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Based on observation, the facility failed to maintain their doors. This was evidenced by two corridor doors that were obstructed from closing or latching. This affected one of three smoke compartments in the Main Hospital and could result in a delay to contain smoke or fire to a room.

Findings:

During a facility tour with staff on 6/20/12, the doors in the facility were observed.

Main Hospital:

1. At 1:46 p.m., the corridor door to Room 2 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to close. The door was obstructed from latching by a bed positioned directly in the swing path of the door.

2. At 1:51 p.m., the corridor door to Room 6 Ante-Room was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

Based on observation, the facility failed to maintain their hazardous areas. This was evidenced by one hazardous area that was not equipped with a self-closing door. This affected one of three smoke compartments in the Main Hospital and could result in a delay to contain smoke or fire to a hazardous area.

Findings:

During a facility tour with staff on 6/20/12, the hazardous areas in the facility were observed.

Main Hospital:

1. At 1:50 p.m., the Soiled Linen Storage Room near Room 7 was observed. The corridor door to the room was not equipped with a self-closing or automatic closing device. The door was held open to the fullest extent and remained in the open position.

Based on observation and interview, the facility failed to maintain their automatic fire sprinkler system. This was evidenced by one post indicator valve that was not supervised. This affected three of three smoke compartments in the Main Hospital and could result in a delayed notification of a suspension in water supplied to the automatic fire sprinkler system.

NFPA 101, 2000 edition
9.7.2.1 Supervisory Signals. Where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.

Findings:

During a facility tour with staff on 6/20/12, the automatic fire sprinkler system was observed.

Main Hospital:

1. At 2:46 p.m., the post indicator valve was tested. Staff moved the valve from the open position to the closed position and the fire alarm control panel was observed. There was no local alarm at the fire alarm control panel that indicated the post indicator valve had been closed. Facilities Staff 1 was interviewed at that time. Facilities Staff 1 indicated that she believed that the post indicator valve had never been equipped with a tamper switch.

Based on record review, observation, and interview, the facility failed to maintain their commercial cooking equipment. This was evidenced by the facility's failure to have two of two semi-annual inspections on their kitchen hood fire suppression system and the facility's failure to have their kitchen hood and interior exhaust professionally cleaned. This affected one of three smoke compartments in the Main Hospital and could result in a malfunction with the kitchen hood fire suppression system or could result in a fire to ignite in the kitchen due to grease build up.

NFPA 96, 1998 edition
8-2 Inspection
An inspection and servicing of the fire-extinguishing system and listed exhaust hoods containing a constant or fire-actuated water system shall be made at least every 6 months by properly trained and qualified persons.
8-3.1 Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Table 8-3.1.
Table 8-3.1
Systems serving solid fuel cooking operations - Monthly
Systems serving high-volume cooking operations such as 24-hour cooking, charbroiling or wok cooking - Quarterly
Systems serving moderate-volume cooking operations - Semiannually
Systems serving low-volume cooking operations, such as churches, day camps, seasonal businesses, or senior centers - Annually

Findings:

During record review and a facility tour with staff on 6/20/12, the facility's commercial cooking equipment was observed.

Main Hospital:

1. At 12:38 p.m., the facility failed to have two of two semi-annual inspections completed on their kitchen hood fire suppression system within the past twelve months. The facility is in the process of upgrading their kitchen hood fire suppression system to meet UL300 standards. Facilities Staff 1 was interviewed at that time. Facilities Staff 1 indicated that the facility may need to request a time limited waiver to completed the upgrade of the kitchen hood fire suppression system.

2. At 1:40 p.m., the facility's kitchen hood and exhaust cleaning records were requested. There were no records that indicated the facility had their kitchen hood and exhaust professionally cleaned during the past twelve months. The kitchen hood and exhaust was observed at that time. The interior of the kitchen hood and exhaust was heavily contaminated with grease deposits.

Based on observation and interview, the facility failed to ensure the safe use of portable space heating devices. This was evidenced by portable space heaters located in patient care areas and portable space heaters that had not been tested or verified to not exceed 212 degrees Fahrenheit. This affected two of three smoke compartments in the Main Hospital and could result in a portable space heater ignited fire emergency.

