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Based on observation, the facility failed to maintain the smoke barrier doors as evidenced by a set of cross-corridor smoke barrier doors that failed to positive latch upon closure. This could result in the spread of smoke and fire from one smoke compartment to the adjacent smoke compartment, and increase the risk of injury to patients, visitors and staff due to smoke and fire. This affected 2 of 5 smoke compartments.

Findings:

During fire alarm testing with the Facility Manager on August 1, 2011, the smoke barrier doors were observed.

At 2:32 p.m., the right leaf of the pair of cross-corridor smoke barrier doors at the entrance to the Patient Suites failed to positive latch. The Facility Manager confirmed that the right leaf failed to positive latch.

Based on record review and interview, the facility failed to conduct 4 of 8 quarterly fire drills as evidenced by incomplete documentation of fire drills. This could result in the failure of any one facility staff member to accomplish all of the tasks expected of them in the event of a fire, and increase the risk of injury to patients, visitors and staff. This affected 5 of 5 smoke compartments.

Findings:

During record review and interview with the Facility Manager on August 1, 2011, through August 2, 2011, fire drill records were reviewed, and staff was interviewed.


1. At 1:30 p.m. August 1, 2011, documentation for the fire drills for one year was requested.

2. At 11:30 a.m. August 2, 2011, the documentation provided showed fire drills conducted for one of two shifts. The dates on the fire drills for the day shifts were July 18, 2011, June, 2011, March 14, 2011, and October 11, 2010. There were no evening shift fire drills provided. The Facility Manager stated that they would conduct a fire drill on each shift in the future.

Based on observation, record review and interview, the facility failed to maintain the fire alarm system and devices in accordance with NFPA 72, and NFPA 80. This was evidenced by the failure of an annunciation device when tested, and the failure to maintain two roll-down windows. This could result in delayed response to a fire, or in the spread of smoke or fire in the event of a fire, and increase the risk on injury to patients, visitors and staff. This affected 3 of 5 smoke compartments.

NFPA 72, 1999 Edition
Section 7-5.2.2 A permanent record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 7-5.2.2.
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination thereof, and business address, and telephone number
(6) Name, address, and representative of approving agency(ies)
(7) Designation of the detector(s) tested, for example, "Tests performed in accordance with Section _______."
(8) Functional test of detectors
(9) *Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type, heat detectors
(12) Other tests as required by equipment manufactures
(13) Other tests as required by the authority having jurisdiction
(14) Signatures of tester and approved authority representative
(15) Disposition of problems identified during test (for example, owner notified, problem corrected/successfully retested, device abandoned in place)

NFPA 80, 1999 Edition
15-2.4.3
All horizontal or vertical sliding and rolling fire doors shall be inspected and tested annually to check for proper operation and full closure. Resetting of the release mechanism shall be done in accordance with the manufacturer's instructions. A written record shall be maintained and shall be made available to the authority having jurisdiction.

Findings:

During observation, record review and interview with the Facility Manager on August 1, 2011 and August 2, 2011, the fire alarm system was tested, records were reviewed, and staff was interviewed.

1. At 1:30 p.m. on August 1, 2011, documentation for testing and maintenance of the two roll-down windows was requested. There was no record of testing and maintenance for the two roll-down windows included in the annual certification for the fire alarm system that was conducted on 4/15/2011. No other documentation for testing and maintenance was provided for review.

2. At 2:20 p.m. on August 1, 2011, the alarm could not be heard within Operating Room 1 when the fire alarm system was activated. There was no strobe or alarm within the surgery room.

3. At 2:22 p.m. on August 1, 2011, the chime/strobe device failed to activate an audible alarm when a manual pull alarm or a smoke alarm was tested in the Operating Room Hallway. The strobe functioned when the alarm was activated.

4. At 2:30 p.m. on August 1, 2011, a policy and procedure was requested for notification of fire within the two Operating Rooms.

5. At 12:01 p.m. on August 2, 2011, a general policy and procedure was provided that an internal page was used for notification of fire in the hospital, that included the Operating Rooms.

