HospitalInspections.org

The facility failed to separate all hazardous areas from other spaces with self-closing doors.

Observation determined:

1) The 90-minute fire door that separated the Boiler Room from the tunnel system had no self-closing device.

2) The door that separated the basement southwest Storage Room from the corridor had no self-closing device.

The facility failed to ensure emergency lighting of at least 1? hour duration was provided. Battery-powered emergency lighting must be provided in anesthetizing locations in accordance with NFPA 70, National Electrical Code, Section 700-12(e).

Observation determined battery pack emergency lighting was not installed in the Operating Room.

The facility failed to conduct quarterly fire drills on each shift.

Fire drill records review indicated:

1) A fire drill was not conducted during the night shift during the first quarter of 2012.

2) A fire drill was not conducted during the night shift during the second quarter of 2012.

The facility failed to ensure complete automatic sprinkler system was installed throughout the building. NFPA 13.

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.

Observation determined: 1) Suspended ceiling tiles were removed/missing from the ceiling of the room housing the fire panel, Computer Server Room and in several corridor locations.
2) Unsealed openings around 2" conduits in several suspended ceiling tiles in Radiology.3) Three (3) outside stairs enclosures attached to the building were of metal clad wood frame construction without automatic fire sprinkler protection. The three enclosed outside stairs served the basement areas to include the Boiler Room, Laundry and the Exercise Room.

The facility failed to ensure the automatic sprinkler system was continuously maintained in reliable operating condition. The frequencies for testing, inspection and maintenance of automatic sprinkler systems are dictated by the requirements as outlined by Table 5-1 of NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition.

Records review determined the last annual automatic fire sprinkler test was April 2, 2012, and the prior test was March 25, 2011, which was more than 12 months between annual tests.

The facility failed to ensure the relative humidity was maintained equal to or greater than 35% in the Operating Room.
Review of the facility's policy indicated the relative humidity was to be maintained between 30% and 60% in the Operating Room.

Transfer switches must be subjected to a maintenance program including connections, inspection or testing for evidence of overheating and excessive contact erosion, removal of dust and dirt, and replacement of contacts when required. NFPA 110, Standard for Emergency and Standby Power Systems

The facility failed to provide documentation of a preventive maintenance program for the emergency generator electrical transfer switch.

The facility failed to ensure two (2) of two (2) generators were exercised under load for 30 minutes per month. Review of emergency generator test records determined documentation of testing for two (2) of two (2) generators under load was not available for August 2012.

Flexible cords and cables must not be used as a substitute for fixed wiring of a structure. NFPA 70, National Electrical Code, 400-8

Observation determined the facility was using flexible cords as a substitute for fixed wiring.

1) An extension cord was in use in the Penthouse to provide electricity to a condensate pump.2) An extension cord was in use in the Penthouse to provide electricity to a Trane unit. 3) A flexible cord was hard-wired into an electrical junction box in the I.T. Server Room and interconnected via plug to an extension cord to a UPS for the server.4) An extension cord was in use in the I.T. Server Room to provide electricity to a UPS that was located near floor level.

The facility failed to separate all hazardous areas from other spaces with self-closing doors.

Observation determined:

1) The 90-minute fire door that separated the Boiler Room from the tunnel system had no self-closing device.

2) The door that separated the basement southwest Storage Room from the corridor had no self-closing device.

The facility failed to ensure emergency lighting of at least 1? hour duration was provided. Battery-powered emergency lighting must be provided in anesthetizing locations in accordance with NFPA 70, National Electrical Code, Section 700-12(e).

Observation determined battery pack emergency lighting was not installed in the Operating Room.

The facility failed to conduct quarterly fire drills on each shift.

Fire drill records review indicated:

1) A fire drill was not conducted during the night shift during the first quarter of 2012.

2) A fire drill was not conducted during the night shift during the second quarter of 2012.

The facility failed to ensure complete automatic sprinkler system was installed throughout the building. NFPA 13.

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.

Observation determined: 1) Suspended ceiling tiles were removed/missing from the ceiling of the room housing the fire panel, Computer Server Room and in several corridor locations.
2) Unsealed openings around 2" conduits in several suspended ceiling tiles in Radiology.3) Three (3) outside stairs enclosures attached to the building were of metal clad wood frame construction without automatic fire sprinkler protection. The three enclosed outside stairs served the basement areas to include the Boiler Room, Laundry and the Exercise Room.

The facility failed to ensure the automatic sprinkler system was continuously maintained in reliable operating condition. The frequencies for testing, inspection and maintenance of automatic sprinkler systems are dictated by the requirements as outlined by Table 5-1 of NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition.

Records review determined the last annual automatic fire sprinkler test was April 2, 2012, and the prior test was March 25, 2011, which was more than 12 months between annual tests.

The facility failed to ensure the relative humidity was maintained equal to or greater than 35% in the Operating Room.
Review of the facility's policy indicated the relative humidity was to be maintained between 30% and 60% in the Operating Room.

Transfer switches must be subjected to a maintenance program including connections, inspection or testing for evidence of overheating and excessive contact erosion, removal of dust and dirt, and replacement of contacts when required. NFPA 110, Standard for Emergency and Standby Power Systems

The facility failed to provide documentation of a preventive maintenance program for the emergency generator electrical transfer switch.

The facility failed to ensure two (2) of two (2) generators were exercised under load for 30 minutes per month. Review of emergency generator test records determined documentation of testing for two (2) of two (2) generators under load was not available for August 2012.

Flexible cords and cables must not be used as a substitute for fixed wiring of a structure. NFPA 70, National Electrical Code, 400-8

Observation determined the facility was using flexible cords as a substitute for fixed wiring.

1) An extension cord was in use in the Penthouse to provide electricity to a condensate pump.2) An extension cord was in use in the Penthouse to provide electricity to a Trane unit. 3) A flexible cord was hard-wired into an electrical junction box in the I.T. Server Room and interconnected via plug to an extension cord to a UPS for the server.4) An extension cord was in use in the I.T. Server Room to provide electricity to a UPS that was located near floor level.