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Based on observation and interview, the facility failed to maintain the battery backed-up emergency lighting units. This was evidenced by the failure of lights on an exit sign to illuminate when tested. This affected the Mobile Radiology Unit at the Main Hospital, and could result in limited visibility during an emergency.

NFPA 101 Life Safety Code, 2012 Edition
19.2.9 Emergency Lighting.
19.2.9.1 Emergency lighting shall be provided in accordance
with Section 7.9

7.9.3 Periodic Testing of Emergency Lighting Equipment.
7.9.3.1 Required emergency lighting systems shall be tested in accordance with one of the three options offered by 7.9.3.1.1, 7.9.3.1.2, or 7.9.3.1.3.
7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows:
(3) Functional testing shall be conducted annually for a minimum of 1 1/2 hours if the emergency lighting system is battery powered.
(4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1 (3).
(5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

7.9.3.1.2 Testing of required emergency lighting systems shall be permitted to be conducted as follows:
(1) Self-testing/self-diagnostic battery-operated emergency lighting equipment shall be provided.
(2) Not less than once every 30 days, self-testing/self-diagnostic battery-operated emergency lighting equipment shall automatically perform a test with a duration of a minimum of 30 seconds and a diagnostic routine.
(3) Self-testing/self-diagnostic battery-operated emergency lighting equipment shall indicate failures by a status indicator.
(4) A visual inspection shall be performed at intervals not exceeding 30 days.
(5) Functional testing shall be conducted annually for a minimum of 1 1/2 hours.
(6) Self-testing/self-diagnostic battery-operated emergency lighting equipment shall be fully operational for the duration of the 1 1/2-hour test.
(7) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

7.9.3.1.3 Testing of required emergency lighting systems shall be permitted to be conducted as follows:
(1) Computer-based, self-testing/self-diagnostic battery-operated emergency lighting equipment shall be provided.
(2) Not less than once every 30 days, emergency lighting equipment shall automatically perform a test with a duration of a minimum of 30 seconds and a diagnostic routine.
(3) The emergency lighting equipment shall automatically perform annually a test for a minimum of 1 1/2 hours.
(4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.3(2) and (3).
(5) The computer-based system shall be capable of providing a report of the history of tests and failures at all times.

Findings:

During a facility tour and interview with the Engineering Staff, the emergency lighting units were observed.

Main Hospital Radiology Unit:

On 5/30/18 at 10:15 a.m., the emergency combination lighting/exit sign located in the Mobile Radiology Unit for the Main Hospital, was observed. The dual lighting unit was battery equipped with a test button. The lights failed to illuminate when tested. Upon interview, Staff 2 confirmed the finding.

Based on observation and interview, the facility failed to maintain their hazardous areas. This was evidenced by not maintaining the minimum opening protection requirement for a hazardous area. This affected two of two floors at the Main Hospital, and could result in a delay in containing smoke and/or fire to hazardous areas.

NFPA 101, Life Safety Code, 2012 Edition.
19.3.2 Protection from Hazards.
19.3.2.1.3 The doors shall be self-closing or automatic-closing.
19.3.2.1.5 Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Rooms with soiled linen in volume exceeding 64 gal (242 L)
(6) Rooms with collected trash in volume exceeding 64 gal (242 L)
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority
having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.

Findings:

During a facility tour and interview with the Engineering Staff , the hazardous areas were observed.

Main Hospital:

1. On 5/30/18 at 9:45 a.m., the Public Safety Office was observed. The room was greater than 50 square feet in size (approximately 400 square feet), and fully sprinklered. The room contained multiple boxed storage items. The door was equipped with a self-closing device that had been disconnected. Upon interview, Staff 2 confirmed the findings.

2. On 5/31/18 at 2:15 p.m., Patient Room 215, was observed. The room was greater than 50 square feet in size (approximately 300 square feet) and fully sprinklered. The room was used for the storage of mattresses, and multiple boxed items stored on shelves. The corridor door was not equipped with a self-closing device. Upon interview, Staff 2 confirmed the findings stating that the room was a patient care room, but now used as a storage room.

