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Based on observation and interview, the facility failed to ensure that smoke barrier walls were maintained to resist the passage of smoke. Failure to ensure smoke barrier continuity would allow smoke and dangerous gases to pass freely between smoke compartments during a fire. This deficient practice affected no patients, all staff and visitors in 1 of 5 smoke compartments in the basement Administration section of the building on the date of the survey. The facility is licensed for 19 hospital beds and had a census of 5 on the day of the survey.

Findings include:

1) During the facility tour conducted on September 19, 2014 from 12:45 PM to 1:15 PM, observation of the Incoming Records room abutting the center stairwell found two (2) four-inch diameter open holes cut through the drywall into an area underneath the building main floor identified as the Dirt Room by the Facility Manager. When asked, the Facility Manager stated he was not aware these holes were left unsealed.

2) During the facility tour conducted on September 19, 2014 from 12:45 PM to 1:15 PM, observation of the Mechanical Room on the basement floor found an approximately four-inch diameter unsealed drain pipe passing through the wall into the suspended ceiling in the adjacent corridor and into what the Facility Manager had identified as the Dirt Room. Further observation found the pipe was unsealed at all penetrations across the corridor. When interviewed, the Facility Manager stated this was a new drain installed by the plumbing contractor and he was not aware the installation was unsealed.

3) During the facility tour conducted on September 19, 2014 from 12:45 PM to 1:15 PM, observation of the ceiling tiles located directly outside of the Mechanical Room on the basement floor found a dislodged ceiling tile with an approximately 3/4 inch by sixteen inch gap to the concealed space above. When interviewed, the Facility Manager stated he was not aware this ceiling tile had become dislodged.

4) During the facility tour conducted on September 19, 2014 from 12:45 PM to 1:15 PM, observation of the Outpatient Records room ceiling found a missing ceiling tile. When interviewed, the Facility Manager stated he was not aware of the missing ceiling tile.

Actual NFPA standard:

18.3.7.3
Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1 hour.
Exception No. 1: Where an atrium is used, smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with Exception No. 2 to 8.2.5.6(1). Not less than two separate smoke compartments shall be provided on each floor.
Exception No. 2*: Dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air conditioning systems.

8.3.6.1
Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Based on observation, operational testing and interview, the facility failed to ensure that smoke compartment doors would fully close. Failure to fully close smoke compartment doors would allow smoke and dangerous gases to pass freely between smoke compartments and corridors affecting safe egress during a fire event. This deficient practice affected all patients, staff and visitors in 2 of 10 smoke compartments in the main and basement floors. The facility is licensed for 19 hospital beds and had a census of 5 on the day of the survey.

Findings include:

1) During the facility tour conducted on September 16, 2014 from 12:45 PM to 1:15 PM, observation and operational testing of the fire barrier doors adjacent to the basement staff classroom found they would not completely close and latch when activated, exposing an approximately 1/4 inch to 1/2 wide gap between the doors. When interviewed, the Facility Manager stated that these doors were routinely inspected and he was not aware they were currently not closing.

2) During the facility tour conducted on September 16, 2014 from 2:00 PM to 3:00 PM, observation and operational testing of the north exit doors leading from the Kitchen/Dining area to the main floor and north stairwell found that they would not completely close when activated. Interview of the Facility Manager found he was not aware these doors were not completely closing.

Actual NFPA standard:

18.3.7.6*
Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 18.2.2.2.6.

Based on observation, operational testing and interview, the facility failed to ensure delayed egress locks installed on a stairwell exit were maintained. Failure to ensure stairwell exits were accessible at all times could potentially affect egress during an emergency. This deficient practice affected 5 patients, staff and visitors on the second floor of the main Hospital on the date of the survey. The facility is licensed for 19 hospital beds and had a census of 5 on the day of the survey.

