HospitalInspections.org

Based on random observation it was determined the hospital failed to maintain all corridor doors to close and latch without impediment. Findings include:

1. During tour of the hospital on 01/03/11 at approximately 12:30 p.m., the corridor door for the kitchen and the freezer/food storage room were observed to be held open with a rubber wedge and/or tied open with a piece of rope.

NFPA (National Fire Protection Association) 101 Life Safety Code - 2000 Edition
19.3.2.1 Hazardous Areas.
Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.

This standard is not met as evidenced by:

Based on observation it was determined the hospital failed to maintain all hazardous room doors with self-closing devices. Findings include:

1. On 01/06/11 at approximately 9:00 a.m., the laundry room was observed not to have a self-closing device on the corridor door.

NFPA (National Fire Protection Association) 13 Standard for Installation of Sprinkler Systems
5-6.6* Clearance to Storage (Standard Pendent and Upright Spray Sprinklers).
The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.

This Standard is not met as evidenced by:

Based on observation it was determined the hospital failed to maintain all components of the sprinkler system in reliable operating condition and in accordance with National Fire Protection Association (NFPA) 13. Findings include:

1. On 01/03/11 at approximately 1:00 p.m., the kitchen dry food storage room was observed to have storage within eighteen (18) inches of the sprinkler head.

Based on observation and staff interview it was determined the hospital failed to maintain all exhaust ventilation in accordance with National Fire Protection Association (NFPA) 90A.
Findings include:

1. On 01/05/11 at approximately 10:30 a.m., a portable air conditioning unit was observed in the pharmacy room. At this time, the return air exhaust duct for the air conditioning unit was observed to be attached to a ceiling tile. An interview with the director of facilities on this same date and time revealed that the air conditioning unit was exhausting air into the concealed space above the lay-in-ceiling. This practice of exhausting air into the ceiling concealed space area is creating a return air plenum. At the time of this survey, there was no certification available to determine that the ceiling concealed space area meets the construction requirements for a return air plenum.

NFPA 96 - Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations
Chapter 7 - Fire-Extinguishing Equipment
7-2.2.1
Automatic fire-extinguishing systems shall be installed in accordance with the terms of their listing, the manufacturer"s instructions, and the following standards where applicable.
(a) NFPA 12, Standard on Carbon Dioxide Extinguishing Systems
(b) NFPA 13, Standard for the Installation of Sprinkler Systems
(c) NFPA 17, Standard for Dry Chemical Extinguishing Systems
(d) NFPA 17A, Standard for Wet Chemical Extinguishing Systems

NFPA 17A - Standard for Wet Chemical Extinguishing Systems
Chapter 5 - Inspection, Maintenance, and Recharging
5-2 Owner's Inspection.
5-2.1
On a monthly basis, inspection shall be conducted in accordance with the manufacturer's listed installation and maintenance manual or owner's manual. As a minimum, this "quick check" or inspection shall include verification of the following:
(a) The extinguishing system is in its proper location.
(b) The manual actuators are unobstructed.
(c) The tamper indicators and seals are intact.
(d) The maintenance tag or certificate is in place.
(e) The system shows no physical damage or condition that might prevent operation.
(f) The pressure gauge(s), if provided, is in operable range.
(g) The nozzle blowoff caps, where provided, are intact and undamaged.
(h) Neither the protected equipment nor the hazard has been replaced, modified, or relocated.
5-2.2
If any deficiencies are found, appropriate corrective action shall be taken immediately.
5-2.3
Personnel making inspections shall keep records for those extinguishing systems that were found to require corrective actions.
5-2.4
At least monthly, the date the inspection is performed and the initials of the person performing the inspection shall be recorded. The records shall be retained until the next semiannual maintenance.

This Standard is not met as evidenced by:

Based on observation it was determined the hospital rangehood wet chemical extinguishing system is not inspected in accordance with NFPA 96 and 17A. Findings include:

1. On 01/03/11 at approximately 1:15 p.m., the hospital rangehood extinguishing system was inspected. During this inspection, the service tag attached to the rangehood extinguishing system was observed not to have a date or initials recorded, to verify a monthly inspection was conducted on the system. The service tag was dated October 2010. Therefore, a monthly inspection record was not available for the time period from November 2010 to January 2011.

