HospitalInspections.org

Waterflow Alarm Devices:
"General. Waterflow alarm apparatus shall be listed for the service and so constructed and installed that any flow of water from a sprinkler system equal to or greater than that from a single automatic sprinkler of the smallest orifice size installed on the system will result in an audible alarm on the premises within 5 minutes after such flow begins and until such flow stops." - NFPA 13, 2010: 6.9.1.

Based on observation the facility failed to provide an adequate orifice for the inspector test flow.

The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 1:00 pm to 3:30 pm on 3/15/2017 that there was the following issue. The output of the inspector test piping did not have an orifice to simulate a single sprinkler head.


Other Occupancies - 2-Hour Separation:
"Sections of health care facilities shall be permitted to be classified as other occupancies, provided that they meet all of the following conditions:
(1) They are not intended to provide services simultaneously for four or more inpatients for purposes of housing, treatment, or customary access by inpatient incapable of self-preservation.
(2) They are separated from areas of health care occupancies by construction having a minimum 2-hour fire resistance rating in accordance with Chapter 8."
(3) For other than previously approved occupancy separation arrangements, the entire building is protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7." - NFPA 101, 2012, 19.1.3.3.

Based on observation the facility failed to provide an adequate fire barrier between the hospital and the clinic.

The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 1:00 pm to 3:30 pm on 3/15/2017 that there were numerous penetrations in the 2-hour fire wall between the hospital and the clinic.


Fire Sprinkler System - Escutcheon Plates:
"Escutcheons used with recessed, flush-type, or concealed sprinklers shall be part of the listed sprinkler assembly." -NFPA 13, 2010, 6.2.7.2

Based on observation the facility failed to provide an escutcheon plate.

The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 1:00 pm to 3:30 pm on 3/15/2017 that there was a missing escutcheon plate in the soiled utility, 1405.

Based on observation the facility failed to provide an adequate door closure.

The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 1:00 pm to 3:30 pm on 3/15/2017 that there was the following issue. The closure on the equipment room, 1106 did not make the door latch on its own.

Based on observation the facility failed to provide adequate smoke barriers.

The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 1:00 pm to 3:30 pm on 3/15/2017 that there were penetrations in smoke barriers above cross corridor doors at the following locations: 1) at the electrical closet, 1317, 2) at O.R. #1, 3) at waiting, and 4) at purchasing.

Securing of the Medical Gas Cylinders:
"Design and Construction. Locations for central supply systems and the storage of positive-pressure gases shall meet the following requirements: (7) They shall be provided with racks, chains, or other fastening to secure all cylinders from falling, whether connected, unconnected, full, or empty." - NFPA 99, 2012: 5.1.3.3.2

Based on observation the facility failed to provide adequate storage of medical gas bottles.

The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 1:00 pm to 3:30 pm on 3/15/2017 that there were the following issues. The medical gas bottles were not secured at the 1) bulk oxygen tank area, 2) the medical gas shed, and 3) at the medical gas bottle room.

Based on observation the facility had not developed a risk management analysis.

The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 1:00 pm to 3:30 pm on 3/15/2017 that the facility had not developed a risk management analysis.

Based on observation the facility failed to provide adequate records.

The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 1:00 pm to 3:30 pm on 3/15/2017 that there were no records of the LIM testing.

Based on observation the facility had not developed a risk management analysis

The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 1:00 pm to 3:30 pm on 3/15/2017 that the facility had not developed a risk management analysis.

Based on observation the facility failed to provide adequate enclosures free of combustibles.

The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 1:00 pm to 3:30 pm on 3/15/2017 that there were the following issues. There was vegetative debris in the medical gas enclosures at 1) the bulk oxygen tank, 2) the medical gas shed, and 3) at the medical gas bottle room.

Based on observation the facility had not developed a training program for medical gas maintenance and handling.

The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 1:00 pm to 3:30 pm on 3/15/2017 that the facility had not developed training program for the maintenance and handling of medical gases and cylinders.