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Based on observation and interview, the facility failed to maintain smoke barriers with at least a one half hour fire resistance rating. The deficient practice affected four of four smoke compartments, staff, and 20 patients. The facility has the capacity for 25 beds with a census of 20 the day of survey.

Findings Include:

1. Observation on 05-23-12 at 10:18 a.m. revealed unsealed penetrations for data cables in the ceiling of the IT room off of the Pharmacy corridor. The cables penetrated through a three inch circular opening in the ceiling and the space around the four one inch electric conduit pipe going through the ceiling. Two one inch circular penetrations were present between the conduit pipes. Interview with the Maintenance Director on 05-23-12 at 10:18 a.m. revealed that the facility was unaware of the open ceiling penetrations in the ceiling.

2. Observation on 05-23-12 at 11:01 a.m. revealed an approximately 10 ' X 2 ? ' section of drop ceiling that was removed in the 1st floor ICU IT room. An open floor penetration around the approximately 4 " data piping to the basement was unsealed. Interview with the Maintenance Director on 05-23-12 at 11:01 a.m. revealed that the facility was unaware of the missing section of ceiling, and the through the floor penetration.

3. Observation on 05-23-12 at 11:15 a.m. revealed an approximately 1 " open penetration around the two 4 " pipes that went through the floor to the basement. Interview with the Maintenance Director on 05-23-12 at 11:15 a.m. revealed that the facility was unaware of the through the floor penetrations.

4. Observation on 05-23-12 at 2:20 p.m. revealed an approximately 3 " open penetration above the ceiling in the wall separating the hospital from the skilled nursing home Interview with the Maintenance Director on 05-23-12 at 2:20 p.m. revealed that the facility was unaware of the through the wall penetration

The census of 20 was verified by the Chief Nursing Officer on 05/23/12. The finding was acknowledged by the Chief Nursing Officer and verified by the Maintenance Supervisor at the exit interview on 05/23/12.

Actual NFPA Standard: NFPA 101, 19.3.7.3. Smoke barriers shall provide at least a one half hour fire resistance rating.
Actual NFPA Standard: NFPA 101, 8.3.6.1. 8.3.6.1
Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service 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 for 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 conditions:
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.

Based on observation, interview, and record review, the facility failed to properly maintain the water based fire protection systems. The deficient practice affected all four smoke compartments, staff and all patients. The facility has the capacity for 25 beds with a census of 20 the day of survey.

Findings include:

1.) During record review of the facility's sprinkler testing reports for the last 12 month period on 05/23/12 at 9:45 a.m., documentation provided by the facility indicated that the sprinkler system had been tested on 07/18/2012 as annual inspections. The facility was unable to provide any documented quarterly test reports of the automatic sprinkler system's water flow and supervisory devices for the year of 2011 or 2012. Interview with the facility Maintenance Supervisor on 05/23/12 at 4:00 p.m. revealed the facility was not aware of the requirement for quarterly sprinkler testing.

2.) During the facility tour on 05/23/12 between 10:00 a.m. and 4:00 p.m., observed that sprinkler head escutcheons were not installed in accordance with the listing in the following locations: 2nd floor corridor opposite room 225; Pharmacy corridor; surgical corridor; Interview with the facility Maintenance Supervisor on 05/23/12 at 4:00 p.m. revealed the facility was not aware of the out of place sprinkler head escutcheons.

3.) Observation on 05/23/12 at 2:40 p.m. revealed that sprinkler heads installed in the Materials Management smoke compartment were a mixture of quick-response heads and standard response heads. One of the 25 sprinkler heads in the smoke compartment was a quick response type sprinkler head. Interview with the Maintenance Supervisor on 05/23/12 at 2:40 p.m. revealed that the facility was not aware that a quick-response type head was installed with the standard response heads in the smoke compartment.

The census of 20 was verified by the Chief Nursing Officer on 05/23/12. The finding was acknowledged by the Chief Nursing Officer and verified by the Maintenance Supervisor at the exit interview on 05/23/12.

Actual NFPA Standards:

Item 1.) NFPA 101, 4.6.12.1
Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

NFPA 25, 1-8*. Records of inspections, tests, and maintenance of the system and its components shall be made available to the authority having jurisdiction upon request. Typical records include, but are not limited to, valve inspections; flow, drain, and pump tests; and trip tests of dry pipe, deluge, and pre-action valves.

NFPA 25, 2-3.3. 2-3.3* Alarm Devices.
Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.