Based on observation and interview, the facility failed to maintain the kitchen hood fire suppression Ansul system. This was evidenced by a dislodged sprinkler nozzle cap. This affected one of two floors at the Main Hospital, and could result in the malfunction of the kitchen hood fire suppression system,

NFPA 101. Life Safety Code, 2012 Edition
19.3.2.5 Cooking Facilities.
19.3.2.5.1 Cooking facilities shall be protected in accordance with 9.2.3
9.2.3 Commercial Cooking Equipment. Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 Edition
10.2 Types of Equipment.
10.2.1 Fire-extinguishing equipment shall include both automatic fire-extinguishing systems as primary protection and portable fire extinguishers as secondary backup.
10.2.2* A placard shall be conspicuously placed near each extinguisher that states that the fire protection system shall be activated prior to using the fire extinguisher.
10.2.2.1 The language and wording for the placard shall be approved by the authority having jurisdiction.
10.2.6 Automatic fire-extinguishing systems shall be installed in accordance with the terms of their listing, the manufacturer's instructions, and the following standards where applicable:
(1) NFPA 12
(2) NFPA 13
(3) NFPA 17
(4) NFPA 17A
NFPA 17A, Standard for Wet Chemical Extinguishing Systems, 2009 Edition.
4.3 Discharge Nozzles. (See also Section 5.5.)
4.3.1 Discharge nozzles shall be listed for their intended use.
4.3.1.1 Discharge nozzles shall be provided with an internal strainer or a separate listed strainer located immediately upstream of the nozzle.
4.3.1.2 Discharge nozzles shall be of brass, stainless steel, or other corrosion-resistant materials, or be protected inside and out against corrosion.
4.3.1.3 Discharge nozzles shall be made of noncombustible materials and shall withstand the expected fire exposure without deformation.
4.3.1.4* Discharge nozzles shall be permanently marked for identification.
4.3.1.5 All discharge nozzles shall be provided with caps or other suitable devices to prevent the entrance of grease vapors, moisture, or other foreign materials into the piping.
4.3.1.6 The protection device shall blow off, blow open, or blow out upon agent discharge.

Findings:

During a facility tour and interview with staff, the kitchen hood fire extinguishing system, was observed.

Main Hospital:

On 5/30/18 at 9:55 a.m., one of five red sprinkler nozzle caps located directly above the deep fryer was dislodged, hanging from the nozzle that it was protecting. Upon interview, Staff 2 confirmed the finding.

Based on record review and interview, the facility failed to maintain their smoke detectors in accordance with NFPA 72, 2010 Edition. This was evidenced by no documented evidence that the smoke detectors were tested for sensitivity. This could result in delayed notification of fire to the building occupants and cause injury from smoke inhalation and burns.

NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition

14.4.5.3* In other than one- and two-family dwellings, sensitivity of smoke detectors and single- and multiple-station smoke alarms shall be tested in accordance with 14.4.5.3.1 through 14.4.5.3.7.

14.4.5.3.1 Sensitivity shall be checked within 1 year after installation.

14.4.5.3.2 Sensitivity shall be checked every alternate year thereafter unless otherwise permitted by compliance with 14.4.5.3.3.

Findings:

On 5/30/18, during document review with the Director of Facilities (DOF), the fire alarm maintenance documents were reviewed.

At 2:30 p.m., there was no written evidence to show 121 smoke detectors located in the Main Building were tested for sensitivity. The DOF said they were already scheduled to be done the week of June 6, 2018.

Based on document review, the facility failed to have a written policy to protect their patients when their fire alarm system was out of service for more than 4 hours in a 24 hour period. This was evidenced by failing to provide a written policy to set a fire watch or evacuate the building and notify the authority having jurisdiction. This could result in injury to patients from fire.

Findings:

On 5/31/18, during document review, the fire watch policy was reviewed.

At 10:40 a.m., there was no written policy for the protection of their patients from fire when their fire alarm system was out of service for more than 4 hours. The Director of Facilities said they will develop a written policy for the protection of their patients during fire alarm outage.

Based on observation, document review, and interview, the facility failed to maintain the automatic fire sprinkler system. This was evidenced by the failure to perform required inspections, and by a sprinkler head with corrosion. This affected two of two floors at the Main Hospital, and could result in the malfunction of the automatic sprinkler system in the event of a fire.