Findings include:

During the facility tour conducted on September 16, 2014 from 3:30 PM to 4:30 PM, observation of operational testing by the Facility Manager of the delayed egress door into the second floor south stairwell exit, found it would not activate when pressure was applied to the panic hardware. Further testing revealed the door lock dropped when activated by the keypad, ruling out an Immediate Jeopardy. Interview of the Facility Manager indicated this door was not operating due to a previous electrical issue caused by recent lightning activity in the area. He further stated he was awaiting additional parts for repair.

The above findings were further acknowledged by the Administrator and Facility Manager during the exit conference conducted on September 16, 2014 from 6:00 PM to 7:00 PM.

Actual NFPA standard:

7.2.1.6.1 Delayed-Egress Locks.
Approved, listed, delayed-egress locks shall be permitted to be installed on doors serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6, or an approved, supervised automatic sprinkler system in accordance with Section 9.7, and where permitted in Chapters 12 through 42, provided that the following criteria are met.
(a) The doors shall unlock upon actuation of an approved, supervised automatic sprinkler system in accordance with Section 9.7 or upon the actuation of any heat detector or activation of not more than two smoke detectors of an approved, supervised automatic fire detection system in accordance with Section 9.6.
(b) The doors shall unlock upon loss of power controlling the lock or locking mechanism.
(c) An irreversible process shall release the lock within 15 seconds upon application of a force to the release device required in 7.2.1.5.4 that shall not be required to exceed 15 lbf (67 N) nor be required to be continuously applied for more than 3 seconds. The initiation of the release process shall activate an audible signal in the vicinity of the door. Once the door lock has been released by the application of force to the releasing device, relocking shall be by manual means only.
Exception: Where approved by the authority having jurisdiction, a delay not exceeding 30 seconds shall be permitted.
(d) * On the door adjacent to the release device, there shall be a readily visible, durable sign in letters not less than 1 in. (2.5 cm) high and not less than 1/8 in. (0.3 cm) in stroke width on a contrasting background that reads as follows:
PUSH UNTIL ALARM SOUNDS
DOOR CAN BE OPENED IN 15 SECONDS

Based on observation and interview, the facility failed to ensure that exit access was immediately available without the use of a tool or key from the egress side. Failure to allow immediate exiting capabilities could accidentally trap occupants during an emergency. This deficient practice affected all patients, staff and visitors on the date of the survey. The facility is licensed for 19 Hospital beds and had a census of 5 on the day of the survey.

Findings include:

1) During the facility tour conducted on September 16, 2014 from 2:15 PM to 4:00 PM, observation and operational testing of the door entering the pre-op exam room from the corridor found it was equipped with a push/pull hospital door latch and a key operated deadbolt. Examination of the interior of the room found that the door leaving the pre-op exam room into the main operating theater corridor was equipped with a keyed passage lock with the keyed operation installed on the interior side of the room preventing access to the egress corridor without the key when locked . When interviewed, the Facility Manager stated that the doors were locked in this fashion to secure entry from the corridor into the pre-op room and from the pre-op room into the operating theater corridor.

During the exit conference, the Administrator and Facility Manager confirmed the above finding would impact exiting capabilities during an emergency.

2) During the facility tour conducted on September 16, 2014 from 2:15 PM to 4:00 PM, observation and operational testing of the doors to primary Sleep Lab #1 and 2 found both rooms to be equipped with push/pull hospital style door latches and double sided, keyed deadbolt locks which could be locked by key on the egress side. When interviewed, the Facility Manager stated the deadbolts were installed to protect the equipment housed inside the rooms.

3) During the facility tour conducted on September 16, 2014 from 2:15 PM to 4:00 PM, observation and operational testing of the door into the secondary Sleep Lab #2 adjacent to the Cardio Pulmonary Testing room found it was equipped with a push/pull hospital style door latch and a double sided, keyed deadbolt lock which could be locked by key on the egress side. Interview of the Facility Manager found this installation was consistent with the locks installed in Finding 2.

