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Based on observation and staff interview, the facility failed to assure that the proper separation between the surgery hospital and the business occupancy is provided. This deficient practice in not providing a 2 hour fire wall for occupancy separation will allow smoke and fire products to pass through to the adjacent occupancy of a fire.

Findings Include:

Based on observation on 1/9/17 between 12:35 PM and 5:00 PM and on 1/10/17 between 8:20 AM and 12:25 PM:
1. On 1/10/17 at 9:25 AM: There are (2) .5" unsealed penetrations through the 2 hour separation wall above the ceiling in the vacuum pump room. Viewed North to South.

2. On 1/10/17 at 9:26 AM: There is a .5" unsealed penetration through the 2 hour separation wall above the ceiling in the vacuum pump room where a peach colored foam has been used to attempt to seal the penetration. There is no documentation available indicating the fire resistance of the foam product used. This is viewed East to West.

3. On 1/10/17 at 9:35 AM: There are (4) unsealed penetrations above the MRI room viewed South to North:
a. 1" unsealed penetration around flex conduit.
b. 2"X4" hole.
c. 1.75" hole.
d. .75" unsealed penetration around flex conduit.

4. On 1/10/17 at 9:46 AM: There is a 2"X3" hole with a single red cable through the 2 hour separation wall above the door way between the MRI room and the adjacent office. Viewed North to South.

5. On 1/10/17 at 9:57 AM: There is a 2"X2" unsealed penetration through the 2 hour separation wall around the conduit above the ceiling in the doctors' office. Viewed North to South.

The Quality Improvement Director was present and acknowledged the findings.
NFPA Standard: NFPA 101 2012 ed. 19.1.3.4.1* Ambulatory care facilities, medical clinics, and similar facilities that are contiguous to health care occupancies, but are primarily intended to provide outpatient services, shall be permitted to be classified as business occupancies or ambulatory health care facilities, provided that the facilities are separated from the health care occupancy by not less than 2-hour fire resistance-rated construction, and the facility is not intended to provide services simultaneously for four or more inpatients who are litterborne.

Based on observation and staff interview the facility failed to ensure proper separation of hazardous areas from other spaces. This deficient practice would allow for the spread of smoke and fire to travel into the adjacent area, affecting 1 of 4 smoke zones. The facility has a capacity of 25 in patients with a census of 10 at the time of survey.

Findings Include:

Based on observation on 1/9/17 between 12:35 PM and 5:00 PM and on 1/10/17 between 8:20 AM and 12:25 PM:
1. On 1/10/17 at 9:18 AM: The electrical room fire rated door was found tied open.

2. On 1/10/17 at 9:22 AM: The fire rated door to the communication room is without a handle and is unable to positively latch.

The Quality Improvement Director was present and acknowledged the findings.

NFPA Standard: NFPA 101 2012 ed. 9.3.2.1 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 8.7.1. 19.3.2.1.1 An automatic extinguishing system, where used in hazardous areas, shall be permitted to be in accordance with 19.3.5.9. 19.3.2.1.2* Where the sprinkler option of 19.3.2.1 is used, the areas shall be separated from other spaces by smoke partitions in accordance with Section 8.4. 19.3.2.1.3 The doors shall be self-closing or automatic-closing. 19.3.2.1.4 Doors in rated enclosures shall be permitted to have nonrated, factory- or field-applied protective plates extending not more than 48 in. (1220 mm) above the bottom of the door. 19.3.2.1.5 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) Rooms with soiled linen in volume exceeding 64 gal (242 L) (6) Rooms with collected trash in volume exceeding 64 gal (242 L) (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.

Based on observation, interview and record review, the facility failed to provide and maintain documentation of annual inspection and testing of the fire alarm system as required by NFPA 72. The absence of complete, verifiable documented maintenance and repair history on the fire alarm system fails to ensure reliability of the alarm system in the event of an emergency.