Based on record review and interview, the facility failed to ensure the maintenance, inspection and testing of smoke detectors in accordance with NFPA 72. This was evidenced by failing to provide records of a sensitivity test by a certified vendor. This could result in a smoke detector malfunction, and increase the risk of injury to patients, visitors and staff in the event of a fire emergency. This affected 5 of 5 smoke compartments.

NFPA 72, 1999 Edtion.
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.

Findings:

During record review and interview with the Facility Manager on August 1, 2011 and August 2, 2011, documents were reviewed, and staff was interviewed.

1. At 1:30 p.m., on August 1, 2011, documentation for sensitivity testing of the smoke detectors was requested.

2. At 12:15 p.m., on August 2, 2011, there was no sensitivity testing of the 46 smoke detectors provided for review. The Facility Manager stated that they were not aware of any previous records of sensitivity testing of the smoke detectors.

Based on observation and interview, the facility failed to maintain the heating, ventilation and air conditioning systems as evidenced by the failure to provide documentation for the testing of the fire dampers. This finding could result in the failure of the dampers to operate in the event of a fire, and increase the risk of injury to residents, visitors and staff in the event of a fire. This affected 5 of 5 smoke compartments.

NFPA 90A, 3-4.7 Maintenance. At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.

Findings:

During document review, observation and interview with the Facility Manager on August 1, 2011 and August 2, 2011, the fire/smoke damper testing and inspection records were requested, the dampers were observed, and staff was interviewed.

1. At 1:30 p.m. on August 1, 2011, the fire/smoke damper testing and inspection records were requested from the facility.

2. At 4:15 p.m. on August 1, 2011, during the facility tour, a fire damper was observed in the laundry chute room.

3. At 10:30 a.m. on August 2, 2011, there were no records provided for review for the testing and maintenance of the fire dampers. The Facility Manager stated that they were unaware of any previous documentation, and would have a certification inspection performed on the fire dampers.

Based on observation, record review and interview, the facility failed to maintain their oxygen storage area in accordance with NFPA 99, and NFPA 70. This was evidenced by two electrical receptacle outlets in the oxygen storage area that were installed less than 152 cm (5 ft) above the floor, and by cylinders that were stored not individually secured. This could result in the increased risk of damage to a cylinder, and affected 1 of 5 smoke compartments.

NFPA 99, Health Care Facilities, 1999 Edition
NFPA 99
4-3.1.1.1 Cylinder and Container Management.
Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.

4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
2.* Enclosures shall be provided for supply systems cylinder storage or manifold locations for oxidizing agents such as oxygen and nitrous oxide. Such enclosures shall be constructed of an assembly of building materials with a fire-resistive rating of at least 1 hour and shall not communicate directly with anesthetizing locations. Other nonflammable (inert) medical gases may be stored in the enclosure. Flammable gases shall not be stored with oxidizing agents. Storage of full or empty cylinders is permitted. Such enclosures shall serve no other purpose.
3. Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.
4. The electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the standards of NFPA 70, National Electrical Code, for ordinary locations. Electric wall fixtures, switches, and receptacles shall be installed in fixed locations not less than 152 cm (5 ft) above the floor as a precaution against their physical damage.

Findings:

During the facility tour, record review and interview with the Facility Manager on August 1, 2011, through August 2, 2011, the oxygen storage room was observed, and certification records were reviewed.

1. At 1:30 p.m. on August 1, 2011, a certification for the medical gas was requested from the Facility Administrator, and the Facility Manager.

2. At 2:40 p.m. on August 1, 2011, there were two light switches installed approximately 44 inches from the top of the light switch to the floor, in the Oxygen Storage Area.
3. At 2:45 p.m. on August 1, 2011, there were 6 oxygen H cylinders in use that were chained at the top and the bottom, 6 full back-up oxygen H cylinders that were chained at the top and the bottom, 4 Nitrogen H cylinders in use that were chained at the top and the bottom, and 2 Nitrous Oxide H cylinders in use that were chained at the top and the bottom. The cylinders were not individually secured.
4. At 12:20 p.m. on August 2, 2011, the medical gas certification showed the two light switches installed under 60 inches as deficiencies according to NFPA 99 on the report. The Facility Manager stated that the building was grandfathered in under existing conditions.