4) During the facility tour conducted on September 16, 2014 from 2:15 PM to 4:00 PM, observation and operational testing of the door to the Cardio Pulmonary Testing room found it was equipped with a push/pull hospital style door latch and a double sided, keyed deadbolt lock which could be locked by key on the egress side. When asked, the Facility Manager stated he was not sure why this door had this lock installed.

5) During the facility tour conducted on September 16, 2014 from 2:15 PM to 4:00 PM, observation and operational testing of the double doors from the operating theater corridor to the main exiting corridor found that the southwest door was equipped with a throw bolt preventing immediate use of both doors during an emergency. Interview of the Facility Manager revealed he was not aware this door was secured in this manner.

Actual NFPA standard:

18.2.1 General.
Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7.
Exception: As modified by 18.2.2 through 18.2.11.

7.2.1.5.4*
A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.
Exception No. 1*: Egress doors from individual living units and guest rooms of residential occupancies shall be permitted to be provided with devices that require not more than one additional releasing operation, provided that such device is operable from the inside without the use of a key or tool and is mounted at a height not exceeding 48 in. (122 cm) above the finished floor. Existing security devices shall be permitted to have two additional releasing operations. Existing security devices other than automatic latching devices shall not be located more than 60 in. (152 cm) above the finished floor. Automatic latching devices shall not be located more than 48 in. (122 cm) above the finished floor.
Exception No. 2: The minimum mounting height for the releasing mechanism shall not be applicable to existing installations.

18.2.2.2.4
Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side.
Exception No. 1: Door-locking arrangements without delayed egress shall be permitted in health care occupancies, or portions of health care occupancies, where the clinical needs of the patients require specialized security measures for their safety, provided that staff can readily unlock such doors at all times. (See 18.1.1.1.5 and 18.2.2.2.5.)
Exception No. 2*: Delayed-egress locks complying with 7.2.1.6.1 shall be permitted, provided that not more than one such device is located in any egress path.
Exception No. 3: Access-controlled egress doors complying with 7.2.1.6.2 shall be permitted.

Based on record review and interview, the facility failed to ensure that fire drills were conducted once per shift per quarter. Failure to adequately train staff could hinder proper response during a fire or emergency event. This deficient practice affected all patients, staff and visitors on the date of the survey. The facility is licensed for 19 hospital beds and had a census of 5 on the day of the survey.

Findings include:

During record review of the facility conducted on September 16, 2014 from 10:00 AM to 11:45 AM, review of the facilities fire drill reports failed to produce a second shift fire drill for the drills conducted during the first and third quarters. When asked, the Facility Manager stated he had only been conducting fire drills during the daytime shift when he was present.

Actual NFPA standard:

18.7.1.2*
Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.

Based on record review and interview, the facility failed to provide records indicating quarterly and annual maintenance of the fire suppression system. Failure to properly maintain sprinklers would result in inadequate suppression during a fire event. This deficient practice affected all patients, staff and visitors on the date of the survey. The facility is licensed for 19 hospital beds and had a census of 5 on the day of the survey.

Findings include:

During record review, no records were available for sprinkler inspections since the quarterly inspection conducted on March 19, 2013. Interview of the Maintenance Director found that the facility had recently changed sprinkler maintenance companies and he was not sure why the reports had not been maintained for inspection.

Actual NFPA standard:

18.7.6 Maintenance and Testing.
(See 4.6.12.)

4.6.12 Maintenance and Testing.
4.6.12.1
Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

1-8* Records.
Records of inspections, tests, and maintenance of the system and its components shall be made available to the authority having jurisdiction upon request. Typical records include, but are not limited to, valve inspections; flow, drain, and pump tests; and trip tests of dry pipe, deluge, and preaction valves.

