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Based on observation, the facility failed to maintain the integrity of the building construction for 2 of 4 smoke compartments as evidenced by penetrations within the facility walls. These penetrations could result in the spread of smoke and fire throughout the facility and increase the risk of injury to patients, visitors and staff due to smoke and fire.

Findings:

During the facility tour with facility staff on September 27, 2010 through September 28, 2010, the facility building construction was observed.

September 27, 2010:

1. At 8:45 a.m., in the Soiled Linen Room, there was an approximately 6 inch by 1/2 inch unsealed penetration on the bottom right of the center back wall.

2. At 10:46 a.m., in the Laundry Room, there was an approximately 1 inch unsealed penetration to the right of the door in the ceiling surrounding a pipe.

Based on observation and interview, the facility failed to maintain 3 sets of smoke barrier double doors in 4 of 4 smoke compartments as evidenced by the failure of the smoke barrier doors to release from the magnetic locks during fire alarm testing. This finding could result in the spread of smoke and fire through the entire facilty and increase the risk of injury to patients, visitors and staff due to smoke and fire.

Findings:

During fire alarm testing with facility staff on September 27, 2010 through September 28, 2010, the smoke barrier doors were observed.

September 27, 2010:

At 4:04 p.m., the smoke barrier double doors failed to release from their magnetic hold open devices during fire alarm testing. Staff II stated that the system worked when they were tested one week ago.

Based on observation and interview, the facility failed to ensure that doors were readily opened from the egress side as evidenced by six delayed egress doors that failed to release during fire alarm testing in 4 of 4 compartments. This failure could result in the delay of evacuation in the event of an emergency and increase the risk of injury to patients, visitors and staff.

Findings:

During fire alarm testing and interview with facility staff on September 27, 2010 through September 28, 2010, the doors in the facility were observed.

September 27, 2010:

At 4:04 p.m., during fire alarm testing, the six delayed egress doors failed to release. Staff II stated that the fire alarm company tested the system a week ago and the system worked.

Based on observation and record review, the facility failed to ensure that all required smoke detectors including those activating door hold-open devices maintained, inspected and tested in accordance with the manufacturer's specifications as evidenced by no current documentation for smoke detector sensitivity testing of the system-based smoke detectors and a smoke detector that was covered with plastic. These findings could result in delayed response to a fire and increase the risk of injury to patients, visitors and staff in the event of a fire.

Findings:

During observation and record review with facility staff on September 27, 2010 through September 28, 2010, the smoke detectors were observed and the smoke detector testing records were reviewed.

September 27, 2010:

At 4:10 p.m., in Patient Lounge A, the smoke detector was covered up with a plastic bag.

September 28, 2010:

At 10:30 a.m., there was no recent documentation for smoke detector sensitivity testing. The last sensitivity test was dated December 17, 2007.


NFPA 72 - 7.2.2 Fire alarm systems and other systems and equipment that are associated with fire alarm systems and accessory equipment shall be tested according to Table 7-2.2 13. Initiating Devices (g) Smoke Detectors
The detectors shall be tested in place to ensure smoke entry into the sensing chamber and an alarm response. Testing with smoke or listed aerosol approved by the manufacturer shall be permitted as acceptable test methods. Other methods approved by the manufacturer that ensure smoke entry into the sensing chamber shall be permitted.
Additionally any of the following tests shall be performed to ensure that each smoke detector is within its listed and marked sensitivity range:
(a)Calibrated test method
(b) Manufacturer's calibrated sensitivity test instrument
(c)Listed control equipment arranged for the purpose
(d) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit when its sensitivity is outside its listed sensitivity range
(e) Other calibrated sensitivity test method approved by the authority having jurisdiction.
Smoke sensitivity testing is required the first year of installation of the smoke detector, the third year and every five years there after.

Based on observation, the facility failed to ensure that the automatic sprinkler system was maintained in 3 of 4 smoke compartments, as evidenced by escutcheon rings that were not flush to the ceiling and failure to provide an 18 inch clearance for the sprinklers. These findings could result in a malfunction during a fire and increase the risk of injury to patients, visitors and staff in the event of a fire.

Findings:

During a tour of the facility with facility staff, on September 27, 2010 through September 28, 2010, the sprinkler system was observed.

