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NAPA 101 Life Safety Code (2012 Edition)
19.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9.

7.9.3 Periodic Testing of Emergency Lighting Equipment.

7.9.3.1 Required emergency lighting systems shall be tested in accordance with one of the three options offered by 7.9.3.1.1, 7.9.3.1.2, or 7.9.3.1.3.

7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows:
(1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1(2).
(2)*The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction.
(3) Functional testing shall be conducted annually for a minimum of 1.5 hours if the emergency lighting system is battery powered.
(4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1(1) and (3).
(5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. 7.9.3.1.2 Testing of required emergency lighting systems shall be permitted to be conducted as follows:
(1) Self-testing/self-diagnostic battery-operated emergency lighting equipment shall be provided.
(2) Not less than once every 30 days, self-testing/self-diagnostic battery-operated emergency lighting equipment shall automatically perform a test with a duration of a minimum of 30 seconds and a diagnostic routine.
(3) Self-testing/self-diagnostic battery-operated emergency lighting equipment shall indicate failures by a status indicator.
(4) A visual in inspection shall be performed at intervals not exceeding 30 days.
(5) Functional testing shall be conducted annually for a minimum of 1.5 hours.
(6) Self-testing/ self-diagnostic batter-operated emergency lighting equipment shall be fully operational for the duration of the 1.5 hour test.
(7) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.


Based on record review and interview, facility failed to ensure emergency lighting devices were tested annually for 1.5 hours as required by the Life Safety Code. Failure to conduct the required annual tests could result in the failure of lighting vital areas during a power outage. This deficient practice presents a risk of injury by fall or the delay of evacuation in the event of an emergency, to all patients, staff / occupants within the facility. The findings are:

A. On 12/09/19 at 3:30 pm, during record review of the emergency lighting inspections, no documentation was provided to indicate emergency lighting devices were tested on a annual basis for 1.5 hours for all devices.

B. On 12/09/19 at 3:35 pm during interview, the Security Staff stated they were only conducting monthly tests.

NFPA 101 Life Safety Code (2012 Edition)

19.2.8 Illumination of Means of Egress. Means of egress shall be illuminated in accordance with section 7.8.

7.10.9.2 Exit signs shall be visually inspected for operation of the illumination sources at intervals not to exceed 30 days or shall be periodically monitored in accordance 9.7.3.1.3.
7.10.9.2 Testing. Exit signs connected to, or provided with, a battery-operated emergency illumination source, where required in 7.10.4

7.9.3 Periodic Testing of Emergency Lighting Equipment.
7.9.3.1 Required emergency lighting systems shall be tested in accordance with one of the three options offered by 7.9.3.1.1, 7.9.3.1.2, or 7.9.3.1.3.
7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows:
(1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1(2).
(2)*The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction.
(3) Functional testing shall be conducted annually for a minimum of 1.5 hours if the emergency lighting system is battery powered.
(4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1(1) and (3).
(5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
7.9.3.1.2 Testing of required emergency lighting systems shall be permitted to be conducted as follows:
(1) Self-testing/self-diagnostic battery-operated emergency lighting equipment shall be provided.
(2) Not less than once every 30 days, self-testing/self-diagnostic battery-operated emergency lighting equipment shall automatically
perform a test with a duration of a minimum of 30 seconds and a diagnostic routine.
(3) Self-testing/self-diagnostic battery-operated emergency lighting equipment shall indicate failures by a status indicator.
(4) A visual in inspection shall be performed at intervals not exceeding 30 days.
(5) Functional testing shall be conducted annually for a minimum of 1.5 hours.
(6) Self-testing/ self-diagnostic batter-operated emergency lighting equipment shall be fully operational for the duration of the 1.5 hour test.
(7) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.



Based on record review and interview, facility failed to ensure battery powered exit sign devices were tested annually for a 1.5 hour duration and documentation to support testing. Not testing internally illuminated exit signs monthly/annually could result in the failure of lighting during a main power outage, leaving the facility without direction to exits. This deficient practice presents a risk of injury by the delay of evacuation in the event of an emergency to all patients, staff/occupants within the facility. The findings are:

A. On 12/09/19 at 3:37 pm, during record review of internally illuminated exit signage, no documentation was provided to indicate exit sign devices were tested for 1.5 hours within the last twelve (12) months.

