HospitalInspections.org

Based on observation and interview with staff, the facility failed to provide self-closing doors to protect hazardous areas. Finding:

A room on the second floor, north west corner was used as a storage room with 7 wooden pallets located in the room. The room had an automatic fire suppression system, however, the door to the room did not have an automatic closer in accordance with NFPA 101, chapter 19 3.2.1.

Based on observation and interview with staff, the facility failed to maintain fire alarm inspection records, as required by NFPA 72, National Fire Alarm Code. Fire alarm systems are to be maintained in accordance with NFPA 72 and records of maintenance are to be kept readily available. 19.3.4, 9.6; Finding:

The facility did not have the most recent report of the annual Fire Alarm inspection on site.

Based on observation and interview with staff, the facility failed to provide a automatic sprinkler system properly maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. Findings:

The fire alarm system was inspected on March 3, 2011. There are three systems, two dry and one wet system. There are 8 deficiencies on the report which have not been corrected and there is no plan of correction. Two of the three systems were yellow tagged. The facility did not have the most recent report of the annual inspection on site.

Based on observation and interview with staff, the facility failed to provide a means of egress that is continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. Finding:

The Wound Care Cart was stored in the corridor adjacent to Nurses Station 1, creating impediments of the corridor.