HospitalInspections.org

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #5) and interview, it was determined that the facility failed to ensure that emergency lighting (battery operated lamps) which provides light for a period of 90 minutes, enabling those inside to move about safely in an emergency are provided in staircases as required by the 2000 edition of the Life Safety Code of the NFPA Section 7.9.

Findings include:

1. The facility lacks emergency battery operated lamps (EBOL) for a period of 90 minutes as determined by the observational tour on 4/7/11 from 8:30 am till 4:00 pm in the following areas:
a. At the two internal staircases and also at the covered external exit staircases from the top floor (fourth floor) through the basement to ensure visibility at night if power is lost and an emergency evacuation is needed.
b. At the outside staircase (2 stories high) located at the side of the hospital.
c. At the Medication preparation room of the second floor.
(Emergency lamps are required to ensure adequate lighting until the essential electrical system (generator) turns on or in the event that the essential electrical system fails as required since March of 2006). (The Engineer stated during an interview on 4/7/11 at 2:45 pm that the EBOLs were ordered but they were not the appropriate size that they required and they had to be ordered from a different company and she provided evidence of a purchase order stated that she expects them to arrive within a week and to mount them).

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #5), it was determined that the facility failed to ensure that smoke detectors and heat detectors are available in required areas of the hospital, smoke detector sensitivity documentation was not found and the fire alarm system is not arranged to transmit an alarm automatically via a central station which is not in accordance with the applicable requirements of NFPA 70 (National Electric Code) and NFPA 72 (National Fire Alarm Code).

Findings include:

1. Smoke detectors connected to the fire alarm panel are needed in the following areas as observed with the facility's Engineer (employee #5) on 4/7/11 from 8:30 am till 4:00 pm (the engineer provided evidence of a work order to place smoke detectors in these areas and as a temporary measure battery operated smoke detectors were placed in these areas):
a. All housekeeping (maintenance) closets throughout the facility (with cleaning chemicals).
b. In the dirty linen closet located at the basement and second floor.
c. In the Physical Therapy Department on the fourth floor.
d. In the Nuclear Medicine Department on the fourth floor including their lunch area.
e. The lunch room of the Administration Offices on the fourth floor.
f. In the area used to make coffee on the fourth floor near room #420.
g. In the air conditioner (A.C) rooms that re-cirulates air through A.C vents and dampers such as the Intensive Care Unit, Nuclear Medicine Department, Radiotherapy Department, "External Clinics" and Operating Room Department.
h. In the dirty utility room of the Intensive Care Unit.
i. In the Intensive Care Unit.
j. In the ice maker machine and microwave area at the second floor.
k. At the biohazardous storage room on the second floor.
l. At the equipment room on the second floor.
m. At the Social Worker's office on the second floor (found with a microwave, refrigerator and a sandwich press).
n. At the Nursing office on the second floor (found with a microwave, refrigerator and a sandwich press).
o. At the Medication preparation room of the second floor.
p. At the biohazardous closet of the operating suite department.
q. In the operating suite department.
r. In the X-ray Department.
s. In the Pharmacy department.
t. At the Chemotherapy department.
u. At the Central Supply department located at the basement.
v. At the Radiotherapy department.
x. At the Endoscope rooms.

2. The facility has an outside company that services the fire alarm system and they provide the facility with a certification once a year as evidenced on 4/7/11 at 2:50 pm with the facility's Engineer (employee #5), however no evidence was found of the following:
a. Smoke detector sensitivity tests.

3. The fire alarm system lacks annunciation to an approved central station as reviewed on 4/7/11 at 2:55 pm. The fire alarm system must be arranged to transmit an alarm automatically via a central station to alert the municipal fire department and fire brigade.

4. The Autoclave room located at the operating suite department on the third floor does not have functional heat detectors as determined by the facility's Engineer (employee #5) on 4/7/11 at 10:05 am.

5. The Laboratory department located on the first floor was visited with the facility's
Engineer (employee #5) on 4/7/11 at 11:00 am and provided evidence that this area does not have functional heat detectors.

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #5), it was determined that the facility failed to ensure that the automatic sprinkler system for the medical record department and central supply department at the basement and the basement are continuously maintained in reliable operating condition and are inspected and tested periodically as required by the 2000 edition of the Life Safety Code of the NFPA Section 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5.

