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Based upon observation and interview the facility failed to ensure hazardous areas are properly separated. Failure of doors to self close and latch securely allows smoke and gases to spread during a fire event.

Findings include:

During the facility tour on January 31, 2011 and on February 1, 2011 observation of hazardous areas revealed:

1) On January 31, 2011 at approximately 4:18 PM the Kitchen door separating the kitchen from the corridor was found to not self close and positively latch. This finding was witnessed and acknowledged by the Director of Maintenance.

2) On January 31, 2011 at approximately 4:25 PM, the Morgue room in the basement was being used as clean linen storage (bagged) while awaiting off site removal. The bags filled the area to waist level creating a hazardous area. The door did not self close and positively latch. This finding was witnessed and acknowledged by the Director of Maintenance.

3) On January 31, 2011 at approximately 4:45 PM the interior separation wall between the Mechanical room and the electrical room, was not sealed where it intersects the exterior wall. The gap was gradual from minute to nearly 1/2 inch at the top of the wall. Interview with the Director of Maintenance confirmed this wall had not been modified since the original construction in 2003. When light on either side of the wall intersection was shut off light passing through could clearly be seen.

4) On February 1, 2011 at approximately 9:15 AM the storage room across from Patient Room #24 was found to not self close and positively latch. This finding was witnessed and acknowledged by the Director of Maintenance.

Actual NFPA reference:

NFPA 101, the Life Safety Code, 2000 Edition

18.3.2.1 Hazardous Areas.
Any hazardous area shall be protected in accordance with Section 8.4. The areas described in Table 18.3.2.1 shall be protected as indicated.

Based upon observation and interview the facility failed to ensure emergency lighting devices were maintained in an operational condition. Failure of emergency lighting units can cause disorientation during a fire event or power outage.

Findings include:

During the facility tour on February 1, 2011 at approximately 8:25 AM, the battery powered emergency lighting unit mounted on the wall of the Doctor's Lounge in the basement would not operate when tested. This testing was witnessed and acknowledged by the Director of Maintenance, who asked if a non-required emergency light was required to be maintained or could it be removed.

Actual NFPA reference:

NFPA 101, the Life Safety Code, 2000 Edition

18.2.9.1
Emergency lighting shall be provided in accordance with Section 7.9.

Based upon record review and interview the facility failed to ensure periodic maintenance and testing of the sprinkler system in accordance with NFPA 25. The lack of quarterly maintenance and testing could lead to a malfunction and the absence of an alarm being sounded during an event.

Findings include:

Record review indicated annual testing of the sprinkler system was conducted on April 5, 2010 by an outside contractor and five year inspection had been conducted on June 26, 2009, but could produce no records of quarterly waterflow alarm testing. Interview with the Director of Maintenance indicated he was unaware of this requirement.

Actual NFPA reference:

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

2-3.3* Alarm Devices.
Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.

Based upon observation and interview the facility failed to ensure portable space heaters located in staff only non sleeping spaces were properly tested to ensure heating elements did on exceed 212 degrees Fahrenheit. Failure to test these devices could result in a fire within the facility.

Findings include:

1) During the facility tour on January 31, 2011 at approximately 4:30 PM, an oil filled portable space heater was discovered in the clean linen side of the laundry, this space is currently being used as a break or record keeping space. Interview with the Director of Maintenance disclosed he was unaware of the device being present and had not tested the unit's surface temperature.

2) During the facility tour on February 1, 2011 at approximately 10:45 AM, an electric space heating device was observed in the finance office of the administrative area. The Director of Maintenance disclosed he was unaware of the device being present and had not tested the unit's surface temperature.

Actual NFPA reference:

NFPA 101 the Life Safety Code, 2000 Edition

18.7.8 Portable Space-Heating Devices.
Portable space-heating devices shall be prohibited in all health care occupancies.
Exception: Portable space-heating devices shall be permitted to be used in nonsleeping staff and employee areas where the heating elements of such devices do not exceed 212°F (100°C).

Based upon observation and interview the facility failed to ensure adequate electrical receptacles were available thereby preventing the need for extension cords and multi plug adaptors. Failure to ensure the proper circuitry is available can overload circuits and cause a fire.

Findings include:

During the facility tour on February 1, 2011 at approximately 8:25 AM; observation revealed a computer in the Doctor's lounge in the basement being powered by a relocatable power tap (RPT), powered by a heavy duty extension cord, powered by a multi plug adaptor which was plugged into a duplex wall outlet. The extension cord and RPT were tightly bound with extreme bends by a plastic tip tie.

Actual NFPA reference:

NFPA 70, National Electrical Code, 199 Edition

110.3 Examination, Identification, Installation, and Use of Equipment.
(A) Examination. In judging equipment, considerations such as the following shall be evaluated:
(1) Suitability for installation and use in conformity with the provisions of this Code
FPN: Suitability of equipment use may be identified by a description marked on or provided with a product to identify the suitability of the product for a specific purpose, environment, or application. Suitability of equipment may be evidenced by listing or labeling.
(2) Mechanical strength and durability, including, for parts designed to enclose and protect other equipment, the adequacy of the protection thus provided
(3) Wire-bending and connection space
(4) Electrical insulation
(5) Heating effects under normal conditions of use and also under abnormal conditions likely to arise in service
(6) Arcing effects
(7) Classification by type, size, voltage, current capacity, and specific use
(8) Other factors that contribute to the practical safeguarding of persons using or likely to come in contact with the equipment
(B) Installation and Use. Listed or labeled equipment shall be installed and used in accordance with any instructions included in the listing or labeling.