HospitalInspections.org

Based on observation and facility staff interview, the facility staff failed to provide continuously maintained exit ways free of all obstructions or impediments continuous to a public way such as a parking lot. This deficient practice affects one exit discharge areas. This deficient practice has the potential to affect all patients, staff and visitors in the facility. Failure to ensure exterior exit ways comply with LSC requirements could delay evacuation out of the building in the event of a fire or other emergency. The facility census was 11.


1. Observation on 03/08/18, during the facility tour, showed the designated hallway #1 exit discharge landing led to a grass covered yard that required residents, staff, and visitors to traverse grass to reach the street.


During an interview on 3/09/18 at 9:30 A.M., the Facilities Director said the building was constructed between 1967-1968 without a sidewalk.


The National Fire Protection Association 101, Life Safety Code 2012 Edition, section 7.7 states:


7.7 Discharge from Exits.

7.7.1* Exit Termination. Exits shall terminate directly, at a
public way or at an exterior exit discharge, unless otherwise
provided in 7.7.1.2 through 7.7.1.4.

Based on observation and facility staff interview, facility staff failed to provide emergency lighting not controlled by light switches inside one medication room. This deficient practice has the potential to affect all patients within the nursing unit served by the medication room. Failure to provide emergency lighting could prevent proper illumination of required areas in the event of power loss. The facility census was 11.

1. Observations on 03/08/18, during the Life Safety Code (LCS) tour, showed the light fixtures in the emergency department medication room controlled by a light switch.

During an interview on 3/13/2018, the facility Administrator said he believed the light switch met code requirements because the emergency department was constructed in 2008 and the lights were installed during the construction.




NFPA 99, 2012 edition, section 6.4.2.2.4.2 states:

"6.4.2.2.4.2 The critical branch shall supply power for task illumination,
fixed equipment, select receptacles, and select power
circuits serving the following areas and functions related to patient
care:
(1) Critical care areas that utilize anesthetizing gases, task illumination,
select receptacles, and fixed equipment
(2) Isolated power systems in special environments
(3) Task illumination and select receptacles in the following:
(a) Patient care rooms, including infant nurseries, selected
acute nursing areas, psychiatric bed areas (omit receptacles),
and ward treatment rooms
(b) Medication preparation areas
(c) Pharmacy dispensing areas
(d) Nurses ' stations (unless adequately lighted by corridor
luminaires)
(4) Additional specialized patient care task illumination and
receptacles, where needed
(5) Nurse call systems
(6) Blood, bone, and tissue banks
(7)*Telephone equipment rooms and closets
(8) Task illumination, select receptacles, and select power circuits
for the following areas:
(a) General care beds with at least one duplex receptacle
per patient bedroom, and task illumination as required
by the governing body of the health care facility
(b) Angiographic labs
(c) Cardiac catheterization labs
(d) Coronary care units
(e) Hemodialysis rooms or areas
(f) Emergency room treatment areas (select)
(g) Human physiology labs
(h) Intensive care units
(i) Postoperative recovery rooms (select)
(9) Additional task illumination, receptacles, and select power
circuits needed for effective facility operation, including
single-phase fractional horsepower motors, which are permitted
to be connected to the critical branch"

Based on observation, the facility staff failed to provide a 1-hour rated separation between a hazardous area (areas that pose a degree of hazard greater than normal to the general occupancy of the building such as areas used for storage or use of combustibles or flammables, toxic, noxious, or corrosive materials, or heat producing appliances) and one designated exit corridors in the facility per NFPA (National Fire Protection Association) requirements. Failure to separate the designated exits and provide rated one hour walls and fire rated doors equipped with a self-closing device puts all patients, staff and visitors at risk of injury or death from a fire by not containing the fire and smoke within the hazardous area and eliminating the two required means of egress. The facility census was 11.


1. Observation on 03/08-09/2018, during the facility tour, showed the following hazardous areas not separated from the designated exit corridors:

-Maintenance shop wall inside the room had 3 holes containing a sprinkler pipe, electrical conduit and one open hole. Observation showed various combustible materials and welding gas storage in the room.

-A room without a door behind the medical records room containing a large quantity of combustible materials. Observation showed the door across the hall from the OR access door did not have a self closure or positive latching. Observation showed the door across the hall from the kitchen did not have a self closing device.

