HospitalInspections.org

Based on observation and staff interview, the facility failed to provide a smoke barrier constructed to resist the passage of smoke. This condition had the potential for smoke to spread throughout the facility. Facility census was 2.

Findings are:
Observation during the facility tour on 8/5/13, at 2:12 pm revealed that the smoke barrier wall failed to extend to roof deck on both sides of the stud wall, starting at the Lab Door through to the Chapel outside wall. The wall stopped approximately two feet before the roof deck. Penetrations failed to be sealed throughout this wall.
Record review of the fire and smoke rating floor plan confirmed that this wall was the required smoke barrier.
In an interview conducted at the time of observation, (8/5/13, at 2:12 pm), Maintenance A confirmed that the smoke barrier wall failed to extend to roof deck.

Based on observation and staff interview, the facility failed to provide separation of hazardous areas from other compartments. This condition had the potential for fire to spread into the exit corridors and other use areas. Facility census was 2.

Findings are:
Observations during the facility tour on 8/5/13, at 1:02 pm revealed the Pre-Op Soiled Utility Door failed to latch when self-closed.
In an interview conducted at the time of observation, (8/5/13, at 1:02 pm), Maintenance A acknowledged the findings.

Based on record review and staff interview, the facility failed to maintain battery backup emergency lighting. This condition had the potential to leave occupants in darkness during a loss of power. Facility census was 2.

Findings are:
Observation during the facility tour on 8/5/13, at 12:50 pm revealed the battery backup emergency light in the Patient Wing Corridor near Room 4 failed to function when tested.
In an interview conducted at the time of record review (8/5/13, at 12:50 pm), Maintenance A acknowledged the findings.

Actual NFPA Standard:
NFPA 101, 7.9.3, Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 ? hours. Equipment shall be fully operation for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Based on observation and staff interview, the facility failed to provide filters in the Kitchen Range Hood that met National Fire Protection Association 96 requirements. This condition had the potential for the accumulation of grease in the filters. Facility census was 2.

Findings are:
Observation during the facility tour on 8/5/13, at 11:38 am revealed mesh constructed filters were installed in the range hood, and failed to be replaced with filters listed in accordance with Underwriters Laboratories 1046. The range hood itself appeared to meet UL 300 requirements.
In an interview conducted at the time of observation, (8/5/13, at 11:38 am), Maintenance A acknowledged the findings.

Actual NFPA Standard:
6.1 Grease Removal Devices.
6.1.1 Listed grease filters, listed baffles, or other listed grease removal devices for use with commercial cooking equipment shall be provided.
6.1.2 Listed grease filters shall be tested in accordance with UL 1046, Standard for Grease Filters for Exhaust Ducts.
6.1.3 Mesh filters shall not be used.

Based on record review and staff interview, the facility failed to provide documentation that the emergency generators had been tested in accordance with the National Fire Protection Association 110. This condition increased the potential that the generator would not function during an emergency. Facility census was 2.

Findings are:
Record review of emergency generator maintenance and testing revealed that the facility failed to provide complete documentation of weekly generator testing for both emergency generators for the last 12 months.
In an interview conducted at the time of record review (8/5/13, at 11:12 am), Maintenance A confirmed that the information was not recorded for every week the past year.

Actual NFPA Standard:
NFPA 110, 6-3.1*
The EPSS shall be maintained to ensure to a reasonable degree that the system is capable of supplying service within the time specified for the type and for the time duration specified for the class.

Note: Please refer to A-6-3.1 for an example of a complete maintenance checklist.

6-4.1*
Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.

Based on observation and staff interview, the facility failed to provide a smoke barrier constructed to resist the passage of smoke. This condition had the potential for smoke to spread throughout the facility. Facility census was 2.

Findings are:
Observation during the facility tour on 8/5/13, at 2:12 pm revealed that the smoke barrier wall failed to extend to roof deck on both sides of the stud wall, starting at the Lab Door through to the Chapel outside wall. The wall stopped approximately two feet before the roof deck. Penetrations failed to be sealed throughout this wall.
Record review of the fire and smoke rating floor plan confirmed that this wall was the required smoke barrier.
In an interview conducted at the time of observation, (8/5/13, at 2:12 pm), Maintenance A confirmed that the smoke barrier wall failed to extend to roof deck.

Based on observation and staff interview, the facility failed to provide separation of hazardous areas from other compartments. This condition had the potential for fire to spread into the exit corridors and other use areas. Facility census was 2.

Findings are:
Observations during the facility tour on 8/5/13, at 1:02 pm revealed the Pre-Op Soiled Utility Door failed to latch when self-closed.
In an interview conducted at the time of observation, (8/5/13, at 1:02 pm), Maintenance A acknowledged the findings.

Based on record review and staff interview, the facility failed to maintain battery backup emergency lighting. This condition had the potential to leave occupants in darkness during a loss of power. Facility census was 2.

Findings are:
Observation during the facility tour on 8/5/13, at 12:50 pm revealed the battery backup emergency light in the Patient Wing Corridor near Room 4 failed to function when tested.
In an interview conducted at the time of record review (8/5/13, at 12:50 pm), Maintenance A acknowledged the findings.

Actual NFPA Standard:
NFPA 101, 7.9.3, Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 ? hours. Equipment shall be fully operation for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Based on observation and staff interview, the facility failed to provide filters in the Kitchen Range Hood that met National Fire Protection Association 96 requirements. This condition had the potential for the accumulation of grease in the filters. Facility census was 2.

Findings are:
Observation during the facility tour on 8/5/13, at 11:38 am revealed mesh constructed filters were installed in the range hood, and failed to be replaced with filters listed in accordance with Underwriters Laboratories 1046. The range hood itself appeared to meet UL 300 requirements.
In an interview conducted at the time of observation, (8/5/13, at 11:38 am), Maintenance A acknowledged the findings.

Actual NFPA Standard:
6.1 Grease Removal Devices.
6.1.1 Listed grease filters, listed baffles, or other listed grease removal devices for use with commercial cooking equipment shall be provided.
6.1.2 Listed grease filters shall be tested in accordance with UL 1046, Standard for Grease Filters for Exhaust Ducts.
6.1.3 Mesh filters shall not be used.

Based on record review and staff interview, the facility failed to provide documentation that the emergency generators had been tested in accordance with the National Fire Protection Association 110. This condition increased the potential that the generator would not function during an emergency. Facility census was 2.

Findings are:
Record review of emergency generator maintenance and testing revealed that the facility failed to provide complete documentation of weekly generator testing for both emergency generators for the last 12 months.
In an interview conducted at the time of record review (8/5/13, at 11:12 am), Maintenance A confirmed that the information was not recorded for every week the past year.

Actual NFPA Standard:
NFPA 110, 6-3.1*
The EPSS shall be maintained to ensure to a reasonable degree that the system is capable of supplying service within the time specified for the type and for the time duration specified for the class.

Note: Please refer to A-6-3.1 for an example of a complete maintenance checklist.

6-4.1*
Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.