HospitalInspections.org

Facility failed to maintain doors in accordance with the 2000 edition of the Life Safety Code NFPA 101. Findings inlcluded the following:

Surveyor observed between 2:00 and 2:30, on 11/01/2011 that one corridor door to Emergency Suite was chocked open at the bottom, providing an impediment to closing.

Facility failed to perform fire drills in accordance with NFPA 101, 2000 Life Safetey Code and Hospital Licensing Rules, HLR 133.141(g). Findings included the following:

Surveyor observed between 1:00 and 2:00 pm that that facility records of fire drills, were not incomplete accordance with HLR 133.141(g) which requires 12 annual fire drills, at least once per shift per quarter.

Facility failed to maintain fire extinguisher in Kitchen in accordance with NFPA 10, Standard for Portable Fire Extinguishers. Findings included the following:

Surveyor observed between 1:00 and 2:00 pm on 11/01/2011, that Class K extinguisher in kitchen was not mounted on wall and did not have placard for use. Provide a placard place conspicuously near the Class " K " fire extinguisher after June 30, 1998. Placard to read: "fire protection system shall be activated prior of using fire extinguisher" [NFPA 10: 4.3.2.2]

Facility failed to maintain HVAC in accordance with the 2000 edition of the Life Safety Code, NFPA 101. Findings included the following:

Survey observed between 1:00 and 2:00 pm on 11/01/2011 that the following conditions existed1. Storage of combustibles such as cardboard boxes in Mechanical rooms.






2. Fire Damper at HVAC penetration through Emergency Lobby Corridor did not close properly with test of fire alarm.







3. Facility did not keep records of air filter changes for central air conditioning equipment.

Facility failed to maintain kitchen cooking equipment in accordnace with NFPA 96. Findings included the following:

Surveyor observed between 2:00 and 2:30 pm on 11/01/2011 that faclity records did not contain records of inspecting and testing the fire protection system at least every 6 months by a properly and qualified persons [NFPA 96: 11.2.1.]

Faclity failed to maintain electrical system in accordance with 1999 edition of Standard for Health Care Facilities. Findings included the following:

Surveyor observed between 2:00 and 2:30 pm on 11/01/2011 that facility records did not include testing of electrical receptacles in patient care areas. Receptacles shall be tested in Patient Care areas as follows:

Physical integrity of each receptacle (visual)
Continuity of the grounding of each receptacle (test)
Correct polarity of hot and neutral connections in each receptacle (test)
The retention force of the grounding blade shal be not less than 4 ox (test)

Testing intervals:
General care areas tested annually
Critical care areas tested semi-annually
wet location tested annually.