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Based on observation and staff interview the facility fails to ensure that projections in to the egress corridor are 6 inches in depth or smaller. This deficient practice could impede occupants from exiting in the event of a fire or other emergency situation by coming in contacting these projections, affecting all occupants in both smoke zones. The facility has a capacity of 25 with a census of 1 at the time of survey.

Findings include:

During the survey on May 31, 2017 at 12:10 p.m. it is observed that the arms on door closing devices extend into the corridor approximately 12 inches at the following locations:

1. West equipment room.
2. Operating room both doors.
3. North mechanical room.
4. East soiled linen room.

The Plant Manager was present at the time of the observation and acknowledged the findings.

Review of the following NFPA Standard revealed: Any required aisle, corridor, or ramp shall be not less than 48 in. (1220 mm) in clear width where serving as means of egress from patient sleeping rooms, unless otherwise permitted by one of the following:

(1) Aisles, corridors, and ramps in adjunct areas not intended for the housing, treatment, or use of inpatients shall be not less than 44 in. (1120 mm) in clear and unobstructed width.
(2) Where corridor width is at least 6ft (1830 mm), noncontinuous projections not more than 6 in. (150 mm) from the corridor wall, above the handrail height, shall be permitted.
(3) Exit access within a room or suite of rooms complying with the requirements of 19.2.5 shall be permitted.
(4) Projections into the required width shall be permitted for wheeled equipment, provided that all of the following conditions are met:
(a) The wheeled equipment does not reduce the clear unobstructed corridor width to less than 60 in. (152.5 mm).
(b) The health care occupancy fire safety plan and training program address the relocation of the wheeled equipment during a fire or similar emergency.
(c) The wheeled equipment is limited to the following:
i. Equipment in use and carts in use
ii. Medical emergency equipment not in use
iii. Patient lift and transport equipment
(5) Where the corridor width is at least 8 ft (2440 mm), projections into the required width shall be permitted for fixed furniture, provided that all of the following conditions are met:
(a) The fixed furniture is securely attached to the floor or to the wall.
(b) The fixed furniture does not reduce the clear unobstructed corridor width to less than 6 ft (1830 mm), except as permitted by 19.2.3.4(2).
(c) The fixed furniture is located only on one side of the corridor.
(d) The fixed furniture is grouped such that each grouping does not exceed an area of 50 ft2 (4.6 m2).
(e) The fixed furniture groupings addressed in 19.2.3.4(5) (d) are separated from each other by a distance of at least 10 ft (3050 mm).
(f) The fixed furniture is located so as to not obstruct access to building service and fire protection equipment.
(g) Corridors throughout the smoke compartment are protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4, or the fixed furniture spaces are arranged and located to allow direct supervision by the facility staff from a nurses' station or similar space.
(h) The smoke compartment is protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.8. 2012 NFPA 101, 19.2.3.4

Based on observation and staff interview the facility failed to provide continuous illumination to the exit sign as required. The deficient practice could leave the exits unidentifiable in emergency situations. This deficiency affects approximately 22 residents in one of two smoke zones. The facility has a capacity of 25 with a census of 1 at the time of survey.

Findings include:
During the survey on May 31st 2017 at 10:30 AM it is observed the normal illumination source for the exit sign located on the east side of the smoke barrier door is provided with a switch that when activated disconnects the power source and turns off the normal illumination for the exit sign..

Plant manager was present and acknowledged the findings.

Review of the following NFPA standard revealed: Every sign required by 7.10.1.2, 7.10.1.5, or 7.10.8.1, other than where operations or processes require low lighting levels, shall be suitably illuminated by a reliable light source. Externally and internally illuminated signs shall be legible in both the normal and emergency lighting mode. Every sign required to be illuminated by 7.10.6.3, 7.10.7, and 7.10.8.1 shall be continuously illuminated as required under the provisions of Section 7.8, unless otherwise provided in 7.10.5.2.2. 2012 NFPA 101, 7.10.5.1 and 7.10.5.2.1

Based on observation and record review, the facility failed to provide complete documentation of annual inspection and testing of the fire alarm system as required by NFPA 72. The absence of complete, verifiable documented maintenance and repair history on the fire alarm system fails to ensure reliability of the alarm system in the event of an emergency, affecting all occupants in all smoke zones. The facility has a capacity of 25 and census of 1 at the time of the survey.

