HospitalInspections.org

1) The facility failed to ensure doors in a two-hour fire resistance rated occupancy separation wall were self-closing.

Observation determined the door in the two-hour fire resistance rated wall separating the hospital from the clinic in the Laboratory Waiting Room was not equipped with a self-closing device.

Failure to ensure doors in a 2-hour fire resistance rated wall are self-closing increases the risk of injury or death due to fire.

This deficiency affected one (1) of two (2) doors in the 2-hour fire resistance rated wall separating the hospital from the clinic.

2) The facility failed to ensure communicating openings in a two-hour fire resistance rated wall occur only in corridors.

Observation determined the two-hour fire resistance rated occupancy separation wall separating the hospital from the clinic had a door through the barrier from the Laboratory Waiting Room on the hospital side of the separation.

Failure to ensure communicating openings through a two-hour fire resistance rated wall occur only in corridors increases the risk of injury or death due to fire.

This deficiency affected one (1) of two (2) communicating openings through the two-hour fire resistance rated occupancy separation wall between the hospital and the clinic.

The facility failed to ensure corridor doors resist the passage of smoke.

Observation determined the Dietary Storage Closet corridor door had two (2) open vents approximately 1' by 1' through the door.

Failure to ensure corridor doors resist the passage of smoke increases the risk of injury or death due to fire.

This deficiency affected one (1) of numerous doors throughout the facility.

The facility failed to separate hazardous areas from other spaces with smoke resistive partitions and self-closing door assemblies.

Observation determined:
1) The corridor door to the Soiled Linen Room on the second floor was not equipped with a self-closing device.
2) The corridor door to the Clean Linen Storage Room did not self-close and latch.
3) The wall separating the Boiler Room from the corridor had a 2" pipe penetrating through the wall with unsealed space around the pipe.
4) The Kitchen Storage Room corridor door did not self-close and latch.
Failure to ensure hazardous areas are separated from corridors with smoke resistive partitions and self-closing doors increases the risk of injury and death.This deficiency affected four (4) of numerous hazardous areas in the facility.

The facility failed to ensure that at least two acceptable exits, remote from each other, are provided for each floor or fire section of the building.

Observation determined the west exit stairway from the second floor was provided with 34 inches clear width between handrails and not the required 36 inches. 7.2.2.2.1(b)

Failure to provide acceptable exits increases the risk of injury or death due to fire.

This deficiency affected one (1) of two (2) required exits from the second floor.

Drills shall be conducted quarterly on each shift to familiarize facility personnel with the signals and emergency action required under varied conditions. 19.7.1.2

The facility failed to conduct fire drills as required.

Fire drill records review determined the facility failed to conduct a Second Shift fire drill during the fourth quarter of 2015.

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

The deficiency affected one (1) of twelve (12) drills in the past year.

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

1) Smoke detectors must not be located in a direct airflow nor closer than 3 ft. (1 m) from an air supply diffuser or return air opening. 19.3.4.5.1, 9.6.2.10.1, NFPA 72 2-3.5.1

Observation determined smoke detectors located throughout the facility were installed within 3 ft. of an air supply diffuser.

This deficiency affected smoke detectors throughout the facility. The smoke detection system serves the entire facility.

2) Record review and interview of staff determined the smoke detector near the cross corridor set of double doors separating the hospital from the nursing home failed the sensitivity test when tested during the annual inspection on 5/10/2016 and had not been replaced or repaired.

This deficiency affected one (1) of numerous smoke detectors in the facility.

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

The facility failed to install the fire alarm system initiating devices in accordance with NFPA 72, Nation Fire Alarm Code.

Review of records determined the control valve tamper switch and the water flow switch of the automatic sprinkler system were connected to the same zone of the fire alarm system. Activation of either switch did not identify if the automatic sprinkler system was in alarm or trouble status. NFPA 72 2.7

Failure to install the fire alarm system initiating devices in accordance with NFPA 72 increases the risk of injury or death due to fire.

This deficiency affected the entire facility. The automatic sprinkler system covers the entire second floor and a portion of the first floor. The fire alarm system covers the entire facility.

The facility failed to test and maintain the automatic sprinkler system as required.

1) Review of records and interview with staff determined that the required semiannual test of the valve supervisor switches had not been performed as required in the past year. The valve supervisory switches were tested by an outside company during the annual inspection on 8/30/2016. Facility staff was performing quarterly water flow tests but did not test the valve supervisory switches during those tests.

Failure to test the automatic sprinkler system as required increases the risk of death or injury due to fire.

The deficiency affected one of numerous required tests of the automatic sprinkler system.

