HospitalInspections.org

1) Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage, and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening Protectives, except as otherwise specified in this code. 8.3.3.1.

Fire-rated door assemblies shall be inspected and tested in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. 7.2.1.15.2

The facility failed to inspect and test fire rated door assemblies throughout the facility.

Review of documentation and interview with staff determined fire rated door assemblies had not been inspected in the past year.

Failure to inspect and test fire rated door assemblies increases the risk of injury or death due to fire.

This deficiency affected all fire rated door assemblies throughout the facility.

2) During its swing, any door in a means of egress shall leave not less than one-half of the required width of an aisle, corridor, passageway, or landing unobstructed and shall not project more than 7 inches into the required width of an aisle, corridor, passageway, or landing, when fully open. 7.2.1.4.3.1

The facility failed to maintain the exit corridors to be free of obstructions.

Observation determined the following corridor doors opened outward into the exit corridor and extended more than 7 inches from the wall when fully opened:

a) The corridor door to the Tub Room on the first floor.
b) The corridor door to the X-Ray Storage Room on the first floor.
c) The corridor door to the Closet across the corridor from Room 110 on the first floor.

Failure to maintain the means of egress to be available at all times increases the risk of death or injury due to fire.

The deficiency affected three (3) of numerous corridor doors in the means of egress throughout the facility.

Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6. 19.3.4.1

A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code and NFPA 72, National Fire Alarm and Signaling Code. 9.6.1.3. 2010 NFPA 72, 14.1.1

The facility failed to test the fire alarm system as required.

Fire alarm system batteries shall be subjected to a load voltage test semiannually. NFPA 72, 14.4.2.2 item 5(e).

Review of fire alarm system test records indicated the semiannual load voltage tests of the sealed lead acid batteries were not performed as required. The most current fire alarm system batteries load voltage test was conducted on 04/10/2018 during the annual inspection by an outside company. No other record of a load voltage test of the fire alarm system batteries was available.

Failure to install, test and maintain the fire alarm system in accordance with NFPA 72 increases the risk of death or injury due to fire.

This deficiency affected one (1) of two (2) load voltage tests of the fire alarm system batteries in the past year. The fire alarm system serves the entire facility.

In spaces served by air-handling systems, detectors shall not be located where airflow prevents operation of the detectors. Detectors should not be located in a direct airflow or closer than 36 in. from an air supply diffuser or return air opening. 19.3.4.5.1, 9.6.2.10.1.1, NFPA 72 17.7.4.1, A.17.7.4.1

The facility failed to ensure the smoke detection system was in compliance with NFPA 72, National Fire Alarm and Signaling Code.

Observation determined smoke detectors throughout the facility were installed within 36 in. of return air openings or air supply diffusers.

Failure to install the smoke detection system as required increases the risk of death or injury due to fire.

This deficiency affected numerous smoke detectors throughout the facility.

The facility failed to install the automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems to provide adequate coverage for all portions of the building.

Observation determined:

1) Ceiling tile throughout the facility were missing or broken.

2) A 2-foot by 4-foot open eggcrate tile was in the ceiling in the Therapy Room on the second floor.

3) Sprinklers in walk-in type coolers and freezers with automatic defrosting shall be of the intermediate-temperature classification or higher. NFPA 13 8.3.2, 8.3.2.5(10)

One (1) sprinkler in the walk-in freezer located in the Kitchen was of ordinary-temperature classification. The walk-in freezer was equipped with an automatic defrosting feature.

4) Where the code permits exceptions for fully sprinklered buildings or smoke compartments, the sprinkler system shall meet all of the following criteria:

a) It shall be in accordance with Section 9.7.
b) It shall be installed in accordance with 9.7.1.1(1), unless it is an approved existing system.
c) It shall be electronically connected to the fire alarm system.
d) It shall be fully supervised.
e) In Type I and Type II construction, where the authority having jurisdiction has prohibited sprinklers, approved alternate protection measures shall be permitted to be substituted for sprinkler protection in specified areas without causing a building to be classified as nonsprinklered. 19.3.5.7.

The main water valve to the sprinkler system was not electronically connected to the fire alarm system and was not fully supervised. The valve was not monitored with a tamper switch.

Failure to install and maintain the automatic sprinkler system in accordance with NFPA 13 increases the risk of injury and death due to fire.

The deficiency affected the entire building. The automatic sprinkler system serves the entire facility.

