HospitalInspections.org

Based on observation and staff interview, it was determined the hospital failed to maintain all exits and egress corridors free of obstructions and readily accessible for instant use in the event of a fire or emergency.

Findings include:

1. During tour of the hospital on 01/26/15 at approximately 2:45 p.m., the forth floor corridor of the hospital designated as egress paths was observed to be obstructed with boxes/files.

2. During tour of the hospital on 01/26/15 at approximately 3:10 p.m., the 3rd floor corridor of the hospital designated as egress paths was observed to be obstructed with a copier and a shred box.

3. During an interview conducted with the hospital maintenance director on 01/28/15 at approximately 10:00 a.m., it was agreed that the 3rd and 4th floor corridors was restricted.

NFPA (National Fire Protection Association) 25 - Standard for the Inspection, Testing, and Maintenance of Water-based Protection Systems
2-1 General.
This chapter provides the minimum requirements for the routine inspection, testing, and maintenance of sprinkler systems. Table 2-1 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance.

Table 2-1 Summary of Sprinkler System Inspection, Testing, and Maintenance
Item Activity Frequency Reference
Alarm devices Inspection Quarterly 2-2.6
Hydraulic nameplate Inspection Quarterly 2-2.7
Alarm devices Test Quarterly 2-3.3
Main drain Test Quarterly Table 9-1

This Standard is not met as evidenced by:

Based on record review and staff interview, it was determined that the hospital failed to maintain the sprinkler system in accordance with NFPA (National Fire Protection Association) 25.

Findings include:

1. On 01/27/15 at approximately 10:00 a.m., a review of the facility sprinkler inspection reports was conducted. At this time, there was no evidence that a sprinkler inspection had been conducted for the forth quarter.

2. During an interview with the hospital maintenance director on 01/27/15 at approximately 3:00 p.m., it was revealed that the sprinkler inspections missed during the forth quarter due to scheduling.

NFPA 90A Standard for installation of Air Conditioning and Ventilating Systems 1999 Edition
Chapter 3 Integration of Air Conditioning and Ventilation System(s) with Building Construction
3-3* Penetrations - Protection of Openings.
3-3.1 Fire-Rated Walls and Partitions.
3-3.1.1*
Approved fire dampers shall be provided where air ducts penetrate or terminate at openings in walls or partitions required to have a fire resistance rating of 2 hours or more.
Exception*: Fire dampers shall not be required where other openings through the wall are not required to be protected.
3-3.1.2
Approved fire dampers shall be provided in all air transfer openings in partitions that are required to have a fire resistance rating and in which other openings are required to be protected.
3-4.5 Damper Closure.
3-4.5.1
All fire dampers and ceiling dampers shall close automatically, and they shall remain closed upon the operation of a listed fusible link or other approved heat-actuated device located where readily affected by an abnormal rise of temperature in the air duct.
3-4.7 Maintenance.
At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.
This Standard is not met as evidenced by:

Based on record review and staff interview, it was determined the hospital failed to continuously maintain fire dampers in reliable operating condition with inspections, testing periodically and in accordance with NFPA (National Fire Protection Association) 90A.

Findings include:

1. On 01/27/15 at approximately 3:05 p.m., a review of the hospital fire damper inspection report prepared by Safe Check company dated June 2012 was conducted. At this time damper identification number 1151(D/D.s left of OR Entrance) and 1161(D/D's next to room 307) failed. At this time, there was no evidence that repairs had been made to the fire dampers.

2. These findings were discussed with the hospital maintenance director on 01/27/15 at approximately 3:10 p.m. and agreed that repairs had not been conducted for the aforementioned fire dampers.

ARTICLE 517 Health Care Facilities
517.2 Definitions
Line Isolation Monitor. A test instrument designed to continually check the balanced and unbalanced impedance from each line of an isolated circuit to ground and equipped with a built-in test circuit to exercise the alarm without adding to the leakage current.

This standard is not met as evidenced by:

Based on record review, staff interview and performance testing, it was determined all hospital Line Isolation Ground and electrical systems were not maintained according to NFPA 70 National Electrical Code.

Findings include:

1. During an inspection of OR # 1 and OR# 2 on 01/27/15 at approximately 1:40 p.m., the safe lights for the X-ray and 120 volt ground alarm panels were not illuminated.

