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The facility failed to provide corridors that were separated from use areas by walls that were smoke resisting. Corridor walls may terminate at a suspended ceiling which can limit the transfer of smoke. Observation determined the corridor walls had unsealed openings below the ceiling in the following locations:1) Spaces around a through-wall pipe penetration of the corridor wall between the corridor and the first floor Utility Room were not sealed to prevent the passage of smoke.2) An opening in the corridor wall between the corridor and the first floor Kitchen was not sealed to prevent the passage of smoke.3) Spaces around data cables above the north Kitchen door in the wall between the corridor and the first floor Kitchen were not sealed to prevent the passage of smoke.4) Spaces around data cables in the wall between the corridor and the Fan Room were not sealed to prevent the passage of smoke.

The facility's fire plan indicated patients were to be evacuated to the other side of the smoke doors in the event of a fire. This plan relies on a smoke barrier to be in place. The facility failed to ensure smoke barriers were maintained to provide at least a half-hour fire resistance rating.

Observation determined one (1) of one (1) smoke barrier had less than a half-hour fire resistance rating. Openings were not sealed with fire rated materials around multiple penetrations of the smoke barrier wall by data cables and pipe, in addition to unsealed openings, above the ceiling.

The facility failed to separate hazardous areas from other spaces by smoke resisting partitions and doors.

Observation determined:

1) Spaces around pipes and in the head of wall joint in the west Boiler Room wall were not sealed.

2) The door to the first floor Utility Room, which was determined to be greater than 50 square feet in area, lacked a self-closing device.

3) Combustible storage was located adjacent to the hydraulic pump for the elevator in the first floor Elevator Equipment Room. 4) Unsealed spaces around a through-wall pipe penetration above the doors to the first floor Central Storage Room.

The facility failed to ensure emergency lighting of at least 1? hour duration was provided. Battery-powered emergency lighting must be provided in anesthetizing locations in accordance with NFPA 70, National Electrical Code, Section 700-12(e).

Observation determined battery pack emergency lighting was not installed in the Operating Room.

The fire alarm system must be in compliance with NFPA 72. This standard requires annual functional testing of the fire alarm system and an annunciation panel located at a constantly occupied area.

1) The facility failed to ensure the fire alarm system was maintained, inspected and tested in accordance with the manufacturer's specifications. NFPA 72, 7-1.1.1.

Review of the fire alarm testing, inspection, and maintenance records indicated there was a fourteen month gap between the fire alarm test in November 2010 and the last fire alarm system test conducted in January 2012. 2) The primary purpose of fire alarm system annunciation is to enable responding personnel to identify the location of a fire quickly and accurately and to indicate the status of emergency equipment or fire safety functions that might affect the safety of occupants in a fire situation. Audible and visible fire alarm panel signals must be monitored at a constantly occupied area. NFPA 72, 1-5.7.1. The annunciation panel must monitor the fire alarm panel's primary functions:

a) Audible and visible signal that would indicate system trouble.

b) Visible signals that indicate which fire alarm zone are into alarm.

c) Audible and visible monitor of the fire alarm system supervisory signal.

Observation determined an annunciation panel was not located at a constantly occupied area. The fire alarm panel was located in Physical Therapy. The door to Physical Therapy is closed and locked after normal business hours.

Visual inspection frequencies and specific testing and maintenance frequencies for smoke detection systems are dictated by the prescriptive requirements of NFPA 72, National Fire Alarm Code (Chapter 10-Inspection, Testing and Maintenance Tables 10.3.1, 10.4.2.2 and 10.4.3). This code identifies specific inspection, testing and maintenance frequencies and methods.

Sensitivity testing of smoke detectors is to be completed for all smoke detectors during the first year in service, and the alternate year following. After the second required calibration test, if the detector has remained within its listed and marked sensitivity range, the length of time between calibration tests may be extended, not to exceed five years.

The facility failed to ensure smoke detectors were maintained, inspected and tested in accordance with NFPA 72.

Review of the fire alarm test results indicated the smoke detection system was not sensitivity tested at frequencies in compliance with the minimum requirements of NFPA 72. If the smoke detection system does not meet the allowance for five (5) years between testing, the system must be tested at least every two (2) years.