Findings include:

1. Review of documentation and observations of the sprinkler system on 4/7/11 at 3:15 pm, the following was determined with the facility's Engineer (employee #5):
a. No evidence was found of sprinkler maintenance documentation.
b. No evidence was found of the separation from public water supply by means of check valves (which permits only one-way flow into the fire protection system, control valves are generally located at the check valves to isolate the system and to permit repair of the check valves.
c. No evidence was found of the control valve and identification with a sign indicating the system or portion of the system it controls.
d. No evidence was found of the weekly valve inspection (hose valves, pressure-regulating valves and valves that isolate backflow prevention devices).
e. No evidence of the annual control valve test with the valve in the open position.
f. No evidence was found of the fire department connection inspection on a quarterly bases to verify visibility and accessibility, coupling and swivels not damaged and rotate smoothly.
g. No evidence was found of tests performed on the sprinkler system (such as weekly no-flow tests and annual flow condition test of the fire pump).
h. The facility has more than six sprinklers in an isolated hazardous area and can not ensure an adequate and reliable water supply dedicated for the sprinkler system. An adequate water supply dedicated to the sprinkler system based on the amount of sprinklers and the area of coverage is required and the supply system needs the appropriate pressure pumps to ensure continuous and automatic pressure. The automatic sprinkler system should have its own electrical generator power source in the event of a power failure. No evidence was provided of a certification from a certified sprinkler technician or the person or company who mounted the sprinkler system that this system has a combination of available flow and pressure and that this sprinkler system can meet the demand of the fire protection system or whether pumps and on-site tank is required (This facility does not have a pump (jockey pump) or its own water reserve (cistern or tank) dedicated for its sprinkler system. A water based fire protection system is only as reliable as its water supply source).

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #5), it was determined that the facility failed to ensure that portable Carbon Dioxide fire extinguishers are maintained related to appropriate inspections and appropriate sizes to ensure their use as required by the 2000 edition of the Life Safety Code of the NFPA Section 9.7.4.1 and NFPA 10.

Findings include:

1. The facility has Carbon Dioxide (Co2) fire extinguishers as observed on 4/7/11 from 8:30 am till 4:00 pm with the facility's Engineer (employee #5) and provided evidence that they are too heavy for some female staff members to use. Two smaller Co2 extinguishers of equal capacity (both combine to the same size as the large extinguishers) to the large extinguisher shall be used instead to ensure that they can be used effectively in the event of an emergency. These Carbon Dioxide (Co2) fire extinguishers were found at the following areas:
a. Located near the recovery room of the operating suite department
b. Located in the room between X-ray rooms #1 and #2
c. Located at the medical record department.

2. Written evidence about required annual carbon dioxide conductivity inspections of the fire extinguisher hose system was not provided by the facility on 4/7/11 at 2:30 pm when requested of the facility's Engineer (employee #5).

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #5), it was determined that the facility failed to monitor means of egress at the back staircase of the "External Clinics" to ensure that it is maintained free from all obstructions in accordance with the 2000 edition of the Life Safety Code of the NFPA Section 7.1.10.1.

Findings include:

The hallway located at the back of the "External Clinics" department was visited on 4/7/11 at 10:00 am with the facility's Engineer (employee #5) and provided evidence that a patient was lying on a stretcher in this hallway reducing the passage width to less than two feet. "Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in case of fire or other emergency".

Based on the review of written documents during the survey for life safety from fire with the facility's Engineer (employee #5), it was determined that the facility failed to ensure that personnel perform the monthly 30 minute load test of the electrical generator and monthly transfer switch tests as required by the NFPA 99, section 3.4.4.1.

Findings include:

1. The facility lacks written evidence that the electrical generator is tested under load conditions for 30 minutes on a monthly basis as reviewed on 4/7/11 at 2:35 pm with the facility's Engineer (employee #5).

2. The facility lacks written evidence that the electrical generators' transfer switch is tested on a monthly basis as reviewed on 4/7/11 at 2:40 pm with the facility's Engineer (employee #5).

Based on observations, interview and review of written documents during the survey for life safety from fire with the facility's Engineer (employee #5), it was determined that the facility failed to provide documentation related to the branches of the Type I Essential Electrical System as required by the NFPA 99, section 3.4.2.2.2.

Findings include:

The entire hospital is supplied by one generator as observed on 4/7/11 at 3:20 pm. The facility's Engineer (employee #5) stated during an interview on 4/7/11 at 3:25 pm that not all areas of the hospital are covered by the generator and the Intensive Care Unit has battery backup cells (which gives approximately four hours of uninterrupted full service to the Intensive Care Unit). A study must be performed to evaluate the facility's energy needs when municipal power is not available, which must divide the essential electrical system include two branches, the "Life Safety Branch" which provides power only to those functions or warning systems, such as alarm systems, exit signs, lighting of means of egress and communication system, necessary for safely leaving any building in an emergency. The "Critical Branch" includes those functions that maintain essential patient services, such as task illumination, fixed equipment, selected receptacles, operating rooms and certain special procedure radiology rooms where loss of lighting due to failure of the essential electrical system might cause severe and immediate danger to a patient undergoing surgery or an invasive radiographic procedure.

