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Based on observation and staff interview the facility fails to properly protect and maintain their hazardous areas in accordance with NFPA 101. The deficient practice would affect no patients or visitors and all staff in 1 of 4 smoke zones. The facility has 14 certified beds and at the time of the survey the census was 7.

Findings include:

During the survey conducted on 2/15/19 the following deficiency is noted:

1. During the survey at 9:25 AM, it is observed that rated door to the boiler room did not properly close and latch when tested.

Staff A was present and acknowledged finding.

NFPA Standard: NFPA 101 19.3.2.1.3 The doors shall be self-closing or automatic-closing.
19.3.2.1.5 Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms (2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops (4) Repair shops (5) Rooms with soiled linen in volume exceeding 64 gal (242 L)
(6) Rooms with collected trash in volume exceeding 64 gal (242 L) (7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction (8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard
19.3.2.1.2* Where the sprinkler option of 19.3.2.1 is used, the areas shall be separated from other spaces by smoke partitions in accordance with Section 8.4.

Based on observation, and staff interview, this facility is not maintaining the sprinkler system in accordance with NFPA 25. By not maintaining the system with an acceptable clearance around sprinkler heads to prevent obstructions to spray patterns. This deficient practice could affect the operation of the heads by obstructing spray patterns, delaying the response time or preventing the operation of the heads that can compromise the effectiveness of the fire suppression system, affecting no patients, and all visitors and staff in 1 of 4 smoke zones. The facility has 14 certified beds and at the time of the survey the census was 7.

Findings include:

During the survey conducted on 2/15/19 the following deficiency is noted:

1. During the survey at 10:16 AM, it is observed that there is storage on a shelf within 18" of a sprinkler head in the back corner of the basement storage room.

Staff A was present and acknowledged the finding.

NFPA Standard: Automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25 per 2012 NFPA 101, 9.7.5.

NFPA Standard: Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction. 2012 NFPA 101 4.6.12.1

NFPA Standard: Requires sprinkler systems to be continuously maintained in proper operating condition and an inspection every quarter of a calendar year. 2012 NFPA 101, 4.6.12.1

Based on document review and staff interview, the facility fails to conduct fire drills as required by Life Safety Code NFPA 101. This deficient practice would affect all patients, visitors, and staff in 4 of 4 smoke zones. The facility has 14 certified beds and at the time of the survey the census was 7.

Findings Include:

During the survey on 2/14/19 the following deficiencies are noted:

1. During document review at 2:45 PM, it is observed that the documentation for testing the fire alarm on silent drills is not being completed within 24 hours of when the drill was completed.
2. During document review at 2:45 PM, it is observed that the fire drill held on 2nd shift in the 3rd quarter of 2018 at 7:30 PM was held as a silent drill.

Staff A was present and acknowledged the findings.

NFPA Standard: NFPA 101 2012 19.7.1.4* Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. 19.7.1.5 Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building. 19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. 19.7.1.7 When drills are conducted between 9:00 p.m. and 6:00 a.m. (2100 hours and 0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

Based upon observation, document review, and staff interview the facility is not inspecting and maintaining their rated door assemblies in compliance with NFPA 80. This deficient practice could prevent the ability of the facility to properly confine smoke and prevent fire from spreading to other zones. This deficient practice would affect all patients, visitors, and staff in 4 of 4 smoke zones. The facility has 14 certified beds and at the time of the survey the census was 7.

Findings include:

During the survey conducted on 2/14/19 the following deficiency is noted:

1. During document review at 4:03 PM, it is observed that there is no documentation for any annual inspection or testing of the fire door assemblies by qualified staff.


Staff A was present and acknowledged the finding.

NFPA Standard: NFPA 80 2010 5.2.1 Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ. 5.2.3.1 Functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing. 5.2.4.2 As a minimum, the following items shall be verified: (1) No open holes or breaks exist in the surfaces of either the door or frame. (2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped. (3) The door, frame, hinges, hardware, and non combustible threshold are secured, aligned, and in working order with no visible signs of damage. (4) No parts are missing or broken. (5) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7 (6) The self-closing device is operational; that is, the active door completely closes when operated from the open position. (7) If a coordinator is installed, the inactive leaf closes before the active leaf. (8) Latching hardware operates and secures the door when it is in the closed position. (9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame. (10) No field modifications to the door assembly have been performed that void the label. (11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity. 3.3.95 Qualified Person. A person who, by possession of a recognized degree, certificate, professional standing, or skill, and who by knowledge, training, and experience, has demonstrated the ability to deal with the subject matter, the work, or the project.

Based on observation and interview, the facility failed to maintain proper space heating appliances within the facility that have heating elements limited to 212 degrees Fahrenheit. This deficient practice would affect all patients, visitors, and staff in 3 of 4 smoke zones. The facility has 14 certified beds and at the time of the survey the census was 7.

Findings include:

During the survey conducted on 2/15/19 the following deficiencies are noted:

1. During the survey at 9:46 AM, It is observed that there are 2 space heaters in use in the business office.
2. During the survey at 9:55 AM, it is observed that there is a space heater in use in the kitchen office.
3. During the survey at 10:25 AM, it is observed that there is a space heater in use in the basement conference room.

Staff A was present and acknowledged the findings.

NFPA Standard: Prohibits the use of portable space heating devices in healthcare occupancies except for nonresident and staff sleeping areas with heating elements that exceed 212 degrees. 2012 NFPA 101, 18/19.7.8

Based on staff interview and document review, the facility failed to maintain and test their electrical receptacles and systems in accordance with NFPA 99. This deficient practice would affect all patients, visitors, and staff in 4 of 4 smoke zones. The facility has 14 certified beds and at the time of the survey the census was 7.

Findings include:

During the survey conducted on 2/14/19 the following deficiency is noted:

1. During document review at 3:50 PM, it is observed that there is no documentation at the time of survey for any testing of the electrical receptacles or electrical systems.

Staff A was present and acknowledged finding.

NFPA Standard: NFPA 99 2012 6.3.3.2 Receptacle Testing in Patient Care Rooms 6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection. 6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified. 6.3.3.2.3 correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed. 6.3.4.1 Maintenance and testing of Electrical System 6.3.4.1. 1 Where hospital-grade receptacles are required at patient bed location and in location where deep sedation or general anesthesia is administered, testing shall be performed after initial installation, replacement, or servicing of the device. 6.3.4.1.2 Additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data. 6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months. 6.3.4.1.4 The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch (see 6.3.2.6.3.6). For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators. 6.3.4.1.5 After any repair or renovation to an electrical distribution system, the LIM circuit shall be tested in accordance with 6.3.3.3.2 6.4.4.1.2.1* Circuit Breakers. Main and feeder circuit breakers shall be inspected annually, and a program for periodically exercising the components shall be established according to manufacturer's recommendations. 6.3.4.2.1.1 A record shall be maintained of the tests required by this chapter and associated repairs or modification. 6.3.4.2.1.2 At a minimum, the record shall contain the date, the rooms or areas tested, and an indication of which items have met, or have failed to meet, the performance requirements of this chapter. 6.3.4.2.2 Isolated Power System (Where Installed). A permanent record shall be kept of the results of each of the tests.