HospitalInspections.org

Based on staff interviews and observations during the survey it was determined that the facility failed to properly maintain the fire sprinkler system. Reference NFPA 25 (1998 Edition) 5.4.1.3 "Inspection, testing and Maintenance of Water-Based Fire Protection Systems".

The findings include:

During the Life Safety tour with a designated staff representatives, it was observed that a number of brass fire department connection caps throughout the second floor "historic" portion of the facility were missing. If fire department connection caps or plugs are not in place, the interior of the connection could be obstructed and thereby rendering the unit non-operational in the event of a fire emergency.

Reference: NFPA 25 "Inspection, Testing and Maintenance of Water-Based Fire Protection Systems"12.7.1: "Fire department connections shall be inspected quarterly. The inspection shall verify the following:
(1) The fire department connections are visible and accessible.
(2) Couplings or swivels are not damaged and rotate smoothly.
(3) Plugs or caps are in place and not damaged.
(4) Gaskets are in place and in good condition.
(5) Identification signs are in place.
(6) The check valve is not leaking.
(7) The automatic drain valve is in place and operating properly.
12.7.2: If the fire department connection plugs or caps are not in place, the interior of the connection shall be inspected for obstructions, and it shall be verified that the fire department connection clapper is operational over its full range.
12.7.3: Components shall be required or replaced as necessary in accordance with the manufactures instructions. Any obstructions that are present shall be removed."

Based on observations and staff interviews conducted during the survey, it was determined that this facility did not comply with the specific requirements of NFPA 101 (2000 Edition); NFPA 70- National Electrical Code and the NFPA 99 (1999 Edition).

The findings include:

It was observed during the facility tour on January 3 and January 5 that several in-use two-to-three prong adapters and extension cords failed to meet the requirements of NFPA 70, National Electric Code and NFPA 99 (1999 Edition) Health Care Facilities. Reference: NFPA 99 (1999 Edition): 8.5.2.1.7.: " Adapters and Extension Cords:" 8.5.2.1.7.1: Adapters and extension cords meeting the requirements of 8.4.1.2.5 shall be permitted to be used. 8.5.2.1.7.2: Three- to- two prong adapters shall not be permitted. 8.5.2.1.7.3: The wiring shall be tested for all of the following: (1) Physical integrity; (2) Polarity; and (3) Continuity of grounding at the time of assembly and periodically thereafter."

Observed areas with in-use non-hospital grade multi-plugged adapters and in-use extension cord devices included: Main Lobby Holiday decorations (piggy-backed plugs); Kitchen area # 28110 (equipment plugged into non-hospital grade surge bar with additional extension surge bar double plugged); and Endo Suite First Floor break room (piggy- backed extension cord and multi-plugged adapter in use for appliances).

Based on staff interviews and observations during the survey it was determined that the facility failed to properly maintain the fire sprinkler system. Reference NFPA 25 (1998 Edition) 5.4.1.3 "Inspection, testing and Maintenance of Water-Based Fire Protection Systems".

The findings include:

During the Life Safety tour with a designated staff representatives, it was observed that a number of brass fire department connection caps throughout the second floor "historic" portion of the facility were missing. If fire department connection caps or plugs are not in place, the interior of the connection could be obstructed and thereby rendering the unit non-operational in the event of a fire emergency.

Reference: NFPA 25 "Inspection, Testing and Maintenance of Water-Based Fire Protection Systems"12.7.1: "Fire department connections shall be inspected quarterly. The inspection shall verify the following:
(1) The fire department connections are visible and accessible.
(2) Couplings or swivels are not damaged and rotate smoothly.
(3) Plugs or caps are in place and not damaged.
(4) Gaskets are in place and in good condition.
(5) Identification signs are in place.
(6) The check valve is not leaking.
(7) The automatic drain valve is in place and operating properly.
12.7.2: If the fire department connection plugs or caps are not in place, the interior of the connection shall be inspected for obstructions, and it shall be verified that the fire department connection clapper is operational over its full range.
12.7.3: Components shall be required or replaced as necessary in accordance with the manufactures instructions. Any obstructions that are present shall be removed."

Based on observations and staff interviews conducted during the survey, it was determined that this facility did not comply with the specific requirements of NFPA 101 (2000 Edition); NFPA 70- National Electrical Code and the NFPA 99 (1999 Edition).

The findings include:

It was observed during the facility tour on January 3 and January 5 that several in-use two-to-three prong adapters and extension cords failed to meet the requirements of NFPA 70, National Electric Code and NFPA 99 (1999 Edition) Health Care Facilities. Reference: NFPA 99 (1999 Edition): 8.5.2.1.7.: " Adapters and Extension Cords:" 8.5.2.1.7.1: Adapters and extension cords meeting the requirements of 8.4.1.2.5 shall be permitted to be used. 8.5.2.1.7.2: Three- to- two prong adapters shall not be permitted. 8.5.2.1.7.3: The wiring shall be tested for all of the following: (1) Physical integrity; (2) Polarity; and (3) Continuity of grounding at the time of assembly and periodically thereafter."

Observed areas with in-use non-hospital grade multi-plugged adapters and in-use extension cord devices included: Main Lobby Holiday decorations (piggy-backed plugs); Kitchen area # 28110 (equipment plugged into non-hospital grade surge bar with additional extension surge bar double plugged); and Endo Suite First Floor break room (piggy- backed extension cord and multi-plugged adapter in use for appliances).