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Based on observation, the facility failed to ensure smoke barrier doors that are held open automatically release and close during the activation of any fire alarm device. This was evidenced by 1 of 3 smoke barrier doors that failed to automatically close when the fire alarm system was activated. This failure had the potential to allow the spread of fire and smoke in the event of a fire, and affected patients in 1 of 3 smoke compartments on the third floor.

Findings:

During the testing of the fire alarm system with staff on 1/28/13, the smoke barrier doors were observed.

At 3:55 p.m., smoke barrier door #61 at the entrance to the third floor nurse's station service area failed to automatically release and latch shut during the testing of the fire alarm system devices. This was acknowledged by staff during the survey.

3. At 10:04 a.m., there was an approximately 4 inch by 4 inch plastic blank cover sealing a penetration in the smoke barrier wall that was located next to the staff lounge on the second floor. Staff acknowledged the plastic cover in the smoke barrier wall, and when staff was asked if the plastic cover had a fire resistance rating, staff responsed that it did not have a fire resistance rating.





27272

Based on observation and interview, the facility failed to maintain the integrity of their smoke barrier walls as evidenced by penetrations in the smoke barrier walls. This could result in the spread of smoke and fire from one smoke compartment to another smoke compartment, and increase the risk of injury to patients, visitors and staff due to smoke and fire. This affected 2 of 3 smoke compartments on the third floor, and 4 of 8 smoke compartments on the second floor.

NFPA 101, Life Safety Code, 2000 Edition
8.3.6.1 Pipes, conduits, ducts, cables, wires, air ducts, pneumatic tube and ducts, and similar building services equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed of the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

During the facility tour with facility staff on 1/28/2013, the smoke barrier walls were observed.

1. At 9:35 a.m., there was an approximately 1/2 inch penetration surrounding a conduit with white wires in the left center of the smoke barrier wall above the cross-corridor smoke barrier door, by Room 2138.
2. At 1:46 p.m., there was an approximately 3/4 inch circular penetration above two red pipes in the center of the smoke barrier wall above the cross-corridor smoke barrier door, by Room 3101.

Based on observation, the facility failed to maintain the 20 minute fire protection rating for their smoke barrier doors as evidenced by the failure of the smoke barrier doors to fully close and positive latch. This could result in the spread of smoke and fire from one smoke compartment to another smoke compartment, and increase the risk of injury to patients, visitors and staff due to smoke and fire. This affected 2 of 3 smoke compartments on the third floor, and 2 of 8 smoke compartments on the second floor.

Findings:

During the facility tour with facility staff on 1/28/2013, the smoke barrier doors were observed.

1. At 3:40 p.m., the left leaf of the double smoke barrier doors failed to latch shut located by the third floor exit stairway.

2. At 3:50 p.m., the right leaf of the double smoke barrier doors failed to latch shut located by Room 2135.

Based on observation, the facility failed to maintain the hazardous areas. This was evidenced by a door to a hazardous area that failed to latch upon self-closure. This failure had the potential to allow the spread of fire and smoke in the event of a fire, and effected 1 of 8 smoke compartments on the second floor.

Findings:

During a tour of the facility with staff on 1/28/13, the hazardous areas were observed.

At 11:03 a.m., the corridor door to the second floor electrical room 2017 failed to latch upon self-closure. The door was open to the fullest extent and released, and the door failed to latch.

Based on document review and interview, the facility failed to activate the fire alarm system during fire drills conducted between 6 a.m., and 9 p.m. This was evidenced by the failure to activate the fire alarm on 8 of 8 fire drills conducted during these hours. This could result in any one staff member not accomplishing all of the tasks required in the event of a fire, and increased risk of injury to patients, visitors and staff in the event of a fire. This affected 11 of 11 smoke compartments.

NFPA 101 Life Safety Code, 2000 Edition
19.7.1.2 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 (nurses, interns,maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.
19.7.1.3 Employees of Health Care facilities occupancies shall be instructed in life safety procedures and devices.
19.7.2.3 All health care occupancy personnel shall be instructed in the use of and response to fire alarms. In addition, they shall be instructed in the use of the code phrase to ensure transmission of an alarm.

