HospitalInspections.org

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Based on the observation on 5/5/2015, the facility failed to maintain corridor doors to latch securely in the door frame. Findings include:

At Room 121, the corridor door did not positive latch.

This deficiency impacted 1 of 4 smoke compartments.
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2000 NFPA 101, 19.3.6.3.1* Corridor Doors. Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.
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Based on the observation on 5/5/2015, the facility failed to maintain smoke barriers at least a one half hour fire resistance rating and resist the passage of smoke. Findings include:

1. In the Main Lobby, there was a 1" gap between block wall and roof above. Located above the drink machines.
2. In the Main Lobby, there was a missing block in the corner above the information desk.
3. At Room 121, there was a ¾ conduit that had separated at the mechanical joint connection.

The deficiency impacted 2 of 4 smoke compartments.
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2000 NFPA 101, 8.3.6.1
2000 NFPA 101 8.3.6.2
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Based on the observation of the exit signs on 5/5/2015, the facility failed to maintain the exit and directional signs with continuous illumination. Findings include:
The exit light above the door inside the portable MRI unit did not have any of the working components for the light. All that was present was the case for the exit light.

The deficiency impacted 1 of 4 smoke compartments.
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2000 NFPA 101 7.10.5.2* Every sign is required to be illuminated by 7.10.6.3 and 7.10.7 shall be continuously illuminated as required under the provisions of Section 7.8.
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Based on review of facility documentation on 5/5/2015, the facility failed to conduct fire drills, maintain the documentation for fire drills, and to provide proof of participation of all on duty staff at the time of the drill(s). Findings include:

First Quarter - First Shift 3/4/15 - 9:15 am: No documentation showing participants
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First Quarter - Second Shift: No fire drill conducted
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First Quarter - Third Shift: No fire drill conducted
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Second Quarter - First Shift: No fire drill conducted
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Second Quarter - Third Shift 6/9/14 at 5:30 am: No documentation showing participants
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Third Quarter - First Shift 7/11/14 at 1:45 pm: No documentation showing participants
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Third Quarter - Second Shift 8/4/14 at 3:10 pm: No documentation showing participants
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Third Quarter - Third Shift 9/9/14 at 6:20 am: No documentation showing participants
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Fourth Quarter First Shift 10/29/14 at 9:00 am: No documentation showing participants
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Fourth Quarter Second Shift 11/11/14 at 3:05pm: No documentation showing participants
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Fourth Quarter Third Shift 12/10/14 at 6:30 am: No documentation showing participants

The deficiency impacted 4 of 4 smoke compartments.
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2000 NFPA 101, 19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. 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. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
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Based on observation on 5/5/2015, the facility failed to maintain the Fire Alarm System. Findings include:

1. During activation of the facility ' s Fire Alarm system the magnetic locks for exit doors near rooms 107 and 134 did not release when fire alarm system was activated.
2. During the testing of Primary Loss of Power this surveyor observed that the magnetic locks for exit doors near rooms 107 and 134 did not release when power was disconnected to Fire alarm system.

This deficiency impacts 2 of 4 smoke compartments.
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1999 NFPA 72, 3-9.7.1 Any device or system intended to actuate the locking or unlocking of exits shall be connected to the fire alarm system serving the protected premises.
1999 NFPA 72, 3-9.7.2 All exits connected in accordance with 3-9.7.1 shall unlock upon receipt of any fire alarm signal by means of the fire alarm system serving the protected premises. Exception: Where otherwise required or permitted by the authority having jurisdiction or other codes.
1999 NFPA 72, 3-9.7.3 All exits connected in accordance with 3-9.7.1 shall unlock upon loss of the primary power to the fire alarm system serving the protected premises. The secondary power supply shall not be utilized to maintain these doors in the locked condition.
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Based on the observation on 05/5/2015, the facility failed to maintain the fire sprinkler system free of external loads by materials either, resting on the pipe, hung from the pipe or attached to system supports. Findings include:

At restroom across from Laboratory there were 10 to 12 blue wires resting on sprinkler line.

This deficiency impacts 1 of 4 smoke compartments.
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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.
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Based on the observation on 5/5/2015, the facility failed to maintain the fire extinguishers per code. Findings include:

The fire extinguisher in the MRI portable unit was not up to date on monthly inspections. Last inspection was February 2015.