-Kitchen Dutch door had a 1/4 inch gap between the top and bottom door leaves. Additionally, the door did not have a self closing device. Observation showed the kitchen contained a counter top deep fryer.

-Cafeteria entrance door did not have a self closing device.

During an interview on 3/13/2018, the facility Administrator said the doors were existing in the building prior to his starting work at the hospital in 1986.


19.3.2.1.5 Hazardous areas shall include, but shall not be restricted
to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Rooms with soiled linen in volume exceeding 64 gal (242 L)
(6) Rooms with collected trash in volume exceeding 64 gal
(242 L)
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including
repair shops, used for storage of combustible supplies and
equipment in quantities deemed hazardous by the authority
having jurisdiction

19.3.6.3.13 Dutch doors shall be permitted where they conform
to 19.3.6.3 and meet all of the following criteria:
(1) Both the upper leaf and lower leaf are equipped with a
latching device.
(2) The meeting edges of the upper and lower leaves are
equipped with an astragal, a rabbet, or a bevel.
(3) Where protecting openings in enclosures around hazardous
areas, the doors comply with NFPA80, Standard for Fire
Doors and Other Opening Protectives.

Based on observation the facility staff failed to ensure the range hood was maintained in accordance with National Fire Protection Association standards. Penetrations in the range hood were not properly sealed. Extinguishing system nozzles were not installed over fire hazard. Range hood did not have a grease removal drip tray. Failure to maintain the range hood, provide a grease removal drip tray and install the extinguishing system over the fire hazard has the potential to affect all building occupants in the event of a fire. The facility census was 11.

Observation during the Life Safety Code (LSC) tour on 3/08-09/2018 showed two penetrations in the back of the range hood above the filter near the ceiling. Observation showed two-two inch round holes.

Observation showed a counter top deep fryer on the work counter below the range hood. Observation showed the extinguishing nozzles were installed at an angle not over the fryer and were approximately three feet from the fryer.

Observation did not show a grease removal drip tray attached to the range hood.

National Fire Protection Association (NFPA) 96, 2011 edition states:


5.1.11 Penetrations shall be sealed with listed devices in accordance
with the requirements of 5.1.12.

5.1.12 Devices that require penetration of the hood, such as
pipe and conduit penetration fittings and fasteners, shall be
listed in accordance with ANSI/UL 1978.

6.2.4 Grease Drip Trays.

6.2.4.1 Grease filters shall be equipped with a grease drip tray
beneath their lower edges.

6.2.4.2 Grease drip trays shall be kept to the minimum size
needed to collect grease.

6.2.4.3 Grease drip trays shall be pitched to drain into an enclosed
metal container having a capacity not exceeding 3.8 L
(1 gal).

Based on record review and facility staff interview, facility staff did not ensure all devices connected to the fire alarm system were inspected and tested per NFPA 72, National Fire Alarm and Signaling Code, 2010 edition. The facility census was 11.

Record review of the annual fire alarm inspections for 2017 showed the facility staff conducted the fire alarm, smoke detector function testing, pull stations, alarms, strobes, kitchen range hood to FACP connection test, magnetic hold open devices, lab roll down door and dialer inspections.

Record review of the annual fire alarm inspection did not show smoke detector sensitivity testing for the facility smoke detectors.

Record review of the annual fire alarm inspection did not show testing of the sprinkler flow alarms, sprinkler tamper alarms and post indicator valve alarm.

Record review of the facility fire alarm inspection records did not show semi annual fire alarm system inspections.

During an interview on 3/13/2018, the facility Administrator said the staff did not know they could not conduct
the facility fire alarm inspection.

Refer to NFPA 72, National Fire Alarm and Signaling Code, 2010 edition, Table 14.3.1, Table 14.4.2.2, Table 14.4.5, sections 14.4.5, 14.4.5.3.1 through section 14.4.5.4 for additional testing information.