Findings Include:

Based on record review on 1/9/17 between 12:35 PM and 5:00 PM and on 1/10/17 between 8:20 AM and 12:25 PM:

1. On 1/9/17 at 2:40 PM: The fire alarm inspection report dated 5/27/16 indicates that the visual notification devices are not synced.

2. On 1/9/17 at 2:43 PM The fire alarm inspection report dated 5/27/16 indicates that the smoke detectors have had sensitivity testing completed however, there are no acceptable ranges or a pass/fail indicator to validate that the detectors are within the acceptable ranges.

The Quality Improvement Director was present and acknowledged the findings.

NFPA Standard: NFPA 72 2010 ed. 14.4.5* Testing Frequency. Unless otherwise permitted by other sections of this Code, testing shall be performed in accordance with the schedules in Table 14.4.5, or more often if required by the authority having jurisdiction.

NFPA Standard: NFPA 72 2010 ed. 14.6.2.4* Arecord of all inspections, testing, and maintenance
shall be provided that includes the following information regarding
tests and all the applicable information requested in
Figure 14.6.2.4: (1) Date (2) Test frequency (3) Name of property (4) Address (5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business address, and telephone number (6) Name, address, and representative of approving agency( ies) (7) Designation of the detector(s) tested (8) Functional test of detectors (9)*Functional test of required sequence of operations (10) Check of all smoke detectors (11) Loop resistance for all fixed-temperature, line-type heat detectors (12) Functional test of mass notification system control units (13) Functional test of signal transmission to mass notification systems (14) Functional test of ability of mass notification system to silence fire alarm notification appliances (15) Tests of intelligibility of mass notification system speakers (16) Other tests as required by the equipment manufacturer ' s published instructions (17) Other tests as required by the authority having jurisdiction (18) Signatures of tester and approved authority representative (19) Disposition of problems identified during test (e.g., system owner notified, problem corrected/successfully retested, device abandoned in place)

Based on record review and staff interviews, the facility failed to assure that the sprinkler system is maintained and tested in accordance with the NFPA 13 and NFPA 25. This deficient practice fails to ensure that the sprinkler system will operate properly in the event of a fire.

Findings Include:

Based on observation on 1/9/17 between 12:35 PM and 5:00 PM and on 1/10/17 between 8:20 AM and 12:25 PM:
1. On 1/10/17 at 9:28 AM: The gauges on the wet sprinkler riser are dated 2010. There is no documentation of calibration testing.

The Quality Improvement Director was present and acknowledged the findings.
NFPA Standard: NFPA 101 2012 ed. 9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe 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. NFPA Standard: NFPA 25 2011 ed. 5.3.2* Gauges. 5.3.2.1 Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. 5.3.2.2 Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced.

Based on observation and staff interview the facility fails to maintain two of four smoke barriers to at least one half hour fire resistance and ensure that all penetrations are properly sealed. This deficient practice would prevent containment of fire and smoke.

Findings Include:

Based on observation on 1/9/17 between 12:35 PM and 5:00 PM and on 1/10/17 between 8:20 AM and 12:25 PM:
1. On 1/10/17 at 10:08 AM: There is a .25" unsealed penetration around a single data cable through the smoke barrier wall above the fire rated doors to the patient rooms area from the lobby. Viewed North to South above the ceiling level.

2. On 1/10/17 at 10:31 AM: There is a 1" unsealed penetration around data cables through the smoke barrier wall above the door leading into the Operation Room corridor near the Pre-op area. Viewed from the East to West above the ceiling.

3. On 1/10/17 at 11:37 AM: There is a .5" unsealed penetration around cables through the smoke barrier wall between Pre-op and the Operating Room corridor. Viewed North to South above the ceiling.

The Quality Improvement Director was present and acknowledged the findings.