Based on observation and interview, the facility failed to ensure fire extinguishers were properly signed per NFPA 10. Failure to ensure extinguishers are signed could result in the wrong extinguisher being used for its intended hazard during a fire. This deficient practice affected all patients, staff and visitors using the kitchen/dining area on the date of the survey. The facility is licensed for 19 hospital beds and had a census of 5 on the day of the survey.
Findings include:
During the facility tour conducted on September 16, 2014 from 12:15 PM to 2:30 PM, observation of the K-style fire extinguisher located in the main kitchen found it was not properly signed for its intended use. Further observation of the Kitchen revealed the pass-through for food and dishes was directly open to the main dining area. Interview of the Facility Manager indicated he was not aware this sign was missing.
Actual NFPA standard:
2-3.2*
Fire extinguishers provided for the protection of cooking appliances that use combustible cooking media (vegetable or animal oils and fats) shall be listed and labeled for Class K fires.
Exception: Extinguishers installed specifically for these hazards prior to June 30, 1998.
2-3.2.1
A placard shall be conspicuously placed near the extinguisher that states that the fire protection system shall be activated prior to using the fire extinguisher.

Based on observation and interview, the facility failed to ensure that exit access was maintained free of obstacles. Failure to provide instant use of exits at all times could prevent the safe evacuation of occupants during and emergency. This deficient practice affected all patients staff and visitors in the X-ray department on the date of the survey. The facility is licensed for 19 hospital beds and had a census of 5 on the day of the survey.

Findings include:

During the facility tour conducted on September 16, 2014 from 3:30 PM to 4:30 PM, observation of the south exit from the X-ray department found the access to the exit was impeded by a portable X-ray machine and (2) soiled linen/trash receptacles located directly outside the door entering the MRI area. When asked, the Facility Manager stated he was aware these items were not allowed to be stored in this location.

(See tag K 075)

Actual NFPA standard:

7.1.10.1*
Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Based on record review, interview and physical inspection, the facility failed to ensure curtains were installed in accordance with NFPA 701. Failure to ensure the flame resistive properties of curtains and loosely hanging decorations would allow fires to develop and spread beyond incipient stages. This deficient practice affected all patients, staff and visitors on the date of the survey. The facility is licensed for 19 hospital beds and had a census of 5 on the day of the survey.

Findings include:


During the facility tour conducted on September 16, 2014 from 12:15 PM to 3:30 PM, observation and physical inspection of curtains installed in rooms 205, 209 and 211 found that only the cubicle privacy curtains were tagged for flame spread ratings in accordance with NFPA 701. Window curtains installed in these rooms were not tagged indicating the flame spread properties of the fabric and did not reveal they had been chemically treated when physically examined.

Actual NFPA standard:

10.3.1*
Where required by the applicable provisions of this Code, draperies, curtains, and other similar loosely hanging furnishings and decorations shall be flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.

Based on observation and interview, the facility failed to ensure highly combustible material was stored in a safe manner. Failure to provide proper protection of hazardous storage would result in smoke and dangerous gases to pass freely through corridors during a fire hindering egress capabilities. This deficient practice affected all patients, staff and visitors using the X-ray department on the date of the survey. The facility is licensed for 19 hospital beds and had a census of 5 on the day of the survey.

Findings include:

1) During the facility tour conducted on September 16, 2014 from 3:30 PM to 4:30 PM, observation of the area outside the bathroom in the X-ray department found (2) 32 gal. soiled linen and trash storage receptacles stored in this location. When interviewed, the Facility Manager stated he was not aware of the requirement to contain these receptacles in a hazardous area storage.

2) During the facility tour conducted on September 16, 2014 from 3:30 PM to 4:30 PM, observation of the exit access from the X-ray department to the southwest exit found (2) 32 gal. soiled linen and trash storage receptacles stored in this area. When asked, staff in the area stated these were used to store used garments and trash accumulated during X-ray procedures.

(See K 072)

Actual NFPA standard:

18.7.5.5
Soiled linen or trash collection receptacles shall not exceed 32 gal (121 L) in capacity. The average density of container capacity in a room or space shall not exceed 0.5 gal/ft2 (20.4 L/m2). A capacity of 32 gal (121 L) shall not be exceeded within any 64-ft2 (5.9-m2) area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) shall be located in a room protected as a hazardous area when not attended.
Exception: Container size and density shall not be limited in hazardous areas.