NFPA 72, National Fire Alarm and Signaling Code, 2010 edition, Section 10.4.3 states:

10.4.3 Inspection, Testing, and Maintenance Personnel. (SIGTMS)

10.4.3.1* Service personnel shall be qualified and experienced
in the inspection, testing, and maintenance of systems addressed
within the scope of this Code. Qualified personnel shall include,
but not be limited to, one or more of the following:
(1)*Personnel who are factory trained and certified for the
specific type and brand of system being serviced
(2)*Personnel who are certified by a nationally recognized
certification organization acceptable to the authority having
jurisdiction
(3)*Personnel who are registered, licensed, or certified by a
state or local authority to perform service on systems addressed
within the scope of this Code
(4) Personnel who are employed and qualified by an organization
listed by a nationally recognized testing laboratory
for the servicing of systems within the scope of this Code
10.4.3.2 Evidence of qualifications shall be provided to the
authority having jurisdiction upon request.

Based on observation and facility staff interview, facility staff failed to ensure areas open to the corridor contain smoke detection
per NFPA 72, National Fire Alarm and Signaling Code. This deficient practice has the potential to effect all facility patients, staff and visitors. This deficient practice could delay fire and emergency personnel response in the event of a fire. The facility census was 11.

Observations on 3/08-09/2018, during the facility tour, showed the following areas open to the designated exit corridors requiring smoke detectors:

-Lab waiting room
-Radiology work room
-Vending machine alcove

During an interview on 3/13/2018, the facility Administrator said the vending machine alcove was constructed in 2008 and never had smoke detection. Additionally, he said the laboratory and radiology work room were renovated in 2008 and never had smoke detection.

19.3.4.1 General. Health care occupancies shall be provided
with a fire alarm system in accordance with Section 9.6.

Refer to NFPA 72, National Fire Alarm and Signaling Code, 2010 edition, sections 17.6.3 Location and Spacing and 17.6.3.3.1 Spacing for additional information.

Based on observation and facility staff interview, the facility staff failed to provide sprinkler coverage in accordance with NFPA 13, Standard For The Installation Of Sprinkler Systems, 2010 edition installation requirements. Facility staff failed to provide correct application of sprinkler heads for the entire building. This deficient practice could delay activation of the sprinkler system for prompt fire extinguishment. This deficient practice has the potential to affect all facility residents. The facility census was 11.

Observation on 3/08/2018, during the facility tour, of the old mechanical room, showed a mix of quick response sprinkler heads and standard response sprinkler heads in the same compartmented space.

During an interview on 3/13/2018, the facility Administrator said the new operating rooms addition was constructed during the early 1980's and the new sprinkler system was connected to the old sprinkler system at that time.



NFPA 13, Standard For The Installation Of Sprinkler Systems, 2010 edition states:

8.3.3 Thermal Sensitivity.
8.3.3.1* Sprinklers in light hazard occupancies shall be one of
the following:
(1) Quick-response type as defined in 3.6.4.7
(2) Residential sprinklers in accordance with the requirements
of 8.4.5
(3) Standard-response sprinklers used for modifications or
additions to existing light hazard systems equipped with
standard-response sprinklers
(4) Standard-response sprinklers used where individual
standard-response sprinklers are replaced in existing light
hazard systems
8.3.3.2 Where quick-response sprinklers are installed, all
sprinklers within a compartment shall be quick-response unless
otherwise permitted in 8.3.3.3.
8.3.3.3 Where there are no listed quick-response sprinklers
in the temperature range required, standard-response sprinklers
shall be permitted to be used.
8.3.3.4 When existing light hazard systems are converted to
use quick-response or residential sprinklers, all sprinklers in a
compartmented space shall be changed.

Based on record review, facility staff failed to inspect the one wet sprinkler system per NFPA 25, Standard for the Inspection, Testing, and maintenance of Water-Based Fire Protection Systems, 2011 edition. Failure to test and maintain the sprinkler systems could affect the sprinkler system's performance in the event of a fire. This deficient practice has the potential to affect all facility residents. The facility had a census of 11.


1) Record review on 03/09/2018 did not show the following inspections:

-five (5) year internal pipe inspections/testing

-five year gauge replacement/calibration records

-five year check valve interior inspections

During an interview on 3/13/2018, the facility Administrator said facility staff was not aware of the five year sprinkler inspection requirements.


Refer to NFPA 25, Standard for the Inspection, Testing, and maintenance of Water-Based Fire Protection Systems, 2011 edition, Chapters 5, 13, and 14 for additional information.



