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NFPA (National Fire Protection Association) 101 - Life Safety Code 2000 edition.
Chapter 19 - Existing Health Care Occupancies
19.3 Protection
19.3.6 Corridors.
19.3.6.1
Corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5.
19.3.6.2.2*
Corridor walls shall form a barrier to limit the transfer of smoke.

This standard is not met as evidenced by:

Based on observation it was determined the hospital failed to maintain all corridor walls to resist the passage of smoke.

Findings include:

1. On 10/31/11 at approximately 2:30 p.m. an inspection of the 2nd floor corridor was conducted. At this time, an opening approximately eight (8) inches by forty-two (42) inches was observed in the drywall construction at the top of the corridor door for an equipment storage room.

Based on random observation it was determined the hospital failed to maintain all corridor doors to close and latch without impediment.

Findings include:

1. During tour of the hospital on 10/31/11 at approximately 2:15 p.m., an equipment storage room corridor door on the 2nd floor was observed to be hitting the door frame and would not close to latch.

Based on review of facility documentation it was determined the hospital failed to inspect, test and maintain all components of the hospital fire alarm system annually and in accordance with NFPA (National Fire Protection Association) 72.

Findings include:

1. On 10/31/11 at approximately 2:00 p.m., the hospital annual fire alarm inspection reports for the previous twelve (12) month period were reviewed. One (1) report dated 06/17/11 and prepared by Simplex Grinnell Company indicated that two (2) heat detectors located in the mechanical room were not tested due to a lack of access.

At the time of this survey, there was no documented evidence available to indicate that the devices had been inspected and tested as of this date 11/01/11.

This practice does not meet the requirement of annually (twelve (12) month interval) inspecting, testing and maintaining all components of the hospital fire alarm system.

NFPA (National Fire Protection Association) 13 Standard for Installation of Sprinkler Systems
5-6.6* Clearance to Storage (Standard Pendent and Upright Spray Sprinklers).
The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.

NFPA 25 - Standard for the Inspection, Testing, and Maintenance of Water-based Protection Systems
2-2 Inspection.
2-2.1 Sprinklers.
2-2.1.1*
Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

This Standard is not met as evidenced by:

Based on observation it was determined the hospital failed to maintain all portions of the automatic sprinkler system in reliable operating condition and in accordance with NFPA 13 and 25.

Findings include:

1. On 11/01/11 at approximately 1:30 p.m., the walk-in freezer located in the kitchen was observed to have food storage within approximately six (6) inches of the sprinkler head.

2. During tour of the kitchen walk-in cooler on 11/01/11 at approximately 1:30 p.m., one (1) of one (1) sprinkler heads in this area was observed to have an accumulation of dust and corroded.

Based on review of facility documentation it was determined the hospital failed to maintain the medical gas system in accordance with NFPA (National Fire Protection Association) 99, Chapter 4.

Findings include:

1. On 10/31/11 at approximately 11:00 a.m., a medical gas system inspection report prepared by Environmental Monitoring Technology and dated 08/22/11 was reviewed. This report indicated the following deficiencies were found during the medical gas inspection:

a. The bulk oxygen system must have a local signal.
b. There is not an emergency oxygen supply connection on the exterior of the buildings served.
c. One or more buildings can not keep oxygen supply if main oxygen pad lines are damaged.
d. A demand check valve is not installed on the oxygen main gauge and pressure sensor.
e. A lag alarm is not installed on the vacuum system.
f. There is not a pressure relief valve (50% above normal line pressure) installed before the header valve on the reserve oxygen supply.
g. There is not a pressure indicator for the reserve oxygen supply header contents.
h. There are no alarms in the critical care areas-ER or OR. Required alarms: High and low oxygen line pressure, low vacuum.

At the time of this survey, there was no documented evidence to indicate the aforementioned deficiencies have been corrected.

Based on random observation it was determined the hospital failed to maintain all electrical wiring in accordance with NFPA (National Fire Protection Association) 70 by using relocatable power taps and extension cords in patient care areas.

Findings include:

1. On 11/01/11 at approximately 10:00 a.m., three (3) electrical power strips (relocatable power taps) were observed to be in use in the following areas:

a. Operating area recovery room.
b. Operating rooms #1 and #2.

Also, at this same time two (2) extension cords were observed in use in operating room #2.

Reference:

Underwriters Laboratories (UL) Directory Guide: Relocatable Power Taps Use and Installation
Relocatable power taps have not been investigated and are not intended for use with general patient care areas or critical patient care areas of health care facilities as defined in Article 517 of ANSI/NFPA 70, "National Electrical Code".

NFPA 70 National Electrical Code- 2002 Edition Article 517 Health Care Facilities
517.2 Definitions

Health Care Facilities. Buildings or portions of buildings that contain, but are not limited to, occupancies such as hospitals; nursing homes; limited care; supervisory care; clinics; medical and dental offices; and ambulatory care, whether permanent or movable.

Patient Care Area: Any portion of a health care facility wherein patients are intended to be examined or treated. Areas of a health care facility in which patient care is administered are classified as general care areas or critical care areas, either of which may be classified as a wet location. The governing body of the facility designates these areas in accordance with the type of patient care anticipated and with the following definitions of the area classification. FPN: Business offices, corridors, lounges, day rooms, dining rooms, or similar areas typically are not classified as patient care areas.

