HospitalInspections.org

Based on observation and interview, the critical access hospital failed to maintain the integrity of a two-hour fire resistance rated wall between the hospital and an adjoining non-conforming occupancy.

Failure to maintain the integrity of an occupancy separation risks spread of smoke and fire into the hospital from the adjoining building with a lesser level of fire protection.

Findings include:

During a tour of the critical access hospital on 08/03/2011, the chief engineer stated that a two-hour fire resistance rated wall was constructed between the former acute care hospital and the present hospital building. The wall was traced on floor plans. Upon visual inspection, it was found that:

a) A rated door in the basement tunnel linking the two buildings could not be fully closed and latched due to settling, warpage or other mechanical reason
b) Three holes had been bored in the concrete barrier adjacent to the door mentioned above. These holes were not sealed
c) A door between the physician sleep room in the old hospital building and a corridor near the entrance lobby in the new hospital building was not provided with a rating label indicating that the door was an approved part of a two-hour fire resistance rated wall.

The hospital chief engineer confirmed the observations.

Based on observation, the critical access hospital failed to maintain doors in a condition that permits them to close without impediment.

Failure to maintain doors in a closing condition risks spread of smoke and fire throughout the hospital corridors.

Findings include:

During a tour of the critical access hospital on 08/02/2011 - 08/03/2011, doors protecting corridor openings in the following locations were observed to not fully close and latch:

Physical therapy office
Physical therapy small office
Dining room door
Business office next to auxiliary office
Business office door behind desks, where a wedge was observed.

The hospital chief engineer confirmed the observations.

The above conditions were corrected during the survey.

Based on observation, the critical access hospital failed to maintain one-hour fire resistance rated construction around an elevator shaft.

Failure to maintain a one-hour fire resistance rating around an elevator shaft risks spread of smoke and fire throughout the building.

Findings include:

During a tour of the critical access hospital on 08/02/2011, it was observed that the door protecting the elevator lobby on the 2nd floor acute care inpatient unit did not latch securely upon closing.

The hospital chief engineer confirmed the observations.

This condition was corrected during the survey.

Based on observation, the critical access hospital failed to maintain smoke barriers in a manner that would resist the passage of smoke and heat between smoke compartments.

Failure to maintain smoke barriers risks spread of smoke and fire between smoke compartments.

Findings include:

During a tour of the critical access hospital on 08/03/2011, it was observed that the smoke barrier walls on the 1st and 2nd floors of the hospital had numerous penetrations, including but not limited to the following:

Above the ceiling in patient room 220 (two penetrations)
Above the ceiling over the nourishment room door opposite patient rooms 208 and 209
Above the ceiling in the bathroom of patient room 209
In the 1st floor lobby
Above the ceiling over the public door to radiology
Above the ceiling opposite the public doors to radiology
Above the ceiling in the emergency department exam rooms 2 and 4
Above the ceiling in the emergency department trauma room 3
In the wall in the nitrous oxide manifold room

The hospital chief engineer confirmed the observations.

These conditions were corrected during the survey.

Based on observation, the critical access hospital failed to maintain doors in smoke barrier openings in a latching condition.

Failure to maintain doors in smoke barrier openings in latching condition risks spread of smoke and fire between smoke compartments.

Findings include:

During a tour of the critical access hospital on 08/02/2011, it was observed that the smoke barrier doors near patient rooms 209 and 220 did not latch when permitted to close automatically.

The hospital engineering manager confirmed the observations.

The condition was corrected during the survey.

Based on observation, the critical access hospital failed to arrange exit access in a manner that was readily accessible at all times, by failing to provide a locked exit access door with an approved release device.

Failure to arrange exit access in a manner that is readily available at all times risks entrapment of patients, staff or visitors during an emergency.

Findings include:

During a tour of the critical access hospital on 08/02/2011, it was observed that the cross-corridor doors leading to surgery, at the west end of the corridor leading from the hospital lobby to the public radiology department access, were marked with an "EXIT" sign. The hospital engineering manager confirmed that this corridor was a route of exit egress from the building. The doors were locked with a magnetic hold device that released upon entry of a code. There was no 15-second delayed egress device, nor was there any other approved release device for this exit door.

The hospital engineering manager confirmed the observation.