NFPA (National Fire Protection Association) 99- Standard for Health Care Facilities

Chapter 3 - Electrical Systems

3-5 Essential Electrical System Requirements - Type 2.
3-5.1 Sources (Type 2 EES).
The requirements for sources for Type 2 essential electrical systems shall conform to those listed in 3-4.1.
3-5.2 Distribution (Type 2 EES).
3-5.2.1 General.
The distribution requirements for Type 2 essential electrical systems shall conform to those listed in 3-4.2.1.

3-4.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches.
(a) Maintenance of Alternate Power Source. The generator set or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.

3-4.4.2 Recordkeeping.
A written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction.

NFPA (National Fire Protection Association) 110 Standard for Health Care Facilities

5-1 General
5-1.4
The EPSS equipment shall be installed as required to meet the user's needs and to be in accordance with this standard, the manufacturer's specifications, and the authority having jurisdiction.

5-3 Lighting.
5-3.1
The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.

6-4 Operational Inspection and Testing.
6-4.1*
Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
6-4.2*
Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
The date and time of day for required testing shall be decided by the owner, based on facility operations.
6-4.2.1
Equivalent loads used for testing shall be automatically replaced with the emergency loads in case of failure of the primary source.
6-4.2.2
Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.

A-6-4.2
Light loading creates a condition termed wet stacking, indicating the presence of unburned fuel or carbon, or both, in the exhaust system. Its presence is readily indicated by the presence of continual black smoke during engine-run operation. The testing requirements of 6-4.2 are intended to reduce the possibility of wetstacking.

This Standard is not met as evidenced by:

Based on review of hospital documentation and observation it was determined the hospital failed to maintain and exercise the hospital emergency power supply system under load and in accordance with NFPA 99 and 110.

Findings include:

1. On 01/03/11 at approximately 2:00 p.m., the facility generator test log for the previous twelve (12) months was reviewed. At this time, the log sheets showed no evidence of a monthly under load test for June, July, August, September, October, and November 2010.
Also, there was no documented evidence in the generator log to indicate that the generator was capable of supplying service within the required ten (10) second interval.

2. On 01/04/11 at approximately 2:00 p.m., an inspection of the generator transfer switch room was conducted. At this time, no battery powered lighting was observed in the transfer switch room.

Based on random observation it was determined the hospital failed to maintain all corridor doors to close and latch without impediment. Findings include:

1. During tour of the hospital on 01/03/11 at approximately 12:30 p.m., the corridor door for the kitchen and the freezer/food storage room were observed to be held open with a rubber wedge and/or tied open with a piece of rope.

NFPA (National Fire Protection Association) 101 Life Safety Code - 2000 Edition
19.3.2.1 Hazardous Areas.
Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.

This standard is not met as evidenced by:

Based on observation it was determined the hospital failed to maintain all hazardous room doors with self-closing devices. Findings include:

1. On 01/06/11 at approximately 9:00 a.m., the laundry room was observed not to have a self-closing device on the corridor door.

NFPA (National Fire Protection Association) 13 Standard for Installation of Sprinkler Systems
5-6.6* Clearance to Storage (Standard Pendent and Upright Spray Sprinklers).
The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.

This Standard is not met as evidenced by:

Based on observation it was determined the hospital failed to maintain all components of the sprinkler system in reliable operating condition and in accordance with National Fire Protection Association (NFPA) 13. Findings include:

1. On 01/03/11 at approximately 1:00 p.m., the kitchen dry food storage room was observed to have storage within eighteen (18) inches of the sprinkler head.

Based on observation and staff interview it was determined the hospital failed to maintain all exhaust ventilation in accordance with National Fire Protection Association (NFPA) 90A.
Findings include:

1. On 01/05/11 at approximately 10:30 a.m., a portable air conditioning unit was observed in the pharmacy room. At this time, the return air exhaust duct for the air conditioning unit was observed to be attached to a ceiling tile. An interview with the director of facilities on this same date and time revealed that the air conditioning unit was exhausting air into the concealed space above the lay-in-ceiling. This practice of exhausting air into the ceiling concealed space area is creating a return air plenum. At the time of this survey, there was no certification available to determine that the ceiling concealed space area meets the construction requirements for a return air plenum.