NFPA (National Fire Protection Association) 101 - Life Safety Code 2000 edition.
Chapter 19 - Existing Health Care Occupancies
19.3 Protection
19.3.6 Corridors.
19.3.6.1
Corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5.
19.3.6.2.2*
Corridor walls shall form a barrier to limit the transfer of smoke.

This standard is not met as evidenced by:

Based on observation it was determined the hospital failed to maintain all corridor walls to resist the passage of smoke.

Findings include:

1. On 10/31/11 at approximately 2:30 p.m. an inspection of the 2nd floor corridor was conducted. At this time, an opening approximately eight (8) inches by forty-two (42) inches was observed in the drywall construction at the top of the corridor door for an equipment storage room.

Based on random observation it was determined the hospital failed to maintain all corridor doors to close and latch without impediment.

Findings include:

1. During tour of the hospital on 10/31/11 at approximately 2:15 p.m., an equipment storage room corridor door on the 2nd floor was observed to be hitting the door frame and would not close to latch.

Based on review of facility documentation it was determined the hospital failed to inspect, test and maintain all components of the hospital fire alarm system annually and in accordance with NFPA (National Fire Protection Association) 72.

Findings include:

1. On 10/31/11 at approximately 2:00 p.m., the hospital annual fire alarm inspection reports for the previous twelve (12) month period were reviewed. One (1) report dated 06/17/11 and prepared by Simplex Grinnell Company indicated that two (2) heat detectors located in the mechanical room were not tested due to a lack of access.

At the time of this survey, there was no documented evidence available to indicate that the devices had been inspected and tested as of this date 11/01/11.

This practice does not meet the requirement of annually (twelve (12) month interval) inspecting, testing and maintaining all components of the hospital fire alarm system.

NFPA (National Fire Protection Association) 13 Standard for Installation of Sprinkler Systems
5-6.6* Clearance to Storage (Standard Pendent and Upright Spray Sprinklers).
The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.

NFPA 25 - Standard for the Inspection, Testing, and Maintenance of Water-based Protection Systems
2-2 Inspection.
2-2.1 Sprinklers.
2-2.1.1*
Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

This Standard is not met as evidenced by:

Based on observation it was determined the hospital failed to maintain all portions of the automatic sprinkler system in reliable operating condition and in accordance with NFPA 13 and 25.

Findings include:

1. On 11/01/11 at approximately 1:30 p.m., the walk-in freezer located in the kitchen was observed to have food storage within approximately six (6) inches of the sprinkler head.

2. During tour of the kitchen walk-in cooler on 11/01/11 at approximately 1:30 p.m., one (1) of one (1) sprinkler heads in this area was observed to have an accumulation of dust and corroded.

Based on review of facility documentation it was determined the hospital failed to maintain the medical gas system in accordance with NFPA (National Fire Protection Association) 99, Chapter 4.

Findings include:

1. On 10/31/11 at approximately 11:00 a.m., a medical gas system inspection report prepared by Environmental Monitoring Technology and dated 08/22/11 was reviewed. This report indicated the following deficiencies were found during the medical gas inspection:

a. The bulk oxygen system must have a local signal.
b. There is not an emergency oxygen supply connection on the exterior of the buildings served.
c. One or more buildings can not keep oxygen supply if main oxygen pad lines are damaged.
d. A demand check valve is not installed on the oxygen main gauge and pressure sensor.
e. A lag alarm is not installed on the vacuum system.
f. There is not a pressure relief valve (50% above normal line pressure) installed before the header valve on the reserve oxygen supply.
g. There is not a pressure indicator for the reserve oxygen supply header contents.
h. There are no alarms in the critical care areas-ER or OR. Required alarms: High and low oxygen line pressure, low vacuum.

At the time of this survey, there was no documented evidence to indicate the aforementioned deficiencies have been corrected.

Based on random observation it was determined the hospital failed to maintain all electrical wiring in accordance with NFPA (National Fire Protection Association) 70 by using relocatable power taps and extension cords in patient care areas.

Findings include:

1. On 11/01/11 at approximately 10:00 a.m., three (3) electrical power strips (relocatable power taps) were observed to be in use in the following areas:

a. Operating area recovery room.
b. Operating rooms #1 and #2.

Also, at this same time two (2) extension cords were observed in use in operating room #2.

Reference:

Underwriters Laboratories (UL) Directory Guide: Relocatable Power Taps Use and Installation
Relocatable power taps have not been investigated and are not intended for use with general patient care areas or critical patient care areas of health care facilities as defined in Article 517 of ANSI/NFPA 70, "National Electrical Code".

NFPA 70 National Electrical Code- 2002 Edition Article 517 Health Care Facilities
517.2 Definitions

Health Care Facilities. Buildings or portions of buildings that contain, but are not limited to, occupancies such as hospitals; nursing homes; limited care; supervisory care; clinics; medical and dental offices; and ambulatory care, whether permanent or movable.

Patient Care Area: Any portion of a health care facility wherein patients are intended to be examined or treated. Areas of a health care facility in which patient care is administered are classified as general care areas or critical care areas, either of which may be classified as a wet location. The governing body of the facility designates these areas in accordance with the type of patient care anticipated and with the following definitions of the area classification. FPN: Business offices, corridors, lounges, day rooms, dining rooms, or similar areas typically are not classified as patient care areas.