HospitalInspections.org

While surveying the facility with the maintenance manager, the inspector observed an MRI trailer contiguous to the main hospital building. Access to the MRI trailer was via a membrane canopy that was observed to be directly exposed to the hospital vestibule area adjacent to the MRI trailer installation. The vestibule adjacent to the MRI trailer installation is also a required, marked means of egress from the building.
An electrical power transformer was observed to be enclosed in housing constructed of combustible material (wood), a combustible (wooden) ramp, and other combustible (wood) components were exposed to the hospital vestibule with no fire resistive construction separating the MRI trailer installation and other non-conforming construction components from the hospital structure. No fire sprinkler coverage was observed in the attached canopy area.
The MRI trailer and combustible construction components are exposed to the hospital structure and a marked means of egress with no recognized fire resistive construction in place between the non-conforming construction and the hospital. The inspector determined through interview with the maintenance manager that the MRI trailer installation had been in place approximately two years. Post survey the inspector reviewed documentation pertaining to construction permits located at the Maine Fire Marshal's Office and determined that no construction permit had been obtained for the MRI trailer installation as required by Maine Law (MRSA Title 25, section 2448).

While surveying the facility with the maintenance manager, the inspector observed the door opening into the stairwell enclosure from the second floor sleep lab area was not capable of latching in the closed position by mechanical means in accordance with NFPA 80 Standard for Fire Doors and Fire Windows. The door was secured in the closed position only by a magnetic lock/latch that releases upon activation of the fire alarm system or upon loss of power. No mechanical means of latching the door was observed to be present. The door serves as an opening protective for a marked egress stair enclosure.

While surveying the facility with the maintenance manager, the inspector observed the door opening into the stairwell enclosure from the second floor sleep lab area was found to be a delayed egress door with a 30 second delay. Signage required by NFPA 101 Life Safety Code section 7.2.1.6.1 (d) (2000 edition) was not observed to be present on the door adjacent to the release device to indicate that the door is a delayed egress door.

While surveying the facility with the maintenance manager, the inspector observed through review of documentation pertaining to the building fire alarm system that the required inspection/testing of the building fire alarm system revealed that "Test sensors not working" on duct detectors (Zones N7-1 and N7-2) located in the x-ray pathology area.

While surveying the facility with the maintenance manager, the inspector observed that no smoke detector was present in the vicinity of the building fire alarm control panel located in the shop area. NFPA 72 National Fire Alarm Code section 1-5.6 (1999 edition) requires a smoke detector at the location of each fire alarm control unit -or- the installation a heat detector in the immediate vicinity of each fire alarm control unit if ambient conditions are not suitable for smoke detectors.

While surveying the facility with the maintenance manager, the inspector observed, through review of documentation pertaining to the building fire alarm system and interview with the facility maintenance manager, that sensitivity testing of smoke detectors as required by NFPA 72 National Fire Alarm Code had not been conducted within the past two years.

While surveying the facility with the maintenance manager, the inspector observed the following deficiencies in the building fire sprinkler system:
a. The ceiling mounted pendant style fire sprinkler head in the director of materials management office was observed to be damaged as evidenced by the bent deflector on the fire sprinkler head.
b. Fire sprinkler heads in the staff core room were observed to be located too close together with spacing between the sprinkler heads in the room measured at 3 feet 8 inches apart and 4 feet apart. Four ceiling mounted pedant style fire sprinkler heads were observed installed the room with no readily apparent reason for the close proximity of the sprinklers.
c. The CPVC fire sprinkler piping above room # 210 in the sleep lab area was observed to be inadequately supported to prevent movement in the event of activation of the system. Approximately 3 to 4 inches of upward movement was observed in the fire sprinkler piping located in the room. The condition was noticed by the inspector due to poorly fitting escutcheon plates.
d. The closet in ICU room # 301 lacks fire sprinkler coverage. No fire sprinklers were observed by the inspector in the closet.
e. Storage on the top shelf in the ICU Med Room was observed obstructing the sidewall sprinkler head located on the same wall as the shelving in the room.

1. While surveying the facility with the maintenance manager, the inspector through interview with the maintenance manager, determined that a ventilation fan located in ceiling of the computer server room was not linked to shut down automatically upon activation of the clean agent extinguishing system protecting the room. The system protecting the room is a total flooding IG-541 system.
NFPA 2001 Standard on Clean Agent Fire Extinguishing Systems (2004 edition):
4.3.3 Operating Devices.
4.3.3.1 Operating devices shall include agent releasing devices or valves, discharge controls, and shutdown equipment necessary for successful performance of the system.

Chapter 5 System Design
5.3.5 Other than the ventilation systems identified in 5.3.5.1 and 5.3.5.3, forced-air ventilating systems shall be shut down or closed automatically where their continued operation would adversely affect the performance of the fire extinguishing system or result in propagation of the fire.
5.3.5.1 Completely self-contained recirculating ventilation systems shall not be required to be shut down.
5.3.5.2 The volume of the ventilation system and associated ductwork shall be considered as part of the total hazard volume when determining the quantity of agent.
5.3.5.3 Ventilation systems necessary to ensure safety shall not be required to be shut down upon activation of the fire suppression system. An extended agent discharge shall be provided to maintain the design concentration for the required duration of protection.


2. While surveying the affiliated Physical Rehab practice located at 3 Horton Place in Topsham, Maine, the inspector observed alcohol based hand sanitizer dispensers (ABHR) installed over carpet throughout the building. The business occupancy is not protected by an automatic fire sprinkler system. ABHR dispensers may not be installed over carpet unless the building is protected by an automatic fire sprinkler system.

While surveying the facility with the maintenance manager, the inspector observed relocatable power taps located in the operating rooms within the surgery suite. The relocatable power taps were observed connected to patient care related electrical equipment. The installation of relocatable power taps within the operating rooms and other patient care areas of the facility is prohibited as evidenced by the following:

Underwriters Laboratories "UL White Book" pertaining to listing of relocatable power taps:
"Relocatable power taps have not been investigated and are not intended for use with general patient care areas or critical patient care areas of health care facilities as defined in Article 517 of ANSI/NFPA 70, ' ' National Electrical Code. ' ' (2010 UL White Book, page 417)

Definition of patient care area pursuant to Article 517 of NFPA 70:
Patient Care Area. Any portion of a health care facility wherein patients are intended to be examined or treated. Areas of a health care facility in which patient care is administered are classified as general care areas or critical care areas, either of which may be classified as a wet location. The governing body of the facility designates these areas in accordance with the type of patient care anticipated and with the following definitions of the area classification.

General Care Areas. Patient bedrooms, examining rooms, treatment rooms, clinics, and similar areas in which it is intended that the patient will come in contact with ordinary appliances such as a nurse call system, electrical beds, examining lamps, telephone, and entertainment devices. In such areas, it may also be intended that patients be connected to electromedical devices (such as heating pads, electrocardiographs, drainage pumps, monitors, otoscopes, ophthalmoscopes, intravenous lines, etc.).
Critical Care Areas. Those special care units, intensive care units, coronary care units, angiography laboratories, cardiac catheterization laboratories, delivery rooms, operating rooms, and similar areas in which patients are intended to be subjected to invasive procedures and connected to line-operated, electromedical devices.