HospitalInspections.org

Based on record review, observation and interview, the facility failed to ensure that rated assemblies were inspected in accordance with NFPA 80 and/or NFPA 105, as applicable. Failure to inspect and test rated assemblies potentially results in a lack of system performance as designed. This deficient practice affected patients, staff and visitors on the date of the survey. The facility is currently licensed for 18 CAH beds.

Findings include:

1) During review of provided facility annual inspection records conducted on June 15, 2017 from approximately 1:00 PM to 2:30 PM, no records were available demonstrating an initial or annual inspection and testing of rated assemblies had been conducted. When asked about the missing documentation, the Engineering Manager stated he was not aware of this requirement.

2) During the facility tour conducted between June 15, 2017 from approximately 2:30 PM to 4:30 PM; and June 16, 2017 from approximately 9:30 AM to 11:00 AM, observation of installed doors revealed doors throughout the facility were rated with fire resistance and smoke resistance labels, ranging from 20 minutes protection up to 60 minutes protection.

Actual NFPA standard:

NFPA 101

19.2 Means of Egress Requirements
19.2.2.2 Doors.
19.2.2.2.1 Doors complying with 7.2.1 shall be permitted.

7.2.1 Door Openings.
7.2.1.15 Inspection of Door Openings.
7.2.1.15.1* Where required by Chapters 11 through 43, the following door assemblies shall be inspected and tested not less than annually in accordance with 7.2.1.15.2 through 7.2.1.15.8:
(1) Door leaves equipped with panic hardware or fire exit hardware in accordance with 7.2.1.7
(2) Door assemblies in exit enclosures
(3) Electrically controlled egress doors
(4) Door assemblies with special locking arrangements subject to 7.2.1.6

7.2.1.15.2 Fire-rated door assemblies shall be inspected and tested in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Smoke door assemblies shall be inspected and tested in accordance with NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives.

NFPA 80
5.2* Inspections.
5.2.1* Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ.

NFPA 105
5.2 Specific Requirements.
5.2.1* Inspections.
5.2.1.1 Smoke door assemblies shall be inspected annually.
5.2.1.2 Doors shall be operated to confirm full closure.
5.2.1.3 Hardware and gaskets shall be inspected annually, and any parts found to be damaged or inoperative shall be replaced.

Based on observation and operational testing the facility failed to ensure that elevator doors communicating between floors would resist the passage of smoke. Failure to ensure elevator doors close with only the minimal clearance necessary, potentially allows fire, smoke and dangerous gases to pass between floors, affecting patient egress during a fire. This deficient practice affected patients, staff and visitors on the date of the survey. The facility is currently licensed for 18 CAH beds.

Findings include:

During the facility tour conducted on June 15, 2017 from approximately 2:00 PM to 2:30 PM, observation and operational testing of the basement staff elevator doors, leading from the Mechanical space corridor into the elevator access, revealed the smoke seal installed on the doors did not fully seal to resist smoke transfer. Further observation revealed that when closed, a gap existed between the leading edges of each door, of approximately 1/2 inch at the bottom and 3/8 inch at the top when checked with a door gauge.

Actual NFPA standard:

8.6 Vertical Openings.
8.6.1 Floor Smoke Barriers. Every floor that separates stories in a building shall meet the following criteria:
(1) It shall be constructed as a smoke barrier in accordance with Section 8.5.
(2) It shall be permitted to have openings as described by 8.6.6, 8.6.7, 8.6.8, 8.6.9, or Chapters 11 through 43.

8.5.4 Opening Protectives.
8.5.4.1* Doors in smoke barriers shall close the opening, leaving only the minimum clearance necessary for proper operation, and shall be without louvers or grilles. The clearance under the bottom of a new door shall be a maximum of 3.4 in. (19 mm).

Based on record review, observation and interview, the facility failed to ensure automatically operated Alcohol Based Hand Rub dispensers (ABHR) were maintained in accordance with NFPA 101. Failure to test and document operation of automatic dispensing ABHR dispensers potentially results in inadvertently spilling flammable liquids, increasing the exposed risk of fires. This deficient practice affected patients, staff and visitors on the date of the survey. The facility is currently licensed for 18 CAH beds.

Findings include:

1) During the review of facility inspection records conducted on June 15, 2017 from approximately 1:00 PM to 2:30 PM, no records were available indicating inspection and testing of ABHR dispensers was performed when refilling dispensers in accordance with manufacturer's care and use instructions.

2) During the facility tour conducted on June 15, 2017 from approximately 2:30 PM to 4:30 PM, observation of installed ABHR dispensers revealed automatic dispensers had been installed throughout the facility. When asked about automatic ABHR dispenser refill testing and documentation, the Environmental Services Manager stated she was not aware that dispensers were required to be tested each time a refill was installed.