The last date documented for a smoke detector system sensitivity test was November 11, 2009. The facility was unable to provide documentation to verify a 5-year testing interval and exceeded the maximum 2-year interval.

The facility failed to maintain exit corridors free of all obstructions or impediments.

Observation determined:

1) Three (3) chairs, one (1) bed stand, one (1) file cabinet, one (1) night stand and a typewriter stand were stored in the first floor corridor. 2) A shelf attached to the corridor wall extended beyond the handrail by the Ambulance Garage.3) A shelf attached to the corridor wall extended beyond the handrail by the Admissions Office.

The facility failed to ensure that loosely hanging fabrics were flame resistant.

Record review determined no documentation was available to indicate decorative wall hangings in the Laboratory Drawing Room had been treated with flame retardant materials.

1) The facility failed to ensure oxygen supply piping and all shut-off valves were identified with markings/labels. 4-3.1.2.3. Observation determined the main oxygen supply line shut-off valve was not identified as the "Main Shut-off valve". No labels or other markings identified the valve. 2) The gas content of medical gas piping systems must be readily identifiable by appropriate labeling with the name and pressure of the gas contained at intervals of not more than 20 feet and at least once in each room and each story traversed by the piping system. Such labeling must be by means of metal tags, stenciling, stamping, or adhesive markers, in a manner that is not readily removable. 4-3.1.2.14. The facility failed to ensure appropriate labeling with the name and pressure of the gas contained in the copper pipes that supply oxygen to patient care areas throughout the facility.Observation determined the piping for the oxygen supply had no markings or labels applied to the piping to indicate the content of the gas line.

The facility failed to ensure electrical wiring and electrical equipment meets NFPA 70 requirements. Observation determined: 1) Power strips were in use for appliances other than computer or entertainment equipment in Physical Therapy for an ice machine, IV warmer, ultrasound unit, and a charging station. 2) Two (2) electrical junction boxes had no cover in the first floor Utility Room. 3) The ground fault circuit interrupter (GFCI) protected receptacle adjacent to the sink in the Kitchen was indicated to have an open ground when tested.

The facility failed to provide corridors that were separated from use areas by walls that were smoke resisting. Corridor walls may terminate at a suspended ceiling which can limit the transfer of smoke. Observation determined the corridor walls had unsealed openings below the ceiling in the following locations:1) Spaces around a through-wall pipe penetration of the corridor wall between the corridor and the first floor Utility Room were not sealed to prevent the passage of smoke.2) An opening in the corridor wall between the corridor and the first floor Kitchen was not sealed to prevent the passage of smoke.3) Spaces around data cables above the north Kitchen door in the wall between the corridor and the first floor Kitchen were not sealed to prevent the passage of smoke.4) Spaces around data cables in the wall between the corridor and the Fan Room were not sealed to prevent the passage of smoke.

The facility's fire plan indicated patients were to be evacuated to the other side of the smoke doors in the event of a fire. This plan relies on a smoke barrier to be in place. The facility failed to ensure smoke barriers were maintained to provide at least a half-hour fire resistance rating.

Observation determined one (1) of one (1) smoke barrier had less than a half-hour fire resistance rating. Openings were not sealed with fire rated materials around multiple penetrations of the smoke barrier wall by data cables and pipe, in addition to unsealed openings, above the ceiling.

The facility failed to separate hazardous areas from other spaces by smoke resisting partitions and doors.

Observation determined:

1) Spaces around pipes and in the head of wall joint in the west Boiler Room wall were not sealed.

2) The door to the first floor Utility Room, which was determined to be greater than 50 square feet in area, lacked a self-closing device.

3) Combustible storage was located adjacent to the hydraulic pump for the elevator in the first floor Elevator Equipment Room. 4) Unsealed spaces around a through-wall pipe penetration above the doors to the first floor Central Storage Room.

The facility failed to ensure emergency lighting of at least 1? hour duration was provided. Battery-powered emergency lighting must be provided in anesthetizing locations in accordance with NFPA 70, National Electrical Code, Section 700-12(e).

Observation determined battery pack emergency lighting was not installed in the Operating Room.

