HospitalInspections.org

The facility failed to maintain the common wall fire barrier with the non-health care occupancy.

Observation determined an electrical conduit with unsealed spaces around the outside of the conduit penetrated through the 2-hr. fire resistance rated wall separating the hospital and the clinic.

Failure to maintain the common wall fire barrier as required increases the risk of death or injury due to fire.

The deficiency affected one (1) of one (1) occupancy separation barrier in the facility.

Ref: 2012 NFPA 101 Section 19.1.3.3, 6.1.14.4.1, 8.3.3.1, 2010 NFPA 80 Section 6.1.4.3.1

The facility failed to maintain the exit corridors to be free of obstructions.

1) During its swing, any door in a means of egress shall leave not less than one-half of the required width of an aisle, corridor, passageway, or landing unobstructed and shall not project more than 7 inches into the required width of an aisle, corridor, passageway, or landing, when fully open. 7.2.1.4.3.1

Observation determined the following corridor doors opened outward into the exit corridor and extended more than 7 inches from the wall when fully opened.

a) The corridor door to the first floor Elevator Equipment Room.
b) The corridor door to the second floor Housekeeping Closet near Room 232.
c) The double set of corridor doors to the Oxygen Equipment Room on the first floor.

Failure to maintain the means of egress to be available at all times increases the risk of death or injury due to fire.

The deficiency affected four (4) of numerous corridor doors in the means of egress throughout the facility.

2) Means of egress must be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. The width of means of egress shall be measured in the clear at the narrowest point of the exit component under consideration. Exception: Projections not more than 4 1/2 in. (114 mm) on each side shall be permitted at 38 in. (965 mm) and below. 7.1.10.1, 7.3.2.2

Observation determined the water fountain in the exit corridor near the Elevator on the second floor extended approximately ten (10) inches from the corridor wall and protruded into the exit corridor.

Failure to ensure exit access is readily available at all times increases the risk of death or injury due to fire.

This deficiency affected exit access to one (1) of four (4) exits from the second floor.

3) The facility failed to inspect and test fire rated door assemblies throughout the facility.

Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage, and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening Protectives, except as otherwise specified in this code. 8.3.3.1.

Fire-rated door assemblies shall be inspected and tested in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. 7.2.1.15.2

Review of documentation and interview with staff determined fire rated door assemblies had not been inspected in the past year.

Failure to inspect and test fire rated door assemblies increases the risk of injury or death due to fire.

This deficiency affected all fire rated door assemblies throughout the facility.

Testing of required emergency lighting systems shall be permitted to be conducted as follows:

1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds.
2) The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction.
3) Functional testing shall be conducted annually for a minimum of 1½ hours if the emergency lighting system is battery powered.
4) The emergency lighting equipment shall be fully operational for the duration of the tests.
5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
7.9.3.1.1

The facility failed to ensure the emergency lighting was in proper operating condition to provide 1½ hours of emergency illumination in the event of failure of normal lighting.

Records review determined 1½ hour annual testing of the emergency battery-powered emergency lighting system was not documented.

Failure to test and maintain the emergency lights in accordance with NFPA 101 increases the risk of death or injury due to fire.

The deficiency affected all emergency battery back-up lights throughout the building.

Smoke detectors must not be located in a direct airflow nor closer than 3 ft. (1 m) from an air supply diffuser or return air opening. 19.3.4.5.1, 9.6.2.10.1.1, NFPA 72 17.7.4.1.

The facility failed to ensure the smoke detection system was in compliance with NFPA 72, National Fire Alarm and Signaling Code.

Observation determined smoke detectors throughout the facility were installed within 3 ft. of an air supply diffuser.

Failure to install the smoke detection system as required increases the risk of death or injury due to fire.

This deficiency affected numerous smoke detectors in the facility. The smoke detection system serves the entire facility.

The facility failed to install the automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems to provide adequate coverage for all portions of the building.

Observation determined:

1) Numerous ceiling tile were removed in the area under construction. The sprinklers in the area were at ceiling grid height and greater than 12 inches from the deck. The construction area was not separated from the Hospital with one-hour construction separation.

2) Numerous ceiling tile were removed in the Mechanical Room next to Radiology.

3) East Stairway #3 lacked sprinkler coverage under the lowest landing of the staircase.

Failure to install and maintain the automatic sprinkler system in accordance with NFPA 13 increases the risk of injury and death due to fire.

The deficiency affected numerous sprinklers in the facility. The automatic sprinkler system serves the entire facility.

Automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. The property owner or designated representative shall correct or repair deficiencies or impairments that are found during the inspection, test, and maintenance required by NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems. 19.7.6, 4.6.12, NFPA 25, 5.1.1.2

The facility failed to ensure the automatic sprinkler system was continuously maintained in a reliable operating condition as required by NFPA 25.

Review of documentation determined the monthly inspections of the gauges and control valves of the automatic sprinkler system were not conducted in the past year.

This deficiency affected two (2) components of numerous inspections of the automatic sprinkler system in the past year. The automatic sprinkler system serves the entire facility.

Failure to inspect and test the automatic sprinkler system in accordance with NFPA 25 increases the risk of injury or death due to fire.

Corridor doors shall not be held open by devices other than those that release when the door is pushed or pulled. 19.3.6.3.10

The facility failed to ensure there were no impediments to the closing of corridor doors.

