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Based on observation and facility staff interview, facility staff failed to provide emergency lighting not controlled by light switches. This deficient practice has the potential to affect all patients, staff and visitors within the facility. Failure to provide emergency lighting could prevent proper illumination of required areas in the event of power loss. The census was 14.

1. Observations on 1/09-10/19, during the Life Safety Code (LCS) tour, showed two of two operating rooms contained light fixtures controlled by light switches. Observation did not show emergency light fixtures in two of two operating rooms.


During an interview on 1/10/2019 at 10:00 A.M., the Maintenance Director said he/she did not know about the missing emergency lights.

NFPA 99, 2012 edition, section 6.4.2.2.4.2 states:

"6.4.2.2.4.2 The critical branch shall supply power for task illumination,
fixed equipment, select receptacles, and select power
circuits serving the following areas and functions related to patient
care:
(1) Critical care areas that utilize anesthetizing gases, task illumination,
select receptacles, and fixed equipment
(2) Isolated power systems in special environments
(3) Task illumination and select receptacles in the following:
(a) Patient care rooms, including infant nurseries, selected
acute nursing areas, psychiatric bed areas (omit receptacles),
and ward treatment rooms
(b) Medication preparation areas
(c) Pharmacy dispensing areas
(d) Nurses ' stations (unless adequately lighted by corridor
luminaires)
(4) Additional specialized patient care task illumination and
receptacles, where needed
(5) Nurse call systems
(6) Blood, bone, and tissue banks
(7)*Telephone equipment rooms and closets
(8) Task illumination, select receptacles, and select power circuits
for the following areas:
(a) General care beds with at least one duplex receptacle
per patient bedroom, and task illumination as required
by the governing body of the health care facility
(b) Angiographic labs
(c) Cardiac catheterization labs
(d) Coronary care units
(e) Hemodialysis rooms or areas
(f) Emergency room treatment areas (select)
(g) Human physiology labs
(h) Intensive care units
(i) Postoperative recovery rooms (select)
(9) Additional task illumination, receptacles, and select power
circuits needed for effective facility operation, including
single-phase fractional horsepower motors, which are permitted
to be connected to the critical branch"

Based on observation and facility staff interview, the facility staff failed to provide a 1-hour rated separation between a hazardous area (areas that pose a degree of hazard greater than normal to the general occupancy of the building such as areas used for storage or use of combustibles or flammables, toxic, noxious, or corrosive materials, or heat producing appliances) and designated exit corridors in the facility per NFPA (National Fire Protection Association) requirements. Failure to provide compliant hazardous area doors equipped with a self closing devices and latching devices puts all patients, staff and visitors at risk of injury or death from a fire by not containing the fire and smoke within the hazardous area. The facility census was 14.

1. Observation on 1/09-10/2019, during the facility tour, showed the materials management storage room containing a large quantity of combustible materials. The room measured over 100 square feet and contained a large quantity of combustible storage. Observation showed the corridor dutch door without a rating and did not have a self closing device.

During an interview on 1/10/2019 at 10:05 A.M., the Maintenance Director said he/she discovered the dutch door during the annual door inspection but was waiting for the results of the building engineering study before purchasing a replacement door to ensure the replacement door had the correct rating.

Please refer to NFPA 101, 2012 edition, Section 19.3.6.3.13 for additional information regarding the use of dutch doors in hazardous areas.

19.3.2.1.1 An automatic extinguishing system, where used in
hazardous areas, shall be permitted to be in accordance with
19.3.5.9.

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.

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

Based on observation and facility staff interview, the facility failed to ensure that one of one fire alarm systems was installed per NFPA 70, The National Electric Code and NFPA 72, National Fire Alarm and Signaling Code. This deficient practice has the potential to effect all facility patients, staff and visitors. This deficient practice could delay fire and emergency personnel response in the event of a fire. The facility census was 14.

1. Observations on 1/09-10/2019, during the facility tour, showed the following areas missing required smoke detector coverage:

- Emergency Department

- Lab corridor

- Library corridor

- Pre-op/PACU nurse's station open to the corridor

- Acute care hall from nurse's station open to corridor extending to office area open to corridor

-Cafeteria


During an interview on 1/10/2019 at approximately 10:00 A.M., Maintenance Director said he/she believed the fire alarm system installation company installed the fire alarm system per code requirements.