B. On 12/09/19 at 3:40 pm, during interview, Security Staff stated, they had just been conducting the monthly tests.

Reference NFPA 17A, 2009 Edition

7.2 Owner's Inspection.
7.2.1 On a monthly basis, inspection shall be conducted in accordance with the manufacturer's listed installation and maintenance manual or the owner's manual.
7.2.2 At a minimum, this "quick check" or inspection shall include verification of the following:
(1) The extinguishing system is in its proper location.
(2) The manual actuators are unobstructed.
(3) The tamper indicators and seals are intact.
(4) The maintenance tag or certificate is in place.
(5) No obvious physical damage or condition exists that might prevent operation.
(6) The pressure gauge(s), if provided, shall be inspected physically or electronically to ensure it is in the operable range.
(7) The nozzle blowoff caps, where provided, are intact and undamaged.
(8) Neither the protected equipment nor the hazard has not been replaced, modified, or relocated.

7.2.3 If any deficiencies are found, appropriate corrective action shall be taken immediately.

7.2.3.1 Where the corrective action involves maintenance, it shall be conducted by a service technician as outlined in 7.3.1.

7.2.4 Personnel making inspections shall keep records for those extinguishing systems that were found to require corrective actions.

7.2.5 At least monthly, the date the inspection is performed and the initials of the person performing the inspection shall be recorded.

7.2.6 The records shall be retained for the period between the semiannual maintenance inspections.


Based on observation and interview, the facility failed to ensure the fire-extinguishing system, which protects the range hood within the kitchen, was inspected at least monthly as required by NFPA 17A (Standard for Wet Chemical Extinguishing Systems). Not maintaining this system is likely to result in less than optimal system performance in the event of fire, which presents the risk of potential harm to all patients, staff and occupants of the facility. The findings are:

A. On 12/10/19 at 1:30 pm, based on observation in the kitchen, the range hood fire-extinguishing system was not inspected monthly (Owners Inspection).

B. On 12/10/19 at 1:32 pm during interview, the Facilities Director stated the inspections will start being conducted.


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Based on observation and interview, the facility failed to ensure the range hoods fire-extinguishing system piping and nozzles are maintained in accordance with NFPA 17A (Standard for Wet Chemical Extinguishing Systems). Not maintaining the piping and position of the extinguishing nozzles is likely to render the system insufficient to suppress fire, and to operate as designed. This deficient practice presents a risk of injury by fire to all patients, staff and occupants within the facility who could potentially utilize the adjacent dining area. The findings are:

A. On 12/10/19 at 1:30 pm, based on observation in the kitchen, the range hoods fire-extinguishing system piping and nozzles, which protects the broiler, was not securely fastened to the supply piping which runs the length of the ventilation hood.

B. On 12/10/19 at 1:35 pm, during interview, the kitchen staff and the Facilities Director stated they had not noticed the loose piping on the suppression system.

Reference NFPA 72, 1999 Edition

14.1 Application.
14.1.1 The inspection, testing, and maintenance of systems, their initiating devices, and notification appliances shall comply with the requirements of this chapter.

14.3 Inspection.
14.3.1* Unless otherwise permitted by 14.3.2 visual inspections shall be performed in accordance with the schedules in Table 14.3.1 or more often if required by the authority having jurisdiction.

14.4.5* Testing Frequency. Unless otherwise permitted by other sections of this Code, testing shall be performed in accordance with the schedules in Table 14.4.5, or more often if required by the authority having jurisdiction.

14.6.2 Maintenance, Inspection, and Testing Records.
14.6.2.1 Records shall be retained until the next test and for 1 year thereafter.