Item 2.) NFPA 13, 3-2.7.2*
Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.

Item 3.) NFPA 101, 4.6.12.1. Every required sprinkler system shall be continuously maintained in proper operating condition.

NFPA 13, 5-3.1.5.2. When existing light hazard systems are converted to use quick-response or residential sprinklers, all sprinklers in a compartment space shall be changed.

Based on interview and record review, it was determined the facility failed to provide continuing safety education for laboratories. This resulted in the potential for the facility ' s inability to effectively deal with the care, health and safety of staff and other individuals when a laboratory emergency occurs. Findings include:

The facility failed to provide continuing safety education for the hospital laboratory and the pathology laboratory. There was no documented orientation and training of new laboratory personnel.

The finding was acknowledged by the Chief Nursing Officer and verified by the Maintenance Supervisor at the exit interview on 05/23/12.

Actual NFPA Standard: NFPA 99, 10-2.1.4 Orientation and Training.
10-2.1.4.1 New laboratory personnel shall be taught general safety practices for the laboratory and specific safety practices for the equipment and procedures they will use.
10-2.1.4.2 Continuing safety education and supervision shall be provided, incidents shall be reviewed monthly, and procedures shall be reviewed annually.

Based on observation and interview, the facility failed to properly store flammable liquids. The deficient practice affected one of four smoke compartments, laboratory staff, and no patients. The facility has the capacity for 25 beds with a census of 20 the day of survey.

Findings include:

1. Observation during the tour of the facility on 05-23-12 at 11:50 a.m. revealed storage of flammable liquids outside of the cabinet designed for flammable and combustible storage occurring in the pathology laboratory. Approximately 5 gallons of xylene and 5 gallons of alcohol waste were stored under the counter next to the approved storage cabinet. Interview with the Maintenance Engineer on 05-23-12 at 11:50 a.m. revealed the facility was unaware that the flammable liquids were required to be stored in the designated cabinet.

2. Observation during the tour of the facility on 05-23-12 at 11:55 a.m. revealed that the storage of flammable liquids in an unrated cabinet was occurring in the hospital laboratory. Approximately 3 one gallon containers of xylene were stored in a non rated cabinet. Interview with the Maintenance Engineer on 05-23-12 at 11:55 a.m. revealed the facility was unaware that the flammable liquids were stored in a non-rated cabinet

The finding was acknowledged by the Administrator and verified by the Maintenance Engineer during the exit interview on 05-23-12.

Actual NFPA Standard: NFPA 30, 4.3 Design, Construction, and Capacity of Storage Cabinets.
4.3.3 Storage cabinets that meet at least one of the following sets of requirements shall be acceptable for storage of liquids:
(a) Storage cabinets that are designed and constructed to limit the internal temperature at the center of the cabinet and 1 in. (25 mm) from the top of the cabinet to not more than 325?F (162.8?C), when subjected to a 10-minute fire test that simulates the fire exposure of the standard time-temperature curve specified in NFPA 251, Standard Methods of Tests of Fire Endurance of Building Construction and Materials, shall be acceptable. All joints and seams shall remain tight and the door shall remain securely closed during the test.
(b) Metal storage cabinets that are constructed in the following manner shall be acceptable. The bottom, top, door, and sides of the cabinet shall be at least No. 18 gauge sheet steel and shall be double-walled, with 11/2 in. (38 mm) air space. Joints shall be riveted, welded, or made tight by some equally effective means. The door shall be provided with a three-point latch arrangement, and the door sill shall be raised at least 2 in. (50 mm) above the bottom of the cabinet to retain spilled liquid within the cabinet.
(c) Wooden cabinets constructed in the following manner shall be acceptable. The bottom, sides, and top shall be constructed of exterior grade plywood that is at least 1 in. (25 mm) thick and of a type that will not break down or delaminate under fire conditions. All joints shall be rabbetted and shall be fastened in two directions with wood screws. Where more than one door is used, there shall be a rabbetted overlap of not less than 1 in. (25 mm). Doors shall be equipped with a means of latching and hinges shall be constructed and mounted in such a manner as to not lose their holding capacity when subjected to fire exposure. A raised sill or pan capable of containing a 2 in. (50 mm) depth of liquid shall be provided at the bottom of the cabinet to retain spilled liquid within the cabinet.
(d) Listed storage cabinets that have been constructed and tested in accordance with 4.3.3(a) shall be acceptable.

