HospitalInspections.org

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Based on observation and staff interview, the facility failed to maintain Exit lights in accordance with NFPA 101. The findings were:

Observation on 11/03/2016 at 8:49 AM located in the O.R. corridor revealed an exit sign that was not illuminated. Interview with the Facility Maintenance Staff at the time of observation indicated that they overlooked the lights in the exits sign.

Ref:
2012 NFPA 101, Section 19.2.10.1
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Based on observation and staff interview, the facility failed to protect hazardous areas in accordance with NFPA 101. The findings were:

Observation on 11/03/2016 at 10:00 AM in the Blood Storage Supply room revealed that the room was greater than 50 square feet and that the room was used for storing combustible material. Further observation revealed that the storage room door was not provided with a self closing or automatic closing device. Interview with the Facility Maintenance Staff at the time of observation acknowledged that they were unaware of the requirement.

Ref:
2012 NFPA 101, Section 19.3.2.1
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Based on observation and staff interview, the facility failed to provide a fire alarm system in accordance with NFPA 72. The findings were:

Observation on 11/03/2016 starting at 9:36 AM located in the Pharmacy corridor adjacent to the stairwell, at the lab door adjacent to an exit, and typical throughout the facility revealed that the manual alarm boxes were measured (from operable part of the fire alarm box to the finished floor) at approximately 63 inches. Interview with the Facility Maintenance Staff at the time of observation indicated they were unaware of the 48 inch height requirement from the operable parts of the manual fire alarm box.

Ref:
2012 NFPA 101, Section 19.3.4.2.2 and 9.6.2.5
2010 NFPA 72, Section 17.14.4
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Based on observation, staff interview and document review, the facility failed to provide documentation in accordance with NFPA 72 for their Supervising Central Station. The findings were:

1. Observation on 11/03/2016 at 10:45 AM located at the main fire panel revealed that the facility did not provide Supervising Central Station specific documentation (typically UL Certification) within three feet of the control unit. Interview with the Facility Maintenance Staff at the time of observation indicated that they were unaware of the requirement.

Ref:
2010 NFPA 72, Section 26.3.4.3

2. Document review on 11/03/2016 at 11:06 AM revealed that the facility was not activating the fire alarm system every month to test the Supervising Central Station alarm systems. Further review revealed that the monthly activation was missing for the months of June 2016 and September 2016. Interview with the Facility Maintenance Staff at the time of review indicated that they were unaware of the monthly activation requirement.

Ref:
2010 NFPA 72, Table 14.4.5 (Component number 24.)
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Based on observation and staff interview, the facility failed to provide a sprinkler system in accordance with NFPA 13. The findings were:

1. Observation on 11/03/2016 at 10:25 AM located at the Gift Shop Closet revealed a sprinkler head that was obstructed by combustibles measured at approximately 14 inches below the head. Interview with the Facility Maintenance Staff at the time of observation indicated they were unaware of the requirement to maintain clearance of 18" below the sprinkler head.

Ref:
2012 NFPA 101, Section 9.7
2011 NFPA 13, Section 8.5.6.1

2. Observation on 11/03/2016 at 9:26 AM located in the Pharmacy, specifically in the Micro Hood area, revealed a missing sprinkler head in the enclosed Micro Hood area. Further observation revealed that the Micro Hood area was separated by a glass barrier (from finished floor to finished ceiling) and was without a sprinkler head. Interview with the Facility Maintenance Staff at the time of observation indicated that they were not sure why there was not a sprinkler head in the area.

Ref:
2012 NFPA 101, section 9.7
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Based on observation and staff interview, the facility failed to provide electrical panels in accordance with NFPA 70. The findings were:

1. Observation on 11/03/2016 at 9:28 AM located in the Pharmacy revealed a receptacle that was not of the ground-fault circuit-interrupter type within 6 feet of a sink. Interview with the Facility Maintenance Staff at the time of observation indicated that they overlooked the missing ground-fault circuit-interrupter.

2. Observation on 11/03/2016 at 9:42 in the Laboratory revealed two receptacles that were not of the ground-fault circuit-interrupter type within 6 feet of a sink. Interview with the Facility Maintenance Staff at the time of observation indicated they were unaware the receptacles were next to the sinks.

Ref:
2012 NFPA 101, Sections 19.5.1.1 and 9.1.2
2011 NFPA 70, Section 210.8(B)(5)
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