HospitalInspections.org

Based on observation, and interview, the facility failed to maintain their exit signs. This was evidenced by an exit sign that failed to illuminate, when observed. This could delay egress in the event of an emergency. This affected 1 of 3 buildings.

NFPA 101, Life Safety Code, 2012 Edition
7.10.1.2.1* Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign that is readily visible from any direction of exit access.

7.10.9.1 Inspection. 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 with 7.9.3.1.3.
7.10.9.2 Testing. Exit signs connected to, or provided with, a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.

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 11/2 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.

Findings:

During a tour of the facility with the Senior Facility Planner Supervisor, the Fire and Construction Safety Manager, the Mechanical Systems Manager, the Director of Emergency Preparedness, the Lead Facilities Mechanic, the Director of Environmental, the Executive Director of General Services, the Director of Facilities, and the Lead Facilities Mechanic, on 6/19/16, the exits signs were observed, and a staff person was interviewed.

Semel Building

1. At 2:29 p.m., the exit sign near Room 47-406, was not illuminating when observed.

2. At 2:30 p.m., the Director of Facilities said during an interview, that the light bulbs appeared to be burnt out, and acknowledged the finding.

Based on observation, document review, and interview, the facility failed to maintain the fire alarm system. This was evidenced by two fire alarm batteries that were expired, by no monthly visual inspections of the batteries, and by an impeded manual fire alarm box. The fire alarm system could fail to transmit a signal, and delay notifying emergency responders. This affected 3 of 3 buildings.

NFPA 101, Life Safety Code, 2012 Edition
9.6.1.5* 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.

9.7.7 Documentation. All required documentation regarding the design of the fire protection system and the procedures for maintenance, inspection, and testing of the fire protection system shall be maintained at an approved, secured location for the life of the fire protection system.

NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition
14.2.1.1.2 Inspection, testing, and maintenance program shall verify correct operation of the system.
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.

Table 14.3.1 Visual Inspection Frequencies
3. Batteries
(a) Lead-acid X (Initial) X (Monthly)
(b) Nickel-cadmium X (Initial) X (Monthly) X (Semi-Annual)
(c) Primary (dry cell) X (Initial) X (Monthly)
(d) Sealed lead-acid X (Initial) X (Monthly) X (Semi-Annual)

5. Fire alarm control unit trouble signals X (weekly)

Table 14.4.2.2
6. Battery tests (specific types)
(a) Primary battery load voltage test The maximum load for a No. 6 primary battery shall not be more than 2 amperes per cell. An individual (1.5 volt) cell shall be replaced when a load of 1 ohm reduces the voltage below 1 volt. A 6 volt assembly shall be replaced when a test load of 4 ohms reduces the voltage below 4 volts.
(b) Lead-acid type
(1) Charger test With the batteries fully charged and connected to the charger, the voltage across the batteries shall be measured with a voltmeter. The voltage shall be 2.30 volts per cell }0.02 volts at 77 (2) Load voltage test Under load, the battery shall not fall below 2.05 volts per cell.
(3) Specific gravity The specific gravity of the liquid in the pilot cell or all of the cells shall be measured as required. The specific gravity shall be within the range specified by the manufacturer. Although the specified specific gravity varies from manufacturer to manufacturer, a range of 1.205.1.220 is typical for regular lead-acid batteries, while 1.240.1.260 is typical for high-performance batteries. A hydrometer that shows only a pass or fail condition of the battery and does not indicate the specific gravity shall not be used, because such a reading does not give a true indication of the battery condition.
(c) Nickel-cadmium type
(1) Charger test With the batteries fully charged and connected to the charger, an ampere meter shall be placed in series with the battery under charge. The charging current shall be in accordance with the manufacturer recommendations for the type of battery used. In the absence of specific information, 1.30 to 1/25 of the battery rating shall be used.
(2) Load voltage test Under load, the float voltage for the entire battery shall be 1.42 volts per cell, nominal. If possible, cells shall be measured individually.
(d) Sealed lead-acid type
(1) Charger test With the batteries fully charged and connected to the charger, the voltage across the batteries shall be measured with a voltmeter. The voltage shall be 2.30 volts per cell }0.02 volts at 77 (2) Load voltage test Under load, the battery shall perform in accordance with the battery manufacturer specifications.
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.