Based on interview and record review, it was determined the facility failed to provide documentation of procedures for laboratory emergencies. This resulted in the potential for the facility ' s inability to effectively deal with the care, health and safety of patients, staff and other individuals when a laboratory emergency occurred. Findings include:

The facility did not develop procedures for laboratory emergencies within the hospital laboratory and the pathology laboratory. There were no plans available detailing procedures for alarm actuation, evacuation and equipment shutdown procedures, and provisions for control of emergencies that could occur in the laboratory, including specific detailed plans for control operations by an emergency control group within the organization or a public fire department. There were no procedures established for extinguishing clothing fires. When asked about the plan, on 05/23/12 at 4:45 p.m. the facility ' s Chief Nursing Officer stated the hospitals emergency operations plan was all encompassing for all departments within the hospital including the laboratories.

The census of 20 was verified by the Chief Nursing Officer on 05/23/12. The finding was acknowledged by the Chief Nursing Officer and verified by the Maintenance Supervisor at the exit interview on 05/23/12.

Actual NFPA Standard: NFPA 99, 10-2.1.3 Emergency Procedures.
10-2.1.3.1 Procedures for laboratory emergencies shall be developed. Such procedures shall include alarm actuation, evacuation, and equipment shutdown procedures, and provisions for control of emergencies that could occur in the laboratory, including specific detailed plans for control operations by an emergency control group within the organization or a public fire department.
10-2.1.3.3* Emergency procedures shall be established for extinguishing clothing fires.

Based on observation and interview, the facility failed to ensure electrical wiring was in accordance with the National Electrical Code. The deficient practice affected four of four smoke compartments, staff, and patients. The facility has the capacity for 25 beds with a census of 20 the day of survey.

Findings include:

1. Observation on 05/23/12 at 10:10 a.m. revealed an unsecured power strip in the dictation room. The power strip was suspended in the air resulting in strain on the wires plugged into it. Interview with the Maintenance Supervisor on 05/23/12 at 10:10 a.m. revealed that the facility was not aware of the improperly secured power strip.

2. Observation on 05/23/12 at 10:19 a.m. revealed an open electric light switch box in the IT room off of the Pharmacy corridor. Interview with the Maintenance Supervisor on 05/23/12 at 10:19 a.m. revealed that the facility was not aware of the missing light switch box cover.

3. Observation on 05/23/12 at 10:30 a.m. revealed an open electric receptacle box in the ICU IT room. Interview with the Maintenance Supervisor on 05/23/12 at 10:30 a.m. revealed that the facility was not aware of the missing electric receptacle box cover.

4. Observation on 05/23/12 at 2:00 p.m. revealed a freezer and a deli case plugged into a power strip that was plugged into a wall outlet in the Cafe kitchen. Interview with the Maintenance Supervisor on 05/23/12 at 2:00 p.m. revealed that the facility was not aware of the requirement that prohibits the use of power strips for appliances.

5. Observation on 05/23/12 at 2:05 p.m. revealed an extension cord run underneath a carpet powering the coffee bar in the Cafe. Interview with the Maintenance Supervisor on 05/23/12 at 2:05 p.m. revealed that the facility was not aware the cord could not be underneath the carpet.

The census of 20 was verified by the Chief Nursing Officer on 05/23/12. The finding was acknowledged by the Chief Nursing Officer and verified by the Maintenance Supervisor at the exit interview on 05/23/12.
Actual NFPA Standard(s):

Item #1
NFPA 70,110-3. Examination, Identification, Installation, and Use of Equipment. (b) Installation and Use. Listed or labeled equipment shall be installed and used in accordance with any instructions included in the listing or labeling.

Item #2
NFPA 70, Article 370-25. Covers and Canopies. In completed installations, each box shall have a cover, faceplate, or fixture canopy


Item#3
NFPA 70, Article 370-25. Covers and Canopies. In completed installations, each box shall have a cover, faceplate, or fixture canopy

Item#4
NFPA 70, 110-3. Examination, Identification, Installation, and Use of Equipment. (b) Installation and Use. Listed or labeled equipment shall be installed and used in accordance with any instructions included in the listing or labeling.
Item #5
NFPA 70, 400-8. Uses Not Permitted
Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
1. As a substitute for the fixed wiring of a structure
2. Where run through holes in walls, structural ceilings suspended ceilings, dropped ceilings, or floors
3. Where run through doorways, windows, or similar openings
4. Where attached to building surfaces
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.
5. Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
6. Where installed in raceways, except as otherwise permitted in this Code