HospitalInspections.org

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Based on observation, the facility failed to maintain the means of egress per the requirements of:

2012 NFPA 101, 19.2.1, and 7.2.1.9.1.3

This deficiency affects 1 powered door leaf.

Findings include:

During a tour of the facility, the surveyor observed the powered door leaf, egress door between the Radiology and Surgery corridors did not have a sign on the egress side that reads: "IN EMERGENCY, PUSH TO OPEN".

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to maintain a horizontal exit per the requirements of:

2012 NFPA 101, 19.2.2.5, 7.2.4.3.1, and 8.3.5.1

This deficiency affects 1 hoizontal exit.

Findings include:

During a tour of the facility, the surveyor observed an unsealed 3" conduit used as a chase for multiple black, red, blue and gray cables in the 2-hour fire barrier above the ceiling over the fire barrier cross-corridor doors between the Radiology and Administration corridors.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to maintain a horizontal exit per the requirements of:

2012 NFPA 101, 19.2.2.5, 7.2.4.3.1, and 8.3.5.1

This deficiency affects 1 horizontal exit.

Findings include:

During a tour of the facility, the surveyor observed an unsealed 3" conduit used as a chase for multiple black, red, blue and gray cables in the 2-hour fire barrier above the ceiling over the fire barrier cross-corridor doors between the Radiology and Administration corridors.

A member of the maintenance staff was present when this deficiency was identified.

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Based on review of documentation, the facility failed to maintain the smoke detectors per the requirements of:

2012 NFPA 101, 19.3.4.1, and 9.6.1.3
2010 NFPA 72, 14.4.5.3.2

This deficiency affects entire building.

Findings include:

During a tour of the facility, the facility failed to provide a smoke detector sensitivity test report conducted within the past two years.

A member of the maintenance staff was present when this deficiency was identified.
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Based on observation, the facility failed to install a quick-response sprinkler per the requirements of:

2012 NFPA 101, 19.3.5.1, and 9.7.1.1(1)
2010 NFPA 13, 8.3.3.2, and 8.3.3.4

This deficiency affects 1 sprinkler compartment.

Findings include:

During a tour of the facility, the surveyor observed a quick-response sprinkler head installed in the same compartment (the Sitting/Waiting area outside the Chapel) with standard-response sprinkler heads.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation and review of documentation, the facility failed to maintain the automatic sprinkler system per requirements of:

2012 NFPA 101, 19.3.5.1, and 9.7.5
2011 NFPA 25, 5.3.1.1.1.3

This deficiency affects the first floor and third floor of this building.

Findings include:

During a tour of the facility, the facility failed to provide documentation that the 2004 fast-response sprinkler heads found throughout the first and third floor of this building had been replaced or a representative sample tested within 20 years of installation.

A member of the maintenance staff was present when this deficiency was identified.
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Based on observation, the facility failed to maintain a corridor door per the requirements of:

2012 NFPA 101, 19.3.6.3.13

This deficiency affects 1 of 2 Pharmacy corridor doors.

Findings include:

During a tour of the facility, the surveyor observed the Pharmacy corridor door was a "Dutch" style door with the following deficiencies:
1. The upper leaf was not equipped with a latching device
2. The meeting edges of the upper and lower leaves were not equipped with an astragal, a rabbet, or a bevel

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to maintain smoke barriers that would provide at least a half hour fire resistance rating and restrict the movement of smoke per the requirements of:

2012 NFPA 101, 19.3.7.3, 8.5.1, 8.5.6.2, and 8.5.6.3

This deficiency affects 1 of 2 smoke barriers.

Findings include:

During a tour of the facility, the surveyor observed a 3/4" unsealed conduit used as a chase with multiple blue, white and black cables above the ceiling on both sides of the smoke barrier between the Main Hospital Lobby and the Radiology corridor.

A member of the maintenance staff was present when this deficiency was identified.

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Based on review of documentation, the facility failed to conduct fire drills per the requirements of:

2012 NFPA 101, 39.7.2, 4.7.2, and 4.7.6

This deficiency affects all occupants of the facility.

Findings include:

During a review of documentation, the facility failed to provide documentation that fire drills were performed periodically, during the past year.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to prohibit a portable space heating device per the requirements of:

2012 NFPA 101, 19.7.8

This deficiency affects 1 of 5 smoke barriers.

Findings include:

During a tour of the facility, the surveyor observed a portable space heating device that was off but plugged in to a receptacle, in the Medicaid Office. The device was sitting on the carpeted floor. The portable space heating device was not located in a patient sleeping smoke compartment. The facility was unable to provide documentation that the heating element did not exceeding 212 degrees.

A member of the maintenance staff was present when this deficiency was identified.