14.6.2.4* A 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 14.6.2.4:


Based on record review and interview, the facility failed to ensure the fire alarm inspection and testing forms included an itemized breakdown of the alarm initiating devices (i.e. smoke/heat detectors, pull stations), the supervisory alarm supervisory devices (i.e. tamper switches) and the alarm notification appliances (i.e. horns/strobes) as required by NFPA 72 (National Fire Alarm and Signaling Code). Not properly documenting all testing of individual components of the fire alarm system could result in components and devices being missed or unaccounted for during the testing, which presents the risk of potential harm to all patients, staff and occupants of the facility. The findings are:


A. Record review of the Fire Alarm Inspection and Testing Form dated 02/11/19 (annual inspection) revealed the following information was not included:

1. The initiating devices (i.e. manual pull stations, smoke detectors, duct detectors, heat detectors and flow switches) were not broken down into an itemized list. Their specific locations within the facility were not identified and did not include the number of the device (i.e. smoke detector #1, located in room 100, etc.)
2. The notification appliances (i.e. horns and strobes) were not broken down into an itemized list and their specific locations within the facility were not identified and did not include the number of the device (i.e. strobe #1, located in the main lobby, etc.)
3. The water flow switches and the tamper switches were not broken down into an itemized list and their specific locations within the facility were not identified and did not include the number of the device (i.e. water flow switch #1, located in the northeast riser room, etc.)
4. The magnetic door locking devices and the magnetic hold open release devices were not broken down into an itemized list and their specific locations within the facility were not identified as well as the number of the device (i.e. magnetic locking device #1, located at the northwest exit doors, etc. or the magnetic hold open device #1 located at medical surgical smoke barrier doors, etc.)
5. The testing results (i.e: pass, fail) for individual devices was not being recorded including the results of the battery load voltage functional test.

B. On 12/10/19 at 8:00 am, during interview, the Facilities Director stated he was in the process of working with the fire alarm company to start providing a breakdown for all testing of individual devices and components.

Reference NFPA (National Fire Protection Association), 101 Life Safety Code (2012 Edition)

9.7.2.1 Supervisory Signals. Where supervised automatic sprinkler systems are required by another section of this code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National fire Alarm and Signaling Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.

NFPA 72 (2010 Edition), National Fire Alarm Code.

Supervisory Signal Initiating Device. An initiating device such as a valve supervisory switch, water level indicator, or low air pressure switch on a dry-pipe sprinkler system in which the change of state signals an off-normal condition and its restoration to normal of a fire protection or life safety system; or a need for action in connection with guard tours, fire suppression systems or equipment, or maintenance features of related systems.


Based on observation and interview, facility failed to ensure installed supervisory tamper switches for anti-freeze systems were electronically supervised by the fire alarm system to ensure valves would stay in the open position. Not having control valves for sprinkler systems electronically supervised could result in the water supply being turned off to the sprinkler system without anyone in the facility knowing. This deficient practice presents a potential risk of injury by fire to all occupants. The findings are:

A. On 12/10/19, at 2:20 pm, observation of anti-freeze systems (2), located at the two (2) canopy's on the southwest corner of the facility. Control valves within the ceiling were not connected to fire alarm system for electronic supervision/monitoring by the fire alarm system.

B. On 12/10/19, at 2:25 pm, during interview, the Facilities Director stated he would schedule the fire alarm company to have the devices connected/properly installed.

Reference NFPA 25, 2011 Edition:

4.1.1* Responsibility for Inspection, Testing, Maintenance, and Impairment. The property owner or designated representative shall be responsible for properly maintaining a water based fire protection system.

4.1.2* Accessibility. The property owner or designated representative shall provide ready accessibility to components of waterbased fire protection systems that require inspection, testing, and maintenance.

4.1.4.1 The property owner or designated representative shall correct or repair deficiencies or impairments that are found during the inspection, test, and maintenance required by this standard.

4.1.4.2* Corrections and repairs shall be performed by qualified maintenance personnel or a qualified contractor.


Based on record review, observation and interview, the facility failed to ensure the automatic sprinkler system was being inspected quarterly as required by with NFPA 25 (Standard for the Inspection, Testing and Maintenance of Water Based Fire Protection Systems). Not maintaining the sprinkler system is likely to result in rendering the sprinkler system inoperable or ineffectual in the event of fire, which presents the risk of potential harm to all patients, staff and occupants of the facility. The findings are:

A. On 12/09/19 at 3:05 pm, record review revealed the sprinkler system was inspected by a professional company on 06/25/19 (annual with quarterly inspection), 09/11/19 (quarterly inspection), and 11/12/19 (quarterly inspection). However, prior to the 06/25/19 inspection, the sprinkler system was last inspected on 04/23/18 (quarterly inspection), which exceeds the quarterly requirement time frame between inspections.

