HospitalInspections.org

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Based on the observation on 7/08/2015, the facility failed to maintain smoke barriers to limit the spread of fire and restrict the movement of smoke. Findings include:

1. An unsealed opening approximately 6"x 12" in the smoke barrier by the Chemical Storage Room.

2. Unsealed penetrations around a group of wiring, in the smoke barrier, by the Activity Room.

The deficiency impacted 1 of 2 smoke compartments.
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NFPA 101, 19.3.7.3

NFPA 101, 8.3.2
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Based on the observation on 7/08/2015, the facility failed to maintain smoke barriers to limit the spread of fire and restrict the movement of smoke. Findings include:

1. Unsealed penetrations, both sides of the smoke barrier, by Patient Room 601.

2. Unsealed penetrations at the end of two sleeve's, in the smoke barrier, by Medical Records near the entrance to the Business Office.

The deficiency impacted 1 of 7 smoke compartments.
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NFPA 101, 19.3.7.3

NFPA 101, 8.3.2
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Based on the observation on 7/07/2015, the facility failed to provide protection of openings in fire barrier. Findings include:

Upon activation of the fire alarm system, the smoke doors in the barrier, by Patient Room 301, failed to close tight so as to resist the passage of smoke.

The deficiency impacted 1 of 7 smoke compartments.
_________

NFPA 101, 19.3.7.6., 8.3.4 Doors in smoke barriers to be self-closing. Doors in smoke barriers shall close the opening in the wall leaving only a minimum clearance to allow door(s) to function properly.
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Based on the observation on 7/7/2015, the facility failed to maintain accessible exits at all times. Findings include:

The exit from ICU is equipped with a 15 second delayed egress magnetic locking device. When this surveyor applied pressure to the exit door, the three seconds audible signal did not function. The locking device did release after approximately 15 seconds or so, but the audible signal never sounded to let you know the locking device was set to disengage.

The deficiency impacted 1 of 7 smoke compartments.
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NFPA 101, 7.2.1.6.1(c) Permits delayed egress locks on doors only in buildings equipped with a sprinkler system or complete fire detection system. 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.
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Based on the observation on 7/8/2015, the facility failed to provide adequate sprinkler coverage. Findings include:

1. Housekeeping Storage Room had a hole in the ceiling tile approximately 1" x 1", also had one missing ceiling tile.

2. Opening in tile approximately 3" x 3" in Linen Room by the Laundry Room.

The deficiency impacted 1 of 7 smoke compartments.
_______

NFPA 13 5-6., Sprinklers shall be arranged to be in compliance.
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Based on the observation on 7/8/2015, the facility failed to provide adequate sprinkler coverage. Findings include:

One ceiling tile was missing in the Mechanical Room behind the Nurses Station.

The deficiency impacted 1 of 2 smoke compartments.
_________

NFPA 13 5-6., Sprinklers shall be arranged to be in compliance.
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Based on the observation on 7/7-8/2015, the facility failed to maintain the automatic sprinkler system. Findings include:

1. Fire department connection not provided with FDC sign.

2. Corrosion build up around the seat/link of a sprinkler in the heater room by the Laundry Room.

3. Escutcheon plate missing on a sprinkler in the corridor in front of Patient Room 500.

4. Escutcheon plate missing on a sprinkler in the Staff Restroom 600 hall.

5. Blue/yellow wiring resting on the sprinkler branch lines, above the ceiling at the fire barrier, by the entrance to ICU.

6. Blue wiring resting on the sprinkler branch lines, above the ceiling, at the smoke barrier by the ER.

7. Two hydraulic nameplates were not legible on the riser.

The deficiency impacted 7 of 7 smoke compartments.
__________

NFPA 25, 1998 Edition, 9-7.1 Fire department connections shall be inspected quarterly. The inspection shall verify the following: (a) The fire department connections are visible and accessible. (b) Couplings or swivels are not damaged and rotate smoothly. (c) Plugs or caps are in place and undamaged. (d) Gaskets are in place and in good condition. (e) Identification signs are in place. (f) The check valve is not leaking. (g) The automatic drain valve is in place and operating properly.

1999 NFPA 25, 2-2.1.1 and 2-4.1.2 Sprinklers that are painted, corroded or damaged shall be replaced with new listed sprinklers of the same characteristics, including orifice size, thermal response, and water distribution.