September 27, 2010:

1. At 8:30 a.m., in the Hallway by Medical Records, there a one inch gap from the ceiling and the escutcheon ring on 2 of 4 fire sprinklers.

2. At 8:35 a.m., in the Office Hallway by the Restraint and Seclusion Room, there a one inch gap from the ceiling and the escutcheon ring on 1 of 2 fire sprinklers.

3. At 8:50 a.m., in the Entrance Hallway, there a one inch gap from the ceiling and the escutcheon ring on 1 of 6 fire sprinklers.

4. At 8:55 a.m., in the Clean Linen Room, there were 8 bundles of towels stacked to the ceiling, blocking sprinklers from dispersing water to extinguish fire.

5. At 8:57 a.m., in Patient Lounge A, there a one inch gap from the ceiling and the escutcheon ring on 1 of 2 fire sprinklers.

6. At 10:45 a.m., in the Kitchen, there a one inch gap from the ceiling and the escutcheon ring on 1 of 4 fire sprinklers.

7. At 10:50 a.m., in Patient Room 9, there a 1/2 inch gap from the ceiling and the escutcheon ring on the pendant head fire sprinkler.

Based on observation, the facility failed to maintain the portable fire extinguishers in 1 of 4 smoke compartments as evidenced by a fire extinguisher mounted greater than 60 inches high from the floor to the top of the extinguisher. This finding could result in delayed respone to a fire and increase the risk of injury to patients visitors and staff in the event of a fire.

Findings:

During a tour of the facility with facility staff on September 27, 2010 through September 28, 2010, the fire extinguishers were observed.

September 27, 2010:

At 10:40 a.m., in the Laundry on the wall near the door, the fire extinguisher was mounted at approximately 75 inches from the floor to the top of the extinguisher.

NFPA 10 Standard for Portable Fire Extinguishers, 1998 Edition
1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 3 1/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in.

Based on observation, the facility failed to ensure the Alcohol Based Hand Dispensers were installed away from ignition sources in 1 of 4 smoke compartments as evidenced by an Alcohol Based Hand Dispenser mounted over an electrical outlet. This failure could result in a fire emergency and increase the risk of injury to patients, visitors and staff.

Findings:

During the facility tour with facility staff on September 27, 2010 through September 28, 2010, the Alcohol Based Hand Dispensers were observed.

September 28, 2010:

At 3:50 p.m., in the Main Hallway by the front entrance, there was an Alcohol Based Hand Dispenser mounted over an electrical outlet.

Based on observation, the facility failed to maintain the integrity of the building construction for 2 of 4 smoke compartments as evidenced by penetrations within the facility walls. These penetrations could result in the spread of smoke and fire throughout the facility and increase the risk of injury to patients, visitors and staff due to smoke and fire.

Findings:

During the facility tour with facility staff on September 27, 2010 through September 28, 2010, the facility building construction was observed.

September 27, 2010:

1. At 8:45 a.m., in the Soiled Linen Room, there was an approximately 6 inch by 1/2 inch unsealed penetration on the bottom right of the center back wall.

2. At 10:46 a.m., in the Laundry Room, there was an approximately 1 inch unsealed penetration to the right of the door in the ceiling surrounding a pipe.

Based on observation and interview, the facility failed to maintain 3 sets of smoke barrier double doors in 4 of 4 smoke compartments as evidenced by the failure of the smoke barrier doors to release from the magnetic locks during fire alarm testing. This finding could result in the spread of smoke and fire through the entire facilty and increase the risk of injury to patients, visitors and staff due to smoke and fire.

Findings:

During fire alarm testing with facility staff on September 27, 2010 through September 28, 2010, the smoke barrier doors were observed.

September 27, 2010:

At 4:04 p.m., the smoke barrier double doors failed to release from their magnetic hold open devices during fire alarm testing. Staff II stated that the system worked when they were tested one week ago.

Based on observation and interview, the facility failed to ensure that doors were readily opened from the egress side as evidenced by six delayed egress doors that failed to release during fire alarm testing in 4 of 4 compartments. This failure could result in the delay of evacuation in the event of an emergency and increase the risk of injury to patients, visitors and staff.

Findings:

During fire alarm testing and interview with facility staff on September 27, 2010 through September 28, 2010, the doors in the facility were observed.