B. On 12/09/19 at 3:45 pm, during observation of the inspection tags attached to the northeast riser confirmed a gap in inspections between 04/23/18 and 06/25/19.

C. On 12/09/19 at 3:46 pm, during interview, the Facilities Director stated he was unsure why there was a gap in the inspections. He stated he's been working at the facility about a year now and ensures all inspections and testing is conducted as required.



Reference NFPA 25, 2011 Edition

5.3.4* Antifreeze Systems. The freezing point of solutions in antifreeze shall be tested annually by measuring the specific gravity with a hydrometer or refractometer and adjusting the solutions if necessary.

5.3.4.1* Solutions shall be in accordance with Table 5.3.4.1(a) and Table 5.3.4.1(b).


Based on observation and interview, the facility failed to ensure the freezing point of the antifreeze solution used in the piping to protect the antifreeze loop portion of the automatic sprinkler system from freezing, was being tested at least every 12 months and the solution concentration was in accordance with NFPA 25 (Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems) and NFPA Tentative Interim Amendments (TIAs). High concentration of antifreeze solution used in the sprinkler system piping is combustible in character and can accelerate fire. Too low concentrations is likely to allow the antifreeze loop to freeze during periods of cold weather, which is likely to render portions of the sprinkler system unreliable to extinguish fire. In the event of fire, this failed practice presents a risk of potential harm to all patients, staff and occupants of the facility. The findings are:


A. Review of the available quarterly sprinkler inspection reports dated 11/12/19, 09/11/19, and 06/25/19, failed to indicate any record of the freezing point (number reading) and the concentration of the antifreeze solution used in the facility's antifreeze loop systems. The facility has two antifreeze loop systems, one protects the porched area located at the physical therapy entrance and the other protects the porched area located at the administrative entrance.

B. On 12/09/19 at 3:33 pm, during interview, the Facilities Director stated he didn't realize the freezing point and the solution concentration was not being tested and properly documented.






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NFPA 101, 2012 Edition
9.7.3 Other Automatic Extinguishing Equipment.
9.7.3.1 In any occupancy where the character of the fuel for fire is such that extinguishment or control of fire is accomplished by a type of automatic extinguishing system in lieu of an automatic sprinkler system, such system shall be installed in accordance with the appropriate standard, as determined in accordance with Table 9.7.3.1.

9.7.3.1 (See Table)

Clean Agent Extinguishing Systems, NFPA 2001 (Standard on Clean Agent Fire Extinguishing Systems - 2012 Edition

4.3 Detection, Actuation, Alarm, and Control Systems.
4.3.1 General.
4.3.1.1 Detection, actuation, alarm, and control systems shall be installed, tested, and maintained in accordance with appropriate NFPA protective signaling systems standards.
(See NFPA 70 and NFPA 72. In Canada refer to CAN/ULC S524-06 and CAN/ULC S529-09.)

4.3.5.4 Alarms indicating failure of supervised devices or equipment shall give prompt and positive indication of any failure and shall be distinctive from alarms indicating operation or hazardous conditions.
4.3.5.5 Warning and instruction signs at entrances to and inside protected areas shall be provided.
4.3.5.5.1 Warning and safety instruction signs shall be located such that they will be readily visible to personnel in the area where the clean agent design concentration exceeds that approved for use in normally occupied spaces. The safety sign format and color and the letter style of the signal words shall be in accordance with ANSI Z535.
4.3.5.5.2 Warning and safety instruction signs shall be located outside each entrance to clean agent cylinder storage rooms. The safety sign format and color and the letter style of the signal words shall be in accordance with ANSI 535.


Based on observation, facility failed to ensure warning/safety instruction signs, and visible notification devices were provided outside the room where clean agent systems are installed for fire protection. Not having warning/instructional signage or visual notification devices at described areas as required could result in staff failing to provide safety measures while patients are be treated in the event a fire has occurred. This deficient practice presents a risk of injury to patients and staff who would potentially utilize the Cath Lab. The findings are:

A. On 12/09/19, at 1:30 pm, observation of clean agent fire suppression system located in Cath Lab, had several items of storage located within the room housing the system, blocking access.