Findings include:

During record review on May 30, 2017 at 2:25 PM the fire alarm vendor inspection and testing report required by NFPA 72 and dated December 8, 2016 is not properly documented. This report revealed there was no initiating device list. The facility has 7 smoke detectors; 7 pull stations, 4 heat detectors and a range hood. None of the devices were individually itemized and listed as being tested and the information required by NFPA 72, device locations, serial numbers, device types, and the type, quantity, method of testing and the results of testing obtained are not reported. According to the facility's annual fire alarm testing report the items passed. This report does not contain all the information requested in NFPA 72, 14.6.2.4.

The Plant Manager was present at the time of the observation and acknowledged the findings.

Review of the following NFPA Standard revealed: Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6. 2012 NFPA 101, 19.3.4.1

Review of the following NFPA Standard revealed: Any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature requiring periodic testing, inspection, or operation to ensure its maintenance shall be tested, inspected, or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction. 2012 NFPA 101, 4.6.12.4

Review of the following NFPA Standard revealed: To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code. 2012 NFPA 101, 9.6.1.5

Review of the following NFPA Standard revealed: 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:
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business address, and telephone number
(6) Name, address, and representative of approving agency(ies)
(7) Designation of the detector(s) tested
(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) Functional test of mass notification system control units
(13) Functional test of signal transmission to mass notification systems
(14) Functional test of ability of mass notification system to silence fire alarm notification appliances
(15) Test of intelligibility of mass notification system speakers
(16) Other tests as required by the equipment manufacturer's published instructions
(17) Other tests as required by the authority having jurisdiction
(18) Signatures of tester and approved authority representative
(19) Disposition of problems identified during test (e.g., system owner notified, problem corrected/successfully retested, device abandoned in place)

Based on observation and staff interview, the facility failed to provide separation of corridors from use areas. This deficient practice would allow smoke and fire products to travel from the use area into the exit corridor, affecting approximately 4 patients in one of two smoke zones. The facility has a capacity of 25 and census of 1 at the time of the survey.

Findings include:

During the survey on May 31st 2017 the following is observed:
1. At 12:00 PM there is a 20 inch by 17.5 inch opening in the corridor wall where a unrated service counter window passes from the kitchen to the exit corridor.
Review of the following NFPA Standard revealed: Corridor walls shall have a minimum l/2-hour fire resistance rating. 2012 NFPA 101, 19.3.6.2.2

Review of the following NFPA Standard revealed: Corridor walls shall form a barrier to limit the transfer of smoke.
2012 NFPA 101, 19.3.6.2.3

Review of the following NFPA Standard revealed: In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.7, a corridor shall be permitted to be separated from all other areas by non-fire-rated partitions and shall be permitted to terminate at the ceiling where the ceiling is constructed to limit the transfer of smoke. 2012 NFPA 101, 19.3.6.2.4

Based on observation and staff interview the facility is not ensuring that room doors fit tightly within the doorframe to resist the passage of smoke. This deficient practice of not ensuring that room fit tightly within the doorframe to resist the passage of smoke prevents the ability of the facility to properly confine fire and smoke products and to properly defend occupants in place, affecting approximately 4 patients in one of two smoke zones. The facility has a capacity of 25 and census of 1 at the time of the survey.

Findings include:

During the survey on May 31, 2017 at 10:30 a.m. the door to the exit corridor from the Director of Nursing's office is sagging below the door stop.

The Plant Manager was present during the survey and acknowledged the findings.

Review of the following NFPA Standard revealed: Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction and the following requirements also shall apply:

(1) The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door.
(2) Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.7. 2012 NFPA 101, 19.3.6.3.5

Based on record review and staff interview the facility failed to provide elements of the written fire safety plan as required. The deficient practice may prevent the staff from identifying the proper procedures to take during an actual emergency, affecting all occupants in both smoke zones. The facility has a capacity of 25 and census of 1 at the time of the survey.

Findings include:

During the record review on May 31, 2017 at 3:50 p.m. the following is revealed:

1. The written fire safety plan indicated that staff should make a coded announcement over the intercom system prior to sounding the fire alarm system to fulfill the use of alarm portion of the required fire safety plan elements.

2. The written fire safety plan did not address rescue of patients in immediate danger as the rooms adjacent to and across from the fire room also described as the triangle of rooms.

The Plant Manager was present at the time of the observation and acknowledged the findings.

