HospitalInspections.org

Based on observation the facility failed to provide an acceptable separation at the smoke barriers.

The inspector observed while accompanied by the Hospital Administrator and DON during the hours of the inspection from 2:00 to 4:00 PM that smoke barriers were not completely sealed at: A.) between the decking and wall above the smoke barrier doors between the Nurse Station and Receiving and B.) penetrations were not sealed at the wall between Pre-op and Surgery.

Based on observation between the hours of 2:00 PM and 4:00 PM accompanied by the Administrator and DON, it was revealed several doors to hazardous areas either did not close automatically or did not close at all. The Clean Linen and Biohazard rooms did not have automatic closures. The Storage, Soiled Linen and Clean Linen doors could not close securely.

Review of records and interview between the time of 2:00 PM and 4:00 PM revealed the firedrills are only being conducted during the first shift. The facility has two shifts, 7 AM to 7 PM and 7 PM to 7 AM. All the recorded drills were between 7 AM and 7 PM.

Based on observation, the requirement of NFPA 72, 7-3.2.1 is not met.

The Standard: Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.


Findings: Review of records by the inspector between the time of 2:00 PM and 4:00 PM revealed the date of the last sensitivity testing of the smoke alarms was indicated as unknown. No other records indicating sensitivity testing was found.

Based on observation the facility failed to meet the requirement of NFPA 99: 4-3.1.1.1.

The Standard: Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over. NFPA 99: 4-3.5.2.2 (b) 2. If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly.

Findings: Between the hours of 2:00 PM and 4:00 PM the inspector observed an unsecured oxygen tank in the medical gas storage room.

Review of records between the time of 2:00 PM and 4:00 PM revealed the required 30 minute generator test was not logged for the month of November.