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #5) and interview, it was determined that the facility failed to ensure that emergency lighting (battery operated lamps) which provides light for a period of 90 minutes, enabling those inside to move about safely in an emergency are provided in staircases as required by the 2000 edition of the Life Safety Code of the NFPA Section 7.9.

Findings include:

1. The facility lacks emergency battery operated lamps (EBOL) for a period of 90 minutes as determined by the observational tour on 4/7/11 from 8:30 am till 4:00 pm in the following areas:
a. At the two internal staircases and also at the covered external exit staircases from the top floor (fourth floor) through the basement to ensure visibility at night if power is lost and an emergency evacuation is needed.
b. At the outside staircase (2 stories high) located at the side of the hospital.
c. At the Medication preparation room of the second floor.
(Emergency lamps are required to ensure adequate lighting until the essential electrical system (generator) turns on or in the event that the essential electrical system fails as required since March of 2006). (The Engineer stated during an interview on 4/7/11 at 2:45 pm that the EBOLs were ordered but they were not the appropriate size that they required and they had to be ordered from a different company and she provided evidence of a purchase order stated that she expects them to arrive within a week and to mount them).

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #5), it was determined that the facility failed to ensure that smoke detectors and heat detectors are available in required areas of the hospital, smoke detector sensitivity documentation was not found and the fire alarm system is not arranged to transmit an alarm automatically via a central station which is not in accordance with the applicable requirements of NFPA 70 (National Electric Code) and NFPA 72 (National Fire Alarm Code).

Findings include:

1. Smoke detectors connected to the fire alarm panel are needed in the following areas as observed with the facility's Engineer (employee #5) on 4/7/11 from 8:30 am till 4:00 pm (the engineer provided evidence of a work order to place smoke detectors in these areas and as a temporary measure battery operated smoke detectors were placed in these areas):
a. All housekeeping (maintenance) closets throughout the facility (with cleaning chemicals).
b. In the dirty linen closet located at the basement and second floor.
c. In the Physical Therapy Department on the fourth floor.
d. In the Nuclear Medicine Department on the fourth floor including their lunch area.
e. The lunch room of the Administration Offices on the fourth floor.
f. In the area used to make coffee on the fourth floor near room #420.
g. In the air conditioner (A.C) rooms that re-cirulates air through A.C vents and dampers such as the Intensive Care Unit, Nuclear Medicine Department, Radiotherapy Department, "External Clinics" and Operating Room Department.
h. In the dirty utility room of the Intensive Care Unit.
i. In the Intensive Care Unit.
j. In the ice maker machine and microwave area at the second floor.
k. At the biohazardous storage room on the second floor.
l. At the equipment room on the second floor.
m. At the Social Worker's office on the second floor (found with a microwave, refrigerator and a sandwich press).
n. At the Nursing office on the second floor (found with a microwave, refrigerator and a sandwich press).
o. At the Medication preparation room of the second floor.
p. At the biohazardous closet of the operating suite department.
q. In the operating suite department.
r. In the X-ray Department.
s. In the Pharmacy department.
t. At the Chemotherapy department.
u. At the Central Supply department located at the basement.
v. At the Radiotherapy department.
x. At the Endoscope rooms.

2. The facility has an outside company that services the fire alarm system and they provide the facility with a certification once a year as evidenced on 4/7/11 at 2:50 pm with the facility's Engineer (employee #5), however no evidence was found of the following:
a. Smoke detector sensitivity tests.

3. The fire alarm system lacks annunciation to an approved central station as reviewed on 4/7/11 at 2:55 pm. The fire alarm system must be arranged to transmit an alarm automatically via a central station to alert the municipal fire department and fire brigade.

4. The Autoclave room located at the operating suite department on the third floor does not have functional heat detectors as determined by the facility's Engineer (employee #5) on 4/7/11 at 10:05 am.

5. The Laboratory department located on the first floor was visited with the facility's
Engineer (employee #5) on 4/7/11 at 11:00 am and provided evidence that this area does not have functional heat detectors.

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #5), it was determined that the facility failed to ensure that the automatic sprinkler system for the medical record department and central supply department at the basement and the basement are continuously maintained in reliable operating condition and are inspected and tested periodically as required by the 2000 edition of the Life Safety Code of the NFPA Section 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5.