B. On 12/10/19, at 1:55 pm, during tour of facility, while entering Cath Lab, no instructional/warning signage was posted outside the room to indicate clean agent system is installed.

C. On 12/10/19, at 2:05 pm, during interview, Facilities Director indicated system will be serviced/evaluated to ensure requirements are met.

Reference NFPA 10, 2010 Edition

7.2.2 Procedures. Periodic inspection or electronic monitoring of fire extinguishers shall include a check of at least the following items:
(1) Location in designated place
(2) No obstruction to access or visibility
(3) Pressure gauge reading or indicator in the operable range or position
(4) Fullness determined by weighing or hefting for self-expelling type extinguishers, cartridge operated extinguishers, and pump tanks
(5) Condition of tires, wheels, carriage, hose, and nozzle for wheeled extinguishers
(6) Indicator for nonrechargeable extinguishers using push-to-test pressure indicators


Based on observation and interview, the facility failed to ensure all fire extinguishers were inspected monthly as required by NFPA 10 (Standard for Portable Fire Extinguishers). Not inspecting fire extinguishers monthly is likely to result is less than optimal performance to extinguish fire when needed, which presents a risk of potential harm to all patients, staff and occupants of the facility. The findings are:


A. On 12/09/19 at 2:45 pm, based on observation, the fire extinguisher located in the northeast sprinkler riser room was not inspected the month of November, 2019.

B. On 12/10/19 at 10:35 am, based on observation, the fire extinguisher located across from the entrance into the nursery was not inspected the month of November, 2019.

C. On 12/10/19 at 11:15 am, based on observation, the fire extinguisher located in the security office was not inspected the month of November 2019.

D. On 12/10/19 at 11:20 am, during interview, the Facilities Director stated he was unaware the inspections were missed for November. He stated monthly inspections would be conducted as required.

Reference NFPA 101, 2012 Edition

19.3.7.3. Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.

Section 8.5.6 Penetrations.

8.5.6.1 The provisions of 8.5.6 shall govern the materials and methods of construction used to protect through-penetrations and membrane penetrations of smoke barriers.

8.5.6.2 Penetrations for cables, cable trays, conduits, pipes, tubes, vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a smoke barrier, or through the ceiling membrane of the roof/ceiling of a smoke barrier assembly, shall be protected by a system or material capable of restricting the transfer of smoke.

8.5.6.3 Where a smoke barrier is also constructed as a fire barrier, the penetrations shall be protected in accordance with the requirements of 8.3.5 to limit the spread of fire for a time period equal to the fire resistance rating of the assembly and 8.5.6 to restrict the transfer of smoke, unless the requirements of 8.5.6.4 are met.


Based on observation and interview, the facility failed to ensure the smoke/fire barrier wall located near the operating room corridor was sealed to resist the passage of smoke and maintain it's fire resistive rating. Incomplete construction, unprotected penetrations, openings and gaps in smoke/fire barriers walls would permit the movement of smoke/fire from one compartment to another, which in the event of fire, presents the risk of potential harm to all patients, staff and occupants of the facility. The findings are:

A. On 12/10/19 at 3:20 pm, during observation of the smoke/fire barrier wall located near the operating room corridor revealed several electrical conduits not sealed at their perimeters. These penetrations were located directly above the barrier doors, above the suspended ceiling.

B. On 12/10/19 at 3:22 pm, during interview, the Facilities Director stated the facility now has a program in place to identify all penetrations and have them sealed. He stated he hasn't yet completed sealing all the penetrations in the facility walls but is working on it.

























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Reference NFPA 101, 2012 Edition

19.3.7.3. Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a fire resistance rating of not less than 1/2 hour.

Section 8.5.6 Penetrations.

8.5.6.1 The provisions of 8.5.6 shall govern the materials and methods of construction used to protect through-penetrations and membrane penetrations of smoke barriers.

8.5.6.2 Penetrations for cables, cable trays, conduits, pipes, tubes, vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a smoke barrier, or through the ceiling membrane of the roof/ceiling of a smoke barrier assembly, shall be protected by a system or material capable of restricting the transfer of smoke.