Based on observation, the critical access hospital failed to provide complete fire sprinkler coverage for all portions of the building.

Failure to provide complete fire sprinkler coverage in the building risks uncontrolled spread of fire and smoke.

Findings include:

During a tour of the critical access hospital on 08/02/2011 - 08/03/2011, it was observed that the approved automatic sprinkler system did not include sprinkler coverage in these areas:

The autoclave access closet, where the ceiling was lowered according to the hospital engineering manager

A closet in the old radiology department, which was used as combustibles storage during the survey

The hospital engineering manager confirmed the observations.

Based on interview and record review, the critical access hospital failed to conduct quarterly maintenance inspections of the approved automatic sprinkler system as required by the Code.

Failure to conduct quarterly inspections of the sprinkler system risks failure of the system in the event of fire.

Reference:
NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition

2-1 General. ...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

[This table indicates that quarterly inspections and testing are required for these parts of the system:

Alarm devices (inspection)
Hydraulic nameplate (inspection)
Alarm devices (test)

Findings include:

a) During review of sprinkler system maintenance records on 08/03/2011, it was found that there was no documentation of quarterly sprinkler system inspections. The hospital engineering manager stated that quarterly inspections were not performed.

b) During a tour of the hospital on 08/03/2011, it was observed that cables were attached to sprinkler system piping in the stairwell leading to the rooftop helipad.

The hospital engineering manager confirmed the observations.

Based on observation, the critical access hospital failed to maintain portable fire extinguishers in accordance with the requirements of NFPA 10.

Failure to maintain portable fire extinguishers risks failure of this critical fire-fighting device.

Findings include:

During a tour of the critical access hospital on 08/03/2011, it was observed that:

a) Portable fire extinguishers in all communication and electrical rooms were placed on the floors of the rooms, rather than mounted at a convenient height
b) The fire extinguishers located in the north and south penthouses of the old hospital building did not show evidence of monthly maintenance checks between March, 2011 and July, 2011.

The hospital engineering manager confirmed the observations.

Based on observation, the hospital failed to maintain cooking facilities in a fire-safe manner.

Failure to maintain cooking facilities in a fire-safe manner risks ignition and spread of fire in the hospital kitchen.

Findings include:

During a tour of the critical access hospital on 08/03/2011, it was observed that the filters over the kitchen stove were coated with a layer of what appeared to be grease and dust.

The hospital engineering manager confirmed the observation.

Based on observation, the critical access hospital failed to maintain corridors free of obstructions or other impediments to instant use.

Failure to maintain corridors free of impediments to use risks inability of patients, staff and visitors to evacuate the hospital quickly in the event of emergency.

Findings include:

During a tour of the critical access hospital on -08/02/2011, it was observed that the following exit access corridors were obstructed:

The acute care unit, where computers on wheels (COWs) were placed in the corridors outside at least two patient rooms
The operating room exit corridor, where a laundry bin was located
The emergency department, where COWs were placed in the exit corridor

The hospital engineering manager confirmed the observations.

Based on observation, the critical access hospital failed to maintain large linen receptacles in a room protected as a hazardous area.

Failure to maintain large receptacles in hazardous areas risks spread of smoke and fire throughout the hospital exit corridors.

Findings include:

During a tour of the hospital on 08/02/2011, it was observed that a linen receptacle exceeding 32 gallons in size was placed in a room referred to as the "old vending machine room" by the hospital engineering manager. This room did not have a door. The room was located in the exit corridor adjacent to the hospital kitchen.

The hospital engineering manager confirmed the observations.

The condition was corrected during the survey.

Based on observation, interview and record review, the critical access hospital failed to maintain emergency lighting and acceptable levels of humidity in the hospital operating rooms.

Failure to maintain emergency lighting in the operating rooms risks blackout during surgery if the hospital generators should fail during an electrical utility outage.

Failure to maintain humidity within acceptable limits in the operating rooms risks ignition of fire in an anesthetizing area.