Table 10.4.2.2, test methods
5. Batteries - General Tests Prior to conducting any battery testing, the person conducting the test shall ensure that all system software stored in volatile memory is protected from loss.
(a) Visual inspection Batteries shall be inspected for corrosion or leakage. Tightness of connections
shall be checked and ensured. If necessary, battery terminals or connections shall be cleaned and coated. Electrolyte level in lead-acid batteries shall be visually inspected.
(b) Battery replacement Batteries shall be replaced in accordance with the recommendations of the alarm equipment manufacturer or when the recharged battery voltage or current falls below the manufacturer's recommendations.
(c) Charger test Operation of battery charger shall be checked in accordance with charger test for the specific type of battery.
(d) Discharge test With the battery charger disconnected, the batteries shall be load tested following
the manufacturer's recommendations. The voltage level shall not fall below the levels specified.
Exception: An artificial load equal to the full fire alarm load connected to the battery shall be permitted to be used in conducting this test.
(e) Load voltage test With the battery charger disconnected, the terminal voltage shall be measured
while supplying the maximum load required by its application.
The voltage level shall not fall below the levels specified for the specific type of battery. If the voltage falls below the level specified, corrective action shall be taken and the batteries shall be retested.
Exception: An artificial load equal to the full fire alarm load connected to the battery shall be permitted to be used in conducting this test.

Reacceptance Monthly Quarterly Semiannually Annually
Table 10.4.4, testing frequencies
Testing frequencies: Initial/Reacceptance, Monthly, Quarterly, Semiannually, Annually
5. Batteries - Central Station Facilities
(a) Lead-acid type
(1) Charger test (Replace battery as needed.) Initial, Annual
(2) Discharge test (30 minutes) Initial, Monthly
(3) Load voltage test. Initial, Monthly
(4) Specific gravity. Initial, semiannual
(b) Nickel-cadmium type
(1) Charger test (Replace battery as needed.) Initial, Quarterly
(2) Discharge test (30 minutes) Initial, Semiannual
(3) Load voltage test. Initial, Semiannual
(c) Sealed lead-acid type. Initial, Monthly
(1) Charger test (Replace battery within 5 years after manufacture or more frequently as needed.)
(2) Discharge test (30 minutes). Monthly, Quarterly
(3) Load voltage test. Monthly, Quarterly

5.13.5* Manual fire alarm boxes shall be installed so that they are conspicuous, unobstructed, and accessible.

Findings:

During a tour of the facility with the Senior Facility Planner Supervisor, the Fire and Construction Safety Manager, the Mechanical Systems Manager, the Director of Emergency Preparedness, the Lead Facilities Mechanic, the Director of Environmental, the Executive Director of General Services, the Director of Facilities, and the Lead Facilities Mechanic, on 6/19/17 to 6/20/17, the fire alarm manual pull boxes were inspected, the fire alarm system inspection and testing records were reviewed, and a staff person was interviewed.

Resnick Hospital
6/19/2017

1. At 11:29 a.m., the manual pull box near Room 4103, was impeded from access with an unattended food cart in front of the device.

2. At 11:30 a.m., the Director of Environmental said during an interview, that the cart should not be left in front of the pull station, and removed the cart upon discovery.

Medical Plaza 300
6/20/2017

3. At 9:30 a.m., the batteries in the fire alarm control panel were dated 7/7/11 and were expired on 7/7/16 (5 Years).

Medical Plaza 300, Resnick Hospital, Semel

4. At 2:28 p.m., there was no documented evidence of visual monthly inspections of the fire alarm control panel batteries for all three buildings. No documented evidence was provided for monthly inspections of the fire alarm batteries.

5. At 2:34 p.m., the Director of Facilities said during an interview, that the facility inspected the fire alarm control panel batteries every quarter, and not monthly.

Based on document review, and interview, the facility failed to maintain their sprinkler system. This was evidenced by no documented monthly inspections of the sprinkler components. this could result in a malfunction of the the sprinkler components in the event of a fire. This affected 3 of 3 buildings.

NFPA 101, Life Safety Code, 2012 Edition
9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition
5.2.4 Gauges.
5.2.4.1* Gauges on wet pipe sprinkler systems shall be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained.

5.3.3 Waterflow Alarm Devices.
5.3.3.1 Mechanical waterflow alarm devices including, but not limited to, water motor gongs, shall be tested quarterly.