NFPA 72, National Fire Alarm and Signaling Code, 2010 edition, section 19.3.4.1 States: "General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6."

Refer to NFPA 72, National Fire Alarm and Signaling Code, 2010 edition, sections 17.6.3 Location and Spacing and 17.6.3.3.1 Spacing for additional information.

Based on observation and facility staff interview, the facility staff failed to provide sprinkler coverage in accordance with NFPA 13, Standard For The Installation Of Sprinkler Systems, 2010 edition installation requirements. Facility staff failed to provide correct application of sprinkler heads for the entire building. This deficient practice could delay activation of the sprinkler system for prompt fire suppression. This deficient practice has the potential to affect all facility patients, staff and visitors. The facility census was 14.

Observation on 1/09-10/2019, during the facility tour, of the pharmacy, showed a mix of quick response sprinkler heads and standard response sprinkler heads in the same compartmented space.

During an interview on 1/10/2019, the facility Maintenance Director said he/she believed the sprinkler system installation company installed the system system per code requirements.

NFPA 13, Standard For The Installation Of Sprinkler Systems, 2010 edition states:

8.3.3 Thermal Sensitivity.
8.3.3.1* Sprinklers in light hazard occupancies shall be one of
the following:
(1) Quick-response type as defined in 3.6.4.7
(2) Residential sprinklers in accordance with the requirements
of 8.4.5
(3) Standard-response sprinklers used for modifications or
additions to existing light hazard systems equipped with
standard-response sprinklers
(4) Standard-response sprinklers used where individual
standard-response sprinklers are replaced in existing light
hazard systems
8.3.3.2 Where quick-response sprinklers are installed, all
sprinklers within a compartment shall be quick-response unless
otherwise permitted in 8.3.3.3.
8.3.3.3 Where there are no listed quick-response sprinklers
in the temperature range required, standard-response sprinklers
shall be permitted to be used.
8.3.3.4 When existing light hazard systems are converted to
use quick-response or residential sprinklers, all sprinklers in a
compartmented space shall be changed.

Based on record review and facility staff interview, the facility staff failed to provide completed fundamental risk assessments and formally documented risk assessment procedures for all building systems categories are determined by a performed by qualified personnel. Failure to have the building systems risk assessments completed puts patients at risk for a potential negative outcome if category one systems (Category 1 system in which a failure of such equipment or system is likely to cause major injury or death of patients or caregivers) fail with no plan on how to respond if the system fails. The facility census was 14.


1. Review of the facility documents for fire safety, building system tests, and policies did not show how the categorical risk assessment scores for the building systems were determined.

2. During an interview on 1/10/2019, the Maintenance Director said he/she did not know how the hospital determined the categorical risk assessment scores.

The National Fire Protection Association 99 Health Care Facilities Code, 2012 edition, Chapter 4 states:

"Chapter 4 Fundamentals

4.1* Building System Categories. Building systems in health
care facilities shall be designed to meet system Category 1
through Category 4 requirements as detailed in this code.

4.1.1* Category 1. Facility systems in which failure of such equipment
or system is likely to cause major injury or death of patients
or caregivers shall be designed to meet system Category 1 requirements
as defined in this code.

4.1.2* Category 2. Facility systems in which failure of such equipment
is likely to cause minor injury to patients or caregivers shall
be designed to meet system Category 2 requirements as defined
in this code.

4.1.3 Category 3. Facility systems in which failure of such equipment
is not likely to cause injury to patients or caregivers, but can
cause patient discomfort, shall be designed to meet system Category
3 requirements as defined in this code.

4.1.4 Category 4. Facility systems in which failure of such equipment
would have no impact on patient care shall be designed to
meet system Category 4 requirements as defined in this code.

4.2* Risk Assessment. Categories shall be determined by following
and documenting a defined risk assessment procedure.

4.3 Application. The Category definitions in Chapter 4 shall
apply to Chapters 5 through 11."

A.4.2 Risk assessment should follow procedures such as those
outlined in ISO/IEC 31010, Risk Management-Risk Assessment
Techniques, NFPA 551, Guide for the Evaluation of Fire Risk Assessments,
Guide for the Evaluation of Fire Risk Assessments, SEMI S10-
0307E, Safety Guideline for Risk Assessment and Risk Evaluation
Process, or other formal process. The results of the assessment
procedure should be documented and records retained.