HospitalInspections.org

Based on observation and interview, the facility failed to ensure stairwells were maintained according to National Fire Protection Association (NFPA) standards. This deficient practice affected three (3) of nine (9) smoke compartments, patients, staff, and other occupants of the building.

The findings include:

During the Life Safety Code survey conducted on 10/07/19 at 12:40 PM with Maintenance Personnel, two tables and a chair were observed to be stored in the lower stairwell near the Mercy Conference Room. In addition, two rolling carts and an extension cord were observed to be stored in the top of the stairwell near Patient Care Room 5. Stairwells may not be used for storage spaces.

An interview with Maintenance Personnel on 10/07/19 at 1:05 PM revealed he was aware stairwells could not be used for storage spaces.

The findings were revealed to the Administrator upon exit.

Reference: NFPA 101 (2012 Edition).

7.2.2.5.3* Usable Space. Enclosed, usable spaces within exit enclosures shall be prohibited, including under stairs, unless otherwise permitted by 7.2.2.5.3.2.

7.2.2.5.3.2 Enclosed, usable space shall be permitted under stairs, provided that both of the following criteria are met:
(1) The space shall be separated from the stair enclosure by the same fire resistance as the exit enclosure.
(2) Entrance to the enclosed, usable space shall not be from within the stair enclosure. (See also 7.1.3.2.3.)

Based on observation and interview, it was determined the facility failed to ensure smoke barriers were properly maintained in accordance with NFPA standards. The deficiency had the potential to affect two (2) of nine (9) smoke compartments, patients, staff, visitors, and other occupants.

The findings include:

On 10/07/19 at 1:15 PM during the Life Safety Tour with Maintenance Personnel, an approximately one-half inch gap was observed around the main sprinkler supply line in the smoke barrier wall near the Kitchen. This opening in the smoke wall would allow for the passage of smoke and fire between smoke compartments.

Interview on 10/07/19 at 1:15 PM, with Maintenance Personnel revealed he was aware of the regulation regarding maintaining smoke barrier walls.

The findings were acknowledged by the Administrator upon exit.

Actual NFPA Standard: Reference: NFPA 101 (2012 Edition).

19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a minimum 1/2-hour fire resistance rating, unless otherwise permitted by one of the following:
(1) This requirement shall not apply where an atrium is used, and both of the following criteria also shall apply:
(a) Smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with 8.6.7(1)(c).
(b) Not less than two separate smoke compartments shall be provided on each floor.
(2) *Smoke dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air-conditioning systems where an approved, supervised automatic sprinkler system in accordance with 19.3.5.8 has been provided for smoke compartments adjacent to the smoke barrier.

Based on observation and interview it was determined the facility failed to ensure doors located in a smoke barrier would resist the passage of smoke in accordance with the National Fire Protection Association (NFPA) standards. The deficiency had the potential to affect two (2) of nine (9) smoke compartments, residents, staff, and visitors.

The findings include:

Observation during a Life Safety Tour on 10/07/19 at 1:00 PM with Maintenance Personnel revealed the cross-corridor doors located in the smoke barrier wall near the kitchen would not resist the passage of smoke due to an improperly placed magnetic lock. The magnetic lock did not allow the door to close completely, creating a gap larger than one-eighth inch. Gaps of this size allow for the passage of smoke in case of a fire.

Interview on 10/07/19 at 1:00 PM with Maintenance Personnel revealed he was not aware the cross-corridor doors were not functioning properly. Further interview with the Maintenance Personnel revealed he was aware of the requirements for doors located in a smoke barrier to resist the passage of smoke.

The findings were acknowledged by the Administrator at the exit interview.

Reference: NFPA 101 (2012 Edition).

8.3.4.1 Every opening in a fire barrier shall be protected to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other.

Reference: NFPA 80 (2011 Edition).

6.3.1.7* Clearances.
6.3.1.7.1 The clearances between the top and vertical edges of the door and the frame, and the meeting edges of doors swinging in pairs, shall be 1/8 in. ± 1/16 in. (3.18 mm ± 1.59 mm) for steel doors and shall not exceed 1/8 in. (3.18 mm) for wood doors.
6.3.1.7.2 Clearances shall be measured from the pull face of the door(s).