Findings:

During a facility tour with staff on 6/20/12, the portable space heaters in the facility were observed.

Main Hospital:

1. At 1:30 p.m., one portable space heater was observed in the Sonography Room, one portable space heater was observed in the Admitting Office, and two portable space heaters were observed in the Medical Records Office. The Sonography Room was a patient care area. The Admitting Office was a patient occupied area. All four portable space heaters had a coil-type heating element. Facilities Staff 1 was interviewed at that time. Facilities Staff 1 could not confirm that the portable space heaters would not exceed 212 degrees Fahrenheit.

Based on record review, the facility failed to maintain the relative humidity levels in their anesthetizing locations. This was evidenced by the facility's failure to maintain the relative humidity level sat thirty-five percent or above in their anesthetizing location. This affected one of one anesthetizing location in the Main Hospital and could result in a fire emergency due to electrostatic charges in an oxygen-rich environment.

Findings:

During record review with staff on 6/20/12, the facility's relative humidity logs for their anesthetizing locations were observed.

Main Hospital:

1. At 12:51 p.m., the relative humidity logs for the facility's anesthetizing location were reviewed. One of one Operating Room had recorded relative humidity levels below thirty-five percent on approximately eighty-two days during the past six months. The policy and procedure for monitoring and maintaining relative humidity levels for their anesthetizing location was requested at that time. The facility's policy indicated that the facility would maintain relative humidity levels in their anesthetizing location between twenty and sixty percent.

Based on observation, the facility failed to maintain their emergency showers. This was evidenced by one emergency shower activation cord that was wrapped up high and out of reach. This affected one of three smoke compartments in the Main Hospital and could result in injury to Laboratory staff.

Findings:

During a facility tour with staff on 6/20/12, the Laboratory was observed.

Main Hospital:

1. At 1:27 p.m., the emergency shower located in the Laboratory was observed. The activation pull cord for the emergency shower was wrapped around the ceiling mount. The cord could not be reached by Laboratory staff. Lab Staff 1 had to use a step stool to reach the emergency shower activation pull cord.

Based on observation, the facility failed to maintain their doors. This was evidenced by two corridor doors that were obstructed from closing or latching. This affected one of three smoke compartments in the Main Hospital and could result in a delay to contain smoke or fire to a room.

Findings:

During a facility tour with staff on 6/20/12, the doors in the facility were observed.

Main Hospital:

1. At 1:46 p.m., the corridor door to Room 2 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to close. The door was obstructed from latching by a bed positioned directly in the swing path of the door.

2. At 1:51 p.m., the corridor door to Room 6 Ante-Room was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

Based on observation, the facility failed to maintain their hazardous areas. This was evidenced by one hazardous area that was not equipped with a self-closing door. This affected one of three smoke compartments in the Main Hospital and could result in a delay to contain smoke or fire to a hazardous area.

Findings:

During a facility tour with staff on 6/20/12, the hazardous areas in the facility were observed.

Main Hospital:

1. At 1:50 p.m., the Soiled Linen Storage Room near Room 7 was observed. The corridor door to the room was not equipped with a self-closing or automatic closing device. The door was held open to the fullest extent and remained in the open position.

Based on observation and interview, the facility failed to maintain their automatic fire sprinkler system. This was evidenced by one post indicator valve that was not supervised. This affected three of three smoke compartments in the Main Hospital and could result in a delayed notification of a suspension in water supplied to the automatic fire sprinkler system.

NFPA 101, 2000 edition
9.7.2.1 Supervisory Signals. Where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.

Findings:

During a facility tour with staff on 6/20/12, the automatic fire sprinkler system was observed.

Main Hospital:

1. At 2:46 p.m., the post indicator valve was tested. Staff moved the valve from the open position to the closed position and the fire alarm control panel was observed. There was no local alarm at the fire alarm control panel that indicated the post indicator valve had been closed. Facilities Staff 1 was interviewed at that time. Facilities Staff 1 indicated that she believed that the post indicator valve had never been equipped with a tamper switch.