Findings:

During record review and interview with facility staff on 1/29/2013, the fire drills were reviewed, and staff was interviewed.

At 11:00 a.m., the fire drills reports presented by the facility recorded the activation of the fire drills as "2. N/A". There were no fire alarms activated on 4 of 4 day shifts, and 4 of 4 evening shifts. During interview with staff, the Director of Facility Services stated that activation of the fire alarm was not conducted during fire drills, and that the fire alarm activation was recorded during false fire alarms.

Based on document review and interview, the facility failed to maintain the humidity levels at 35% or greater in accordance with NFPA 99, 1999 Edition. This was evidenced by documentation of humidity levels less than 35 percent on various days. This failure affected 1 of 8 smoke compartments on the second floor, and had the potential to increase the risk of a fire in the surgery suite.

Findings:

During document review and interview on 1/29/13, the humidity logs were reviewed, and staff was interviewed.

1. At 9:00 a.m., the facility provided daily humidity level print outs for 9 of 9 operating rooms.

Humidity levels for the month of January were recorded as follows:
Operating room 2, on 1/2/13 at 19.7%, on 1/3/13 at 18.5%, on 1/4/13 at 18.9%, on 1/5/13 at 27.4 %, on 1/7/13 at 27%, on 1/11/13/ at 21.2%, on 1/12/13 at 23.9%, on 1/13/13 at 19.2%, on 1/14/13 at 27.4%, on 1/15/13 at 25.9 %, on 1/17/13 at 27%, on 1/18/13 at 29.7%.

Operating room 3, on 1/2/13 at 19.7%, on 1/3/13 at 18.5%, on 1/4/13 at 26.7%, on 1/5/13 at 29.3%, on 1/7/13 at 26.6%, on 1/11/13 at 22.4%, on 1/12/13 at 24.2%, on 1/13/13 at 20.7%, on 1/14/13 at 18.1%, on 1/15/13 at 21.5%, on 1/17/13 at 28.5%.
Operating room 4, on 1/2/13 at 28.4%, on 1/3/13 at 27.7%, on 1/4/13 at 28.5%, on 1/11/13 at 28.5%, on 1/13/13 at 26.9%, 1/14/13 at 26.9%, on 1/15/13 at 28.1%.

Humidity levels for December were recorded as follows:
Operating room 2, on 12/19/12 at 18.9%, on 12/20/12 at 17%, on 12/31/12 at 25.9%.
Operating room 3, on 12/19/12 at 19.2%, on 12/20/12 at 17.4%, on 12/31/12 at 27.4%.
Operating room 4, on 12/19/12 at 25.8% and 12/20/12 at 25.4%.

Humidity levels for November were recorded as follows:
Operating room 2, on 11/5/12 as 24.7%, on 11/10/12 as 27.9%, on 11/11/12 as 18.2%, on 11/12/12 as 13.8%, on 11/13/12 as 17.1%,
Operating room 3, on 1/11/12 at 26.4%, on 11/12/12 at 23.2%, on 11/13/12 at 22.2%.
Operating room 4, on 1/11/12 at 28.1%, on 11/12/12 at 23.2%, on 11/13/12 at 27.1%.
Operating room 5, on 11/13/12 at 27.4%.

Humidity levels for October were recorded as follows:
Operating room 2, on 10/26/12 as 21.5% and 10/27/12 as 24.7%.

Humidity levels for September were recorded as follows:
Operating room 8, on 9/21/12 as 24.2%, on 9/22/12 as 17.7% and 9/23/12 as 24.4%.

2. During an interview with facility staff on 1/29/13, between 9:00 a.m., and 10:30 a.m., the documentation for any of the corrective actions taken when the humidity levels were out of range was requested. Staff stated there was no documentation for any of the corrective actions taken when the humidity levels were out of range, and also stated the facility was in the process of submitting/implementing a new Policy and Procedure for a humidity levels corrective action plan.