Based on observation, document review and interview, the facility failed to maintain humidity levels in the operating rooms equal to or above 35 percent in accordance with NFPA 99. This was evidenced by humidity levels with a humidity reading below 35 percent. This could result in ignition of flammable solutions used in the operating rooms, and increase the risk of injury to patients, visitors and staff. This affected 1 of 5 smoke compartments.

NFPA 99 (1999 Edition)
5-4.1.1 The mechanical ventilation sytem suppling anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater.

Findings:

During record review and interview with the Facility Manager on August 1, 2011, through on August 2, 2011, the records of humidity levels for the operating rooms were reviewed, and staff was interviewed.

1. At 1:30 p.m., on August 1, 2011, documentation for humidity levels for the two Operating Rooms was requested.

2. At 9:15 a.m., on August 2, 2011, the records provided showed from September 1, 2010 to July 29, 2011, the humidity levels in Operating Room 1 were out of range 39 times, and Operating Room 2 was out of range 41 times. The facilty's policy stated that normal ranges were between 20% and 60%. In an interview with the Facility Manager, staff verified that ranges were not being checked at below 35%, and there was no written documentation for repairs or corrections.

Based on observation, the facility failed to maintain its electrical equipment and wiring in accordance with NFPA 70. This was evidenced by an electrical appliance plugged into a surge protector, and not directly into an electrical outlet. This could result in an electrical fire, and increase the risk of injury to residents, visitors and staff in the event of a fire. This affected 1 of 5 smoke compartments.

NFPA 70 (1999 Edition) 240-4, Flexible cord, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent.
A. Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified.

NFPA 70 Section 400-8 1999 Ed. Uses not permitted. Unless specifically permitted in section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for a fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors.
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this code

Findings:

During the facility tour with the Facility Manager on August 1, 2011, the electrical wiring and connections were observed.

At 3:10 p.m., there was a microwave plugged into a surge protector and not directly into the wall, in the Nourishment Center.

Based on observation, the facility failed to maintain the smoke barrier doors as evidenced by a set of cross-corridor smoke barrier doors that failed to positive latch upon closure. This could result in the spread of smoke and fire from one smoke compartment to the adjacent smoke compartment, and increase the risk of injury to patients, visitors and staff due to smoke and fire. This affected 2 of 5 smoke compartments.

Findings:

During fire alarm testing with the Facility Manager on August 1, 2011, the smoke barrier doors were observed.

At 2:32 p.m., the right leaf of the pair of cross-corridor smoke barrier doors at the entrance to the Patient Suites failed to positive latch. The Facility Manager confirmed that the right leaf failed to positive latch.

Based on record review and interview, the facility failed to conduct 4 of 8 quarterly fire drills as evidenced by incomplete documentation of fire drills. This could result in the failure of any one facility staff member to accomplish all of the tasks expected of them in the event of a fire, and increase the risk of injury to patients, visitors and staff. This affected 5 of 5 smoke compartments.

Findings:

During record review and interview with the Facility Manager on August 1, 2011, through August 2, 2011, fire drill records were reviewed, and staff was interviewed.


1. At 1:30 p.m. August 1, 2011, documentation for the fire drills for one year was requested.

2. At 11:30 a.m. August 2, 2011, the documentation provided showed fire drills conducted for one of two shifts. The dates on the fire drills for the day shifts were July 18, 2011, June, 2011, March 14, 2011, and October 11, 2010. There were no evening shift fire drills provided. The Facility Manager stated that they would conduct a fire drill on each shift in the future.

Based on observation, record review and interview, the facility failed to maintain the fire alarm system and devices in accordance with NFPA 72, and NFPA 80. This was evidenced by the failure of an annunciation device when tested, and the failure to maintain two roll-down windows. This could result in delayed response to a fire, or in the spread of smoke or fire in the event of a fire, and increase the risk on injury to patients, visitors and staff. This affected 3 of 5 smoke compartments.