2000 NFPA 13, 3-2.7.2 Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.

1998 NFPA 25, 2-2.2* Pipe and Fittings. Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.
NFPA 25 1998 Edition 2-2.7* Hydraulic Nameplate. The hydraulic nameplate, if provided, shall be inspected quarterly to verify that it is attached securely to the sprinkler riser and is legible.
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Based on the observation on 7/8/2015, the facility failed to maintain the electrical system. Findings include:

1. Three open blanks in the electrical panel in Mechanical Room 3.

2. One open blank in electrical panel number sixteen, in Mechanical Room 5.

3. Cover missing on a junction box in Mechanical Room 5.

4. Six way adapter plugged into a two electrical outlet in Room 3.

5. Six way adapter plugged into a two electrical outlet in the Respiratory.

The facility is not provided with adequate number of receptacles for appliances in some rooms.

The deficiency impacted 4 of 7 the smoke compartments.
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1999 NFPA 70, 373-4 Unused opening shall be effectively closed to afford protection substantially equivalent to that of the enclosures.

1999 NFPA 70, 370-25 and 410-12. Each box in completed installations to have a cover, face plate, or fixture canopy.

Review of 1999 NFPA 70, 400-7 and 400-8, HCFA Transmittal Notice 22-99, and Interpretative Guidelines for
F 0323 Extension cords should not be used to take the place of adequate wiring in a facility. If extension cords are used, the cords should be properly secured and not be placed overhead, under carpets or rugs, or anywhere that the cord can cause trips, falls, or overheat. Extension cords should be connected to only one device to prevent overloading of the circuit. The cord itself should be of a size and type for the expected electrical load and made of material that will not fray or cut easily. Electrical cords including extension cords should have proper grounding if required and should not have any grounding devices removed or not used if required.
Power strips may not be used as a substitute for adequate electrical outlets in a facility. Power strips may be used for a computer, monitor, and printer. Power strips are not designed to be used with medical devices in patient care areas. Precautions needed if power strips are used include: installing internal ground fault and over-current protection devices; preventing cords from becoming tripping hazards; and using power strips that are adequate for the number and types of devices used. Overload on any circuit can potentially cause overheating and fire. The use of ground fault circuit interruption (GFCIs) may be required in locations near water sources to prevent electrocution of staff or residents.
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Based on the observation on 7/08/2015, the facility failed to maintain smoke barriers to limit the spread of fire and restrict the movement of smoke. Findings include:

1. An unsealed opening approximately 6"x 12" in the smoke barrier by the Chemical Storage Room.

2. Unsealed penetrations around a group of wiring, in the smoke barrier, by the Activity Room.

The deficiency impacted 1 of 2 smoke compartments.
_________

NFPA 101, 19.3.7.3

NFPA 101, 8.3.2
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.
Based on the observation on 7/08/2015, the facility failed to maintain smoke barriers to limit the spread of fire and restrict the movement of smoke. Findings include:

1. Unsealed penetrations, both sides of the smoke barrier, by Patient Room 601.

2. Unsealed penetrations at the end of two sleeve's, in the smoke barrier, by Medical Records near the entrance to the Business Office.

The deficiency impacted 1 of 7 smoke compartments.
____________

NFPA 101, 19.3.7.3

NFPA 101, 8.3.2
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Based on the observation on 7/07/2015, the facility failed to provide protection of openings in fire barrier. Findings include:

Upon activation of the fire alarm system, the smoke doors in the barrier, by Patient Room 301, failed to close tight so as to resist the passage of smoke.

The deficiency impacted 1 of 7 smoke compartments.
_________

NFPA 101, 19.3.7.6., 8.3.4 Doors in smoke barriers to be self-closing. Doors in smoke barriers shall close the opening in the wall leaving only a minimum clearance to allow door(s) to function properly.
.

.
Based on the observation on 7/7/2015, the facility failed to maintain accessible exits at all times. Findings include:

The exit from ICU is equipped with a 15 second delayed egress magnetic locking device. When this surveyor applied pressure to the exit door, the three seconds audible signal did not function. The locking device did release after approximately 15 seconds or so, but the audible signal never sounded to let you know the locking device was set to disengage.

The deficiency impacted 1 of 7 smoke compartments.
________

NFPA 101, 7.2.1.6.1(c) Permits delayed egress locks on doors only in buildings equipped with a sprinkler system or complete fire detection system. 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.
.

