HospitalInspections.org

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Based on observation, the facility failed to maintain an emergency release switch for the full-time magnetic locks on the Geri-psych Hall per the requirements of:

2012 NFPA 101, 19.2.2.2.5.2 (1), and 19.2.2.2.6

This deficiency affects 1 of 3 full-time magnetic locks.

Findings include:

During a tour of the facility, the surveyor observed one of the full time magnetic locked egress doors (East side/Macon Street exit) on the Geri-psych Hall failed to automatically unlock upon activation of the emergency release switch.

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 the magnetic hold open devices for two sets of cross-corridor fire doors per the requirements of:

2012 NFPA 101, 19.2.2.2.7, and 7.2.1.8.2

This deficiency affects two sets of cross-corridor fire doors.

Findings include:

During a tour of the facility, the surveyor observed (on the Back Hall between the Main Hospital Building and Geri-psych), the following magnetic hold open devices failed to release during loss of power to the fire alarm control panel:

1. The cross-corridor doors in the 2 hour-rated fire wall that separates the three story construction type from the single story construction type (between Maintenance Shop/Boiler Room)

2. The cross-corridor doors in the 2 hour-rated fire wall between Tele-Computer Room/Storage

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 set of access control doors per the requirements of:

2012 NFPA 101, 19.3.4.1, and 9.6.1.3
2010 NFPA 72, 21.9

This deficiency affects 1 set of 2 sets of access control doors.

Findings include:

During a tour of the facility, the surveyor observed the access control doors (between the Main Hospital Building and the Operating Room Suite) on the second floor failed to automatically release upon loss of power to the fire alarm system.

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 the magnetic hold open devices for a set of cross-corridor smoke doors per the requirements of:

2012 NFPA 101, 19.3.7.8, 8.5.4.4, and 7.2.1.8.2

This deficiency affects one set of cross-corridor smoke doors of one set on the third floor.

Findings include:

During a tour of the facility, the surveyor observed the magnetic hold open devices for the set of cross-corridor smoke doors on the 3rd floor between Patient Rooms 307/309 failed to release during loss of power to the fire alarm control panel.

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 provide a remote manual stop station for the emergency generator per the requirements of:

2012 NFPA 101, 19.2.9.1, and 7.9.2.4
2010 NFPA 110, 5.6.5.6, and 5.6.5.6.1

This deficiency affects one of one generator.

Findings include:

During a tour of the facility, the facility failed to provide a labeled, remote manual stop station for the 750 kW emergency generator. This was required when this generator was installed, in 1998.

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