NFPA 72, 1999 Edition
Section 7-5.2.2 A permanent record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 7-5.2.2.
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination thereof, and business address, and telephone number
(6) Name, address, and representative of approving agency(ies)
(7) Designation of the detector(s) tested, for example, "Tests performed in accordance with Section _______."
(8) Functional test of detectors
(9) *Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type, heat detectors
(12) Other tests as required by equipment manufactures
(13) Other tests as required by the authority having jurisdiction
(14) Signatures of tester and approved authority representative
(15) Disposition of problems identified during test (for example, owner notified, problem corrected/successfully retested, device abandoned in place)

NFPA 80, 1999 Edition
15-2.4.3
All horizontal or vertical sliding and rolling fire doors shall be inspected and tested annually to check for proper operation and full closure. Resetting of the release mechanism shall be done in accordance with the manufacturer's instructions. A written record shall be maintained and shall be made available to the authority having jurisdiction.

Findings:

During observation, record review and interview with the Facility Manager on August 1, 2011 and August 2, 2011, the fire alarm system was tested, records were reviewed, and staff was interviewed.

1. At 1:30 p.m. on August 1, 2011, documentation for testing and maintenance of the two roll-down windows was requested. There was no record of testing and maintenance for the two roll-down windows included in the annual certification for the fire alarm system that was conducted on 4/15/2011. No other documentation for testing and maintenance was provided for review.

2. At 2:20 p.m. on August 1, 2011, the alarm could not be heard within Operating Room 1 when the fire alarm system was activated. There was no strobe or alarm within the surgery room.

3. At 2:22 p.m. on August 1, 2011, the chime/strobe device failed to activate an audible alarm when a manual pull alarm or a smoke alarm was tested in the Operating Room Hallway. The strobe functioned when the alarm was activated.

4. At 2:30 p.m. on August 1, 2011, a policy and procedure was requested for notification of fire within the two Operating Rooms.

5. At 12:01 p.m. on August 2, 2011, a general policy and procedure was provided that an internal page was used for notification of fire in the hospital, that included the Operating Rooms.

Based on record review and interview, the facility failed to ensure the maintenance, inspection and testing of smoke detectors in accordance with NFPA 72. This was evidenced by failing to provide records of a sensitivity test by a certified vendor. This could result in a smoke detector malfunction, and increase the risk of injury to patients, visitors and staff in the event of a fire emergency. This affected 5 of 5 smoke compartments.

NFPA 72, 1999 Edtion.
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.

Findings:

During record review and interview with the Facility Manager on August 1, 2011 and August 2, 2011, documents were reviewed, and staff was interviewed.

1. At 1:30 p.m., on August 1, 2011, documentation for sensitivity testing of the smoke detectors was requested.

2. At 12:15 p.m., on August 2, 2011, there was no sensitivity testing of the 46 smoke detectors provided for review. The Facility Manager stated that they were not aware of any previous records of sensitivity testing of the smoke detectors.

Based on observation and interview, the facility failed to maintain the heating, ventilation and air conditioning systems as evidenced by the failure to provide documentation for the testing of the fire dampers. This finding could result in the failure of the dampers to operate in the event of a fire, and increase the risk of injury to residents, visitors and staff in the event of a fire. This affected 5 of 5 smoke compartments.

NFPA 90A, 3-4.7 Maintenance. At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.

Findings:

During document review, observation and interview with the Facility Manager on August 1, 2011 and August 2, 2011, the fire/smoke damper testing and inspection records were requested, the dampers were observed, and staff was interviewed.

1. At 1:30 p.m. on August 1, 2011, the fire/smoke damper testing and inspection records were requested from the facility.

2. At 4:15 p.m. on August 1, 2011, during the facility tour, a fire damper was observed in the laundry chute room.

3. At 10:30 a.m. on August 2, 2011, there were no records provided for review for the testing and maintenance of the fire dampers. The Facility Manager stated that they were unaware of any previous documentation, and would have a certification inspection performed on the fire dampers.