This deficiency impacted 1 of 4 smoke compartments.
_______________
2000 NFPA 101, 9.7.4.1* Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
NFPA 10 1998, 4-3.4.2 At least monthly, the date the inspection was performed and the initials of the person performing the inspection shall be recorded.
1998 NFPA 10, 4-4.4* Maintenance Recordkeeping. Each fire extinguisher shall have a tag or label securely attached that indicates the month and year the maintenance was performed and that identifies the person performing the service.
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Based on the observation of the facilities designated smoking area on 5/5/2015, the facility failed to maintain smoking area.

The self closing metal butt can located at the exit next to room 134 on the North side of the facility had trash inside the can.

This deficiency impacted 1 of 4 smoke compartments.
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NFPA 101, 19.7.4
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* Based on the observation on 5/6/2015, the facility failed to maintain the HVAC per code. Findings include:

During the survey, the following is an example of what was observed:

The facility was observed using the egress corridors as a return air plenum for the HVAC

This deficiency impacted 4 of 4 smoke compartments.
______________

1999 NFPA 90A, 2-3.11.1 Egress corridors in health care, detention and correctional, and residential occupancies shall not be used as a portion of a supply, return, or exhaust air system serving adjoining areas. An air transfer opening(s) shall not be permitted in walls or in doors separating egress corridors from adjoining areas.
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Based on the observation of the all oxygen storage areas, inside and outside of the facility, on 5/5/2015, oxygen cylinders were found unsecured and capable of being knocked over. Findings include:

1. In the Med gas manifold room at the back of the facility this surveyor observed one blue nitrogen cylinder sitting on the floor unsecured.
2. In the oxygen storage room on the back of the facility this surveyor observed approximately six unsecured portable oxygen tanks.

This deficiency impacted 1 of 4 smoke compartments.
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Review of 1999 NFPA 99, 4-3.1.1.1 and 4-5.1.1.1 Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.
NFPA 1999 4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement). (a) * Nonflammable Gases (Any Quantity; In-Storage, Connected, or Both) 3. Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.
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Based on the observation on 5/5/2015, the facility failed to maintain electrical system. Findings include.

At Room 121, there was a junction box above ceiling that was missing a cover plate.

This deficiency impacted 1 of 4 smoke compartments.
_____________

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

.
Based on the observation on 5/5/2015, the facility failed to maintain corridor doors to latch securely in the door frame. Findings include:

At Room 121, the corridor door did not positive latch.

This deficiency impacted 1 of 4 smoke compartments.
_____________

2000 NFPA 101, 19.3.6.3.1* Corridor Doors. Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.
.

.
Based on the observation on 5/5/2015, the facility failed to maintain smoke barriers at least a one half hour fire resistance rating and resist the passage of smoke. Findings include:

1. In the Main Lobby, there was a 1" gap between block wall and roof above. Located above the drink machines.
2. In the Main Lobby, there was a missing block in the corner above the information desk.
3. At Room 121, there was a ¾ conduit that had separated at the mechanical joint connection.

The deficiency impacted 2 of 4 smoke compartments.
________________

2000 NFPA 101, 8.3.6.1
2000 NFPA 101 8.3.6.2
.

.
Based on the observation of the exit signs on 5/5/2015, the facility failed to maintain the exit and directional signs with continuous illumination. Findings include:
The exit light above the door inside the portable MRI unit did not have any of the working components for the light. All that was present was the case for the exit light.

The deficiency impacted 1 of 4 smoke compartments.
___________

2000 NFPA 101 7.10.5.2* Every sign is required to be illuminated by 7.10.6.3 and 7.10.7 shall be continuously illuminated as required under the provisions of Section 7.8.
.

.
Based on review of facility documentation on 5/5/2015, the facility failed to conduct fire drills, maintain the documentation for fire drills, and to provide proof of participation of all on duty staff at the time of the drill(s). Findings include:

First Quarter - First Shift 3/4/15 - 9:15 am: No documentation showing participants
------------------------
First Quarter - Second Shift: No fire drill conducted
-------------------------
First Quarter - Third Shift: No fire drill conducted
------------------------
Second Quarter - First Shift: No fire drill conducted
------------------------
Second Quarter - Third Shift 6/9/14 at 5:30 am: No documentation showing participants
--------------------------
Third Quarter - First Shift 7/11/14 at 1:45 pm: No documentation showing participants
--------------------------
Third Quarter - Second Shift 8/4/14 at 3:10 pm: No documentation showing participants
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Third Quarter - Third Shift 9/9/14 at 6:20 am: No documentation showing participants
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Fourth Quarter First Shift 10/29/14 at 9:00 am: No documentation showing participants
-------------------------
Fourth Quarter Second Shift 11/11/14 at 3:05pm: No documentation showing participants
------------------------------
Fourth Quarter Third Shift 12/10/14 at 6:30 am: No documentation showing participants

The deficiency impacted 4 of 4 smoke compartments.
__________________

2000 NFPA 101, 19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. 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. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
.