8.5.6.3 Where a smoke barrier is also constructed as a fire barrier, the penetrations shall be protected in accordance with the requirements of 8.3.5 to limit the spread of fire for a time period equal to the fire resistance rating of the assembly and 8.5.6 to restrict the transfer of smoke, unless the requirements of 8.5.6.4 are met.


Based on observation and interview, the facility failed to ensure that the smoke barriers within the facility were properly sealed to resist the passage of smoke/fire. Not having all smoke/fire barriers properly sealed, could result in the passage of smoke/fire from one area to another. This deficient practice presents a risk of injury by fire/smoke to all patients, staff and occupants within the facility. The findings are:


A. On 12/09/19 at 1:55 pm, during observation of elevator mechanical room located adjacent to main mechanical room (east side of facility), had three (3) wall penetrations surrounding piping passing thru smoke barrier wall on west side.

B. On 12/10/19 at 2:35 pm, during observation of soiled utility room adjacent to room #199 (emergency room at staff entrance), revealed two 1 x 2 inch penetrations at fire smoke barrier.

C. On 12/10/19 at 2:40 pm, during interview, the Director of Facilities stated the penetrations would be sealed properly.

NFPA (National Fire Protection Association), 101 Life Safety Code 2012 Edition

19.5.2 Heating, Ventilating, and Air-Conditioning.
19.5.2.1 Heating, ventilating, and air-conditioning shall comply with the provisions of Section 9.2 and shall be installed in accordance with manufacture's specifications, unless otherwise modified by 19.5.2.2.


NFPA (National Fire Protection Association), 99 (Health Care Facilities Code), 2012 Edition

9.3.7.5.3 Mechanical Ventilation.
9.3.7.5.3.1 Mechanical exhaust to maintain a negative pressure in the space shall be provided continuously, unless an alternative design is approved by the authority having jurisdiction.
9.3.7.5.3.2 Mechanical exhaust shall be at a rate of 1 L/sec of airflow for each 300 L (1 cfm per 5 ft3 of fluid) designed to be stored in the space and not less than 24 L/sec (50 cfm) nor
more than 235 L/sec (500 cfm).
9.3.7.5.3.3 Mechanical exhaust inlets shall be unobstructed and shall draw air from within 300 mm (1 ft) of the floor and adjacent to the cylinder or containers.
9.3.7.5.3.4 Mechanical exhaust air fans shall be supplied with electrical power from the essential electrical system.


Based on observation and interview, the facility failed to ensure mechanical ventilation was continuously maintained in janitors closets where cleaning agents/chemicals are stored. Not maintaining mechanical ventilation in locations [described above] could result in the release of noxious fumes/odors. This deficient practice presents a risk of harm to patients, staff and occupants within the facility. The findings are:

A. On 12/10/19 at 10:40 am, observation of janitorial closet #409, mechanical exhaust ventilation was not operating when checked.

B. On 12/10/19 at 1:35 pm, observation of janitorial closet in kitchen area, mechanical exhaust ventilation was not operating when checked.

C. On 12/10/19 at 2:10 pm during interview, Facilities Director stated, "the fan will be repaired as soon as possible."

Based on record review and staff interview, the facility failed to ensure the Firefighter's Service is operated monthly and a written record maintained for all three (3) elevator banks. Not operating and documenting the Firefighter's Service test monthly is likely to result in an undetected malfunction of the service. In the event the elevators need to be used by firefighting personal for transport of occupants during an emergency, the Firefighters service may not be available. This failed practice presents the risk of potential harm to all patients, staff and occupants of the facility. The findings are:

A. On 12/09/19 at 3:50 pm, record review of the elevator inspection and maintenance records failed to reveal evidence the Firefighters Service is being operated and documented monthly for all three (3) elevator banks.

B. On 12/09/19 at 3:51 pm, during interview, the Facilities Director stated the Firefighters service isn't being operated.



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NFPA 101, 2012 Edition

19.5.3 Elevators, Escalators, and Conveyors, shall comply with provisions of Section 9.4.

9.4 Elevators, Escalators, and Conveyors.
9.4.1* General. An elevator, other than an elevator in accordance with 7.2.13, shall not be considered a component in a required means of egress but shall be permitted as a component
in an accessible means of egress.
9.4.2 Code Compliance.
9.4.2.1 Except as modified herein, new elevators, escalators, dumbwaiters, and moving walks shall be in accordance with the requirements of ASME A17.1 CSA B44, Safety Code for Elevators and Escalators.