September 27, 2010:

At 4:04 p.m., during fire alarm testing, the six delayed egress doors failed to release. Staff II stated that the fire alarm company tested the system a week ago and the system worked.

Based on observation and record review, the facility failed to ensure that all required smoke detectors including those activating door hold-open devices maintained, inspected and tested in accordance with the manufacturer's specifications as evidenced by no current documentation for smoke detector sensitivity testing of the system-based smoke detectors and a smoke detector that was covered with plastic. These findings could result in delayed response to a fire and increase the risk of injury to patients, visitors and staff in the event of a fire.

Findings:

During observation and record review with facility staff on September 27, 2010 through September 28, 2010, the smoke detectors were observed and the smoke detector testing records were reviewed.

September 27, 2010:

At 4:10 p.m., in Patient Lounge A, the smoke detector was covered up with a plastic bag.

September 28, 2010:

At 10:30 a.m., there was no recent documentation for smoke detector sensitivity testing. The last sensitivity test was dated December 17, 2007.


NFPA 72 - 7.2.2 Fire alarm systems and other systems and equipment that are associated with fire alarm systems and accessory equipment shall be tested according to Table 7-2.2 13. Initiating Devices (g) Smoke Detectors
The detectors shall be tested in place to ensure smoke entry into the sensing chamber and an alarm response. Testing with smoke or listed aerosol approved by the manufacturer shall be permitted as acceptable test methods. Other methods approved by the manufacturer that ensure smoke entry into the sensing chamber shall be permitted.
Additionally any of the following tests shall be performed to ensure that each smoke detector is within its listed and marked sensitivity range:
(a)Calibrated test method
(b) Manufacturer's calibrated sensitivity test instrument
(c)Listed control equipment arranged for the purpose
(d) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit when its sensitivity is outside its listed sensitivity range
(e) Other calibrated sensitivity test method approved by the authority having jurisdiction.
Smoke sensitivity testing is required the first year of installation of the smoke detector, the third year and every five years there after.

Based on observation, the facility failed to ensure that the automatic sprinkler system was maintained in 3 of 4 smoke compartments, as evidenced by escutcheon rings that were not flush to the ceiling and failure to provide an 18 inch clearance for the sprinklers. These findings could result in a malfunction during a fire and increase the risk of injury to patients, visitors and staff in the event of a fire.

Findings:

During a tour of the facility with facility staff, on September 27, 2010 through September 28, 2010, the sprinkler system was observed.

September 27, 2010:

1. At 8:30 a.m., in the Hallway by Medical Records, there a one inch gap from the ceiling and the escutcheon ring on 2 of 4 fire sprinklers.

2. At 8:35 a.m., in the Office Hallway by the Restraint and Seclusion Room, there a one inch gap from the ceiling and the escutcheon ring on 1 of 2 fire sprinklers.

3. At 8:50 a.m., in the Entrance Hallway, there a one inch gap from the ceiling and the escutcheon ring on 1 of 6 fire sprinklers.

4. At 8:55 a.m., in the Clean Linen Room, there were 8 bundles of towels stacked to the ceiling, blocking sprinklers from dispersing water to extinguish fire.

5. At 8:57 a.m., in Patient Lounge A, there a one inch gap from the ceiling and the escutcheon ring on 1 of 2 fire sprinklers.

6. At 10:45 a.m., in the Kitchen, there a one inch gap from the ceiling and the escutcheon ring on 1 of 4 fire sprinklers.

7. At 10:50 a.m., in Patient Room 9, there a 1/2 inch gap from the ceiling and the escutcheon ring on the pendant head fire sprinkler.

Based on observation, the facility failed to maintain the portable fire extinguishers in 1 of 4 smoke compartments as evidenced by a fire extinguisher mounted greater than 60 inches high from the floor to the top of the extinguisher. This finding could result in delayed respone to a fire and increase the risk of injury to patients visitors and staff in the event of a fire.

Findings:

During a tour of the facility with facility staff on September 27, 2010 through September 28, 2010, the fire extinguishers were observed.

September 27, 2010:

At 10:40 a.m., in the Laundry on the wall near the door, the fire extinguisher was mounted at approximately 75 inches from the floor to the top of the extinguisher.

NFPA 10 Standard for Portable Fire Extinguishers, 1998 Edition
1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 3 1/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in.