Actual NFPA standard:

NFPA 101

19.3.2.6* Alcohol-Based Hand-Rub Dispensers.
Alcohol-based hand-rub dispensers shall be protected in accordance with
8.7.3.1, unless all of the following conditions are met:

(1) Where dispensers are installed in a corridor, the corridor shall have a minimum width of 6 ft (1830 mm).
(2) The maximum individual dispenser fluid capacity shall be as follows:

(a) 0.32 gal (1.2 L) for dispensers in rooms, corridors, and areas open to corridors
(b) 0.53 gal (2.0 L) for dispensers in suites of rooms

(3) Where aerosol containers are used, the maximum capacity of the aerosol dispenser shall be 18 oz. (0.51 kg) and shall be limited to Level 1 aerosols as defined in NFPA30B, Code for the Manufacture and Storage of Aerosol Products.
(4) Dispensers shall be separated from each other by horizontal spacing of not less than 48 in. (1220 mm).
(5) Not more than an aggregate 10 gal (37.8 L) of alcohol-based hand-rub solution or 1135 oz (32.2 kg) of Level 1 aerosols, or a combination of liquids and Level 1 aerosols not to exceed, in total, the equivalent of 10 gal
(37.8 L) or 1135 oz (32.2 kg), shall be in use outside of a storage cabinet in a single smoke compartment, except as otherwise provided in 19.3.2.6(6).
(6) One dispenser complying with 19.3.2.6 (2) or (3) per room and located in that room shall not be included in the aggregated quantity addressed in 19.3.2.6(5).
(7) Storage of quantities greater than 5 gal (18.9 L) in a single smoke compartment shall meet the requirements of NFPA 30, Flammable and Combustible Liquids Code.
(8) Dispensers shall not be installed in the following locations:
(a) Above an ignition source within a 1 in. (25 mm) horizontal distance from each side of the ignition source
(b) To the side of an ignition source within a 1 in. (25mm) horizontal distance from the ignition source
(c) Beneath an ignition source within a 1 in. (25 mm) vertical distance from the ignition source
(9) Dispensers installed directly over carpeted floors shall be permitted only in sprinklered smoke compartments.
(10) The alcohol-based hand-rub solution shall not exceed 95 percent alcohol content by volume.
(11) Operation of the dispenser shall comply with the following criteria:
(a) The dispenser shall not release its contents except when the dispenser is activated, either manually or automatically by touch-free activation.
(b) Any activation of the dispenser shall occur only when an object is placed within 4 in. (100 mm) of the sensing device.
(c) An object placed within the activation zone and left in place shall not cause more than one activation.
(d) The dispenser shall not dispense more solution than the amount required for hand hygiene consistent with label instructions.
(e) The dispenser shall be designed, constructed, and operated in a manner that ensures that accidental or malicious activation of the dispensing device is minimized.
(f) The dispenser shall be tested in accordance with the manufacturer ' s care and use instructions each time a new refill is installed.

Based on record review, and interview, the facility failed to ensure fire suppression systems were maintained in accordance with NFPA 25. Failure to test or replace dry barrel pendants as required has the potential to hinder system performance during a fire event. This deficient practice affected staff and vendors of the main Kitchen on the date of the survey. The facility is currently licensed for 18 CAH beds.

Findings include:

During review of provided fire suppression system inspection records conducted on June 15, 2017 from approximately 1:00 PM to 2:30 PM, no records were found for replacement or testing of dry barrel pendants within the last ten years. Interview of the Engineering Manager revealed that the dry barrel pendants had not been replaced or tested in the last ten years.

Actual NFPA standard:

NFPA 25

5.3.1.1.1.6* Dry sprinklers that have been in service for 10 years shall be replaced or representative samples shall be tested and then retested at 10-year intervals.

Based on record review and interview, the facility failed to ensure Emergency Power Supply Systems (EPSS) were maintained in accordance to NFPA 110. Failure to inspect and test generators under load potentially creates unburned carbon in exhaust systems, hindering performance of the equipment during an emergency. This deficient practice affected patients, staff and visitors on the date of the survey. The facility is currently licensed for 18 CAH beds.

Findings include:

During review of the EPSS inspection and monthly load testing documentation provided on June 15, 2017 from approximately 1:00 PM 2:30 PM, monthly load test inspections provided only indicated a maximum of 21% load was achieved during monthly tests. Furthermore, annual load bank testing was documented as only being conducted on a tri-annual basis.

When asked about the load bank being performed only tri-annually , the Engineering Manager stated that he was not aware a load bank must be conducted annually, if the monthly exercise standard is not met.

Actual NFPA standard:

NFPA 110

8.4 Operational Inspection and Testing.
8.4.1* EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly.

8.4.2* Diesel generator sets in service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(1) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
(2) Under operating temperature conditions and at not less than 30 percent of the EPS nameplate kW rating

8.4.2.3 Diesel-powered EPS installations that do not meet the requirements of 8.4.2 shall be exercised monthly with the available EPSS load and shall be exercised annually with supplemental loads at not less than 50 percent of the EPS nameplate kW rating for 30 continuous minutes and at not less than 75 percent of the EPS nameplate kWrating for 1 continuous hour for a total test duration of not less than 1.5 continuous hours.