HospitalInspections.org

The surveyor determined through observation during a walk-through of the facility with the Maintenance Director September 10, 2014 that the facility did not maintain an exit door in accordance with requirements of the 2000 edition of NFPA 101, Life Safety Code. This deficient practice, which was acknowledged by the Maintenance Director during the survey, has the potential to affect 2 or more staff during a fire emergency.

The surveyor observed a hasp and lock mechanism on the outside of kitchen cooler-freezer door.

This door serves as the exit from the cooler-freezer and utilization of this mechanism while anyone is within the cooler or freezer would prevent them from exiting.

Section 7.2.1.5 of the 2000 edition of NFPA 101 states: "Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side."

This is also noncompliant with Section 7.2.1.4.5 of the 2000 edition of NFPA 101. The forces required to fully open any door manually in a means of egress shall not exceed 15 lbf (67 N) to release the latch, 30 lbf (133 N) to set the door in motion, and 15 lbf (67 N) to open the door to the minimum required width. Opening forces for interior side-hinged or pivoted-swinging doors without closers shall not exceed 5 lbf (22 N).

A review of the records with the Maintenance Director September 10, 2014 found the facility failed to properly document fire drills per the Life Safety Code, NFPA 101. This deficient practice, which was acknowledged by the Maintenance Director during the survey, has the potential to affect all patients, staff and visitors during a fire emergency.

The facility failed to produce documentation for 2 of 4 required fire drills during the 1st and 3rd quarters for the first/day shift, and 0 of 4 required fire drills for the second/night shift.

The facility produced 2 of 4 required fire drills during the 1st and 3rd quarters for the first/day shift (July and February, 2014), and 0 of 4 required fire drills for the second/night shift over the past 12 months. This leaves a 17 month gap between the February 2014 fire drill and the last previous documented fire drill which was dated as having occurred 8/31/12.

Since the facility operates on 2, 12-hour shifts, which require at least 8 fire drills need to be performed and documented annually (one per shift, per quarter) in order to meet the requirements of NFPA 101, Section 18/19.7.1.2.

NFPA 101, Section 18/19.7.1.2 states: "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."

A review of the records with the Maintenance Director September 10, 2014 found the facility failed to provide documentation of fire alarm system maintenance as required by the 1999 edition of NFPA 72, the National Fire Alarm Code. This deficient practice, which was acknowledged by the Maintenance Director during the survey, has the potential to affect all patients, staff and visitors during a fire emergency.

Item 1] The facility failed to provide documentation showing annual maintenance on the fire alarm system within the last 12 months. The last documented annual maintenance service was dated 03/28/13.

The 1999 edition of NFPA 72, Section 7-3.2, states, "Testing shall be performed in accordance with the schedules in Chapter 7 or more often if required by the authority having jurisdiction. If automatic testing is performed at least weekly by a remotely monitored fire alarm control unit specifically listed for the application, the manual testing frequency shall be permitted to be extended to annual. Table 7-3.2 shall apply."

Item 2] The facility did not provide documentation showing sensitivity testing of the smoke detectors within the past 24 months, nor did it provide documentation per NFPA 72 that would preclude sensitivity testing of the smoke detectors within the past 24 months.

The 1999 edition of NFPA 72, Section 7-3.2.1 states, in part: " Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter . . . "

Item 1]
A walk-through of the facility with the Maintenance Director and others determined, by observation, September 10, 2014 that the facility did not meet the requirements of the 1999 edition of the NFPA 110, the Standard for Emergency and Standby Power Systems. This deficient practice, which was acknowledged by the Maintenance Director during the survey, has the potential to affect all patients, staff and visitors during a fire emergency.

The facility did not install a battery-powered emergency light at the emergency transfer switch and emergency generator; this equipment is co-located in the same structure.

Section 5-3.1 of the 1999 edition of NFPA 110 states:
The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.

Section 5-3.2 of the 1999 edition of NFPA 110 states:
The intensity of illumination in the separate building or room housing the EPS equipment for Level 1 shall be 30 ft-candles (32.3 lux), unless otherwise specified by a requirement recognized by the authority having jurisdiction.

Exception: This requirement shall not apply to units housed outdoors.

Item 2]
The surveyor determined through observation during a walk-through of the structure with the Maintenance Director September 10, 2014 that the facility did not comply with clearance requirements prescribed in NFPA 13, the Standard for the Installation of Sprinkler Systems. This deficient practice, which was acknowledged by the Maintenance Director during the survey, has the potential to affect 2 or more staff during a fire emergency.

The facility failed to maintain the required 18-inch clearance underneath sprinkler heads in the basement Records Room..

According to Section 5-5.6 of the 1999 edition of NFPA 13, entitled, Clearance to Storage, "The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater." (This 18-inch "rule" extends throughout the room)

A review of the records with the Maintenance Director September 10, 2014 found the facility failed to document compliance with the 1999 edition of NFPA 110, the Standard for Emergency and Standby Power Systems, for Level 1 emergency power systems. This deficient practice, which was acknowledged by the Maintenance Director during the survey, has the potential to affect all patients, staff and visitors during a fire emergency.

The facility failed to provide documentation showing weekly inspections and monthly load testing of the facility's two (2) emergency generators.

(One Diesel prime mover, the other a Natural Gas prime mover; the facility did provide documentation showing annual servicing of these generators.)

NFPA 110, Section 6 - 4.1 states, "Level 1 and Level 2 EPSSs, including all appurtenant components shall be inspected weekly and shall be exercised under load at least once monthly."

