HospitalInspections.org

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Based on observation and interview with the Facility Manager (FM), the facility failed to ensure that one exit door opened properly in accordance with NFPA 101 (2012 edition) section 7.1.10.1. Exit doors that fail to open can lead to delays in evacuation or access. This had the potential to affect the three staff who work in the area and any patients who attempt to exit the area using the door in an emergency.

Findings:

Observation on 11/15/21 at 11:20 am revealed an exit door in the lower level near the back surgery corridor would not open. The surveyor pushed vigorously against the exit door three times. With additional effort, the door opened to reveal padding had been applied to the outside. During an interview at the time of the observation, the FM stated the padding had been added to prevent bugs from entering the facility.

The code requires under NFPA 101 (2012 edition) section 7.1.10.1 "means of egress shall be continuously maintained free of all obstructions or impediments to full and instant use in case of a fire or other emergency."

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Based on review of fire safety documentation and interview with the Facilities Manager (FM) and local contractor, the facility failed to ensure that it had conducted a smoke detection sensitivity test in the past 24 months in accordance with NFPA 72 (2010 edition) section 14.4.5.3.2. Failure to complete sensitivity testing for smoke detectors could lead to a detector not reacting to smoke and allow for a fire to advance. This had the potential to affect all 16 residents in the nursing facility.

Findings:

Review of the most recent facility fire safety document titled, "Annual Report," dated 6/10/21 revealed the report failed to describe a smoke detection sensitivity report had been completed.

During an interview on 11/15/21 at 2:45 PM the FM stated no record of a smoke detection sensitivity report was available. The FM stated the contractor was called and confirmed a smoke detection sensitivity test was never completed.

The code requires under NFPA 72 (2010 edition) section 14.4.5.3.2. that "sensitivity shall be checked every other year unless otherwise permitted."

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Based on document review and interview with the Facilities Manager (FM), the facility failed to ensure that sprinkler inspections were completed in accordance with NFPA 25 (2011 edition) table 5.1.1.2. Lack of timely inspections could lead to alarm failures going undetected. This problem has the potential to affect the current 18 patients.

Findings:

Review of the facility documents titled, "Sprinkler Inspection," revealed the facility had not completed one of the three quarterly inspections. There was no "Sprinkler Inspection" form was for the June 2021 inspection.

During an interview on 11/15/21 at 2:50 pm the FM stated the facility did not have the report needed and/or "someone forgot to call the company and make an appointment."

The code under NFPA 25 (2011 edition) table 5.1.1.2. requires "on a quarterly basis, the waterflow device, alarm devices associated with the sprinkler system, valve supervisory system devices all need to be checked."
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Based on observations and interview with the Facilities Manager (FM), the facility failed to ensure that smoke/fire wall barriers were complete from outside wall to outside wall and ceiling to floor in accordance with NFPA 101 (2012 edition) section 19.3.7.3. to 8.5 to 8.5.2.1. Lack of complete smoke/fire barrier walls could allow for the advancement of a fire or smoke from barrier to barrier. This had the potential to affect all 18 current patients in the hospital.

Findings:

Observation of a smoke/fire door at the entrance to the acute care wing on 11/15/21 at 10:30 am revealed the smoke/fire door was hollowed out for 8 inches from the bottom of the door at the base of the left wing of the set of doors. The entire base of the door was missing leaving only the laminate on the exterior on both sides. During an interview at the time of the observation the FM verified the condition of the door and indicated the door is consistently hit by food carts which damage the door.

Observation of the smoke/fire door at the corridor entrance from the wing built in 1985 to the wing built in 2007 revealed the right leaf of the set of corridor smoke/fire barrier doors was split down the entire length of the door or from the very top to the very bottom. During an interview at the time of the observation the FM confirmed the condition of the door.

Observation of the smoke/fire wall constructed of dry wall near the surgery entrance on 11/15/21 at 12:45 pm revealed two holes, both with blue cable running through the hole. One hole was 3 inches in diameter, the second opening was around the edges of a sealed sleeve with an opening measuring 8 inches wide by 3 inches high. During an interview at the time of the observation the FM confirmed the openings and condition of the smoke/fire barrier wall.

Observation of a smoke/fire wall near the surgery entrance on 11/15/21 at 12:47 pm revealed double doors with two holes. One hole was 3 inches in diameter with a copper pipe going through a cinder block/concrete wall. The second was an electrical J shaped pipe that was also penetrating the same wall with a 5-inch diameter hole. During an interview at the time of the observation the FM verified the holes present in the wall.

Observation on 11/15/21 at 12:50 pm revealed a long air duct that had been covered with drywall but was not sealed around the edges. The edges were approximately 10 feet in length and 12 inches high in dry wall. Interview with the FM at the time of the observation verified the condition of the wall and the openings.

