HospitalInspections.org

Based on observation and interview, the hazardous areas are not maintained in accordance with NFPA 101-2000, Section 19.3.2.1. This deficient practice could affect all patients, visitors and staff.

Findings include:

During facility tour between 1:30 PM and 3:30 PM on 01/11/2010, observation revealed that:

1. The old pool locker rooms are now used for storage and the doors do not positively latch,
2. The door from the storage closet in the Case Managers office did not self-close.

These deficient practices were verified by plant operations staff (CC) at the time of the inspection.

Based on observation and interview, a hard surface is not provided from all exits to the public way in accordance with NFPA 101-2000, Sections 7.1, 7.1.10 and 7.5.4. This deficient practice could affect all patients, visitors and staff.

Findings include:

During facility tour between 1:30 PM and 3:30 PM on 01/11/2010, observation revealed that two required exterior exits located at the 1st floor cafeteria and 1st floor south back corridor do not have a hard surface of travel to the public way.

This deficient practice was verified by a facilities worker (NN) at the time of the inspection.

Based on observation and interview, smoke detectors are not located in all required areas in accordance with the 2007 Minnesota State Fire Code (MSFC), section 907.2.6.1. This could affect the staff occupying the room.

Findings include:

During facility tour between 1:30 PM and 3:30 PM on 01/11/2010, observation revealed that the doctor on-call room does not have a smoke detector.

This deficient practice was verified by plant operations staff (CC) at the time of the inspection.

Based on observation and interview, the fire sprinkler system is not installed in accordance with NFPA 13-1999, section 5-1.1 and 5-6.5.2.3. This could affect all patients, visitors and staff.

Findings include:

During facility tour between 1:30 PM and 3:30 PM on 01/11/2010, observation revealed:

1. The storage rooms in the 1st floor large conference room are not fire sprinkler protected,
2. It does not appear that the elevator pits are fire sprinkler protected.

These deficient practices were verified by plant operations staff (CC) at the time of the inspection.

Based on observation and interview, the fire sprinkler system is not maintained in accordance with NFPA 25-1999, section 2-3.2. This could affect all patients, visitors and staff.

Findings include:

During facility tour between 1:30 PM and 3:30 PM on 01/11/2010, observation revealed that the pressure gauge in the fire sprinkler system main riser has not been replaced or recalibrated within the last 5 years.

This deficient practice was verified by plant operations staff (CC) at the time of the inspection.