HospitalInspections.org

Based on observation and facility staff interview, the facility staff failed to ensure all designated exit corridors are illuminated with emergency egress lights not controlled by a light switch. Five of five designated exit corridors contained switches controlling the emergency egress lighting fixtures. Failure to provide emergency egress lighting fixtures not controlled by a light switch has the potential to affect all facility residents. This deficient practice could delay the safe evacuation of patients, staff and visitors in the event of an emergency. The facility census was 8.


1. Observation on 5/10/17, during the building tour, showed five of five designated exit hallways contained switches controlling the emergency egress lighting fixtures.

During an interview on 5/10/17 at 3:09 P.M., the Director of Facilities said the emergency lights always had light switches and were installed during the building construction.


19.2.8 Illumination of Means of Egress. Means of egress shall
be illuminated in accordance with Section 7.8.


7.8.1.2 Illumination of means of egress shall be continuous
during the time that the conditions of occupancy require that
the means of egress be available for use, unless otherwise provided
in 7.8.1.2.2.

Based on observation and facility staff interview, facility staff failed to provide emergency lighting not controlled by light switches inside one medication alcove, Operating room recovery suite, post anesthesia care unit (PACU) and operating rooms sterile hall. This deficient practice has the potential to affect all patients, staff and visitors. Failure to provide emergency lighting could prevent proper illumination of required areas in the event of power loss. The facility census was 8.

1. Observations on 05/10/17, during the Life Safety Code (LCS) tour, showed the following light fixtures in the building controlled by a light switch:

-Medication alcove in the emergency department

-Operating rooms recovery suite

-Post anesthesia care unit (PACU)

Operating rooms suite sterile hallway



During an interview on 5/10/17 at 3:09 P.M., the Director of Facilities said the emergency lights always had light switches and were installed during the building construction.


NFPA 99, 2012 edition, section 6.4.2.2.4.2 states:

"6.4.2.2.4.2 The critical branch shall supply power for task illumination,
fixed equipment, select receptacles, and select power
circuits serving the following areas and functions related to patient
care:
(1) Critical care areas that utilize anesthetizing gases, task illumination,
select receptacles, and fixed equipment
(2) Isolated power systems in special environments
(3) Task illumination and select receptacles in the following:
(a) Patient care rooms, including infant nurseries, selected
acute nursing areas, psychiatric bed areas (omit receptacles),
and ward treatment rooms
(b) Medication preparation areas
(c) Pharmacy dispensing areas
(d) Nurses ' stations (unless adequately lighted by corridor
luminaires)
(4) Additional specialized patient care task illumination and
receptacles, where needed
(5) Nurse call systems
(6) Blood, bone, and tissue banks
(7)*Telephone equipment rooms and closets
(8) Task illumination, select receptacles, and select power circuits
for the following areas:
(a) General care beds with at least one duplex receptacle
per patient bedroom, and task illumination as required
by the governing body of the health care facility
(b) Angiographic labs
(c) Cardiac catheterization labs
(d) Coronary care units
(e) Hemodialysis rooms or areas
(f) Emergency room treatment areas (select)
(g) Human physiology labs
(h) Intensive care units
(i) Postoperative recovery rooms (select)
(9) Additional task illumination, receptacles, and select power
circuits needed for effective facility operation, including
single-phase fractional horsepower motors, which are permitted
to be connected to the critical branch"

Based on observation, the facility staff failed to provide a 1-hour rated separation between a hazardous area (areas that pose a degree of hazard greater than normal to the general occupancy of the building such as areas used for storage or use of combustibles or flammables, toxic, noxious, or corrosive materials, or heat producing appliances) and one designated exit corridors in the facility per NFPA (National Fire Protection Association) requirements. Failure to separate the designated exits and provide the one hour rated separation walls and provide a fire rated door equipped with a self-closing device puts all patients, staff and visitors at risk of injury or death from a fire by not containing the fire and smoke within the hazardous area and eliminating the two required means of egress. The facility census was 8.


1. Observation on 05/10/2017, during the facility tour, showed a room behind the information technology room containing a large quantity of combustible materials. Observation showed the door did not have a self closure and the door was not rated.


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

Based on observation and facility staff interview, facility staff failed to ensure areas open to the corridor contain smoke detection
per NFPA 72, National Fire Alarm and Signaling Code. This deficient practice has the potential to effect all facility patients, staff and visitors. This deficient practice could delay fire and emergency personnel response in the event of a fire. The facility census was 8.

Observations on 5/10/2017, during the facility tour, showed the old obstetrics alcove area open to the designated exit corridor.

During an interview on 5/10/2017 at 4:40 P.M., the Director of Facilities said the smoke detectors were not installed during the building construction.

19.3.4.1 General. Health care occupancies shall be provided
with a fire alarm system in accordance with Section 9.6.

Refer to NFPA 72, National Fire Alarm and Signaling Code, 2010 edition, sections 17.6.3 Location and Spacing and 17.6.3.3.1 Spacing for additional information.

Based on observation and facility staff interview, facility staff failed to ensure the building sprinkler system met NFPA 13, Standard For The Installation Of Sprinkler Systems, 2010 edition installation requirements. The facility census was 8.

Observation on 5/10/2017, during the facility tour, showed the following:

1. Observation of electrical rooms #1270 and #1290 did not show a sprinkler. Observation showed the building construction type as Type II (000). Type II (000) construction type requires complete sprinkler coverage.