All automatic sprinkler 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. 9.7.5

The facility failed to ensure the automatic sprinkler system was continuously maintained in a reliable operating condition as required by NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems.

Review of documentation determined:

1) No record was available to indicate the sprinkler system gauges and control valves were inspected monthly.

2) The annual inspection of the sprinkler system was completed by an outside company on 09/12/2017 and 10/01/2018, exceeding one year between inspections.

3) The backflow preventer valve was inspected by an outside company on 09/12/2017 and 10/01/2018, exceeding one year between inspections.

4) A quarterly flow test of the sprinkler system was not completed during the 3rd quarter of 2018.

Failure to test and maintain the automatic sprinkler system in accordance with NFPA 25 increases the risk of death or injury due to fire.

The deficiency affected numerous tests of the automatic sprinkler system. The automatic sprinkler system serves the entire building.

Fire dampers shall be tested and inspected in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Each damper shall be tested and inspected 1 year after installation. The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years. All tests shall be completed in a safe manner by personnel wearing personal protective equipment. Full unobstructed access to the fire or combination fire/smoke damper shall be verified and corrected as required. If the damper is equipped with a fusible link, the link shall be removed for testing to ensure full closure and lock-in-place if so equipped. The operational test of the damper shall verify that there is no damper interference due to rusted, bent, misaligned, or damaged frame or blades, or defective hinges or other moving parts. The damper frame shall not be penetrated by any foreign objects that would affect fire damper operations. The damper shall not be blocked from closure in any way. The fusible link shall be reinstalled after testing is complete. If the link is damaged or painted, it shall be replaced with a link of the same size, temperature, and load rating. All inspections and testing shall be documented, indicating the location of the fire damper or combination fire/smoke damper, date of inspection, name of inspector, and deficiencies discovered. The documentation shall have a space to indicate when and how the deficiencies were corrected. All documentation shall be maintained and made available for review by the AHJ. 19.5, NFPA 80, 19.4

The facility failed to test and inspect fire dampers as required by NFPA 80.

On 10/15/2018, record review indicated the fire dampers were last inspected and tested in June 2012, exceeding 6 years since the last inspection.

Failure to maintain fire dampers in accordance with NFPA 80 increases the risk of death or injury due to fire.

This deficiency affected the entire facility.

Fire drills shall be conducted quarterly on each shift to familiarize facility personnel with the signals and emergency action required under varied conditions. 19.7.1.6

The facility failed to conduct fire drills as required.

Fire drill records review determined no fire drills were conducted on the Second Shift during the second quarter or the Third Shift during the third quarter of 2018.

Failure to conduct fire drills as required increases the risk of death or injury due to fire.

The deficiency affected two (2) of twelve (12) drills in the past year.

Ground-fault circuit-interruption for personnel shall be provided as required. The ground-fault circuit-interrupter shall be installed in a readily accessible location. All 125-volt, single-phase, 15- and 20-ampere receptacles located in areas other than kitchens where receptacles are installed within 6 ft. of the outside edge of the sink shall have ground-fault circuit-interrupter protection for personnel. NFPA 70, 210.8, 210.8(A)(7)

The facility failed to provide electrical wiring and equipment in accordance with NFPA 70, National Electrical Code.

Observation determined electrical receptacles throughout the facility were installed within 6 ft. of a sink and were not ground-fault circuit-interrupter protected.

Failure to provide electrical wiring and equipment in accordance with NFPA 70 increases the risk of injury or death due to fire.

The deficiency affected numerous receptacles throughout the facility.

The facility failed to ensure the emergency generator was in compliance with NFPA 110, Standard for Emergency and Standby Power Systems, and NFPA 99, Health Care Facilities Code.

1) All Level 1 and Level 2 installations of an emergency generator shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building.

For Level 1 and Level 2 systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified. NFPA 101 Section 19.2.9.1, 7.9.2.4, NFPA 110 Section 5.6.5.2(u).

Observation determined there was no remote stop switch for the generator located external to the weatherproof enclosure. The generator was located outside the building.

2) Generator sets serving essential electrical systems shall be tested in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly. NFPA 99 6.4.4.1.1.4, NFPA 110 8.3, 8.4.1

Review of generator test records did not indicate the weekly inspection of the emergency generator was completed.

Failure to ensure the emergency generator is in compliance with NFPA 99 and NFPA 110, increases the risk of death or injury due to fire.

The deficiency affected one (1) of one (1) emergency generator for the hospital.