Observation determined corridor doors throughout the facility had a kick down door stop installed on the door that required a manual releasing action to close.

Failure to ensure there were no impediments to the closing of corridor doors increases the risk of death or injury due to fire.

The deficiency affected numerous corridor doors in the facility.

Fire dampers shall be tested and inspected in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Each damper shall be tested and inspected 1 year after installation. The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years. All tests shall be completed in a safe manner by personnel wearing personal protective equipment. Full unobstructed access to the fire or combination fire/smoke damper shall be verified and corrected as required. If the damper is equipped with a fusible link, the link shall be removed for testing to ensure full closure and lock-in-place if so equipped. The operational test of the damper shall verify that there is no damper interference due to rusted, bent, misaligned, or damaged frame or blades, or defective hinges or other moving parts.The damper frame shall not be penetrated by any foreign objects that would affect fire damper operations. The damper shall not be blocked from closure in any way. The fusible link shall be reinstalled after testing is complete. If the link is damaged or painted, it shall be replaced with a link of the same size, temperature, and load rating. All inspections and testing shall be documented, indicating the location of the fire damper or combination fire/smoke damper, date of inspection, name of inspector, and deficiencies discovered. The documentation shall have a space to indicate when and how the deficiencies were corrected. All documentation shall be maintained and made available for review by the AHJ. 19.5, NFPA 80, 19.4

The facility failed to test and inspect fire dampers as required by NFPA 80.

On 03/20/2018, no record was available indicating the last inspection and testing of the fire dampers throughout the facility.

Failure to maintain fire dampers in accordance with NFPA 80 increases the risk of death or injury due to fire.

This deficiency affected the entire facility.

Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel with the signals and emergency action required under varied conditions. When drills are conducted between 9:00pm and 6:00am, a coded announcement shall be permitted to be used instead of audible alarms. Drills shall be held at expected and unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency. A written record of each drill shall be completed by the person responsible for conducting the drill and maintained in an approved manner. 19.7.1, 19.7.1.4, 19.7.1.6, 19.7.1.7, 4.7.4, 4.7.6

Fire drill records review determined:

1) The last four (4) fire drills on the first shift occurred at 11:05am, 11:00am, 2:50pm, and 2:55pm.

2) The last four (4) fire drills on the second shift occurred at 3:05pm, 3:07pm, 3:15pm. and 3:44pm.

Fire drills are required to be conducted under varied conditions. The condition of the time of the day was not varied.

Failure to conduct fire drills as required increases the risk of death or injury due to fire.

The deficiency affected eight (8) of twelve (12) drills in the past year.

Ground-fault circuit-interruption for personnel shall be provided as required. The ground-fault circuit-interrupter shall be installed in a readily accessible location. All 125-volt, single-phase, 15- and 20-ampere receptacles located in areas other than kitchens where receptacles are installed within 6 ft. of the outside edge of the sink shall have ground-fault circuit-interrupter protection for personnel. NFPA 70, 210.8, 210.8(A)(7)

The facility failed to provide electrical wiring and equipment in accordance with NFPA 70, National Electrical Code.

Observation determined the electrical receptacle in the second floor Nurses Office was installed within 6 ft. of a sink and was not ground-fault circuit-interrupter protected.

Failure to provide electrical wiring and equipment in accordance with NFPA 70 increases the risk of injury or death due to fire.

The deficiency affected one (1) of numerous receptacles in the facility.

Emergency generators and standby power systems shall be installed, tested, and maintained in accordance with NFPA 110. Critical care rooms (Category 1 Room) shall be served only by a Type I EES. General care rooms (Category 2 Room) shall be served by a Type I or Type II EES. A Type I EES serving a critical care room (Category 1 Room) shall be permitted to serve general care rooms (Category 2 Room) in the same facility. NFPA 99, 6.3.2.2.10, NFPA 110, 5.6.5.6, 5.6.5.6.1

The facility failed to ensure the emergency generator was in compliance with NFPA 99, Health Care Facilities Code and NFPA 110, Standard for Emergency and Standby Power Systems.

All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building. For systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified. The remote manual stop station shall be labeled.

Observation determined there was no remote stop switch for the emergency generator located outside of the Generator Room.

Failure to ensure the emergency generator was in compliance with NFPA 99 and NFPA 110 increases the risk of death or injury due to fire.

The deficiency affected one (1) of one (1) emergency generator which provides all emergency power to the facility.

A remote annunciator that is storage battery powered shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station. The annunciator shall be hard-wired to indicate alarm conditions of the emergency or auxiliary power source as follows:
1) Individual visual signals shall indicate the following:
a) When the emergency or auxiliary power source is operating to supply power to load
b) When the battery charger is malfunctioning
2) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
a) Low lubricating oil pressure
b) Low water temperature
c) Excessive water temperature
d) Low fuel when the main fuel storage tank contains less than a 4-hour operating supply
e) Overcrank (failed to start)
f) Overspeed
NFPA 99 6.4.1.1.17

The facility failed to ensure the emergency generator was in compliance with NFPA 99, Standard for Health Care Facilities.

Observation determined there was no remote annunciator located at a work site readily observable by personnel.

Failure to ensure the emergency generator was in compliance with NFPA 99 increases the risk of death or injury due to fire.

The deficiency affected one (1) of one (1) emergency generator which provides all emergency power to the facility.