The surveyor determined through observation during a walk-through of the facility with the Maintenance Director September 10, 2014 that the facility did not maintain an exit door in accordance with requirements of the 2000 edition of NFPA 101, Life Safety Code. This deficient practice, which was acknowledged by the Maintenance Director during the survey, has the potential to affect 2 or more staff during a fire emergency.

The surveyor observed a hasp and lock mechanism on the outside of kitchen cooler-freezer door.

This door serves as the exit from the cooler-freezer and utilization of this mechanism while anyone is within the cooler or freezer would prevent them from exiting.

Section 7.2.1.5 of the 2000 edition of NFPA 101 states: "Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side."

This is also noncompliant with Section 7.2.1.4.5 of the 2000 edition of NFPA 101. The forces required to fully open any door manually in a means of egress shall not exceed 15 lbf (67 N) to release the latch, 30 lbf (133 N) to set the door in motion, and 15 lbf (67 N) to open the door to the minimum required width. Opening forces for interior side-hinged or pivoted-swinging doors without closers shall not exceed 5 lbf (22 N).

A review of the records with the Maintenance Director September 10, 2014 found the facility failed to properly document fire drills per the Life Safety Code, NFPA 101. This deficient practice, which was acknowledged by the Maintenance Director during the survey, has the potential to affect all patients, staff and visitors during a fire emergency.

The facility failed to produce documentation for 2 of 4 required fire drills during the 1st and 3rd quarters for the first/day shift, and 0 of 4 required fire drills for the second/night shift.

The facility produced 2 of 4 required fire drills during the 1st and 3rd quarters for the first/day shift (July and February, 2014), and 0 of 4 required fire drills for the second/night shift over the past 12 months. This leaves a 17 month gap between the February 2014 fire drill and the last previous documented fire drill which was dated as having occurred 8/31/12.

Since the facility operates on 2, 12-hour shifts, which require at least 8 fire drills need to be performed and documented annually (one per shift, per quarter) in order to meet the requirements of NFPA 101, Section 18/19.7.1.2.

NFPA 101, Section 18/19.7.1.2 states: "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."

A review of the records with the Maintenance Director September 10, 2014 found the facility failed to provide documentation of fire alarm system maintenance as required by the 1999 edition of NFPA 72, the National Fire Alarm Code. This deficient practice, which was acknowledged by the Maintenance Director during the survey, has the potential to affect all patients, staff and visitors during a fire emergency.

Item 1] The facility failed to provide documentation showing annual maintenance on the fire alarm system within the last 12 months. The last documented annual maintenance service was dated 03/28/13.

The 1999 edition of NFPA 72, Section 7-3.2, states, "Testing shall be performed in accordance with the schedules in Chapter 7 or more often if required by the authority having jurisdiction. If automatic testing is performed at least weekly by a remotely monitored fire alarm control unit specifically listed for the application, the manual testing frequency shall be permitted to be extended to annual. Table 7-3.2 shall apply."

Item 2] The facility did not provide documentation showing sensitivity testing of the smoke detectors within the past 24 months, nor did it provide documentation per NFPA 72 that would preclude sensitivity testing of the smoke detectors within the past 24 months.

The 1999 edition of NFPA 72, Section 7-3.2.1 states, in part: " Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter . . . "

Item 1]
A walk-through of the facility with the Maintenance Director and others determined, by observation, September 10, 2014 that the facility did not meet the requirements of the 1999 edition of the NFPA 110, the Standard for Emergency and Standby Power Systems. This deficient practice, which was acknowledged by the Maintenance Director during the survey, has the potential to affect all patients, staff and visitors during a fire emergency.

The facility did not install a battery-powered emergency light at the emergency transfer switch and emergency generator; this equipment is co-located in the same structure.

Section 5-3.1 of the 1999 edition of NFPA 110 states:
The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.

Section 5-3.2 of the 1999 edition of NFPA 110 states:
The intensity of illumination in the separate building or room housing the EPS equipment for Level 1 shall be 30 ft-candles (32.3 lux), unless otherwise specified by a requirement recognized by the authority having jurisdiction.

Exception: This requirement shall not apply to units housed outdoors.

Item 2]
The surveyor determined through observation during a walk-through of the structure with the Maintenance Director September 10, 2014 that the facility did not comply with clearance requirements prescribed in NFPA 13, the Standard for the Installation of Sprinkler Systems. This deficient practice, which was acknowledged by the Maintenance Director during the survey, has the potential to affect 2 or more staff during a fire emergency.

The facility failed to maintain the required 18-inch clearance underneath sprinkler heads in the basement Records Room..

According to Section 5-5.6 of the 1999 edition of NFPA 13, entitled, Clearance to Storage, "The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater." (This 18-inch "rule" extends throughout the room)

A review of the records with the Maintenance Director September 10, 2014 found the facility failed to document compliance with the 1999 edition of NFPA 110, the Standard for Emergency and Standby Power Systems, for Level 1 emergency power systems. This deficient practice, which was acknowledged by the Maintenance Director during the survey, has the potential to affect all patients, staff and visitors during a fire emergency.

The facility failed to provide documentation showing weekly inspections and monthly load testing of the facility's two (2) emergency generators.

(One Diesel prime mover, the other a Natural Gas prime mover; the facility did provide documentation showing annual servicing of these generators.)

NFPA 110, Section 6 - 4.1 states, "Level 1 and Level 2 EPSSs, including all appurtenant components shall be inspected weekly and shall be exercised under load at least once monthly."