Findings include:

During a tour of the critical access hospital on 08/02/2011, it was stated by the hospital engineering manager that:

a) Emergency backup lighting provided in the operating rooms was not tested for 30 seconds on a monthly basis and for 90 minutes on an annual basis. When the emergency light test button was pressed in the endoscopy procedure room, the light did not activate.

b) There was no means for maintaining humidity in the operating rooms at minimum 35%. Review of the operating room humidity logs for two years found that six months' data was not recorded in 2009 - 2010 and in 2010 - 2011. The missing data was for the winter months, when humidity typically decreases in this community. The logs did show humidity dropping in October 2009 and October 2010 before the logs ended for six months. During the time that humidity was documented, levels were noted as low as 23%. The humidity logs had a reference of "30% - 60%", rather than the minimum 35% required by the Code.

The hospital engineering manager confirmed the observations.

Based on observation, interview and record review, the critical access hospital failed to test the fire pump weekly as required by the Code.

Failure to test the fire pumps as required by the Code risks failure of these pumps during a fire emergency.

Reference:
NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition

5-1.1 Table 5-1.1 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance.

Table 5-1.1 Summary of Fire Pump Inspection, Testing, and Maintenance
Pump operation, No-flow condition: Test Weekly

Findings include:

During a tour of the critical access hospital on 08/02/2011, it was observed that a fire pump was located on the fire suppression system originating in the hospital basement. Review of engineering records on 08/03/2011 found no evidence that the fire pump was tested weekly in a "no flow" condition. The hospital engineering manager stated that there was no plan to test the fire pump weekly.

Based on observation, the critical access hospital failed to maintain the Type I EES in three required branches with the appropriate electrical loads located on each branch.

Failure to locate appropriate electrical loads on the correct branch risks failure of the hospital emergency essential electrical system.

Findings include:

During a tour of the critical access hospital on 08/02/2011, it was observed that electrical distribution and circuit panels for the life safety, critical and equipment branches did not include only the permitted electrical loads on each panel. Examples include, but are not limited to:

Heart telemetry functions located on the life safety branch (rather than the proper critical branch)
Heart telemetry functions located on the equipment branch (rather than the proper critical branch)
Datascope repeater located on the life safety branch (rather than the proper critical branch)
Emergency department exit corridor lighting located on the critical branch (rather than the proper life safety branch)

The hospital engineering manager confirmed the observations.

Based on observation and interview, the critical access hospital failed to maintain the integrity of a two-hour fire resistance rated wall between the hospital and an adjoining non-conforming occupancy.

Failure to maintain the integrity of an occupancy separation risks spread of smoke and fire into the hospital from the adjoining building with a lesser level of fire protection.

Findings include:

During a tour of the critical access hospital on 08/03/2011, the chief engineer stated that a two-hour fire resistance rated wall was constructed between the former acute care hospital and the present hospital building. The wall was traced on floor plans. Upon visual inspection, it was found that:

a) A rated door in the basement tunnel linking the two buildings could not be fully closed and latched due to settling, warpage or other mechanical reason
b) Three holes had been bored in the concrete barrier adjacent to the door mentioned above. These holes were not sealed
c) A door between the physician sleep room in the old hospital building and a corridor near the entrance lobby in the new hospital building was not provided with a rating label indicating that the door was an approved part of a two-hour fire resistance rated wall.

The hospital chief engineer confirmed the observations.

Based on observation, the critical access hospital failed to maintain doors in a condition that permits them to close without impediment.

Failure to maintain doors in a closing condition risks spread of smoke and fire throughout the hospital corridors.

Findings include:

During a tour of the critical access hospital on 08/02/2011 - 08/03/2011, doors protecting corridor openings in the following locations were observed to not fully close and latch:

Physical therapy office
Physical therapy small office
Dining room door
Business office next to auxiliary office
Business office door behind desks, where a wedge was observed.

The hospital chief engineer confirmed the observations.

The above conditions were corrected during the survey.

Based on observation, the critical access hospital failed to maintain one-hour fire resistance rated construction around an elevator shaft.

Failure to maintain a one-hour fire resistance rating around an elevator shaft risks spread of smoke and fire throughout the building.

Findings include:

During a tour of the critical access hospital on 08/02/2011, it was observed that the door protecting the elevator lobby on the 2nd floor acute care inpatient unit did not latch securely upon closing.

The hospital chief engineer confirmed the observations.

This condition was corrected during the survey.