Findings include:

1. Review of documentation and observations of the sprinkler system on 4/7/11 at 3:15 pm, the following was determined with the facility's Engineer (employee #5):
a. No evidence was found of sprinkler maintenance documentation.
b. No evidence was found of the separation from public water supply by means of check valves (which permits only one-way flow into the fire protection system, control valves are generally located at the check valves to isolate the system and to permit repair of the check valves.
c. No evidence was found of the control valve and identification with a sign indicating the system or portion of the system it controls.
d. No evidence was found of the weekly valve inspection (hose valves, pressure-regulating valves and valves that isolate backflow prevention devices).
e. No evidence of the annual control valve test with the valve in the open position.
f. No evidence was found of the fire department connection inspection on a quarterly bases to verify visibility and accessibility, coupling and swivels not damaged and rotate smoothly.
g. No evidence was found of tests performed on the sprinkler system (such as weekly no-flow tests and annual flow condition test of the fire pump).
h. The facility has more than six sprinklers in an isolated hazardous area and can not ensure an adequate and reliable water supply dedicated for the sprinkler system. An adequate water supply dedicated to the sprinkler system based on the amount of sprinklers and the area of coverage is required and the supply system needs the appropriate pressure pumps to ensure continuous and automatic pressure. The automatic sprinkler system should have its own electrical generator power source in the event of a power failure. No evidence was provided of a certification from a certified sprinkler technician or the person or company who mounted the sprinkler system that this system has a combination of available flow and pressure and that this sprinkler system can meet the demand of the fire protection system or whether pumps and on-site tank is required (This facility does not have a pump (jockey pump) or its own water reserve (cistern or tank) dedicated for its sprinkler system. A water based fire protection system is only as reliable as its water supply source).

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #5), it was determined that the facility failed to ensure that portable Carbon Dioxide fire extinguishers are maintained related to appropriate inspections and appropriate sizes to ensure their use as required by the 2000 edition of the Life Safety Code of the NFPA Section 9.7.4.1 and NFPA 10.

Findings include:

1. The facility has Carbon Dioxide (Co2) fire extinguishers as observed on 4/7/11 from 8:30 am till 4:00 pm with the facility's Engineer (employee #5) and provided evidence that they are too heavy for some female staff members to use. Two smaller Co2 extinguishers of equal capacity (both combine to the same size as the large extinguishers) to the large extinguisher shall be used instead to ensure that they can be used effectively in the event of an emergency. These Carbon Dioxide (Co2) fire extinguishers were found at the following areas:
a. Located near the recovery room of the operating suite department
b. Located in the room between X-ray rooms #1 and #2
c. Located at the medical record department.

2. Written evidence about required annual carbon dioxide conductivity inspections of the fire extinguisher hose system was not provided by the facility on 4/7/11 at 2:30 pm when requested of the facility's Engineer (employee #5).

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #5), it was determined that the facility failed to monitor means of egress at the back staircase of the "External Clinics" to ensure that it is maintained free from all obstructions in accordance with the 2000 edition of the Life Safety Code of the NFPA Section 7.1.10.1.

Findings include:

The hallway located at the back of the "External Clinics" department was visited on 4/7/11 at 10:00 am with the facility's Engineer (employee #5) and provided evidence that a patient was lying on a stretcher in this hallway reducing the passage width to less than two feet. "Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in case of fire or other emergency".

Based on the review of written documents during the survey for life safety from fire with the facility's Engineer (employee #5), it was determined that the facility failed to ensure that personnel perform the monthly 30 minute load test of the electrical generator and monthly transfer switch tests as required by the NFPA 99, section 3.4.4.1.

Findings include:

1. The facility lacks written evidence that the electrical generator is tested under load conditions for 30 minutes on a monthly basis as reviewed on 4/7/11 at 2:35 pm with the facility's Engineer (employee #5).

2. The facility lacks written evidence that the electrical generators' transfer switch is tested on a monthly basis as reviewed on 4/7/11 at 2:40 pm with the facility's Engineer (employee #5).

Based on observations, interview and review of written documents during the survey for life safety from fire with the facility's Engineer (employee #5), it was determined that the facility failed to provide documentation related to the branches of the Type I Essential Electrical System as required by the NFPA 99, section 3.4.2.2.2.

Findings include:

The entire hospital is supplied by one generator as observed on 4/7/11 at 3:20 pm. The facility's Engineer (employee #5) stated during an interview on 4/7/11 at 3:25 pm that not all areas of the hospital are covered by the generator and the Intensive Care Unit has battery backup cells (which gives approximately four hours of uninterrupted full service to the Intensive Care Unit). A study must be performed to evaluate the facility's energy needs when municipal power is not available, which must divide the essential electrical system include two branches, the "Life Safety Branch" which provides power only to those functions or warning systems, such as alarm systems, exit signs, lighting of means of egress and communication system, necessary for safely leaving any building in an emergency. The "Critical Branch" includes those functions that maintain essential patient services, such as task illumination, fixed equipment, selected receptacles, operating rooms and certain special procedure radiology rooms where loss of lighting due to failure of the essential electrical system might cause severe and immediate danger to a patient undergoing surgery or an invasive radiographic procedure.