Based on observation and interview, the facility failed to ensure that smoke barrier walls were maintained to resist the passage of smoke. Failure to ensure smoke barrier continuity would allow smoke and dangerous gases to pass freely between smoke compartments during a fire. This deficient practice affected no patients, all staff and visitors in 1 of 5 smoke compartments in the basement Administration section of the building on the date of the survey. The facility is licensed for 19 hospital beds and had a census of 5 on the day of the survey.

Findings include:

1) During the facility tour conducted on September 19, 2014 from 12:45 PM to 1:15 PM, observation of the Incoming Records room abutting the center stairwell found two (2) four-inch diameter open holes cut through the drywall into an area underneath the building main floor identified as the Dirt Room by the Facility Manager. When asked, the Facility Manager stated he was not aware these holes were left unsealed.

2) During the facility tour conducted on September 19, 2014 from 12:45 PM to 1:15 PM, observation of the Mechanical Room on the basement floor found an approximately four-inch diameter unsealed drain pipe passing through the wall into the suspended ceiling in the adjacent corridor and into what the Facility Manager had identified as the Dirt Room. Further observation found the pipe was unsealed at all penetrations across the corridor. When interviewed, the Facility Manager stated this was a new drain installed by the plumbing contractor and he was not aware the installation was unsealed.

3) During the facility tour conducted on September 19, 2014 from 12:45 PM to 1:15 PM, observation of the ceiling tiles located directly outside of the Mechanical Room on the basement floor found a dislodged ceiling tile with an approximately 3/4 inch by sixteen inch gap to the concealed space above. When interviewed, the Facility Manager stated he was not aware this ceiling tile had become dislodged.

4) During the facility tour conducted on September 19, 2014 from 12:45 PM to 1:15 PM, observation of the Outpatient Records room ceiling found a missing ceiling tile. When interviewed, the Facility Manager stated he was not aware of the missing ceiling tile.

Actual NFPA standard:

18.3.7.3
Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1 hour.
Exception No. 1: Where an atrium is used, smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with Exception No. 2 to 8.2.5.6(1). Not less than two separate smoke compartments shall be provided on each floor.
Exception No. 2*: Dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air conditioning systems.

8.3.6.1
Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Based on observation, operational testing and interview, the facility failed to ensure that smoke compartment doors would fully close. Failure to fully close smoke compartment doors would allow smoke and dangerous gases to pass freely between smoke compartments and corridors affecting safe egress during a fire event. This deficient practice affected all patients, staff and visitors in 2 of 10 smoke compartments in the main and basement floors. The facility is licensed for 19 hospital beds and had a census of 5 on the day of the survey.

Findings include:

1) During the facility tour conducted on September 16, 2014 from 12:45 PM to 1:15 PM, observation and operational testing of the fire barrier doors adjacent to the basement staff classroom found they would not completely close and latch when activated, exposing an approximately 1/4 inch to 1/2 wide gap between the doors. When interviewed, the Facility Manager stated that these doors were routinely inspected and he was not aware they were currently not closing.

2) During the facility tour conducted on September 16, 2014 from 2:00 PM to 3:00 PM, observation and operational testing of the north exit doors leading from the Kitchen/Dining area to the main floor and north stairwell found that they would not completely close when activated. Interview of the Facility Manager found he was not aware these doors were not completely closing.

Actual NFPA standard:

18.3.7.6*
Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 18.2.2.2.6.

Based on observation, operational testing and interview, the facility failed to ensure delayed egress locks installed on a stairwell exit were maintained. Failure to ensure stairwell exits were accessible at all times could potentially affect egress during an emergency. This deficient practice affected 5 patients, staff and visitors on the second floor of the main Hospital on the date of the survey. The facility is licensed for 19 hospital beds and had a census of 5 on the day of the survey.