Based on observation, the critical access hospital failed to maintain smoke barriers in a manner that would resist the passage of smoke and heat between smoke compartments.

Failure to maintain smoke barriers risks spread of smoke and fire between smoke compartments.

Findings include:

During a tour of the critical access hospital on 08/03/2011, it was observed that the smoke barrier walls on the 1st and 2nd floors of the hospital had numerous penetrations, including but not limited to the following:

Above the ceiling in patient room 220 (two penetrations)
Above the ceiling over the nourishment room door opposite patient rooms 208 and 209
Above the ceiling in the bathroom of patient room 209
In the 1st floor lobby
Above the ceiling over the public door to radiology
Above the ceiling opposite the public doors to radiology
Above the ceiling in the emergency department exam rooms 2 and 4
Above the ceiling in the emergency department trauma room 3
In the wall in the nitrous oxide manifold room

The hospital chief engineer confirmed the observations.

These conditions were corrected during the survey.

Based on observation, the critical access hospital failed to maintain doors in smoke barrier openings in a latching condition.

Failure to maintain doors in smoke barrier openings in latching condition risks spread of smoke and fire between smoke compartments.

Findings include:

During a tour of the critical access hospital on 08/02/2011, it was observed that the smoke barrier doors near patient rooms 209 and 220 did not latch when permitted to close automatically.

The hospital engineering manager confirmed the observations.

The condition was corrected during the survey.

Based on observation, the critical access hospital failed to arrange exit access in a manner that was readily accessible at all times, by failing to provide a locked exit access door with an approved release device.

Failure to arrange exit access in a manner that is readily available at all times risks entrapment of patients, staff or visitors during an emergency.

Findings include:

During a tour of the critical access hospital on 08/02/2011, it was observed that the cross-corridor doors leading to surgery, at the west end of the corridor leading from the hospital lobby to the public radiology department access, were marked with an "EXIT" sign. The hospital engineering manager confirmed that this corridor was a route of exit egress from the building. The doors were locked with a magnetic hold device that released upon entry of a code. There was no 15-second delayed egress device, nor was there any other approved release device for this exit door.

The hospital engineering manager confirmed the observation.

Based on observation, the critical access hospital failed to provide complete fire sprinkler coverage for all portions of the building.

Failure to provide complete fire sprinkler coverage in the building risks uncontrolled spread of fire and smoke.

Findings include:

During a tour of the critical access hospital on 08/02/2011 - 08/03/2011, it was observed that the approved automatic sprinkler system did not include sprinkler coverage in these areas:

The autoclave access closet, where the ceiling was lowered according to the hospital engineering manager

A closet in the old radiology department, which was used as combustibles storage during the survey

The hospital engineering manager confirmed the observations.

Based on interview and record review, the critical access hospital failed to conduct quarterly maintenance inspections of the approved automatic sprinkler system as required by the Code.

Failure to conduct quarterly inspections of the sprinkler system risks failure of the system in the event of fire.

Reference:
NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition

2-1 General. ...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

[This table indicates that quarterly inspections and testing are required for these parts of the system:

Alarm devices (inspection)
Hydraulic nameplate (inspection)
Alarm devices (test)

Findings include:

a) During review of sprinkler system maintenance records on 08/03/2011, it was found that there was no documentation of quarterly sprinkler system inspections. The hospital engineering manager stated that quarterly inspections were not performed.

b) During a tour of the hospital on 08/03/2011, it was observed that cables were attached to sprinkler system piping in the stairwell leading to the rooftop helipad.

The hospital engineering manager confirmed the observations.

Based on observation, the critical access hospital failed to maintain portable fire extinguishers in accordance with the requirements of NFPA 10.

Failure to maintain portable fire extinguishers risks failure of this critical fire-fighting device.

Findings include:

During a tour of the critical access hospital on 08/03/2011, it was observed that:

a) Portable fire extinguishers in all communication and electrical rooms were placed on the floors of the rooms, rather than mounted at a convenient height
b) The fire extinguishers located in the north and south penthouses of the old hospital building did not show evidence of monthly maintenance checks between March, 2011 and July, 2011.

The hospital engineering manager confirmed the observations.

Based on observation, the hospital failed to maintain cooking facilities in a fire-safe manner.