NFPA 101, Life Safety Code, 2012 Edition.
19.3.5 Extinguishment Requirements.
19.3.5.3 Where required by 19.1.6, buildings containing hospitals
or limited care facilities shall be protected throughout by an
approved, supervised automatic sprinkler system in accordance
with Section 9.7, unless otherwise permitted by 19.3.5.5.

9.7 Automatic Sprinklers and Other Extinguishing Equipment.
9.7.5 Maintenance and Testing. All automatic sprinkler and
standpipe systems required by this Code shall be inspected,
tested, and maintained in accordance with NFPA 25, Standard
for the Inspection, Testing, and Maintenance of Water-Based Fire Protection
Systems.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition.

4.3 Records
4.3.1* Records shall be made for all inspections, tests, and maintenance of the system and its components and shall be made available to the authority having jurisdiction upon request.

Chapter 5 Sprinkler Systems.
5.1.1 Minimum Requirements.
5.1.1.1 This chapter shall provide the minimum requirements for the routine inspection, testing, and maintenance of sprinkler systems.
5.2.1 Sprinklers.
5.2.1.1.1 Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall).
5.2.1.1.2 Any sprinkler that shows signs of any of the following
shall be replaced:
(1) Leakage
(2) Corrosion
(3) Physical damage
(4) Loss of fluid in the glass bulb heat responsive element
(5)*Loading
(6) Painting unless painted by the sprinkler manufacturer

5.2.1.4 The supply of spare sprinklers shall be inspected annually for the following:
(1) The correct number and type of sprinklers as required by 5.4.1.4 and 5.4.1.5
(2) A sprinkler wrench for each type of sprinkler as required by 5.4.1.6
5.2.2* Pipe and Fittings. Sprinkler pipe and fittings shall be inspected annually from the floor level.
5.2.3* Hangers and Seismic Braces. Sprinkler pipe hangers and seismic braces shall be inspected annually from the floor level.

5.2.4 Gauges
5.2.4.1* Gauges on a wet pipe sprinkler shall be inspected monthly to ensure that they are in good condition and the normal water supply pressure is being maintained.

13.3.2.1.1 Valves secured with locks or supervised in accordance with applicable NFPA standards shall be permitted to be inspected monthly.
13.3.2.2* The valve inspection shall verify that the valves are in the following condition:
(1) In the normal open or closed position
(2)*Sealed, locked, or supervised
(3) Accessible
(4) Provided with correct wrenches
(5) Free from external leaks
(6) Provided with applicable identification

13.4.1.1* Alarm valves and system riser check valves shall be externally inspected monthly and shall verify the following:
(1) The gauges indicate normal supply water pressure is being maintained.
(2) The valve is free of physical damage.
(3) All valves are in the appropriate open or closed position.
(4) The retarding chamber or alarm drains are not leaking.
13.6.1.1.1 Valves secured with locks or electrically supervised in accordance with applicable NFPA standards shall be inspected monthly.

Findings:

During observation, document review and interview with staff, the automatic fire sprinkler system was observed, and maintenance records were requested.

Main Hospital:

1. On 5/30/18 at 9:55 a.m., the sprinkler head inside the Kitchen Dishwashing Room, was observed. The pendant style sprinkler was covered in a light green colored corrosion build-up. Upon interview, Staff 2 confirmed the findings.



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2. At 2:50 p.m, there was no written evidence to show the automatic sprinkler system was inspected annually. The Director of Facilities(DOF) said that they were in the process of scheduling the inspection. The last documented inspection was done in 1/6/16 by an outside contractor.

3. At 3:00 p.m., there was no documentation for the required monthly inspection of the automatic fire sprinkler system. The DOF said he will include it in their monthly preventive maintenance.

Based on document review, the facility failed to have a written policy to protect their patients when their automatic fire sprinkler system was out of service for more than 10 hours in a 24 hour period. This was evidenced by failing to provide a written policy to set a fire watch or evacuate the building and notify the authority having jurisdiction. This could result in injury to patients from fire.

Findings:

On 5/31/18, during document review, the fire watch policy was reviewed.

At 10:40 a.m., there was no written policy for the protection of their patients from fire when their automatic fire sprinkler system is out of service for more than 10 hours in a 24 hour period. The Director of Facilities said they will develop a written policy for the protection of their patients when their automatic fire sprinkler was non-operational for more than 10 hours.

