HospitalInspections.org

Based on observation and interview with staff, the facility failed to provide a fire barrier having at least a two-hour fire resistance rating constructed of materials as required for the addition. Findings include:

The required two - hour wall separating the hospital from the nursing home doesn't meet the minimum requirements of a 2-HR UL Rating. The opposing swing doors do not latch, the duct penetrating the wall is not provided with a damper (the duct did not have a access panel to determine if a damper existed).

Based on observation and interview with staff, the facility failed to provide doors and windows to corridor openings capable of resisting the passage of smoke. Findings:

(1) The doors to the kitchen do not latch tightly in its frame.
(2) The window for pass through does not have a device to shut when not in use.

Based on observation and interview with staff, the facility failed to provide Smoke barriers that are constructed to provide at least a one half hour fire resistance rating. Findings:

The smoke barriers do not extend from floor to roof deck and from outside wall to outside wall. The attic space between the deck and the plaster ceiling is not part of the separation wall. The plaster ceiling has been penetrated by large holes created for hangers and access to space above plaster ceiling which allow for the passage of fire and smoke.

Based on observation and interview with staff, the facility failed to maintain fire alarm systems in accordance with NFPA 72 and to keep records of maintenance readily available.
Finding:

There was no documentation that the dampers connected to the fire alarm system had been tested as part of the annual inspection.

Based on observation and interview with staff, the facility failed to provide an automatic sprinkler system installed in accordance with NFPA 13 to provide complete coverage for all portions of the building. Finding:

The sprinkler head on the east side of the double pair of doors east of the nursing home was above the ceiling grid.

Based on observation and interview with staff, the facility failed to provide heating, ventilating, and air conditioning that complies with the provisions of section 9.2. Findings:
(1) The boiler equipment is not provided with emergency shut down.
(2) There is welding equipment and biomedical waste in the furnace/ boiler room.

Based on observation and interview with staff, the facility failed to maintain means of egress free of all obstructions or impediments. Finding:

Trash dolly's, trash bens, beds, etc. were stored in the corridors through out the facility.

Based on observation the facility failed to maintain a piped in medical gas system that complies with NFPA 99, Chapter 4. Findings:

(1) The normal light on the alarm panel in the recovery room was not lit.
(2) Nitrous Oxide is piped into the recovery room.

Based on observation and interview with staff, the facility failed to maintain relative humidity equal to or greater than 35% in anesthetizing locations. Findings

The humidifier was not operable and records of humidity levels are not maintained..

(1) Based on observation and interview with staff, the facility failed to maintain the Emergency Generator Location in accordance with NFPA 110 1999 edition. Findings:
(a) The emergency generator area was not clean 36 inches from the skid rails.
(b) The room is also used as a smoking area violating the requirement that no other use for the room is permitted.
(c) Storage is not permitted in this area. Duct work, couches, chairs, butt cans, etc. are stored in the room.

(2) Based on review of records, the facility failed to electrical check equipment in accordance with NFPA 99 1999 edition chapter 7. Finding:
(a) The IV Pumps located in recovery and in room 109 have not been inspected annually.

Based on observation and interview with the Director of Engineering , the facility failed to exercise the generator under load for 30 minutes per month. Finding:

The facility was running the generator weekly; however, there was no documentation that they were exercising it under load.

Based on observation and interview with staff, the facility failed to maintain Electrical wiring and equipment is in accordance with NFPA 70. Findings:

Electrical J Boxes were found to be open with wires hanging out.