Ref: 2000 NFPA 101 Section 19.3.5.1, 9.7.5, 1998 NFPA 25 Section 9-3.4.3

2) Heat from a fire stratifies to the ceiling and travels along the ceiling to activate the sprinkler. When ceilings are removed, it delays the activation of the automatic fire sprinkler system.

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.

Observation determined suspended ceiling tiles were missing in the Kitchen Storage Room.

Failure to maintain the automatic sprinkler system increases the risk of injury or death due to fire.

This deficiency affected one (1) of two (2) smoke compartments in the facility.

The facility failed to maintain the means of egress free of obstructions or impediments to full instant access in case of fire.

Observation determined several chairs placed in the exit corridor near the Laboratory.

Failure to maintain exit access free of obstructions increases the risk of injury or death due to fire.

This deficiency affected one (1) of three (3) exit corridors in the facility.

The facility failed to ensure storage and administration of medical gas was in accordance with NFPA 99, Standard for Health Care Facilities.

Observation determined:
1) One light switch and one electrical receptacle in the Oxygen Storage Room on the second floor were located less than 5' above the floor.
2) The corridor door to the Oxygen Storage Room on the second floor was not equipped with a self-closing device.
3) Four (4) Helios liquid oxygen tanks, each capable of storing 1,322 cubic feet of oxygen, were being used and stored in patient rooms throughout the second floor. Three (3) additional oxygen tanks, each capable of storing 251 cubic feet of oxygen were stored in the Oxygen Storage Room. The entire second floor of the hospital is one (1) smoke compartment. The amount of oxygen stored and in use exceeds the amount allowed in the smoke compartment by NFPA 99 with ought special protection.

Failure to store oxygen in accordance with NFPA 99 increases the risk of injury or death due to fire.

This deficiency affected one (1) of two (2) smoke compartments in the facility.

The facility failed to ensure electrical wiring and electrical equipment met the requirements of NFPA 70, National Electrical Code. 19.5.1, 9.1.2

Observation determined two ceiling mounted exhaust fans in the second floor Clean and Soiled Utility Rooms were powered by a temporary flex electrical cord that was plugged into an electrical receptacle.

Failure to ensure electrical wiring is in accordance with NFPA 70 increases the risk of death or injury due to fire.

The deficiency affected two (2) of numerous electrical devices throughout the facility.

1) The facility failed to ensure doors in a two-hour fire resistance rated occupancy separation wall were self-closing.

Observation determined the door in the two-hour fire resistance rated wall separating the hospital from the clinic in the Laboratory Waiting Room was not equipped with a self-closing device.

Failure to ensure doors in a 2-hour fire resistance rated wall are self-closing increases the risk of injury or death due to fire.

This deficiency affected one (1) of two (2) doors in the 2-hour fire resistance rated wall separating the hospital from the clinic.

2) The facility failed to ensure communicating openings in a two-hour fire resistance rated wall occur only in corridors.

Observation determined the two-hour fire resistance rated occupancy separation wall separating the hospital from the clinic had a door through the barrier from the Laboratory Waiting Room on the hospital side of the separation.

Failure to ensure communicating openings through a two-hour fire resistance rated wall occur only in corridors increases the risk of injury or death due to fire.

This deficiency affected one (1) of two (2) communicating openings through the two-hour fire resistance rated occupancy separation wall between the hospital and the clinic.

The facility failed to ensure corridor doors resist the passage of smoke.

Observation determined the Dietary Storage Closet corridor door had two (2) open vents approximately 1' by 1' through the door.

Failure to ensure corridor doors resist the passage of smoke increases the risk of injury or death due to fire.

This deficiency affected one (1) of numerous doors throughout the facility.

The facility failed to separate hazardous areas from other spaces with smoke resistive partitions and self-closing door assemblies.

Observation determined:
1) The corridor door to the Soiled Linen Room on the second floor was not equipped with a self-closing device.
2) The corridor door to the Clean Linen Storage Room did not self-close and latch.
3) The wall separating the Boiler Room from the corridor had a 2" pipe penetrating through the wall with unsealed space around the pipe.
4) The Kitchen Storage Room corridor door did not self-close and latch.
Failure to ensure hazardous areas are separated from corridors with smoke resistive partitions and self-closing doors increases the risk of injury and death.This deficiency affected four (4) of numerous hazardous areas in the facility.

The facility failed to ensure that at least two acceptable exits, remote from each other, are provided for each floor or fire section of the building.

Observation determined the west exit stairway from the second floor was provided with 34 inches clear width between handrails and not the required 36 inches. 7.2.2.2.1(b)

Failure to provide acceptable exits increases the risk of injury or death due to fire.

