HospitalInspections.org

Facility failed to maintain doors to corridor in accordance with the 2000 edition of the Life Safety Code, NFPA (National Fire Protection Association) 101. Findings included the following:

Surveyor observed between 10:00 and 11: 00 am on 7/22/15 that door to Emergency Treatment Room contain door hold open device which would provide impediment to closing the door.

Facility failed to maintain doors to hazardous areas in accordance with NFPA 101. Findings included the following:

Surveyor observed between 10:00 and 11:00 am on 7/22/15 that doors to medical records and clean room did not have self closing devices as required.

Facility failed to maintain fire alarm system in accordance with the National Fire Alarm Code, NFPA 72. Findings included the following:

Surveyor observed between 10:00 and 11:00 am on 7/22/15 that power circuit for fire alarm control panel in nurses station was not identified. Fire alarm system control panels shall be permanently labeled to identify the panel and circuit breakers that supply power to them [NFPA 72, 1996: 1-5.2.8.2].

Facility failed to maintain kitchen hood protection equipment in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commerical Cooking Operations. Findings included the following:

Surveyor observed between 10:00 and 11:00 am on 7/22/15 that in the kitchen the most recent kitchen hood protection equipment inspection tag was dated September, 2012. This equipment shall be inspected semi-annually according to the type of hazard.

Facility failed to maintain disaster drills in accordance with NFPA 101 and cross-reference to NFPA 99. Findings included the following:

Surveyor observed between 10:00 and 11:00 am on 7/22/15 that facility records did not include any after-action reports of disaster drills in accordance NFPA 99, 11.5.3.9. At least one semi-annual drill shall rehearse mass casualty response for health care facilities with emergency services, disaster receiving stations or both.

Facility failed to maintain emergency generator load testing in accordance with the 1999 edition of NFPA 99, Standard for Health Care Facilities. Findings included the following:

Surveyor observed between 10:00 an 11:00 am on 7/22/15 that facility records did not include monthly load testing of generator.

Facility failed to maintain electrical panels in accordance with the National Electrical Code, NFPA 70. Findings included the following:

Surveyor observed between 10:00 and 11:00 am on 7/22/15 that in the basement, emergency electrical panels were not completely labeled. They shall be labeled "LIFE SAFETY", "CRITICAL", or "EQUIPMENT" as applicable [NFPA 70, 1996: 110-22 and 700-9(a)].