Findings include:

During the facility tour conducted on September 16, 2014 from 3:30 PM to 4:30 PM, observation of operational testing by the Facility Manager of the delayed egress door into the second floor south stairwell exit, found it would not activate when pressure was applied to the panic hardware. Further testing revealed the door lock dropped when activated by the keypad, ruling out an Immediate Jeopardy. Interview of the Facility Manager indicated this door was not operating due to a previous electrical issue caused by recent lightning activity in the area. He further stated he was awaiting additional parts for repair.

The above findings were further acknowledged by the Administrator and Facility Manager during the exit conference conducted on September 16, 2014 from 6:00 PM to 7:00 PM.

Actual NFPA standard:

7.2.1.6.1 Delayed-Egress Locks.
Approved, listed, delayed-egress locks shall be permitted to be installed on doors serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6, or an approved, supervised automatic sprinkler system in accordance with Section 9.7, and where permitted in Chapters 12 through 42, provided that the following criteria are met.
(a) The doors shall unlock upon actuation of an approved, supervised automatic sprinkler system in accordance with Section 9.7 or upon the actuation of any heat detector or activation of not more than two smoke detectors of an approved, supervised automatic fire detection system in accordance with Section 9.6.
(b) The doors shall unlock upon loss of power controlling the lock or locking mechanism.
(c) An irreversible process shall release the lock within 15 seconds upon application of a force to the release device required in 7.2.1.5.4 that shall not be required to exceed 15 lbf (67 N) nor be required to be continuously applied for more than 3 seconds. The initiation of the release process shall activate an audible signal in the vicinity of the door. Once the door lock has been released by the application of force to the releasing device, relocking shall be by manual means only.
Exception: Where approved by the authority having jurisdiction, a delay not exceeding 30 seconds shall be permitted.
(d) * On the door adjacent to the release device, there shall be a readily visible, durable sign in letters not less than 1 in. (2.5 cm) high and not less than 1/8 in. (0.3 cm) in stroke width on a contrasting background that reads as follows:
PUSH UNTIL ALARM SOUNDS
DOOR CAN BE OPENED IN 15 SECONDS

Based on observation and interview, the facility failed to ensure that exit access was immediately available without the use of a tool or key from the egress side. Failure to allow immediate exiting capabilities could accidentally trap occupants during an emergency. This deficient practice affected all patients, staff and visitors on the date of the survey. The facility is licensed for 19 Hospital beds and had a census of 5 on the day of the survey.

Findings include:

1) During the facility tour conducted on September 16, 2014 from 2:15 PM to 4:00 PM, observation and operational testing of the door entering the pre-op exam room from the corridor found it was equipped with a push/pull hospital door latch and a key operated deadbolt. Examination of the interior of the room found that the door leaving the pre-op exam room into the main operating theater corridor was equipped with a keyed passage lock with the keyed operation installed on the interior side of the room preventing access to the egress corridor without the key when locked . When interviewed, the Facility Manager stated that the doors were locked in this fashion to secure entry from the corridor into the pre-op room and from the pre-op room into the operating theater corridor.

During the exit conference, the Administrator and Facility Manager confirmed the above finding would impact exiting capabilities during an emergency.

2) During the facility tour conducted on September 16, 2014 from 2:15 PM to 4:00 PM, observation and operational testing of the doors to primary Sleep Lab #1 and 2 found both rooms to be equipped with push/pull hospital style door latches and double sided, keyed deadbolt locks which could be locked by key on the egress side. When interviewed, the Facility Manager stated the deadbolts were installed to protect the equipment housed inside the rooms.

3) During the facility tour conducted on September 16, 2014 from 2:15 PM to 4:00 PM, observation and operational testing of the door into the secondary Sleep Lab #2 adjacent to the Cardio Pulmonary Testing room found it was equipped with a push/pull hospital style door latch and a double sided, keyed deadbolt lock which could be locked by key on the egress side. Interview of the Facility Manager found this installation was consistent with the locks installed in Finding 2.

