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Based on observation, interview and record review, the facility failed to ensure a two hour fire barrier was without openings to comply with the documentation requirements in NFPA 72, 2010 edition; failed to ensure when the fire alarm system was activated by a pull station all fire safety functions were actuated; and failed to ensure its sprinkler system was inspected in accordance with NFPA 25, 2011 edition. This has the potential to affect all patients and visitors to the facility. The facility has a capacity of 883 beds, and the census was 530 patients.

See deficiencies under A710 and A724.

This deficiency substantiates Substantial Allegation OH00095079.

Based on observation, interview and record review, the hospital failed to meet the applicable provisions of the 2012 edition of the Life Safety Code of the National Fire Protection Association (NFPA). This has the potential to affect all patients and visitors to the facility. The facility has a capacity of 883 beds and the census was 530 patients.

Findings include:

K133 Failed to ensure two hour fire barrier was without openings
K341 Failed to comply with the documentation requirements in NFPA 72, 2010 edition,
K344 Failed to ensure when the fire alarm system was activated by a pull station all fire safety functions were actuated
K353 Failed to ensure its sprinkler system was inspected in accordance with NFPA 25, 2011 edition


This deficiency substantiates Substantial Allegation OH00095079.

Based on record review and staff interview, the facility failed to ensure the smoke detection system activated in the event of a fire and failed to address worm equipment which contributed to an actual fire. This had the potential to affect all patients and visitors to the facility. The facility had a capacity of 883 patients, and the census was 530 patients.

Findings include:

Review of the facility's "after action review" revealed a fire had occurred at the facility in the early morning hours of 12/11/17. The review revealed in response to smoke, staff activated a pull station and the fire alarm was triggered. The review revealed after the activation of the fire alarm system, maintenance personnel, alerted by the fire alarm, reasoned the fire to be in an air handling unit, and found it there. The review revealed said personnel extinguished the fire using portable fire extinguishers. The source of the fire was slipped belts that caught fire from friction of the air handler.

A review of an air handler inspection report dated 11/14/17 revealed the condition of two pulleys were "worn."

A review of an engineering report by a "nationally recognized leader in sustainability" engineering company was revealed staff saw smoke on the second floor of the building and pulled a pull station on 12/11/17 at 3:08 A.M. The report revealed, "The area in which the fire alarm pull station was engaged, the smoke would have passed through at least (3) smoke detectors and/or Fire/Smoke dampers. None of these devices were tripped during this event." The report revealed it analyzed the fan wheel and motor of the affected air handling unit. One or more belts rolled off the pulleys, balled up in the bottom of a safety cage, got tangled with the motor shaft which is "assumed" to have eventually started the fire. The report explains the return fan is equipped with four belts on a pulley system that connects the motor shaft to the shaft of the return air fan. The review revealed the belts have been replaced. The report recommended the safety cage, the bottom of which the belts came off to and got tangled with the motor shaft, be modified such that if the belts do roll off the pulley system they do not become trapped in the bottom of the safety cage, or install a kill switch on the door to the air handling unit fan section to kill the unit operation. It was recommended increasing preventative maintenance checks on the belts to closely monitor the fan operation and recommended the duct detectors be tested from within the duct. .

A review of a fire alarm history report for 12/11/17 documented the smoke detection system was providing a false negative result. It did confirm the smoke detectors in the affected air handling unit did not trip, nor did the smoke detectors on the second floor where witnesses saw smoke.

On 01/17/18 at 9:30 AM in an interview, Staff R confirmed the belts had been replaced, but not the pulleys, which are on order. Staff R said maintenance checks on the affected parts to the air handling unit have not been increased.

On 01/17/18 at 9:30 A.M. in an interview, Staff Q explained modifications to the safety cage is still a work in progress At 11:35 A.M., Staff Q confirmed the duct detectors had not yet been tested from within the duct itself, or how witnesses could see smoke but not have it activate smoke detectors in the area.

During interview on 01/17/18 at 11:00 A.M., Staff N Staff N said when she arrived to the facility in the early morning of 12/11/17 staff reported to her witnessing smoke coming out of the ventilation vents and seeing a haze of smoke on the floor.

This deficiency substantiates Substantial Allegation OH00095079.