NFPA 96 - Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations
Chapter 7 - Fire-Extinguishing Equipment
7-2.2.1
Automatic fire-extinguishing systems shall be installed in accordance with the terms of their listing, the manufacturer"s instructions, and the following standards where applicable.
(a) NFPA 12, Standard on Carbon Dioxide Extinguishing Systems
(b) NFPA 13, Standard for the Installation of Sprinkler Systems
(c) NFPA 17, Standard for Dry Chemical Extinguishing Systems
(d) NFPA 17A, Standard for Wet Chemical Extinguishing Systems

NFPA 17A - Standard for Wet Chemical Extinguishing Systems
Chapter 5 - Inspection, Maintenance, and Recharging
5-2 Owner's Inspection.
5-2.1
On a monthly basis, inspection shall be conducted in accordance with the manufacturer's listed installation and maintenance manual or owner's manual. As a minimum, this "quick check" or inspection shall include verification of the following:
(a) The extinguishing system is in its proper location.
(b) The manual actuators are unobstructed.
(c) The tamper indicators and seals are intact.
(d) The maintenance tag or certificate is in place.
(e) The system shows no physical damage or condition that might prevent operation.
(f) The pressure gauge(s), if provided, is in operable range.
(g) The nozzle blowoff caps, where provided, are intact and undamaged.
(h) Neither the protected equipment nor the hazard has been replaced, modified, or relocated.
5-2.2
If any deficiencies are found, appropriate corrective action shall be taken immediately.
5-2.3
Personnel making inspections shall keep records for those extinguishing systems that were found to require corrective actions.
5-2.4
At least monthly, the date the inspection is performed and the initials of the person performing the inspection shall be recorded. The records shall be retained until the next semiannual maintenance.

This Standard is not met as evidenced by:

Based on observation it was determined the hospital rangehood wet chemical extinguishing system is not inspected in accordance with NFPA 96 and 17A. Findings include:

1. On 01/03/11 at approximately 1:15 p.m., the hospital rangehood extinguishing system was inspected. During this inspection, the service tag attached to the rangehood extinguishing system was observed not to have a date or initials recorded, to verify a monthly inspection was conducted on the system. The service tag was dated October 2010. Therefore, a monthly inspection record was not available for the time period from November 2010 to January 2011.

NFPA (National Fire Protection Association) 99- Standard for Health Care Facilities

Chapter 3 - Electrical Systems

3-5 Essential Electrical System Requirements - Type 2.
3-5.1 Sources (Type 2 EES).
The requirements for sources for Type 2 essential electrical systems shall conform to those listed in 3-4.1.
3-5.2 Distribution (Type 2 EES).
3-5.2.1 General.
The distribution requirements for Type 2 essential electrical systems shall conform to those listed in 3-4.2.1.

3-4.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches.
(a) Maintenance of Alternate Power Source. The generator set or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.

3-4.4.2 Recordkeeping.
A written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction.

NFPA (National Fire Protection Association) 110 Standard for Health Care Facilities

5-1 General
5-1.4
The EPSS equipment shall be installed as required to meet the user's needs and to be in accordance with this standard, the manufacturer's specifications, and the authority having jurisdiction.

5-3 Lighting.
5-3.1
The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.

6-4 Operational Inspection and Testing.
6-4.1*
Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
6-4.2*
Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
The date and time of day for required testing shall be decided by the owner, based on facility operations.
6-4.2.1
Equivalent loads used for testing shall be automatically replaced with the emergency loads in case of failure of the primary source.
6-4.2.2
Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.

A-6-4.2
Light loading creates a condition termed wet stacking, indicating the presence of unburned fuel or carbon, or both, in the exhaust system. Its presence is readily indicated by the presence of continual black smoke during engine-run operation. The testing requirements of 6-4.2 are intended to reduce the possibility of wetstacking.

This Standard is not met as evidenced by:

Based on review of hospital documentation and observation it was determined the hospital failed to maintain and exercise the hospital emergency power supply system under load and in accordance with NFPA 99 and 110.

Findings include:

1. On 01/03/11 at approximately 2:00 p.m., the facility generator test log for the previous twelve (12) months was reviewed. At this time, the log sheets showed no evidence of a monthly under load test for June, July, August, September, October, and November 2010.
Also, there was no documented evidence in the generator log to indicate that the generator was capable of supplying service within the required ten (10) second interval.

2. On 01/04/11 at approximately 2:00 p.m., an inspection of the generator transfer switch room was conducted. At this time, no battery powered lighting was observed in the transfer switch room.