HospitalInspections.org

Based on observations, it was determined the facility failed to maintain the doors protecting the corridors.

The findings included:

1. Observation of the door from E. R. room on 08/03/2015 at 9:06 AM, revealed the door was sticking to the door frame not allowing the door to close within the door frame. National Fire Protection Association (NFPA) 80, 15-1.2 (1999 Edition)

2. Observation on 8/03/2015 at 9:05 A.M., revealed the door to chapel did not close within the door frame. NFPA 80, 15-1.2 (1999 Edition)

3. Observation on 8/03/2015 at 9:11 A.M. revealed the door to the doctor dictation room did not close and within the door frame.

4. Observation on 8/03/2015 at 9:15 A.M. revealed the door to the nurse dictation room did not close within the door frame.
5. Observation on 8/03/2015 at 9:11 A.M. revealed the door to the material manger office did not close within the door frame.
6. Observation on 8/03/2015 at 10:45 A.M. revealed the door to the conference room did not close within the door frame.

These findings were verified by the maintenance director during the survey and acknowledged by the administrator during the exit conference on 8/03/2015.

Based on observation, it was determined the facility failed to provide clear direction of egress from 1 of 2 exit paths.
NFPA 101, 7.10.8.1


The findings included:

Observation of the exit signs in the egress paths the on 08/03/2015 from 8:00 A.M. until 2:00 P.M. revealed the signs were not illuminated in these areas:

a. The exit sign by the billing office was not illuminated.
b. The exit sign outside the material office was not illuminated.
c. The exit sign by the vending machine was not illuminated.
d. The exit sign in the material office was not illuminated.

These findings were verified by the maintenance director during the survey and acknowledged by the administrator during the exit conference on 8/03/2015.

National Fire Protection Association (NFPA) 72, 1999 edition
2-3.5 Heating, Ventilating, and Air-Conditioning (HVAC).2-3.5.1*In spaces served by air-handling systems, detectors shall not be located where airflow prevents operation of the detectors.

This STANDARD is not met as evidenced by:

Based on observation, it was determined the facility has smoke detectors within 3 feet from all airflow registers.

The findings included:

1. Observation on 8/03/2015 9:25 A.M. in the triage med screening room revealed the smoke detector was located closer than 3 feet of the supply vent.
2. Observation on 8/03/2015 at 10:00 A.M. revealed the smoke detector was located closer than 3 feet of the supply vent.


These findings were verified by the maintenance supervisor and acknowledged by the administrator during the exit conference on 8/03/15.

Based on observation, it was determined the facility failed to maintain and test a complete automatic sprinkler system.

The findings included:

a. Observations during the initial tour on 8/0315 at 10:30 AM revealed 1 of 6 sprinkler heads in the conference room were not of the same type and in need of replacement.
NFPA 25, 2-2.1.1 (1999 Edition)
b. Observations during record review on 8/03/2015 at 12:55 A.M. revealed that no sprinkler report could be provided for review for the year 2014.

c. Review of the facility's sprinkler testing records on 8/03/2015 12:55 PM in the maintenance office revealed the facility failed to conduct an obstruction investigation on its sprinkler system every 5 years as required.

NFPA 25 1998 edition
10-2.2* Obstruction Prevention.
Systems shall be examined internally for obstructions where conditions exist that could cause obstructed piping. If the condition has not been corrected or the condition is one that could result in obstruction of piping despite any previous flushing procedures that have been performed, the system shall be examined internally for obstructions every 5 years. This investigation shall be accomplished by examining the interior of a dry valve or preaction valve and by removing two cross main flushing connections.






These findings were verified by the maintenance supervisor and acknowledged by the administrator during the exit conference on 8/03/15.

Based on observation the facility failed to prevent the use of unapproved space heaters.

The findings included:

a. On 8/03/2015 8:00 A.M. a space heater in the Continuous Quality and IT room did not have an automatic shut off.
b. On 8/03/2015 at 10:21 A.M. in the main office a space heater was found and did not have a automatic shut off.
c. On 8/03/2015 at 9:50 A.M. in the X Ray 2 has a space heater that goes above 212 degrees.



These findings were verified by the maintenance supervisor and acknowledged by the administrator during the exit conference on 8/03/15.

Based on observation, it was determined the facility failed to keep oxygen bottles in a secure condition and identify full and empty cylinders.

The findings included:

a. Observation of the manager office room on 8/03/2015 9:56 A.M. revealed 1 of 1 cylinder was not secured.

b. Observation of the oxygen storage building on 8/03/2015 at 10:22 A.M. revealed that full and empty cylinders were not identified.

These findings were verified by the maintenance supervisor and acknowledged by the administrator during the exit conference on 8/03/15.

Based on observation the facility failed to provide a load bank test and conduct 30 minutes monthly load test and provide a report.

The findings included:

a. On 8/03/2015 at 1:38 P.M. `during record review no documentation could be provided for the generator having a load bank test conducted.
b. On 8/03/2015 1:38 P.M. during record review no documentation could be provided for the generator being under load for 30 minutes monthly.



This finding was verified by the maintenance supervisor and acknowledged by the administrator during the exit conference on 8/03/15.

NFPA 70E, 3-1.2.3.6 & 3-10.4.7.2
Based on observation, the facility failed to maintain lighting fixtures.

The findings included:

During the initial tour of the facility on 8/03/15, observations from 8:00 AM until 2:00 PM revealed light fixtures in the following areas did not have bulb protection.
a. The ceiling mounted light fixtures in the storage room in the conference room closets did not have protective covers.
b. The ceiling mounted light fixtures in the environmental service room by room 205 did not have protective covers.
c. The ceiling mounted light fixture in the linen room by room 210 did not have a protective cover.
d. The ceiling mounted light fixture at the South exit did not have a protective cover.
e. The ceiling mounted light fixture in the back flow room did not have a protective cover.
f. The ceiling mounted light fixture in the mechanical room in the new part of the building had two set of lights that did not have protective covers.
g. The ceiling mounted light fixture in the basement over the work bench did have have protective covers.
h. The ceiling mounted light fixture in the mangers office did have have protective covers.


These findings were verified by the maintenance supervisor and acknowledged by the administrator during the exit conference on 8/0315.