The fire alarm system must be in compliance with NFPA 72. This standard requires annual functional testing of the fire alarm system and an annunciation panel located at a constantly occupied area.

1) The facility failed to ensure the fire alarm system was maintained, inspected and tested in accordance with the manufacturer's specifications. NFPA 72, 7-1.1.1.

Review of the fire alarm testing, inspection, and maintenance records indicated there was a fourteen month gap between the fire alarm test in November 2010 and the last fire alarm system test conducted in January 2012. 2) The primary purpose of fire alarm system annunciation is to enable responding personnel to identify the location of a fire quickly and accurately and to indicate the status of emergency equipment or fire safety functions that might affect the safety of occupants in a fire situation. Audible and visible fire alarm panel signals must be monitored at a constantly occupied area. NFPA 72, 1-5.7.1. The annunciation panel must monitor the fire alarm panel's primary functions:

a) Audible and visible signal that would indicate system trouble.

b) Visible signals that indicate which fire alarm zone are into alarm.

c) Audible and visible monitor of the fire alarm system supervisory signal.

Observation determined an annunciation panel was not located at a constantly occupied area. The fire alarm panel was located in Physical Therapy. The door to Physical Therapy is closed and locked after normal business hours.

Visual inspection frequencies and specific testing and maintenance frequencies for smoke detection systems are dictated by the prescriptive requirements of NFPA 72, National Fire Alarm Code (Chapter 10-Inspection, Testing and Maintenance Tables 10.3.1, 10.4.2.2 and 10.4.3). This code identifies specific inspection, testing and maintenance frequencies and methods.

Sensitivity testing of smoke detectors is to be completed for all smoke detectors during the first year in service, and the alternate year following. After the second required calibration test, if the detector has remained within its listed and marked sensitivity range, the length of time between calibration tests may be extended, not to exceed five years.

The facility failed to ensure smoke detectors were maintained, inspected and tested in accordance with NFPA 72.

Review of the fire alarm test results indicated the smoke detection system was not sensitivity tested at frequencies in compliance with the minimum requirements of NFPA 72. If the smoke detection system does not meet the allowance for five (5) years between testing, the system must be tested at least every two (2) years.

The last date documented for a smoke detector system sensitivity test was November 11, 2009. The facility was unable to provide documentation to verify a 5-year testing interval and exceeded the maximum 2-year interval.

The facility failed to maintain exit corridors free of all obstructions or impediments.

Observation determined:

1) Three (3) chairs, one (1) bed stand, one (1) file cabinet, one (1) night stand and a typewriter stand were stored in the first floor corridor. 2) A shelf attached to the corridor wall extended beyond the handrail by the Ambulance Garage.3) A shelf attached to the corridor wall extended beyond the handrail by the Admissions Office.

The facility failed to ensure that loosely hanging fabrics were flame resistant.

Record review determined no documentation was available to indicate decorative wall hangings in the Laboratory Drawing Room had been treated with flame retardant materials.

1) The facility failed to ensure oxygen supply piping and all shut-off valves were identified with markings/labels. 4-3.1.2.3. Observation determined the main oxygen supply line shut-off valve was not identified as the "Main Shut-off valve". No labels or other markings identified the valve. 2) The gas content of medical gas piping systems must be readily identifiable by appropriate labeling with the name and pressure of the gas contained at intervals of not more than 20 feet and at least once in each room and each story traversed by the piping system. Such labeling must be by means of metal tags, stenciling, stamping, or adhesive markers, in a manner that is not readily removable. 4-3.1.2.14. The facility failed to ensure appropriate labeling with the name and pressure of the gas contained in the copper pipes that supply oxygen to patient care areas throughout the facility.Observation determined the piping for the oxygen supply had no markings or labels applied to the piping to indicate the content of the gas line.

The facility failed to ensure electrical wiring and electrical equipment meets NFPA 70 requirements. Observation determined: 1) Power strips were in use for appliances other than computer or entertainment equipment in Physical Therapy for an ice machine, IV warmer, ultrasound unit, and a charging station. 2) Two (2) electrical junction boxes had no cover in the first floor Utility Room. 3) The ground fault circuit interrupter (GFCI) protected receptacle adjacent to the sink in the Kitchen was indicated to have an open ground when tested.