13.3.2.1 All valves shall be inspected weekly.
13.3.2.1.1 Valves secured with locks or supervised in accordance with applicable NFPA standards shall be permitted to be inspected monthly.

Findings:

During document review with the Senior Facility Planner Supervisor, the Fire and Construction Safety Manager, the Mechanical Systems Manager, the Director of Emergency Preparedness, the Lead Facilities Mechanic, the Director of Environmental, the Executive Director of General Services, the Director of Facilities, and the Lead Facilities Mechanic, on 6/20/16, the sprinkler component inspection documents were requested, and a staff person was interviewed.

Medical Plaza 300, Resnick Hospital, Semel

1. At 2:48 p.m., there was no documented evidence of monthly visual inspections of the sprinkler gauges and valves as required. The facility provided documented evidence of quarterly inspections only.

2. At 2:49 p.m., the Director of Facilities said during and interview, that all of the gauges and valves were inspected quarterly with the sprinkler flow test. The Director of Facilities stated, that the facility did not inspect the valves and gauges monthly.

Based on observation, and interview, the facility failed to install fire extinguishers within the maximum height. This was evidenced by a fire extinguisher mounted greater that 5 feet high from the floor to the top of the fire extinguisher. This could result in delayed access to a fire extinguisher in the event of a fire. This affected 1 of 3 buildings.

NFPA 101, Life Safety Code, 2012 Edition
19.3.5.12 Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1.
9.7.4.1* Where required by the provisions of another section of this Code, portable fire extinguishers shall be selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

NFPA 10, Standard for Portable Fire Extinguishers, 2010 Edition
6.1.3.8 Installation Height.
6.1.3.8.1 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor.
6.1.3.8.2 Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be installed so that the top of the fire extinguisher is not more than 31/2 ft (1.07 m) above the floor.
6.1.3.8.3 In no case shall the clearance between the bottom of the hand portable fire extinguisher and the floor be less
than 4 in. (102 mm).

Findings:

During a tour of the facility with the Senior Facility Planner Supervisor, the Fire and Construction Safety Manager, the Mechanical Systems Manager, the Director of Emergency Preparedness, the Lead Facilities Mechanic, the Director of Environmental, the Executive Director of General Services,and the Director of Facilities on 6/19/17, the fire extinguishers were observed, and a staff person was interviewed.

Semel

1. At 2:46 p.m., the fire extinguisher in Room 77-420, was mounted at approximately 6 feet 7 inches from the floor to the top of the handle.

2. At 2:47 p.m., the Executive Director of General Services said during an interview, that the fire extinguisher was mounted that high to keep it out of the reach of the children.

Based on observation, and interview, the facility failed to maintain their subdivision of building space. This was evidenced by an unsealed penetration. This could allow the spread of smoke and fire to other areas of the building. This affect 1 of 3 buildings.

NFPA 101, Life Safety Code, 2012 Edition
19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a minimum 1/2 -hour fire resistance rating, unless otherwise permitted by one of the following:
(1) This requirement shall not apply where an atrium is used, and both of the following criteria also shall apply:
(a) Smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with 8.6.7(1)(c).
(b) Not less than two separate smoke compartments shall be provided on each floor.
(2)*Smoke dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air-conditioning systems where an approved, supervised automatic sprinkler system in accordance with 19.3.5.8 has been provided for smoke compartments adjacent to the smoke barrier.

Finding:

During a tour of the facility with the Senior Facility Planner Supervisor, the Fire and Construction Safety Manager, the Mechanical Systems Manager, the Director of Emergency Preparedness, the Lead Facilities Mechanic, the Director of Environmental, the Executive Director of General Services, the Director of Facilities, and the Lead Facilities Mechanic on 6/19/17, the separation walls were observed, and a staff person was interviewed.

Resnick Hospital

1. At 1:46 p.m., there was an approximately 1 inch round unsealed pipe through the smoke barrier wall near Room 4612 E. There was a string going through the pipe.

2. At 1:47 p.m., the Senior Project Manager said during an interview, that the pipe was there to install some data lines, and acknowledged the finding.

Based on observation, and interview, the facility failed to maintain their utilities. This was evidenced by utilizing an extension cord as permanent wiring, and by appliances plugged into power strips. This could result in an electrical fire. This affected 2 of 3 buildings.