The code requires under NFPA 101 (2012 edition) section 19.3.7.3. to 8.5 to 8.5.2.1. that "smoke barriers shall be continuous from outside wall to outside wall and from floor to floor."
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Based on fire alarm record review and interview with the facility Facilities Manager (FM), the facility failed to ensure that all smoke dampers throughout the facility HVAC system (heating, ventilation, and air conditioning) were maintained in accordance with NFPA 101 (2012 edition) 9.2.1 to NFPA 90A (2012 edition) section 5.4.8.2 to NFPA 105 (2010 edition) 6.5.2 to 6.6.5. This had the potential to affect the safety of all 16 residents. Lack of smoke damper maintenance could result in problems going undetected and allowing smoke and fire to travel throughout the HVAC system. This had the potential to affect the safety of the current 18 patients in the facility.

Findings:

Review of the annual fire alarm inspection report dated 6/10/21 located in the fire safety binder revealed no reference to smoke damper maintenance.

During an interview on 11/15/21 at 3:00 PM, the FM stated the contractor had been contacted and was unable to locate a maintenance report for the smoke dampers during the past four years for the nursing facility.

The code requires under NFPA 101 (2012 edition) section 9.2.1 refers smoke damper maintenance to NFPA 90A (2012 edition) section 5.4.8.2. referring to NFPA 105 (2010 edition) section 6.5.2. requiring smoke damper maintenance every "four years." Section 6.5.7. requires "testing to prove there is no interference," section 6.5.8. testing that "damper frame has no penetrations of foreign objects that would affect operation," section 6.5.9. that "Damper must be verified it is not blocked," section 6.5.10 "reinstall fusible link after testing, section 6.6.2. that "all exposed moving parts shall be dried lubricated," and section 6.6.5. "all smoke damper actuation shall be initiated according to the manufacturer with all such actions documented."
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Based on observation and interview with the Facilities Manager (FM), the facility failed to ensure it had a remote annunciator panel at a location readily observed by operating personnel in accordance with NFPA 99 (2012 edition), NFPA 101 (2012 edition) section 6.4.1.1.17, 6.4.1.1.16.2 and 16.4.1.1.16.2. Lack of a remote annunciator could leave generator problems to go undetected. This had the potential to affect all 18 current patients.

Findings:

Observation of all staffed area's including all nursing stations and areas readily observable to operating room personnel on 11/15/21 from 10:15 AM to 11:20 AM revealed the facility lacked a remote annunciator panel outside the generating room at a readily observable area or regular workstation.

Interview on 11/15/21 at 11:30 AM the FM stated the facility was not familiar with the requirement.

The code requires under NFPA 99 (2012 edition) section 6.4.1.1.17 and 6.4.1.1.16.2 "A remote annunciator that is storage battery powered shall be provided to operate outside of the generating room at a location readily observed by operating personnel at a regular workstation." Section 16.4.1.1.16.2 indicates the following warnings shall be present for the remote annunciator including " ...overcrank, low water temperature, high engine temperature-pre alarm, high engine temperature, low lube oil pressure-pre-alarm, low lube oil pressure, overspeed, low fuel main tank, low coolant, EPS supplying load, control switch not in automatic position, high battery voltage, low battery cranking voltage, low voltage in battery, battery charger A/C failure, lamp test, contacts for local or remote common alarm, audible alarm silencing switch, low starting air pressure, low starting hydraulic pressure, air shutdown damper when used, remote emergency stop."

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Based on fire safety record review and interview with the Facility Manager (FM), the facility failed to maintain the generator in accordance with NFPA 110 (2010 edition) section 7.13.4.3. and 8.4.1. Lack of generator testing could result in late recognition of problems and breakdowns. This had the potential to affect the 18 current patients in the facility.

Findings:

1. Review of the facility fire safety documents revealed the facility lacked documentation of a weekly generator check. The documentation indicated daily checks were completed, however, the daily checks were not thorough enough to meet standards for the weekly generator inspections and testing.

During an interview on 11/15/21 at 3:00 pm, the FM confirmed the daily logs did not cover all items needed in a weekly generator inspection.

The code requires under NFPA 101 section 8.4.1.- EPSS including all appurtenant components shall be inspected weekly and exercised under load at least monthly. Table 8.3.1 indicates the following items should be checked on a weekly basis; main fuel tank, day tank level, day tank float switch, supply transfer pump operations, solenoid valve operation, water in system, flexible hose and connectors, oil level, lube oil heater, cooling system level, adequate cooling water to heat exchanges, adequate fresh air through radiator, water pumps, condition of flexible hoses and connection, jacket water heater, exhaust system leakage, drain exhaust condensate trap.

2. Review of the facility fire safety documents revealed the facility was lacking a load bank test.

During an interview on 11/15/21 at 3:20 pm, the FM stated the facility was unable to locate the test and the contractor had no record of the load bank tests.

The code under NFPA 110 (2010 edition) section 7-13.4.3. requires "a load test shall be applied for 2 hours, full load test. The building load shall be permitted to serve as part or all of the load, supplemented by a load bank of sufficient size to provide a load equal to 100% of the nameplate KW [Kilowatt] rating of the EPS [emergency power supply]."
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