HospitalInspections.org

Based on observations it was determined the facility failed to maintain the hazardous areas.

The findings include:

Observation on 3/1/10 at 10:30 a.m. revealed the fire door's latch located between the generator room and the air handing room was removed from the door. National Fire Protection Association (NFPA) 80, 15-1.2

This finding was acknowledged by the Administrator and verified by the Director of Plant Operations at the exit interview on 3/1/10.

Based on observations it was determined the facility failed to maintain the corridors clear and unobstructed.

The findings include:

Observation of the surgery corridor on 3/1/10 at 9:55 a.m. revealed cribs, beds and carts were stored in the corridor. Further observation of the surgery corridor at 10:26 a.m. revealed the equipment remained in the corridor for more then 30 minutes. National Fire Protection Association (NFPA) 101, 19.2.3.3

This finding was acknowledged by the Administrator and verified by the Director of Plant Operations at the exit interview on 3/1/10.

Based on observations it was determined the facility failed to maintain fire alarm system.

The findings include:

1. Observation of the cafeteria on 3/1/10 at 9:35 a.m. revealed a wall was obstructing the fire alarm's visible (strobe) device. National Fire Protection Association (NFPA) 72, 4-4.3.1

2. Observation of the pharmacy corridor on 3/1/10 at 11:10 a.m. revealed there was no audible and visible (strobe) device installed in the corridor. NFPA 101, 9.6.3.6

These findings were acknowledged by the Administrator and verified by the Director of Plant Operations at the exit interview on 3/1/10.

Based on observations and records review, it was determined the facility failed to maintain the sprinkler system.

The findings included:

1. Records review on 3/1/10 at 11:16 a.m. revealed the facility was unable to provide documentation that the sprinkler system's obstruction investigation was conducted every 5 years. The sprinkler system was installed November 2003. National Fire Protection Association (NFPA) 25, 10-2.2

2. Records review on 3/1/10 at 11:17 a.m. revealed the facility was unable to provide documentation that the sprinkler system's quarterly inspections were conducted by a certified sprinkler company. NFPA 25, 2-2.1

3. Records review on 3/1/10 at 11:18 a.m. revealed the facility was unable to provide documentation that the sprinkler system's gages test or replacement were conducted every 5 years. NFPA 25, 2-2.1

These findings were acknowledged by the Administrator and verified by the Director of Plant Operations at the exit interview on 3/1/10

Based on observations it was determined the facility failed to maintain the cooking facilities.

The findings included:

1. Observations of the kitchen on 2/21/10 at 12:39 PM, revealed the deep fat fryer was not centered under the fire extinguisher nozzle. National Fire Protection Association (NFPA) 96, 9.1

2. Observations of the kitchen on 3/1/10 at 11:38 a.m. revealed there were no
instructions for manually operating the kitchen's hood fire-extinguishing system posted conspicuously in the kitchen. Interview with kitchen staff member #1 at 11:40 a.m. revealed that staff member #1 did not know how to manually operate the kitchen's hood fire extinguishing system. The instructions shall be reviewed periodically by the employees. NFPA 96, 8-1.4

These findings were acknowledged by the Administrator and verified by the Director of Plant Operations at the exit interview on 3/1/10.

Based on observations it was determined the facility failed to post precautionary signs were oxygen was being stored.

The findings include:

Observation on 3/1/10 at 10:05 a.m. revealed oxygen was being stored in the Respiratory room with no precautionary signs posted on the door. National Fire Protection Association (NFPA) 55, 4.1.1

This finding was acknowledged by the Administrator and verified by the Director of Plant Operations at the exit interview on 3/1/10.