NFPA 101, Life Safety Code, 2012 Edition
18.5.1.1 Utilities shall comply with the provisions of Section 9.1
9.1.2 Electrical Systems. 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.

NFPA 70, National Electrical Code, 2011 Edition
400.8 Uses Not Permitted. Unless specifically permitted in 400.7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
Exception to (4): Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of 368.56(B)
(5) Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings
(6) Where installed in raceways, except as otherwise permitted in this Code
(7) Where subject to physical damage

240.5 Protection of Flexible Cords, Flexible Cables, and Fixture Wires. Flexible cord and flexible cable, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent by either 240.5(A) or (B).
(A) Ampacities. Flexible cord and flexible cable shall be protected by an overcurrent device in accordance with their ampacity as specified in Table 400.5(A)(1) and Table 400.5(A)(2). Fixture wire shall be protected against overcurrent in accordance with its ampacity as specified in Table 402.5. Supplementary overcurrent protection, as covered in 240.10, shall be permitted to be an acceptable means for providing this protection.
(B) Branch-Circuit Overcurrent Device. Flexible cord shall be protected, where supplied by a branch circuit, in accordance with one of the methods described in 240.5(B)(1), (B)(3), or (B)(4). Fixture wire shall be protected, where supplied by a branch circuit, in accordance with 240.5(B)(2).

Finding:

During a tour of the facility with the Senior Facility Planner Supervisor, the Fire and Construction Safety Manager, the Mechanical Systems Manager, the Director of Emergency Preparedness, the Lead Facilities Mechanic, the Director of Environmental, the Executive Director of General Services, and the Director of Facilities on 6/19/17, the electrical system was examined, and a staff person was interviewed.

Resnick Hospital

1. At 1:35 p.m., there was a refrigerator in Room 4612 F, that was plugged into a power strip. The power strip was not rated for the appliance.

Semel

2. At 2:34 p.m., there was a microwave oven, that was plugged into a power strip in Room 77-419.

3. At 2:39 p.m., there was a refrigerator, plugged into a power strip in Room 77-437.

4. At 2:52 p.m., there was an orange extension cord, plugged into a power strip in Room 78-215.

5. At 2:53 p.m., the Director of Environmental Services said during an interview, that management conducted rounds frequently, and removed items that were not allowed, or corrected the issue.

Based on document review, and interview, the facility failed to maintain their electrical system. This was evidenced by no documented testing of their outlets in 1 of 3 buildings. This could result in an electrical fire and/or shock. This affected 1 of 3 buildings.

NFPA 99, Healthcare Facilities Code, 2012 Edition
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.
6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).
6.3.3.3 Isolated Power Systems.
6.3.3.3.1 Patient Care Rooms. If installed, the isolated power system shall be tested in accordance with 6.3.3.3.2.
6.3.3.3.2 Line Isolation Monitor Tests. The line isolation monitor (LIM) circuit shall be tested after installation, and prior to being placed in service, by successively grounding each line of the energized distribution system through a resistor whose value is 200 × V (ohms), where V equals measured line voltage. The visual and audible alarms (see 6.3.2.6.3.2) shall be activated.
6.3.3.4 Ground-Fault Protection Testing. When equipment ground-fault protection is first installed, each level shall be performance-tested to ensure compliance with 6.3.2.5.
6.3.4* Administration of Electrical System.
6.3.4.1 Maintenance and Testing of Electrical System.
6.3.4.1.1 Where hospital-grade receptacles are required at patient bed locations and in locations where deep sedation or general anesthesia is administered, testing shall be performed after initial installation, replacement, or servicing of the device.

Finding:

During document review with the Senior Facility Planner Supervisor, the Fire and Construction Safety Manager, the Mechanical Systems Manager, the Director of Emergency Preparedness, the Lead Facilities Mechanic, the Director of Environmental, the Executive Director of General Services,and the Director of Facilities on 6/21/17, the electrical system testing documents were requested, and a staff person was interviewed.

Semel

1. At 8:00 a.m., there was no documented evidence of testing the electrical outlets within the past 12 months in the Semel building. No documented evidence was provided.

2. At 8:03 a.m., the Director of Facilities said during an interview, that the facility could not find any documented testing of the electrical outlets in the Semel building. The Director of Facilities stated, that the building was under separate building service personnel.