NFPA Standard:101 2012 ed. 19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a minimum 1/2-hour fire resistance rating, unless otherwise permitted by one of the following: (1) This requirement shall not apply where an atrium is used, and both of the following criteria also shall apply: (a) Smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with 8.6.7(1)(c). (b) Not less than two separate smoke compartments shall be provided on each floor. (2)*Smoke dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air-conditioning systems where an approved, supervised automatic sprinkler system in accordance with 19.3.5.8 has been provided for smoke compartments adjacent to the smoke barrier.

Based on record review and staff interview of the facilities last 24 months of fire drill records, the facility is not conducting fire drills as required quarterly on each shift and properly recording the results and facts relating to the fire drills. This deficient practice affects the ability of the staff to properly respond in the event of an actual emergency.

Findings Include:

Based on record review and staff interview on 1/9/17:

1. At 1:37 PM: The fire drill recorded on 3/30/16 at 07:05 AM was ran as a silent drill outside of silent drill times between 9:00 PM and 6:00 AM. The alarm was not sounded at the time of the drill or the following day.

2. The silent fire drill recorded on 9/29/16 at 4:41 AM did not have a recorded audible test and none was received by the monitoring company the next day.

3. The silent fire drill recorded on 9/29/16 at 5:23 PM was ran as a silent drill outside of silent drill times between 9:00 PM and 6:00 AM. The drill did not have fire alarm activation and none was received by the monitoring company the next day.

4. The fire drill recorded on 12/22/16 at 12:21 PM did not have fire alarm activation recorded and none was received by the monitoring company.

5. The silent fire drill recorded on 9/24/15 at 10:00 PM did not have a recorded audible test and none was received by the monitoring company the next day.

6. The silent fire drill recorded on 6/23/15 at 11:00 PM did not have a recorded audible test and none was received by the monitoring company the next day.

The Quality Improvement Director was present and acknowledged the finding.


NFPA Standard: 101, 2012 Ed. 19.7.1.4* Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. 19.7.1.5 Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building. 19.7.1.6 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.
19.7.1.7 When drills are conducted between 9:00 p.m. and 6:00 a.m. (2100 hours and 0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

Based on observation and staff interview, the facility failed to assure that medical gas storage is protected in accordance with NFPA 99. This deficient practice fails to ensure the proper operation of the vacuum system.

Findings Include:

Based on observation on 1/9/17 between 12:35 PM and 5:00 PM and on 1/10/17 between 8:20 AM and 12:25 PM:
1. On 1/9/17 at 2:49 PM: The medical gas testing report dated on 9/30/16, states that:
a. Vacuum: Lag alarm not tied into master panel.
b. Vacuum: Receiver cannot be isolated from system.
c. Vacuum: Receiver does not have a manual drain.
d. Vacuum: No demand check valve on gauge.
e. Manifold: (oxygen, medical air & carbon dioxide): No demand check on main line gauge.
The Quality Improvement Director was present and acknowledged the findings.
NFPA Standard: NFPA 99 2012 ed.
5.1.3.7.3 Vacuum Receivers. Receivers for vacuum shall meet the following requirements: (1) They shall be made of materials deemed suitable by the manufacturer. (2) They shall comply with Section VIII, " Unfired Pressure Vessels, " of the ASME Boiler and Pressure Vessel Code. (3) They shall be capable of withstanding a gauge pressure of 415 kPa (60 psi) and 760 mm (30 in.) gauge HgV. (4) They shall be equipped with a manual drain. (5) They shall be of a capacity based on the technology of the pumps.

Based on record review and staff interview the facility failed to assure the generator is properly maintained to NFPA 110. This deficient practice fails to ensure that the generator will not fail when needed in the event of an emergency.

.Findings Include:

Based on observation on 1/9/17 between 12:35 PM and 5:00 PM and on 1/10/17 between 8:20 AM and 12:25 PM:
1. On 1/9/17 at 3:50 PM: The load bank test report recorded on 1/7/17 indicates: There is a fuel leak at the fuel solenoid mounting. Blow by is high and a lot of condensation in oil. Oil should be changed is diluted with fuel.