.
Based on the observation on 7/8/2015, the facility failed to provide adequate sprinkler coverage. Findings include:

1. Housekeeping Storage Room had a hole in the ceiling tile approximately 1" x 1", also had one missing ceiling tile.

2. Opening in tile approximately 3" x 3" in Linen Room by the Laundry Room.

The deficiency impacted 1 of 7 smoke compartments.
_______

NFPA 13 5-6., Sprinklers shall be arranged to be in compliance.
.

.
Based on the observation on 7/8/2015, the facility failed to provide adequate sprinkler coverage. Findings include:

One ceiling tile was missing in the Mechanical Room behind the Nurses Station.

The deficiency impacted 1 of 2 smoke compartments.
_________

NFPA 13 5-6., Sprinklers shall be arranged to be in compliance.
.

.
Based on the observation on 7/7-8/2015, the facility failed to maintain the automatic sprinkler system. Findings include:

1. Fire department connection not provided with FDC sign.

2. Corrosion build up around the seat/link of a sprinkler in the heater room by the Laundry Room.

3. Escutcheon plate missing on a sprinkler in the corridor in front of Patient Room 500.

4. Escutcheon plate missing on a sprinkler in the Staff Restroom 600 hall.

5. Blue/yellow wiring resting on the sprinkler branch lines, above the ceiling at the fire barrier, by the entrance to ICU.

6. Blue wiring resting on the sprinkler branch lines, above the ceiling, at the smoke barrier by the ER.

7. Two hydraulic nameplates were not legible on the riser.

The deficiency impacted 7 of 7 smoke compartments.
__________

NFPA 25, 1998 Edition, 9-7.1 Fire department connections shall be inspected quarterly. The inspection shall verify the following: (a) The fire department connections are visible and accessible. (b) Couplings or swivels are not damaged and rotate smoothly. (c) Plugs or caps are in place and undamaged. (d) Gaskets are in place and in good condition. (e) Identification signs are in place. (f) The check valve is not leaking. (g) The automatic drain valve is in place and operating properly.

1999 NFPA 25, 2-2.1.1 and 2-4.1.2 Sprinklers that are painted, corroded or damaged shall be replaced with new listed sprinklers of the same characteristics, including orifice size, thermal response, and water distribution.

2000 NFPA 13, 3-2.7.2 Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.

1998 NFPA 25, 2-2.2* Pipe and Fittings. Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.
NFPA 25 1998 Edition 2-2.7* Hydraulic Nameplate. The hydraulic nameplate, if provided, shall be inspected quarterly to verify that it is attached securely to the sprinkler riser and is legible.
.

.
Based on the observation on 7/8/2015, the facility failed to maintain the electrical system. Findings include:

1. Three open blanks in the electrical panel in Mechanical Room 3.

2. One open blank in electrical panel number sixteen, in Mechanical Room 5.

3. Cover missing on a junction box in Mechanical Room 5.

4. Six way adapter plugged into a two electrical outlet in Room 3.

5. Six way adapter plugged into a two electrical outlet in the Respiratory.

The facility is not provided with adequate number of receptacles for appliances in some rooms.

The deficiency impacted 4 of 7 the smoke compartments.
____________

1999 NFPA 70, 373-4 Unused opening shall be effectively closed to afford protection substantially equivalent to that of the enclosures.

1999 NFPA 70, 370-25 and 410-12. Each box in completed installations to have a cover, face plate, or fixture canopy.

Review of 1999 NFPA 70, 400-7 and 400-8, HCFA Transmittal Notice 22-99, and Interpretative Guidelines for
F 0323 Extension cords should not be used to take the place of adequate wiring in a facility. If extension cords are used, the cords should be properly secured and not be placed overhead, under carpets or rugs, or anywhere that the cord can cause trips, falls, or overheat. Extension cords should be connected to only one device to prevent overloading of the circuit. The cord itself should be of a size and type for the expected electrical load and made of material that will not fray or cut easily. Electrical cords including extension cords should have proper grounding if required and should not have any grounding devices removed or not used if required.
Power strips may not be used as a substitute for adequate electrical outlets in a facility. Power strips may be used for a computer, monitor, and printer. Power strips are not designed to be used with medical devices in patient care areas. Precautions needed if power strips are used include: installing internal ground fault and over-current protection devices; preventing cords from becoming tripping hazards; and using power strips that are adequate for the number and types of devices used. Overload on any circuit can potentially cause overheating and fire. The use of ground fault circuit interruption (GFCIs) may be required in locations near water sources to prevent electrocution of staff or residents.
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