9.4.6 Elevator Testing.
9.4.6.1 Elevators shall be subject to periodic inspections and tests as specified in ASME A17.1/CSA B44, Safety Code for Elevators and Escalators.
9.4.6.2 All elevators equipped with fire fighters ' emergency operations in accordance with 9.4.3 shall be subject to a monthly operation with a written record of the findings made and kept on the premises as required by ASMEA17.1/CSA B44, Safety Code for Elevators and Escalators. Code.


Based on observation and interview, facility failed to ensure communications in elevators were operable and monitored by a constantly attended station. Not having communications within all elevators operating properly, this deficient practice could result in patients, staff and occupants being trapped without communications in the event of a failure of operations. event of an emergency. The findings are:

A. On 12/10/19 at 11:00 am, observation of elevator # 3, communications were tested and found inoperable.

B. On 12/10/19 at 11:05 am, based on above statement, interview with Security and Facilities Director were then asked if a monthly test of Fire Fighters emergency operations were tested.

C. On 12/10/19 at 11:10 pm, during interview, Security stated communications were checked monthly, although not the Fire Fighters emergency operation has not been checked monthly.

Based on observation and interview, the facility failed to ensure portable space heating devices are not used in patient areas. Space heaters can cause fires when they malfunction due to improper use, which presents a risk of potential harm to all patients, staff and occupants of the facility. The findings are:

A. On 12/10/19 at 11:20 am, during observation, an electric space heater was observed in the Doctor Dictation office. The unit was plugged in to an electrical outlet and in use. This room is adjacent and open to the nurse station.

B. On 12/10/19 at 11:21 am, during observation, an electric space heater was observed under the counter at the nurse station. The unit was plugged in but not on. The nurse station centrally located and open to medical surgical patient rooms on both sides of the corridors.

C. On 12/10/19 at 11:22 am, during interview, the Facilities Director stated he didn't realize portable heating units were being used in the area (medical surgical). He stated portable space heating devices are not allowed in the hospital.

NFPA 101 Life Safety Code, 2012 Edition

19.5.1 Utilities shall comply with the provisions of Section 9.1.

9.1.3 Emergency Generators and Standby Power Systems. Where required for compliance with this Code, emergency generators and standby power systems shall comply with 9.1.3.1 and 9.1.3.2.
9.1.3.1 Emergency generators and standby power systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems.

National Fire Protection Association (NFPA 99) Health Care Facilities Code, 2012 Edition

6.4.1.1.17 Alarm Annunciator A remote annunciator that is storage battery powered shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see 700.12 of NFPA 70, National Electrical Code). The annunciator shall be hard-wired to indicate alarm conditions of the emergency or auxiliary power source as follows:

(1) Individual visual signals shall indicate the following:
(a) When the emergency or auxiliary power source is operating to supply power to load
(b) When the battery charger is malfunctioning

(2) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
(a) Low lubricating oil pressure
(b) Low water temperature (below that required in 6.4.1.1.11)
(c) Excessive water temperature
(d) Low fuel when the main fuel storage tank contains less than a 4-hour operating supply
(e) Overcrank (failed to start)
(f) Overspeed

6.4.1.1.17.1* A remote, common audible alarm shall be provided as specified in 6.4.1.1.17.4 that is powered by the storage battery and located outside of the EPS service room at a work site observable by personnel. [110:5.6.6]

Based on observation and interview, the facility failed to ensure that remote annunciators [2 generators at facility] were installed at a constantly attended station, which would readily alert staff to problems with the emergency generator as required by NFPA 99 Healthcare Facilities Code, 2012 Edition. Not having remote annunciators at a 24 hour attended station could result in staff not knowing potential problems with emergency backup power. This deficient practice presents a risk of potential harm to all patients, staff and occupants within the facility. The findings are:

A. On 12/11/19 at 9:40 am, observation of Kohler Generator remote annunciator was installed in Front End Business Office.

B. On 12/11/19 at 9:50 am, during interview, Facilities Director stated it would be relocated to a constantly attended station.