2. Observation of the interior of the walk in freezer in the kitchen did not show a sprinkler head installed inside. Observation showed the building construction type as Type II (000). Type II (000) construction type requires complete sprinkler coverage.

3. Observation of electrical room #1010 showed a sprinkler sprig extending five feet without lateral support bracing.

4. Observation of electrical room #1006 showed a sprinkler sprig extending five feet without lateral support bracing.

5. Observation of electrical room #1366 showed a sprinkler sprig extending five feet without lateral support bracing.

6. Observation of electrical room #1278 showed a sprinkler sprig extending five feet without lateral support bracing.

7. Observation of electrical room #1104 showed a sprinkler sprig extending six feet without lateral support bracing.

8. Observation of the Operating room janitor's closet showed a sprinkler sprig extending five feet without lateral support bracing.

9. Observation of the Operating room electrical closet showed a sprinkler sprig extending five feet without lateral support bracing.



During an interview on 5/15/2017 at 11:40 A.M., the Director of Facilities said the sprinklers were not installed during the building construction.

NFPA 13, 2010 edition, section 9.2.3.7

9.2.3.7 Sprigs. Sprigs 4 ft (1.2 m) or longer shall be restrained
against lateral movement.

Refer to NFPA 101, 2012 edition, Table 19.1.6.1 Construction Type Limitations for information regarding complete sprinkler coverage for Type II (000) construction types.

Please refer to NFPA 13, 2010 edition, Sections 8.15.10, 8.15.10.1, 8.15.10.2 and 8.15.10.3 for sprinkler requirements in electrical rooms.

Based on staff interview and record review, facility staff failed to inspect the wet, antifreeze & dry sprinkler systems per NFPA 25, Standard for the Inspection, Testing, and maintenance of Water-Based Fire Protection Systems, 2011 edition. The facility census was 8.

Record review on 5/11/2017 did not show the following inspections:

-no monthly pressure checks for anti freeze sprinkler system of dry deluge sprinkler system

-annual inspection for the dry sprinkler system for any year

-No quarterly dry/deluge sprinkler system inspections

- 5 year backflow/check valve inspections for the wet, antifreeze or dry deluge sprinkler systems

-5 year internal pipe inspections & gauge replacements/calibrations for the wet, antifreeze or dry deluge sprinkler systems

During an interview on 5/15/2017 at 11:45 A.M., the Director of Facilities said the sprinkler inspections were missed.

Refer to NFPA 25, Standard for the Inspection, Testing, and maintenance of Water-Based Fire Protection Systems, 2011 edition, Chapters 5, 13 and 14 for additional information.

Based on observation facility staff failed to ensure all electrical rooms comply with NFPA 70 (National Electrical Code) 2011 edition requirements. Facility electrical rooms did not have a ceiling separating the electrical rooms from the open space above the corridors and adjacent areas. Failure to ensure all electrical rooms have a ceiling separating the electrical rooms has the potential to prevent or delay evacuation out of the building in the event of a fire or other emergency by allowing smoke, fumes and the products of fire into the open space above the corridors and adjacent areas from in the event of a fire. The facility census was 8.

Observation of the facility electrical rooms on 5/10/17, during the facility tour, showed the following:

-Electrical room #1104 showed the room was not sealed at the underside of the roof deck.

-Electrical room #1010 showed the room was not sealed at the underside of the roof deck.

-Electrical room #1366 showed the room was not sealed at the underside of the roof deck.

-Electrical room #1270 showed the room did not have a ceiling and shared the airspace above the room.

-Electrical room #1290 showed the room did not have a ceiling and shared the airspace above the room.

-Electrical room #1281 showed the room was not sealed at the underside of the roof deck.

-Operating room electrical room showed the room was not sealed at the underside of the roof deck. Additional observation showed two junction boxes containing live electrical wires without a junction box cover.


NFPA 101, 2012 edition, Section 19.5.1 states:
"19.5 Building Services.
19.5.1 Utilities.
19.5.1.1 Utilities shall comply with the provisions of Section 9.1."

NFPA 101, 2012 edition, Section 9.1.2 states:

"9.1.2 Electrical Systems. Electrical wiring and equipment
shall be in accordance with NFPA 70, National Electrical Code,
unless such installations are approved existing installations,
which shall be permitted to be continued in service."

NFPA 70, National Electrical Code, Article 110.26 Requirements for Electrical installations state:

"(1) Indoor. Indoor installations shall comply with
110.26(E)(1)(a) through (E)(1)(d).

(a) Dedicated Electrical Space. The space equal to the
width and depth of the equipment and extending from the
floor to a height of 1.8 m (6 ft) above the equipment or to
the structural ceiling, whichever is lower, shall be dedicated
to the electrical installation. No piping, ducts, leak protection
apparatus, or other equipment foreign to the electrical
installation shall be located in this zone.
Exception: Suspended ceilings with removable panels shall
be permitted within the 1.8-m (6-ft) zone.

(b) Foreign Systems. The area above the dedicated
space required by 110.26(E)(1)(a) shall be permitted to
contain foreign systems, provided protection is installed to
avoid damage to the electrical equipment from condensation,
leaks, or breaks in such foreign systems.

(c) Sprinkler Protection. Sprinkler protection shall be
permitted for the dedicated space where the piping complies
with this section.

(d) Suspended Ceilings. A dropped, suspended, or
similar ceiling that does not add strength to the building
structure shall not be considered a structural ceiling."