HospitalInspections.org

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to maintain 1 hour fire rated wall construction in accordance with the following requirements of 2000 NFPA 101, Section 18.3.2.1.


Findings include:

On facility tour between 11:00 AM and 6:00 PM on 09/06 - 07/2011, observation revealed, the 3rd floor - storage room # 3-272 and 3-272A, the following was found:
a. No 45 minute doors on the north and south entrances
b. No automatic door closer



These deficient practices were confirmed by the Manager of Facilities Operations (TS) and Safety Officer (SM) at the time of discovery .

This STANDARD is not met as evidenced by:

Based on documentation review and staff interview, the facility failed to assure fire drills were conducted once per shift per quarter as required by 2000 NFPA 101, Section 18.7.1.2.


Findings include:

On facility tour between 11:00 AM and 6:00 PM on 09/06 - 07/2011, the review of the fire drill documentation for the past 12 months (September 2010 to August 2011) revealed, that the facility failed to vary time/conditions on the evening shifts - 2030, 2136, 2002 and 1930 hours.

This deficient practice was confirmed by the Manager of Facilities Operations (TS) and Safety Officer (SM) at the time of discovery .

This STANDARD is not met as evidenced by:

Based on documentation review and staff interview, the facility failed to maintain the fire alarm system in accordance with the requirements of 2000 NFPA 101, Sections 19.3.4.1 and 9.6, as well as 1999 NFPA 72, 2-3.2.1


Findings include:

On facility tour between 11:00 AM and 6:00 PM on 09/06 - 07/2011, the review of the available documentation, revealed that the annual inspection was not properly documented with the required information.


This deficient practice was confirmed by the Manager of Facilities Operations (TS) and Safety Officer (SM) at the time of discovery .

This STANDARD is not met as evidenced by:

Based on documentation review and staff interview, the facility failed to test the emergency generators in accordance with the requirements of 2000 NFPA 101 - 9.1.3 and 1999 NFPA 110 6-4.1.

Findings include:

On facility tour between 11:00 AM and 6:00 PM on 09/06 - 07/2011, documentation review of the weekly emergency generator inspection log (September 2010 to September 2011), revealed that the weekly inspection have not been done.


This deficient practice was confirmed by the Manager of Facilities Operations (TS) and Safety Officer (SM) at the time of discovery .

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to install isolated power systems per 2000 NFPA 101 -19.3.2.3, 1999 NFPA 99 3-3.2.1 and 1999 NFPA 70 - Article 517-20(a).

Findings include:

On facility tour between 11:00 AM and 6:00 PM on 09/06 - 07/2011, observation revealed that in operating room # 1, 2, 3 and 4, there was no isolated power system. The Manager of Facilities Operations (TS) and Safety Officer (SM) could not tell me if the operating rooms are considered wet or dry locations. We spoke to the director of the area and he explained to us that the four operating rooms are considered wet and they can not tolerate electrical circuit interruptions during surgeries.


This deficient practice was confirmed by the Manager of Facilities Operations (TS) and Safety Officer (SM) at the time of discovery .




*TEAM COMPOSITION*
Gary Schroeder, Life Safety Code Spc.