Based on record review, observation, and interview, the facility failed to maintain their commercial cooking equipment. This was evidenced by the facility's failure to have two of two semi-annual inspections on their kitchen hood fire suppression system and the facility's failure to have their kitchen hood and interior exhaust professionally cleaned. This affected one of three smoke compartments in the Main Hospital and could result in a malfunction with the kitchen hood fire suppression system or could result in a fire to ignite in the kitchen due to grease build up.

NFPA 96, 1998 edition
8-2 Inspection
An inspection and servicing of the fire-extinguishing system and listed exhaust hoods containing a constant or fire-actuated water system shall be made at least every 6 months by properly trained and qualified persons.
8-3.1 Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Table 8-3.1.
Table 8-3.1
Systems serving solid fuel cooking operations - Monthly
Systems serving high-volume cooking operations such as 24-hour cooking, charbroiling or wok cooking - Quarterly
Systems serving moderate-volume cooking operations - Semiannually
Systems serving low-volume cooking operations, such as churches, day camps, seasonal businesses, or senior centers - Annually

Findings:

During record review and a facility tour with staff on 6/20/12, the facility's commercial cooking equipment was observed.

Main Hospital:

1. At 12:38 p.m., the facility failed to have two of two semi-annual inspections completed on their kitchen hood fire suppression system within the past twelve months. The facility is in the process of upgrading their kitchen hood fire suppression system to meet UL300 standards. Facilities Staff 1 was interviewed at that time. Facilities Staff 1 indicated that the facility may need to request a time limited waiver to completed the upgrade of the kitchen hood fire suppression system.

2. At 1:40 p.m., the facility's kitchen hood and exhaust cleaning records were requested. There were no records that indicated the facility had their kitchen hood and exhaust professionally cleaned during the past twelve months. The kitchen hood and exhaust was observed at that time. The interior of the kitchen hood and exhaust was heavily contaminated with grease deposits.

Based on observation and interview, the facility failed to ensure the safe use of portable space heating devices. This was evidenced by portable space heaters located in patient care areas and portable space heaters that had not been tested or verified to not exceed 212 degrees Fahrenheit. This affected two of three smoke compartments in the Main Hospital and could result in a portable space heater ignited fire emergency.

Findings:

During a facility tour with staff on 6/20/12, the portable space heaters in the facility were observed.

Main Hospital:

1. At 1:30 p.m., one portable space heater was observed in the Sonography Room, one portable space heater was observed in the Admitting Office, and two portable space heaters were observed in the Medical Records Office. The Sonography Room was a patient care area. The Admitting Office was a patient occupied area. All four portable space heaters had a coil-type heating element. Facilities Staff 1 was interviewed at that time. Facilities Staff 1 could not confirm that the portable space heaters would not exceed 212 degrees Fahrenheit.

Based on record review, the facility failed to maintain the relative humidity levels in their anesthetizing locations. This was evidenced by the facility's failure to maintain the relative humidity level sat thirty-five percent or above in their anesthetizing location. This affected one of one anesthetizing location in the Main Hospital and could result in a fire emergency due to electrostatic charges in an oxygen-rich environment.

Findings:

During record review with staff on 6/20/12, the facility's relative humidity logs for their anesthetizing locations were observed.

Main Hospital:

1. At 12:51 p.m., the relative humidity logs for the facility's anesthetizing location were reviewed. One of one Operating Room had recorded relative humidity levels below thirty-five percent on approximately eighty-two days during the past six months. The policy and procedure for monitoring and maintaining relative humidity levels for their anesthetizing location was requested at that time. The facility's policy indicated that the facility would maintain relative humidity levels in their anesthetizing location between twenty and sixty percent.

Based on observation, the facility failed to maintain their emergency showers. This was evidenced by one emergency shower activation cord that was wrapped up high and out of reach. This affected one of three smoke compartments in the Main Hospital and could result in injury to Laboratory staff.

Findings:

During a facility tour with staff on 6/20/12, the Laboratory was observed.

Main Hospital:

1. At 1:27 p.m., the emergency shower located in the Laboratory was observed. The activation pull cord for the emergency shower was wrapped around the ceiling mount. The cord could not be reached by Laboratory staff. Lab Staff 1 had to use a step stool to reach the emergency shower activation pull cord.