2. On 1/10/17 at 10:24 AM: The generator annunciator panel is located approximately 75 feet away and through double 20 minute fire rated doors from the staffed nurses' station. This station is staffed 24 hours a day and is not guaranteed for staff to hear the audible generator alarm located in the recovery room area.

3. On 1/10/17 at 11:02 PM: There is no remote generator shutdown.


The Quality Improvement Director was present and acknowledged the findings.

NFPA Standard: NFPA 110 2010 ed. 5.6.5.6* All installations shall have a remote manual stop station
of a type to prevent inadvertent or unintentional operation located
outside the room housing the prime mover, where so installed,
or elsewhere on the premises where the prime mover is
located outside the building.
5.6.5.6.1 The remote manual stop station shall be labeled.

Based on observation and staff interview, the facility did not ensure that electrical wiring and equipment is installed and maintained in accordance with NFPA 70, National Electrical Code. This deficient practice does not ensure prevention of an electrical fire or electric shock hazard.

Findings Include:

Based on observation on 1/9/17 between 12:35 PM and 5:00 PM and on 1/10/17 between 8:20 AM and 12:25 PM:
1. On 1/10/17 at 10:09 AM: There is a length of sheathed non-metallic 2 conductor wire hanging above the ceiling level above the fire rated doors between the lobby and the patient rooms area. The electrical wire is not connected to anything.

2. On 1/10/17 at 10:17 AM: There is an approved power strip powering a secured medication dispensing machine in the patient rooms area nurses station. The power strip is ran through a wall.

The Quality Improvement Director was present and acknowledged the findings.

NFPA Standard: NFPA 70 2011 ed. 314.28
(C) Covers. All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where used, metal covers shall comply with the grounding requirements of 250.110.

NFPA Standard: NFPA 70 2011 ed 400.8 Uses Not Permitted. Unless specifically permitted in 400.7, flexible cords and cables shall not be used for the following: (1) As a substitute for the fixed wiring of a structure (2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors (3) Where run through doorways, windows, or similar openings (4) Where attached to building surfaces Exception to (4): Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of 368.56(B) (5) Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings (6) Where installed in raceways, except as otherwise permitted in this Code (7) Where subject to physical damage

NFPA Standard: NFPA 70 2011 ed. 400.9 Splices. Flexible cord shall be used only in continuous lengths without splice or tap where initially installed invapplications permitted by 400.7(A). The repair of hard-servicevcord and junior hard-service cord (see Trade Name column invTable 400.4) 14 AWG and larger shall be permitted if conductorsvare spliced in accordance with 110.14(B) and the completedvsplice retains the insulation, outer sheath properties, andvusage characteristics of the cord being spliced.

Based on observation and staff interview, the facility failed to assure that medical gas storage is protected in accordance with NFPA 99, including the storage of empty oxygen and full oxygen cylinders in the oxygen storage area. This deficient practice fails to ensure the proper storage of oxygen and could allow and empty cylinder to be retrieved in an emergent situation requiring a full one.

Findings Include:

Based on observation on 1/9/17 between 12:35 PM and 5:00 PM and on 1/10/17 between 8:20 AM and 12:25 PM:

1. On 1/10/17 at 11:24 AM: There are 2 empty "E" oxygen cylinders stored in the full oxygen rack.

The Quality Improvement Director was present and acknowledged the findings.

NFPA Standard: 99 2012 edition, 11.3.4.1 A precautionary sign, readable from a distance of
1.5 m (5 ft), shall be displayed on each door or gate of the
storage room or enclosure.11.3.4.2 The sign shall include the following wording as a
minimum:
CAUTION:
OXIDIZING GAS(ES) STORED WITHIN
NO SMOKING

NFPA Standatd: NFPA 99 2012 ed. 11.6.5.2 If empty and full cylinders are stored within the
same enclosure, empty cylinders shall be segregated from
full cylinders.