.
Based on observation on 5/5/2015, the facility failed to maintain the Fire Alarm System. Findings include:

1. During activation of the facility ' s Fire Alarm system the magnetic locks for exit doors near rooms 107 and 134 did not release when fire alarm system was activated.
2. During the testing of Primary Loss of Power this surveyor observed that the magnetic locks for exit doors near rooms 107 and 134 did not release when power was disconnected to Fire alarm system.

This deficiency impacts 2 of 4 smoke compartments.
_____________
1999 NFPA 72, 3-9.7.1 Any device or system intended to actuate the locking or unlocking of exits shall be connected to the fire alarm system serving the protected premises.
1999 NFPA 72, 3-9.7.2 All exits connected in accordance with 3-9.7.1 shall unlock upon receipt of any fire alarm signal by means of the fire alarm system serving the protected premises. Exception: Where otherwise required or permitted by the authority having jurisdiction or other codes.
1999 NFPA 72, 3-9.7.3 All exits connected in accordance with 3-9.7.1 shall unlock upon loss of the primary power to the fire alarm system serving the protected premises. The secondary power supply shall not be utilized to maintain these doors in the locked condition.
.

.
Based on the observation on 05/5/2015, the facility failed to maintain the fire sprinkler system free of external loads by materials either, resting on the pipe, hung from the pipe or attached to system supports. Findings include:

At restroom across from Laboratory there were 10 to 12 blue wires resting on sprinkler line.

This deficiency impacts 1 of 4 smoke compartments.
_____________
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.
.

.
Based on the observation on 5/5/2015, the facility failed to maintain the fire extinguishers per code. Findings include:

The fire extinguisher in the MRI portable unit was not up to date on monthly inspections. Last inspection was February 2015.

This deficiency impacted 1 of 4 smoke compartments.
_______________
2000 NFPA 101, 9.7.4.1* Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
NFPA 10 1998, 4-3.4.2 At least monthly, the date the inspection was performed and the initials of the person performing the inspection shall be recorded.
1998 NFPA 10, 4-4.4* Maintenance Recordkeeping. Each fire extinguisher shall have a tag or label securely attached that indicates the month and year the maintenance was performed and that identifies the person performing the service.
.

.
Based on the observation of the facilities designated smoking area on 5/5/2015, the facility failed to maintain smoking area.

The self closing metal butt can located at the exit next to room 134 on the North side of the facility had trash inside the can.

This deficiency impacted 1 of 4 smoke compartments.
-----------------------------------------------
NFPA 101, 19.7.4
.

.
* Based on the observation on 5/6/2015, the facility failed to maintain the HVAC per code. Findings include:

During the survey, the following is an example of what was observed:

The facility was observed using the egress corridors as a return air plenum for the HVAC

This deficiency impacted 4 of 4 smoke compartments.
______________

1999 NFPA 90A, 2-3.11.1 Egress corridors in health care, detention and correctional, and residential occupancies shall not be used as a portion of a supply, return, or exhaust air system serving adjoining areas. An air transfer opening(s) shall not be permitted in walls or in doors separating egress corridors from adjoining areas.
.

.
Based on the observation of the all oxygen storage areas, inside and outside of the facility, on 5/5/2015, oxygen cylinders were found unsecured and capable of being knocked over. Findings include:

1. In the Med gas manifold room at the back of the facility this surveyor observed one blue nitrogen cylinder sitting on the floor unsecured.
2. In the oxygen storage room on the back of the facility this surveyor observed approximately six unsecured portable oxygen tanks.

This deficiency impacted 1 of 4 smoke compartments.
------------------------------

Review of 1999 NFPA 99, 4-3.1.1.1 and 4-5.1.1.1 Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.
NFPA 1999 4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement). (a) * Nonflammable Gases (Any Quantity; In-Storage, Connected, or Both) 3. Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.
.

.
Based on the observation on 5/5/2015, the facility failed to maintain electrical system. Findings include.

At Room 121, there was a junction box above ceiling that was missing a cover plate.

This deficiency impacted 1 of 4 smoke compartments.
_____________

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