This deficiency affected one (1) of two (2) required exits from the second floor.

Drills shall be conducted quarterly on each shift to familiarize facility personnel with the signals and emergency action required under varied conditions. 19.7.1.2

The facility failed to conduct fire drills as required.

Fire drill records review determined the facility failed to conduct a Second Shift fire drill during the fourth quarter of 2015.

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

The deficiency affected one (1) of twelve (12) drills in the past year.

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

1) Smoke detectors must not be located in a direct airflow nor closer than 3 ft. (1 m) from an air supply diffuser or return air opening. 19.3.4.5.1, 9.6.2.10.1, NFPA 72 2-3.5.1

Observation determined smoke detectors located throughout the facility were installed within 3 ft. of an air supply diffuser.

This deficiency affected smoke detectors throughout the facility. The smoke detection system serves the entire facility.

2) Record review and interview of staff determined the smoke detector near the cross corridor set of double doors separating the hospital from the nursing home failed the sensitivity test when tested during the annual inspection on 5/10/2016 and had not been replaced or repaired.

This deficiency affected one (1) of numerous smoke detectors in the facility.

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

The facility failed to install the fire alarm system initiating devices in accordance with NFPA 72, Nation Fire Alarm Code.

Review of records determined the control valve tamper switch and the water flow switch of the automatic sprinkler system were connected to the same zone of the fire alarm system. Activation of either switch did not identify if the automatic sprinkler system was in alarm or trouble status. NFPA 72 2.7

Failure to install the fire alarm system initiating devices in accordance with NFPA 72 increases the risk of injury or death due to fire.

This deficiency affected the entire facility. The automatic sprinkler system covers the entire second floor and a portion of the first floor. The fire alarm system covers the entire facility.

The facility failed to test and maintain the automatic sprinkler system as required.

1) Review of records and interview with staff determined that the required semiannual test of the valve supervisor switches had not been performed as required in the past year. The valve supervisory switches were tested by an outside company during the annual inspection on 8/30/2016. Facility staff was performing quarterly water flow tests but did not test the valve supervisory switches during those tests.

Failure to test the automatic sprinkler system as required increases the risk of death or injury due to fire.

The deficiency affected one of numerous required tests of the automatic sprinkler system.

Ref: 2000 NFPA 101 Section 19.3.5.1, 9.7.5, 1998 NFPA 25 Section 9-3.4.3

2) Heat from a fire stratifies to the ceiling and travels along the ceiling to activate the sprinkler. When ceilings are removed, it delays the activation of the automatic fire sprinkler system.

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.

Observation determined suspended ceiling tiles were missing in the Kitchen Storage Room.

Failure to maintain the automatic sprinkler system increases the risk of injury or death due to fire.

This deficiency affected one (1) of two (2) smoke compartments in the facility.

The facility failed to maintain the means of egress free of obstructions or impediments to full instant access in case of fire.

Observation determined several chairs placed in the exit corridor near the Laboratory.

Failure to maintain exit access free of obstructions increases the risk of injury or death due to fire.

This deficiency affected one (1) of three (3) exit corridors in the facility.

The facility failed to ensure storage and administration of medical gas was in accordance with NFPA 99, Standard for Health Care Facilities.

Observation determined:
1) One light switch and one electrical receptacle in the Oxygen Storage Room on the second floor were located less than 5' above the floor.
2) The corridor door to the Oxygen Storage Room on the second floor was not equipped with a self-closing device.
3) Four (4) Helios liquid oxygen tanks, each capable of storing 1,322 cubic feet of oxygen, were being used and stored in patient rooms throughout the second floor. Three (3) additional oxygen tanks, each capable of storing 251 cubic feet of oxygen were stored in the Oxygen Storage Room. The entire second floor of the hospital is one (1) smoke compartment. The amount of oxygen stored and in use exceeds the amount allowed in the smoke compartment by NFPA 99 with ought special protection.

Failure to store oxygen in accordance with NFPA 99 increases the risk of injury or death due to fire.

This deficiency affected one (1) of two (2) smoke compartments in the facility.

The facility failed to ensure electrical wiring and electrical equipment met the requirements of NFPA 70, National Electrical Code. 19.5.1, 9.1.2

Observation determined two ceiling mounted exhaust fans in the second floor Clean and Soiled Utility Rooms were powered by a temporary flex electrical cord that was plugged into an electrical receptacle.

Failure to ensure electrical wiring is in accordance with NFPA 70 increases the risk of death or injury due to fire.

The deficiency affected two (2) of numerous electrical devices throughout the facility.