HospitalInspections.org

Based on record review and interview, the facility failed to have annual fire door inspections per the requirements of;

NFPA 101, 2012 Edition 19.2.2.2.1, 7.2.1.15.1
NFPA 80, 2010 Edition 4.8.5.2, 5.2.1

This deficiency affected 10 of 10 smoke compartments.

The findings include:

Record review and interview with the maintenance director and chief nursing officer, on 2/9/18 at 10:30 AM revealed the facility failed to have annual fire door inspections.

The chief nursing officer was present when the deficiency was identified and acknowledged by the administration during the exit conference on 2/9/18.

Based on testing, the facility failed to maintain hazardous area doors per the requirements of;

NFPA 101, 2012 Edition 19.3.2.1.2, 8.4.3.5, 7.2.1.8

This deficiency affected 1 of 10 smoke compartments.

The findings include:

Testing with the maintenance director and chief nursing officer, on 2/9/18 at 11:07 AM revealed the dirty utility room door in surgery failed to be self-closing all the way.

The administrative staff was present when the deficiency was identified and acknowledged by the administration during the exit conference on 2/9/18.

Based on observation, the facility failed to maintain 18" of clearance from the sprinkler heads per the requirements of;

NFPA 101, 2012 Edition 19.3.5.1, 9.7.1.1
NFPA 13, 2010 Edition 8.5.5.2.

This deficiency affected 1 of 10 smoke compartments.

The findings include:

Observation with the maintenance director and chief nursing officer, on 2/9/18 at 11:16 AM revealed 3 of 10 sprinkler heads in sterile supply do not have 18" of clearance from the storage racks.

The administrative staff was present when the deficiency was identified and acknowledged by the administration during the exit conference on 2/9/18.

Based on observation, the facility failed to provide doors in the corridor that can resist the passage of smoke per the requirements of;

NFPA 101 2012 Edition 19.3.6.5.

This deficiency affected 1 of 10 smoke compartments.

The findings include:

Observation with the maintenance director and chief nursing officer , on 2/9/18 at 12:00 PM revealed the pharmacy clean room door in the corridor has a louvered opening in it and is not capable of resisting the passage of smoke.

The administrative staff was present when the deficiency was identified and acknowledged by the administration during the exit conference on 2/9/18.

Based on observation and testing, the facility failed to maintain door openings in a 2 hour separation building separation from other occupancies per the requirements of;

NFPA 101 2012 Ed. 19.7.6, 4.6.12, 4.6.12.1
NFPA 80 2010 Ed. 6.1.4.2.1, 6.1.4.3.1

This deficiency affected 2 of 10 smoke compartments.

The findings include:

Observation on testing with the maintenance director and chief nursing officer, on 2/9/18 at 10:10 AM revealed the 90 minute fire doors located in the 2 hour separation wall for the health care facility and business occupancy where administration offices are located has 1 of 2 doors not provided with lower latching and no floor strikes are provided in the floor for positive latching. Top of the door has holes in the door frame from previous hardware that has been removed.

The administrative staff was present when the deficiency was identified and acknowledged by the administration during the exit conference on 2/9/18.

Based on observation, the facility failed to prohibit the use of portable space heaters in non-patient care areas where the heating element doesn't exceed 212 degrees Fahrenheit.

NFPA 101 2012 Edition 19.7.8

This deficiency affected 1 of 10 smoke compartments.

The findings include:

Observation with the maintenance director and chief nursing officer, on 2/9/18 at 9:43 AM revealed the x-ray work room was using a portable space heater and no documentation could be provided that the heating element does not exceed 212 degrees Fahrenheit.

The administrative staff was present when the deficiency was identified and acknowledged by the administration during the exit conference on 2/9/18.