Based on observation and interview, the facility failed to maintain the corridor doors. This was evidenced by corridor doors that were obstructed from fully closing and latching. This affected two of two floors at the Main Hospital, and could result in the inability to contain smoke and/or fire to a room.

Findings:

During a tour of the facility and interview with staff, the corridor doors were observed.

Main Hospital:

1. On 5/30/18 at 9:30 a.m., the corridor door to the PBX Room, was observed. The door was equipped with a self-closing device. The door was opened to the fullest extent and allowed to close. The door failed to fully close and latch. Upon interview, Staff 2 confirmed the finding.

2. On 5/31/18 at 1:45 p.m., the corridor door to Room 246, was observed. The door was obstructed from fully closing and latching by a bio-hazard container stationed in the swing path of the door. Upon interview, Staff 2 confirmed the finding.

3. On 5/31/18 at 1:50 p.m., the Second Floor corridor door to the East-Wing Nurses Locker Room, was observed. The door was equipped with a self-closing device. The door was opened to the fullest extent and allowed to close. The door failed to fully close and latch. Upon interview, Staff 3 confirmed the finding.

Based on observation and interview, the facility failed to maintain the integrity of the fire/smoke barrier walls. This was evidenced by not sealing penetrations with a fire rated material. This affected two of two floors at the Main Hospital, and could allow the spread of fire and/or smoke to other areas of the facility.

NFPA 101, Life Safety Code, 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.
8.5.6.2 Penetrations for cables, cable trays, conduits, pipes, tubes, vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a smoke barrier, or through the ceiling membrane of the roof/ceiling of a smoke barrier assembly, shall be protected by a system or material capable of restricting the transfer of smoke.
8.5.6.3 Where a smoke barrier is also constructed as a fire barrier, the penetrations shall be protected in accordance with the requirements of 8.3.5 to limit the spread of fire for a time period equal to the fire resistance rating of the assembly and 8.5.6 to restrict the transfer of smoke, unless the requirements of 8.5.6.4 are met.
8.5.6.4 Where sprinklers penetrate a single membrane of a fire resistance-rated assembly in buildings equipped throughout with an approved automatic fire sprinkler system, noncombustible escutcheon plates shall be permitted, provided that the space around each sprinkler penetration does not exceed 1/2 in. (13 mm), measured between the edge of the membrane and the sprinkler.
8.5.6.5 Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be securely set in the smoke barrier, and the space between the item and the sleeve shall be filled with a material capable of restricting the transfer of smoke.

Findings:

During a facility tour and interview with staff, the fire/smoke barrier walls were observed.

Main Hospital:

1. On 5/30/18 at 11:50 a.m., the one hour rated fire/smoke barrier wall located above the cross-corridor entry doors to the Dietary Wing, was observed. There was an approximately one half-inch unsealed penetration inside a metal conduit that had cables traveling through it. Upon interview, Staff 2 confirmed the finding after viewing the wall.

2. On 5/30/18 at 3:50 p.m., the one hour rated fire/smoke barrier wall located above the cross-corridor doors by Room 245, was observed. There was an approximately four by four inch unsealed penetration where the wall board was missing. Upon interview, Staff 3 confirmed the finding after viewing the wall.

Based on document review and interview, the facility failed to maintain their diesel powered emergency power supply system. This was evidenced by not having written documentation for the required annual fuel quality test. This could result in failure of the generator to provide emergency power to essential equipment during power outage.

NFPA 101, Life Safety Code, 2012 Edition

19.5 Building Services.
19.5.1 Utilities.

19.5.1.1 Utilities shall comply with the provisions of Section 9.1.

9.1.3.1 Emergency generators and standby power systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems.

NFPA 110, Standard for Emergency and Standby Power Systems, 2010 Edition

8.3.7.1 Maintenance of lead-acid batteries shall include the monthly testing and recording of electrolyte specific gravity. Battery conductance testing shall be permitted in lieu of the testing of specific gravity when applicable or warranted.

8.3.8 A fuel quality test shall be performed at least annually using tests approved by ASTM standards.

Findings:

On 5/30/2018, the generator maintenance documents were reviewed with the Director of Facilities (DOF).

At 3:10 p.m., there was no written evidence to show the generator diesel fuel was tested annually for fuel quality. The DOF confirmed the finding.