Based on observation, record review and interview, the facility failed to maintain their oxygen storage area in accordance with NFPA 99, and NFPA 70. This was evidenced by two electrical receptacle outlets in the oxygen storage area that were installed less than 152 cm (5 ft) above the floor, and by cylinders that were stored not individually secured. This could result in the increased risk of damage to a cylinder, and affected 1 of 5 smoke compartments.

NFPA 99, Health Care Facilities, 1999 Edition
NFPA 99
4-3.1.1.1 Cylinder and Container Management.
Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.

4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
2.* Enclosures shall be provided for supply systems cylinder storage or manifold locations for oxidizing agents such as oxygen and nitrous oxide. Such enclosures shall be constructed of an assembly of building materials with a fire-resistive rating of at least 1 hour and shall not communicate directly with anesthetizing locations. Other nonflammable (inert) medical gases may be stored in the enclosure. Flammable gases shall not be stored with oxidizing agents. Storage of full or empty cylinders is permitted. Such enclosures shall serve no other purpose.
3. Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.
4. The electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the standards of NFPA 70, National Electrical Code, for ordinary locations. Electric wall fixtures, switches, and receptacles shall be installed in fixed locations not less than 152 cm (5 ft) above the floor as a precaution against their physical damage.

Findings:

During the facility tour, record review and interview with the Facility Manager on August 1, 2011, through August 2, 2011, the oxygen storage room was observed, and certification records were reviewed.

1. At 1:30 p.m. on August 1, 2011, a certification for the medical gas was requested from the Facility Administrator, and the Facility Manager.

2. At 2:40 p.m. on August 1, 2011, there were two light switches installed approximately 44 inches from the top of the light switch to the floor, in the Oxygen Storage Area.
3. At 2:45 p.m. on August 1, 2011, there were 6 oxygen H cylinders in use that were chained at the top and the bottom, 6 full back-up oxygen H cylinders that were chained at the top and the bottom, 4 Nitrogen H cylinders in use that were chained at the top and the bottom, and 2 Nitrous Oxide H cylinders in use that were chained at the top and the bottom. The cylinders were not individually secured.
4. At 12:20 p.m. on August 2, 2011, the medical gas certification showed the two light switches installed under 60 inches as deficiencies according to NFPA 99 on the report. The Facility Manager stated that the building was grandfathered in under existing conditions.

Based on observation, document review and interview, the facility failed to maintain humidity levels in the operating rooms equal to or above 35 percent in accordance with NFPA 99. This was evidenced by humidity levels with a humidity reading below 35 percent. This could result in ignition of flammable solutions used in the operating rooms, and increase the risk of injury to patients, visitors and staff. This affected 1 of 5 smoke compartments.

NFPA 99 (1999 Edition)
5-4.1.1 The mechanical ventilation sytem suppling anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater.

Findings:

During record review and interview with the Facility Manager on August 1, 2011, through on August 2, 2011, the records of humidity levels for the operating rooms were reviewed, and staff was interviewed.

1. At 1:30 p.m., on August 1, 2011, documentation for humidity levels for the two Operating Rooms was requested.

2. At 9:15 a.m., on August 2, 2011, the records provided showed from September 1, 2010 to July 29, 2011, the humidity levels in Operating Room 1 were out of range 39 times, and Operating Room 2 was out of range 41 times. The facilty's policy stated that normal ranges were between 20% and 60%. In an interview with the Facility Manager, staff verified that ranges were not being checked at below 35%, and there was no written documentation for repairs or corrections.

Based on observation, the facility failed to maintain its electrical equipment and wiring in accordance with NFPA 70. This was evidenced by an electrical appliance plugged into a surge protector, and not directly into an electrical outlet. This could result in an electrical fire, and increase the risk of injury to residents, visitors and staff in the event of a fire. This affected 1 of 5 smoke compartments.

NFPA 70 (1999 Edition) 240-4, Flexible cord, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent.
A. Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified.

NFPA 70 Section 400-8 1999 Ed. Uses not permitted. Unless specifically permitted in section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for a fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors.
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this code

Findings:

During the facility tour with the Facility Manager on August 1, 2011, the electrical wiring and connections were observed.

At 3:10 p.m., there was a microwave plugged into a surge protector and not directly into the wall, in the Nourishment Center.