4) During the facility tour conducted on September 16, 2014 from 2:15 PM to 4:00 PM, observation and operational testing of the door to the Cardio Pulmonary Testing room found it was equipped with a push/pull hospital style door latch and a double sided, keyed deadbolt lock which could be locked by key on the egress side. When asked, the Facility Manager stated he was not sure why this door had this lock installed.

5) During the facility tour conducted on September 16, 2014 from 2:15 PM to 4:00 PM, observation and operational testing of the double doors from the operating theater corridor to the main exiting corridor found that the southwest door was equipped with a throw bolt preventing immediate use of both doors during an emergency. Interview of the Facility Manager revealed he was not aware this door was secured in this manner.

Actual NFPA standard:

18.2.1 General.
Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7.
Exception: As modified by 18.2.2 through 18.2.11.

7.2.1.5.4*
A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.
Exception No. 1*: Egress doors from individual living units and guest rooms of residential occupancies shall be permitted to be provided with devices that require not more than one additional releasing operation, provided that such device is operable from the inside without the use of a key or tool and is mounted at a height not exceeding 48 in. (122 cm) above the finished floor. Existing security devices shall be permitted to have two additional releasing operations. Existing security devices other than automatic latching devices shall not be located more than 60 in. (152 cm) above the finished floor. Automatic latching devices shall not be located more than 48 in. (122 cm) above the finished floor.
Exception No. 2: The minimum mounting height for the releasing mechanism shall not be applicable to existing installations.

18.2.2.2.4
Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side.
Exception No. 1: Door-locking arrangements without delayed egress shall be permitted in health care occupancies, or portions of health care occupancies, where the clinical needs of the patients require specialized security measures for their safety, provided that staff can readily unlock such doors at all times. (See 18.1.1.1.5 and 18.2.2.2.5.)
Exception No. 2*: Delayed-egress locks complying with 7.2.1.6.1 shall be permitted, provided that not more than one such device is located in any egress path.
Exception No. 3: Access-controlled egress doors complying with 7.2.1.6.2 shall be permitted.

Based on record review and interview, the facility failed to ensure that fire drills were conducted once per shift per quarter. Failure to adequately train staff could hinder proper response during a fire or emergency event. This deficient practice affected all patients, staff and visitors on the date of the survey. The facility is licensed for 19 hospital beds and had a census of 5 on the day of the survey.

Findings include:

During record review of the facility conducted on September 16, 2014 from 10:00 AM to 11:45 AM, review of the facilities fire drill reports failed to produce a second shift fire drill for the drills conducted during the first and third quarters. When asked, the Facility Manager stated he had only been conducting fire drills during the daytime shift when he was present.

Actual NFPA standard:

18.7.1.2*
Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.

Based on record review and interview, the facility failed to provide records indicating quarterly and annual maintenance of the fire suppression system. Failure to properly maintain sprinklers would result in inadequate suppression during a fire event. This deficient practice affected all patients, staff and visitors on the date of the survey. The facility is licensed for 19 hospital beds and had a census of 5 on the day of the survey.

Findings include:

During record review, no records were available for sprinkler inspections since the quarterly inspection conducted on March 19, 2013. Interview of the Maintenance Director found that the facility had recently changed sprinkler maintenance companies and he was not sure why the reports had not been maintained for inspection.

Actual NFPA standard:

18.7.6 Maintenance and Testing.
(See 4.6.12.)

4.6.12 Maintenance and Testing.
4.6.12.1
Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

1-8* Records.
Records of inspections, tests, and maintenance of the system and its components shall be made available to the authority having jurisdiction upon request. Typical records include, but are not limited to, valve inspections; flow, drain, and pump tests; and trip tests of dry pipe, deluge, and preaction valves.