5.3.2* Gauges.
5.3.2.1 Gauges shall be replaced every 5 years or tested every
5 years by comparison with a calibrated gauge.

5.3.2.2 Gauges not accurate to within 3 percent of the full
scale shall be recalibrated or replaced.

14.2 Internal Inspection of Piping.
14.2.1 Except as discussed in 14.2.1.1 and 14.2.1.4 an inspection
of piping and branch line conditions shall be conducted
every 5 years by opening a flushing connection at the end of
one main and by removing a sprinkler toward the end of one
branch line for the purpose of inspecting for the presence of
foreign organic and inorganic material.
14.2.1.1 Alternative nondestructive examination methods
shall be permitted.
14.2.1.2 Tubercules or slime, if found, shall be tested for indications
of microbiologically influenced corrosion (MIC).
14.2.1.3* If the presence of sufficient foreign organic or
inorganic material is found to obstruct pipe or sprinklers,
an obstruction investigation shall be conducted as described
in Section 14.3.


13.4.2 Check Valves.
13.4.2.1 Inspection. Valves shall be inspected internally every
5 years to verify that all components operate correctly, move
freely, and are in good condition.


13.4 System Valves.
13.4.1 Inspection of Alarm Valves. Alarm valves shall be inspected
as described in 13.4.1.1 and 13.4.1.2.

13.4.1.1* Alarm valves and system riser check valves shall be
externally inspected monthly and shall verify the following:
(1) The gauges indicate normal supply water pressure is being
maintained.
(2) The valve is free of physical damage.
(3) All valves are in the appropriate open or closed position.
(4) The retarding chamber or alarm drains are not leaking.

13.4.1.2* Alarm valves and their associated strainers, filters,
and restriction orifices shall be inspected internally every
5 years unless tests indicate a greater frequency is necessary.

Based on observation and facility staff interview, facility staff failed to ensure corridor doors latched. This deficient practice has the potential to affect all patients, staff and visitors. Failure to ensure corridor doors latch has the potential to prevent or delay evacuation out of the building in the event of a fire or other emergency by allowing smoke, fumes and the products of fire from entering the exit corridors in the event of a fire. The facility census was 11.

Observation on 3/08-09/2018, during the building tour, showed the following doors did not latch:

-Medical records door on 2 hall contained a roller latch
-Housekeeping corridor door on employee corridor did not positive latch
-Operating room corridor door on 2 hall did not contain a latching mechanism

During an interview on 3/13/2018, the facility Administrator said the doors were installed during the original 1967-1968 building construction.



Roller latches are prohibited by CMS regulation.

Based on record review and facility staff interview, facility staff failed to conduct an annual load bank test of the emergency generator. Facility staff failed to provide an emergency stop switch for the emergency generator. The facility census was 11.

1) Observation during the facility tour showed the emergency generator emergency stop switch located within the generator enclosure.

2) Review of the facility supplied generator inspection records did not show annual testing with the available building electrical load was a minimum of 30% of the generator nameplate rating.

During an interview on 3/09/2018, the Facilities Director said the building pulled approximately 11% of the 180 KW emergency generator .

NFPA 110, Standard for Emergency and Standby Power Systems, 2010 edition states:

5.6.5.6* All installations shall have a remote manual stop station
of a type to prevent inadvertent or unintentional operation located
outside the room housing the prime mover, where so installed,
or elsewhere on the premises where the prime mover is
located outside the building.

5.6.5.6.1 The remote manual stop station shall be labeled.

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

8.4.2.1 The date and time of day for required testing shall be
decided by the owner, based on facility operations.

8.4.2.2 Equivalent loads used for testing shall be automatically
replaced with the emergency loads in case of failure of
the primary source.

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.

Based on observation, the facility staff failed to ensure extension cords were not used permanently, multi plug adaptors were not used and surge protectors met NFPA requirements. The facility census was 11.


Observation on 3/08-09/2018, during the facility tour, showed multiple power taps without the correct rating and one multi plug extension cord in the Laboratory. Additional observation showed the power taps were not UL 1363, 1363A or 60601-1 rated.


Refer to NFPA 70, National Electrical Code, 2011 edition, Article 400.8 for additional information.