011, with the Senior Administrator and Administrator and Maintenance Operator, the facility failed to maintain a rated barrier. The door did not latch at the door frame when closed at soiled utility across from the chapel.

Based on observations during the tour of the facility on the morning of 7/21/2011, with the Senior Administrator and Administrator and Maintenance Operator, the facility failed to assure that the egress door out of a suite was in compliance. The exit door from the emergency department suite to the egress corridor was equipped with three latching arrangements from the egress side. Door shall be operable with not more than one releasing operation.

Based on observations during the tour of the facility on the morning of 7/21/2011, with the Senior Administrator and Administrator and Maintenance Operator, the facility failed to assure correct cross labeling of the FACP and the electrical panel that provides the power for the FACP. The FACP panel and subpanels were not always labeled as to which electrical panel and breaker supplied the power for the FACP. Also the breakers shall be labeled at the panel that supplies power to the FACP. The label shall be placed immediately adjacent to the breaker and say " Fire Alarm Control Panel " and the breaker shall be colored red.

Based on observations during the tour of the facility on the morning of 7/21/2011, with the Senior Administrator and Administrator and Maintenance Operator, the facility failed to maintain continuous maintenance on the automatic sprinkler system. At the sprinkler head storage box, provide six spare sprinkler heads of each type and a sprinkler wrench which is also to be stored in the box.

Based on observations during the tour of the facility on the morning of 7/21/2011, with the Senior Administrator and Administrator and Maintenance Operator, the facility failed to provide an acceptable means to protect the means of egress. The corridor door outside the administration area had plants impeding into the egress path. Additionally the imaging department had furniture impeding into the egress path.

Based on observations during the tour of the facility on the morning of 7/21/2011, with the Senior Administrator and Administrator and Maintenance Operator, the facility failed to assure that the essential electrical system was in full compliance. A receptacle in Christy ' s office and a receptacle in South 110 and a view box in OR were supplied with power from the life safety branch of the essential electrical system and need to be moved to the either the critical or equipment branch panel. The life safety branch of the emergency system shall supply power for the following lighting, receptacles and equipment: 1. Illumination of means of egress as required in NFPA 101, Life Safety Code; 2. Exit signs and exit direction signs required in NFPA 101, Life safety Code; 3. Alarm and alerting systems including the following: a. Fire Alarms, b. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, "Gas and Vacuum Systems;" 4. (Hospital or ASC) communication systems, where used for issuing instruction during emergency conditions; 5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location; 6. Elevator ... 7. Automatically opened doors used for building egress. No functions other than those listed above in items 1 through 7 shall be connected to the life safety branch.