Review of the following NFPA Standard revealed: The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan required by 19.7.1.1. A copy of the plan required by 19.7.1.1 shall be readily available at all times in the telephone operator's location or at the security center. 2012 NFPA 101, 19.7.1.1, 19.7.1.2, 19.7.1.3

Review of the following NFPA Standard revealed: For health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel. 2012 NFPA 101, 19.7.2.1.1

Review of the following NFPA Standard revealed: The basic response required of staff shall include the following:(1) Removal of all occupants directly involved with the fire emergency (2) Transmission of an appropriate fire alarm signal to warn other building occupants and summon staff (3) Confinement of the effects of the fire by closing doors to isolate the fire area (4) Relocation of patients as detailed in the health care occupancy's fire safety plan. 2012 NFPA 101, 19.7.2.1.2

Review of the following NFPA Standard revealed: Fire Safety Plan. A written health care occupancy fire safety plan shall provide for all of the following:

(1) Use of alarms
(2) Transmission of alarms to fire department
(3) Emergency phone call to fire department
(4) Response to alarms
(5) Isolation of fire
(6) Evacuation of immediate area
(7) Evacuation of smoke compartment
(8) Preparation of floors and building for evacuation
(9) Extinguishment of fire
2012 NFPA 101, 19.7.2.2

Based on observation and staff interview the facility failed to provide a remote manual stop as required for the emergency generator power supplies as required. The deficient practice may prevent the emergency power supply from being available at the time of a power loss, affecting all residents in all smoke zones. The facility has a capacity of 25 and census of 1 at the time of the survey.

Findings include:

During the survey on May 31, 2017 at 10:45 a.m., it is observed that there is not a remote emergency manual stop for the generator set exterior to the generator housing.

The Plant Manager was present at the time of the observation and acknowledged the findings.

Review of the following NFPA Standard revealed: All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building. 2010 NFPA 110, 5.6.5.6

Review of the following NFPA Standard revealed: The remote manual stop station shall be labeled. .
2010 NFPA 110, 5.6.5.6.1

Based on observation and staff interview, the facility fails to assure that all relocatable power taps meet the requirements of UL 1363 and are installed in accordance with the requirements NFPA 70 National Electrical Code and NFPA 99. This deficient practice increases the risk of an electrical fire and affects all patients in both smoke zones. The facility has a capacity of 25 and census of 1 at the time of the survey.

Findings include:

During the survey on May 31st 2017 the following is observed:

1. At 9:35 AM there are two power strips being powered by power strips in the CEO's office.
2. At 9:45 AM there are two unapproved power strips in use in patient care room 109. Upon finding this the Plant Manager stated that this would be found throughout the building in patient care rooms. But these are not located in the patient care vicinity. This is confirmed by finding multiple other unapproved power strips in use throughout.

Plant manager was present and acknowledged the findings.

Review of the following NFPA Standard revealed: Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service. 2012 NFPA 101, 9.1.2

Review of the following NFPA Standard revealed: Where used as permitted in 400.7(A)(3), (A)(6), and (A)(8), each flexible cord shall be equipped with an attachment plug and shall be energized from a receptacle outlet or cord connector body.

Exception: As permitted in 368.56. 2011 NFPA 70, 400.7

Review of the following NFPA Standard revealed: Unless specifically permitted, flexible cords and cable shall not be used as a substitute for fixed wiring of a structure. 1999 NFPA 70, 400-8

Review of the following NFPA Standard revealed: In no case shall the load exceed the branch-circuit ampere rating. An individual branch circuit shall be permitted to supply any load for which it is rated. A branch circuit supplying two or more outlets or receptacles shall supply only the loads specified according to its size as specified in 210.23(A) through (D) and as summarized in 210.24 and Table 210.24. 2011 NFPA 70, 210.23

Review of the following NFPA Standard revealed: The flexible cord, including the grounding conductor, shall be of a type suitable for the particular application; shall be listed for use at a voltage equal to or greater than the rated power line voltage of the appliance; and shall have an ampacity, as given in Table 400.5(A) of NFPA 70, National Electrical Code, equal to or greater than the current rating of the device. 2012 NFPA 99, 10.2.3.1.1

Review of the following NFPA Standard revealed: Nonpatient care-related electrical equipment, including facility- or patient-owned appliances that are used in the patient care vicinity and will, in normal use, contact patients, shall be visually inspected by the patient's care staff or other personnel. 2012 NFPA 99, 10.4.2.1