Based on observation, the facility failed to ensure smoke barrier doors that are held open automatically release and close during the activation of any fire alarm device. This was evidenced by 1 of 3 smoke barrier doors that failed to automatically close when the fire alarm system was activated. This failure had the potential to allow the spread of fire and smoke in the event of a fire, and affected patients in 1 of 3 smoke compartments on the third floor.

Findings:

During the testing of the fire alarm system with staff on 1/28/13, the smoke barrier doors were observed.

At 3:55 p.m., smoke barrier door #61 at the entrance to the third floor nurse's station service area failed to automatically release and latch shut during the testing of the fire alarm system devices. This was acknowledged by staff during the survey.

3. At 10:04 a.m., there was an approximately 4 inch by 4 inch plastic blank cover sealing a penetration in the smoke barrier wall that was located next to the staff lounge on the second floor. Staff acknowledged the plastic cover in the smoke barrier wall, and when staff was asked if the plastic cover had a fire resistance rating, staff responsed that it did not have a fire resistance rating.





27272

Based on observation and interview, the facility failed to maintain the integrity of their smoke barrier walls as evidenced by penetrations in the smoke barrier walls. This could result in the spread of smoke and fire from one smoke compartment to another smoke compartment, and increase the risk of injury to patients, visitors and staff due to smoke and fire. This affected 2 of 3 smoke compartments on the third floor, and 4 of 8 smoke compartments on the second floor.

NFPA 101, Life Safety Code, 2000 Edition
8.3.6.1 Pipes, conduits, ducts, cables, wires, air ducts, pneumatic tube and ducts, and similar building services equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed of the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

During the facility tour with facility staff on 1/28/2013, the smoke barrier walls were observed.

1. At 9:35 a.m., there was an approximately 1/2 inch penetration surrounding a conduit with white wires in the left center of the smoke barrier wall above the cross-corridor smoke barrier door, by Room 2138.
2. At 1:46 p.m., there was an approximately 3/4 inch circular penetration above two red pipes in the center of the smoke barrier wall above the cross-corridor smoke barrier door, by Room 3101.

Based on observation, the facility failed to maintain the 20 minute fire protection rating for their smoke barrier doors as evidenced by the failure of the smoke barrier doors to fully close and positive latch. This could result in the spread of smoke and fire from one smoke compartment to another smoke compartment, and increase the risk of injury to patients, visitors and staff due to smoke and fire. This affected 2 of 3 smoke compartments on the third floor, and 2 of 8 smoke compartments on the second floor.

Findings:

During the facility tour with facility staff on 1/28/2013, the smoke barrier doors were observed.

1. At 3:40 p.m., the left leaf of the double smoke barrier doors failed to latch shut located by the third floor exit stairway.

2. At 3:50 p.m., the right leaf of the double smoke barrier doors failed to latch shut located by Room 2135.

Based on observation, the facility failed to maintain the hazardous areas. This was evidenced by a door to a hazardous area that failed to latch upon self-closure. This failure had the potential to allow the spread of fire and smoke in the event of a fire, and effected 1 of 8 smoke compartments on the second floor.

Findings:

During a tour of the facility with staff on 1/28/13, the hazardous areas were observed.

At 11:03 a.m., the corridor door to the second floor electrical room 2017 failed to latch upon self-closure. The door was open to the fullest extent and released, and the door failed to latch.

Based on document review and interview, the facility failed to activate the fire alarm system during fire drills conducted between 6 a.m., and 9 p.m. This was evidenced by the failure to activate the fire alarm on 8 of 8 fire drills conducted during these hours. This could result in any one staff member not accomplishing all of the tasks required in the event of a fire, and increased risk of injury to patients, visitors and staff in the event of a fire. This affected 11 of 11 smoke compartments.

NFPA 101 Life Safety Code, 2000 Edition
19.7.1.2 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 (nurses, interns,maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.
19.7.1.3 Employees of Health Care facilities occupancies shall be instructed in life safety procedures and devices.
19.7.2.3 All health care occupancy personnel shall be instructed in the use of and response to fire alarms. In addition, they shall be instructed in the use of the code phrase to ensure transmission of an alarm.