Based on observation and interview, the facility failed to ensure fire extinguishers were properly signed per NFPA 10. Failure to ensure extinguishers are signed could result in the wrong extinguisher being used for its intended hazard during a fire. This deficient practice affected all patients, staff and visitors using the kitchen/dining area on the date of the survey. The facility is licensed for 19 hospital beds and had a census of 5 on the day of the survey.
Findings include:
During the facility tour conducted on September 16, 2014 from 12:15 PM to 2:30 PM, observation of the K-style fire extinguisher located in the main kitchen found it was not properly signed for its intended use. Further observation of the Kitchen revealed the pass-through for food and dishes was directly open to the main dining area. Interview of the Facility Manager indicated he was not aware this sign was missing.
Actual NFPA standard:
2-3.2*
Fire extinguishers provided for the protection of cooking appliances that use combustible cooking media (vegetable or animal oils and fats) shall be listed and labeled for Class K fires.
Exception: Extinguishers installed specifically for these hazards prior to June 30, 1998.
2-3.2.1
A placard shall be conspicuously placed near the extinguisher that states that the fire protection system shall be activated prior to using the fire extinguisher.

Based on observation and interview, the facility failed to ensure that exit access was maintained free of obstacles. Failure to provide instant use of exits at all times could prevent the safe evacuation of occupants during and emergency. This deficient practice affected all patients staff and visitors in the X-ray department on the date of the survey. The facility is licensed for 19 hospital beds and had a census of 5 on the day of the survey.

Findings include:

During the facility tour conducted on September 16, 2014 from 3:30 PM to 4:30 PM, observation of the south exit from the X-ray department found the access to the exit was impeded by a portable X-ray machine and (2) soiled linen/trash receptacles located directly outside the door entering the MRI area. When asked, the Facility Manager stated he was aware these items were not allowed to be stored in this location.

(See tag K 075)

Actual NFPA standard:

7.1.10.1*
Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Based on record review, interview and physical inspection, the facility failed to ensure curtains were installed in accordance with NFPA 701. Failure to ensure the flame resistive properties of curtains and loosely hanging decorations would allow fires to develop and spread beyond incipient stages. This deficient practice affected all patients, staff and visitors on the date of the survey. The facility is licensed for 19 hospital beds and had a census of 5 on the day of the survey.

Findings include:


During the facility tour conducted on September 16, 2014 from 12:15 PM to 3:30 PM, observation and physical inspection of curtains installed in rooms 205, 209 and 211 found that only the cubicle privacy curtains were tagged for flame spread ratings in accordance with NFPA 701. Window curtains installed in these rooms were not tagged indicating the flame spread properties of the fabric and did not reveal they had been chemically treated when physically examined.

Actual NFPA standard:

10.3.1*
Where required by the applicable provisions of this Code, draperies, curtains, and other similar loosely hanging furnishings and decorations shall be flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.

Based on observation and interview, the facility failed to ensure highly combustible material was stored in a safe manner. Failure to provide proper protection of hazardous storage would result in smoke and dangerous gases to pass freely through corridors during a fire hindering egress capabilities. This deficient practice affected all patients, staff and visitors using the X-ray department on the date of the survey. The facility is licensed for 19 hospital beds and had a census of 5 on the day of the survey.

Findings include:

1) During the facility tour conducted on September 16, 2014 from 3:30 PM to 4:30 PM, observation of the area outside the bathroom in the X-ray department found (2) 32 gal. soiled linen and trash storage receptacles stored in this location. When interviewed, the Facility Manager stated he was not aware of the requirement to contain these receptacles in a hazardous area storage.

2) During the facility tour conducted on September 16, 2014 from 3:30 PM to 4:30 PM, observation of the exit access from the X-ray department to the southwest exit found (2) 32 gal. soiled linen and trash storage receptacles stored in this area. When asked, staff in the area stated these were used to store used garments and trash accumulated during X-ray procedures.

(See K 072)

Actual NFPA standard:

18.7.5.5
Soiled linen or trash collection receptacles shall not exceed 32 gal (121 L) in capacity. The average density of container capacity in a room or space shall not exceed 0.5 gal/ft2 (20.4 L/m2). A capacity of 32 gal (121 L) shall not be exceeded within any 64-ft2 (5.9-m2) area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) shall be located in a room protected as a hazardous area when not attended.
Exception: Container size and density shall not be limited in hazardous areas.