2. During an interview conducted with the OR manager on 01/27/15 at approximately 2:00 p.m., it was agreed the the two OR room safe lights were not illuminated,

Based on observation and staff interview, it was determined the hospital failed to maintain all exits and egress corridors free of obstructions and readily accessible for instant use in the event of a fire or emergency.

Findings include:

1. During tour of the hospital on 01/26/15 at approximately 2:45 p.m., the forth floor corridor of the hospital designated as egress paths was observed to be obstructed with boxes/files.

2. During tour of the hospital on 01/26/15 at approximately 3:10 p.m., the 3rd floor corridor of the hospital designated as egress paths was observed to be obstructed with a copier and a shred box.

3. During an interview conducted with the hospital maintenance director on 01/28/15 at approximately 10:00 a.m., it was agreed that the 3rd and 4th floor corridors was restricted.

NFPA (National Fire Protection Association) 25 - Standard for the Inspection, Testing, and Maintenance of Water-based Protection Systems
2-1 General.
This chapter provides the minimum requirements for the routine inspection, testing, and maintenance of sprinkler systems. Table 2-1 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance.

Table 2-1 Summary of Sprinkler System Inspection, Testing, and Maintenance
Item Activity Frequency Reference
Alarm devices Inspection Quarterly 2-2.6
Hydraulic nameplate Inspection Quarterly 2-2.7
Alarm devices Test Quarterly 2-3.3
Main drain Test Quarterly Table 9-1

This Standard is not met as evidenced by:

Based on record review and staff interview, it was determined that the hospital failed to maintain the sprinkler system in accordance with NFPA (National Fire Protection Association) 25.

Findings include:

1. On 01/27/15 at approximately 10:00 a.m., a review of the facility sprinkler inspection reports was conducted. At this time, there was no evidence that a sprinkler inspection had been conducted for the forth quarter.

2. During an interview with the hospital maintenance director on 01/27/15 at approximately 3:00 p.m., it was revealed that the sprinkler inspections missed during the forth quarter due to scheduling.

NFPA 90A Standard for installation of Air Conditioning and Ventilating Systems 1999 Edition
Chapter 3 Integration of Air Conditioning and Ventilation System(s) with Building Construction
3-3* Penetrations - Protection of Openings.
3-3.1 Fire-Rated Walls and Partitions.
3-3.1.1*
Approved fire dampers shall be provided where air ducts penetrate or terminate at openings in walls or partitions required to have a fire resistance rating of 2 hours or more.
Exception*: Fire dampers shall not be required where other openings through the wall are not required to be protected.
3-3.1.2
Approved fire dampers shall be provided in all air transfer openings in partitions that are required to have a fire resistance rating and in which other openings are required to be protected.
3-4.5 Damper Closure.
3-4.5.1
All fire dampers and ceiling dampers shall close automatically, and they shall remain closed upon the operation of a listed fusible link or other approved heat-actuated device located where readily affected by an abnormal rise of temperature in the air duct.
3-4.7 Maintenance.
At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.
This Standard is not met as evidenced by:

Based on record review and staff interview, it was determined the hospital failed to continuously maintain fire dampers in reliable operating condition with inspections, testing periodically and in accordance with NFPA (National Fire Protection Association) 90A.

Findings include:

1. On 01/27/15 at approximately 3:05 p.m., a review of the hospital fire damper inspection report prepared by Safe Check company dated June 2012 was conducted. At this time damper identification number 1151(D/D.s left of OR Entrance) and 1161(D/D's next to room 307) failed. At this time, there was no evidence that repairs had been made to the fire dampers.

2. These findings were discussed with the hospital maintenance director on 01/27/15 at approximately 3:10 p.m. and agreed that repairs had not been conducted for the aforementioned fire dampers.

ARTICLE 517 Health Care Facilities
517.2 Definitions
Line Isolation Monitor. A test instrument designed to continually check the balanced and unbalanced impedance from each line of an isolated circuit to ground and equipped with a built-in test circuit to exercise the alarm without adding to the leakage current.

This standard is not met as evidenced by:

Based on record review, staff interview and performance testing, it was determined all hospital Line Isolation Ground and electrical systems were not maintained according to NFPA 70 National Electrical Code.

Findings include:

1. During an inspection of OR # 1 and OR# 2 on 01/27/15 at approximately 1:40 p.m., the safe lights for the X-ray and 120 volt ground alarm panels were not illuminated.

2. During an interview conducted with the OR manager on 01/27/15 at approximately 2:00 p.m., it was agreed the the two OR room safe lights were not illuminated,