Findings:

During record review and interview with facility staff on 1/29/2013, the fire drills were reviewed, and staff was interviewed.

At 11:00 a.m., the fire drills reports presented by the facility recorded the activation of the fire drills as "2. N/A". There were no fire alarms activated on 4 of 4 day shifts, and 4 of 4 evening shifts. During interview with staff, the Director of Facility Services stated that activation of the fire alarm was not conducted during fire drills, and that the fire alarm activation was recorded during false fire alarms.

Based on document review and interview, the facility failed to maintain the humidity levels at 35% or greater in accordance with NFPA 99, 1999 Edition. This was evidenced by documentation of humidity levels less than 35 percent on various days. This failure affected 1 of 8 smoke compartments on the second floor, and had the potential to increase the risk of a fire in the surgery suite.

Findings:

During document review and interview on 1/29/13, the humidity logs were reviewed, and staff was interviewed.

1. At 9:00 a.m., the facility provided daily humidity level print outs for 9 of 9 operating rooms.

Humidity levels for the month of January were recorded as follows:
Operating room 2, on 1/2/13 at 19.7%, on 1/3/13 at 18.5%, on 1/4/13 at 18.9%, on 1/5/13 at 27.4 %, on 1/7/13 at 27%, on 1/11/13/ at 21.2%, on 1/12/13 at 23.9%, on 1/13/13 at 19.2%, on 1/14/13 at 27.4%, on 1/15/13 at 25.9 %, on 1/17/13 at 27%, on 1/18/13 at 29.7%.

Operating room 3, on 1/2/13 at 19.7%, on 1/3/13 at 18.5%, on 1/4/13 at 26.7%, on 1/5/13 at 29.3%, on 1/7/13 at 26.6%, on 1/11/13 at 22.4%, on 1/12/13 at 24.2%, on 1/13/13 at 20.7%, on 1/14/13 at 18.1%, on 1/15/13 at 21.5%, on 1/17/13 at 28.5%.
Operating room 4, on 1/2/13 at 28.4%, on 1/3/13 at 27.7%, on 1/4/13 at 28.5%, on 1/11/13 at 28.5%, on 1/13/13 at 26.9%, 1/14/13 at 26.9%, on 1/15/13 at 28.1%.

Humidity levels for December were recorded as follows:
Operating room 2, on 12/19/12 at 18.9%, on 12/20/12 at 17%, on 12/31/12 at 25.9%.
Operating room 3, on 12/19/12 at 19.2%, on 12/20/12 at 17.4%, on 12/31/12 at 27.4%.
Operating room 4, on 12/19/12 at 25.8% and 12/20/12 at 25.4%.

Humidity levels for November were recorded as follows:
Operating room 2, on 11/5/12 as 24.7%, on 11/10/12 as 27.9%, on 11/11/12 as 18.2%, on 11/12/12 as 13.8%, on 11/13/12 as 17.1%,
Operating room 3, on 1/11/12 at 26.4%, on 11/12/12 at 23.2%, on 11/13/12 at 22.2%.
Operating room 4, on 1/11/12 at 28.1%, on 11/12/12 at 23.2%, on 11/13/12 at 27.1%.
Operating room 5, on 11/13/12 at 27.4%.

Humidity levels for October were recorded as follows:
Operating room 2, on 10/26/12 as 21.5% and 10/27/12 as 24.7%.

Humidity levels for September were recorded as follows:
Operating room 8, on 9/21/12 as 24.2%, on 9/22/12 as 17.7% and 9/23/12 as 24.4%.

2. During an interview with facility staff on 1/29/13, between 9:00 a.m., and 10:30 a.m., the documentation for any of the corrective actions taken when the humidity levels were out of range was requested. Staff stated there was no documentation for any of the corrective actions taken when the humidity levels were out of range, and also stated the facility was in the process of submitting/implementing a new Policy and Procedure for a humidity levels corrective action plan.