Failure to maintain cooking facilities in a fire-safe manner risks ignition and spread of fire in the hospital kitchen.

Findings include:

During a tour of the critical access hospital on 08/03/2011, it was observed that the filters over the kitchen stove were coated with a layer of what appeared to be grease and dust.

The hospital engineering manager confirmed the observation.

Based on observation, the critical access hospital failed to maintain corridors free of obstructions or other impediments to instant use.

Failure to maintain corridors free of impediments to use risks inability of patients, staff and visitors to evacuate the hospital quickly in the event of emergency.

Findings include:

During a tour of the critical access hospital on -08/02/2011, it was observed that the following exit access corridors were obstructed:

The acute care unit, where computers on wheels (COWs) were placed in the corridors outside at least two patient rooms
The operating room exit corridor, where a laundry bin was located
The emergency department, where COWs were placed in the exit corridor

The hospital engineering manager confirmed the observations.

Based on observation, the critical access hospital failed to maintain large linen receptacles in a room protected as a hazardous area.

Failure to maintain large receptacles in hazardous areas risks spread of smoke and fire throughout the hospital exit corridors.

Findings include:

During a tour of the hospital on 08/02/2011, it was observed that a linen receptacle exceeding 32 gallons in size was placed in a room referred to as the "old vending machine room" by the hospital engineering manager. This room did not have a door. The room was located in the exit corridor adjacent to the hospital kitchen.

The hospital engineering manager confirmed the observations.

The condition was corrected during the survey.

Based on observation, interview and record review, the critical access hospital failed to maintain emergency lighting and acceptable levels of humidity in the hospital operating rooms.

Failure to maintain emergency lighting in the operating rooms risks blackout during surgery if the hospital generators should fail during an electrical utility outage.

Failure to maintain humidity within acceptable limits in the operating rooms risks ignition of fire in an anesthetizing area.

Findings include:

During a tour of the critical access hospital on 08/02/2011, it was stated by the hospital engineering manager that:

a) Emergency backup lighting provided in the operating rooms was not tested for 30 seconds on a monthly basis and for 90 minutes on an annual basis. When the emergency light test button was pressed in the endoscopy procedure room, the light did not activate.

b) There was no means for maintaining humidity in the operating rooms at minimum 35%. Review of the operating room humidity logs for two years found that six months' data was not recorded in 2009 - 2010 and in 2010 - 2011. The missing data was for the winter months, when humidity typically decreases in this community. The logs did show humidity dropping in October 2009 and October 2010 before the logs ended for six months. During the time that humidity was documented, levels were noted as low as 23%. The humidity logs had a reference of "30% - 60%", rather than the minimum 35% required by the Code.

The hospital engineering manager confirmed the observations.

Based on observation, interview and record review, the critical access hospital failed to test the fire pump weekly as required by the Code.

Failure to test the fire pumps as required by the Code risks failure of these pumps during a fire emergency.

Reference:
NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition

5-1.1 Table 5-1.1 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance.

Table 5-1.1 Summary of Fire Pump Inspection, Testing, and Maintenance
Pump operation, No-flow condition: Test Weekly

Findings include:

During a tour of the critical access hospital on 08/02/2011, it was observed that a fire pump was located on the fire suppression system originating in the hospital basement. Review of engineering records on 08/03/2011 found no evidence that the fire pump was tested weekly in a "no flow" condition. The hospital engineering manager stated that there was no plan to test the fire pump weekly.

Based on observation, the critical access hospital failed to maintain the Type I EES in three required branches with the appropriate electrical loads located on each branch.

Failure to locate appropriate electrical loads on the correct branch risks failure of the hospital emergency essential electrical system.

Findings include:

During a tour of the critical access hospital on 08/02/2011, it was observed that electrical distribution and circuit panels for the life safety, critical and equipment branches did not include only the permitted electrical loads on each panel. Examples include, but are not limited to:

Heart telemetry functions located on the life safety branch (rather than the proper critical branch)
Heart telemetry functions located on the equipment branch (rather than the proper critical branch)
Datascope repeater located on the life safety branch (rather than the proper critical branch)
Emergency department exit corridor lighting located on the critical branch (rather than the proper life safety branch)

The hospital engineering manager confirmed the observations.