Based on observation and interview, the facility failed to maintain clothes dryers as required by National Fire Protection Association (NFPA) standards. This deficient practice affected residents, staff, and other occupants of the building.

The findings include:

1. Observation on 10/07/19 at 1:35 PM with Maintenance Personnel revealed the exhaust ductwork for the facility clothes dryers was assembled using screws that extended into the ductwork. The tip of the screws that extend into the ductwork could catch lint and create a potential fire hazard.

An interview with Maintenance Personnel on 10/07/19 at 1:35 PM revealed he was unaware that screws could not be used in ductwork.

2. Observation on 10/07/19 at 1:06 PM with Maintenance Personnel revealed nine (9) boxes, four (4) pieces of equipment, and combustible storage (blanket and curtain) were partially blocking access to electrical panels in the electrical room near the Benedictine Conference Room. A minimum of a 36-inch clearance is required in front of all electrical equipment, including controls and panels, extending from the floor to a height of 6 feet and 6 inches or the height of the equipment whichever is higher.

Interview with Maintenance Personnel on 10/07/19 at 1:06 PM revealed he was aware of the regulation. However, he was unaware that items had been placed near the electrical panels.

The findings were revealed to the Administrator upon exit.

Reference:

NFPA 54 (2011 Edition).

10.4.4.2 Ducts for exhausting clothes dryers shall not be assembled with screws or other fastening means that extend into the duct and that would catch lint and reduce the efficiency of the exhaust system.

NFPA 70 (2011 Edition).

110.26 Spaces About Electrical Equipment. Access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment.

Based on observation and interview, it was determined the facility failed to ensure electrical wiring was maintained in accordance with National Fire Protection Association (NFPA) standards. The deficiency had the potential to affect one (1) of nine (9) smoke compartments, residents, staff, and visitors.

The findings include:

Observation on 10/07/19 at 1:30 PM with Maintenance Personnel revealed a power strip was observed not UL1363 rated. The strip was powering an M Drive, CPAP, and COT monitor. The strip was not mounted to the wall or a cart as required when a power strip is utilized to power medical equipment in patient care areas.

Interview on 10/07/19 at 1:30 PM with Maintenance Personnel revealed he was unaware of the regulations regarding the use of power strips and power taps in patient care areas.

The findings were acknowledged by the Administrator during the exit conference.

Actual NFPA Standard:

Reference: NFPA 101 (2012 Edition).

9.1.2 Electric.
Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

Reference: NFPA 99 (2012 Edition).

3-3.2.1.2 (D) Minimum Number of Receptacles. The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

Reference: CMS S&C Letter 14-46: Categorical Waiver for Power Strips Use in Patient Care Areas

Based on observation and interview it was determined the facility failed to maintain compressed gas storage according to National Fire Protection Association (NFPA) standards. This deficient practice affected two (2) of nine (9) smoke compartments, patients, staff, and other occupants of the building.

The findings include:

During the Life Safety Code tour on 10/07/19 at 1:30 PM with Maintenance Personnel, flammable storage (cardboard boxes containing supplies, alcohol, corrosive chemicals, and other combustibles) was observed within five (5) feet of three (3) oxygen cylinder tanks located in a storage room near the Laundry. Additionally, combustible storage (cardboard boxes containing supplies) was observed within five (5) feet of three (3) oxygen cylinder tanks located in a storage room near the Time Clock. Oxygen cylinders, while in storage, must be kept five (5) feet from combustibles.

An interview with Maintenance Personnel on 10/07/19 at 1:45 PM revealed he was aware of the oxygen storage requirement.

The findings were revealed to the Administrator upon exit.

Reference: NFPA 99 (2012 Edition).

11.3.2.3 Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or materials by one of the following:
(1) Minimum distance of 6.1 m (20 ft)
(2) Minimum distance of 1.5 m (5 ft) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems
(3) Enclosed cabinet of noncombustible construction having a minimum fire protection rating of 1/2 hour