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Based on observations and interview, it was determined the facility failed to maintain smoke barriers that would resist the passage of smoke between smoke compartments in accordance with NFPA standards. The deficiency had the potential to affect three (3) of eight (8) smoke compartments, residents, staff and visitors. The facility has seventy five (75) certified beds with a census of nineteen (19) on the day of the survey.


The findings include:

Observation, on 10/23/12 at 11:26 AM, with the Director of Engineering revealed the smoke partition, extending above the ceiling located at door #1012 had been penetrated by data lines and sealed with unrated quick foam.

Interview, on 10/23/12 at 11:26 AM, with the Director of Engineering revealed new data lines had been installed recently and was not aware the data lines had been sealed with quick foam.

Observation, on 10/23/12 between 9:30 AM and 4:30 PM, with the Director of Engineering revealed a ceiling tile missing located above computer equipment located in the Server Room, and the Computer Room.

Interview, on 10/23/12 between 9:30 PM and 4:30 PM, with the Director of Engineering revealed the IT department had been running new data lines, as well as an outside contractor and they did not replace the ceiling tiles.

Interview, on 10/24/12 at 6:14 PM, with the Director of Quality and Risk Management revealed she thought the Maintenance Staff was checking work that was being performed over the ceiling and not aware quick foam could not be used to seal penetrations. She depends on the Maintenance Staff to report any concerns to the monthly Quality Meeting. Further interview revealed the facility did not provide Life Safety Code training for staff.



Reference: NFPA 101 (2000 Edition).

8.3.6.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(a) The space between the penetrating item and the smoke barrier shall
1. Be filled with a material capable of maintaining the smoke resistance of the smoke barrier, or
2. Be protected by an approved device designed for the specific purpose.
(b) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall
1. Be filled with a material capable of maintaining the smoke resistance of the smoke barrier, or
2. Be protected by an approved device designed for the specific purpose.
(c) Where designs take transmission of vibration into consideration, any vibration isolation shall
1. Be made on either side of the smoke barrier, or
2. Be made by an approved device designed for the specific purpose.

Based on observation and interview, it was determined the facility failed to ensure cross -corridor doors located in a smoke barrier would resist the passage of smoke in accordance with NFPA standards. The deficiency had the potential to affect four (4) of eight (8) smoke compartments, residents, staff and visitors. The facility has seventy five (75) certified beds with a census of nineteen (19) on the day of the survey.

The findings include:

Observation, on 10/23/12 between 9:00 AM and 4:30 PM, with the Director of Engineering revealed the cross-corridor doors located in the two (2) smoke barriers would not close completely when tested, and would not resist the passage of smoke. The doors were held open with unbalanced air pressure that would cause a draft when the doors tried to close and the draft was strong enough to force the door open when manually pushed shut. The doors are identified on the facility map as door #1033, and #1035.

Interview, on 10/23/12 between 9:00 AM and 4:30 PM, with the Director of Engineering revealed he was aware of the unbalanced air problem and was in the process of having a contractor rebalance the facility. He was also aware the doors would not close due to the air pressure problem, but thought that since the HVAC units would shut down with the activation of the Fire Alarm system that they would still be in compliance.

Interview, on 10/24/12 at 6:12 PM, with the Director of Quality and Risk Management revealed she was aware the facility air was not balanced, but not aware it was causing a problem with the smoke barrier doors. Further interview revealed the facility did not provide Life Safety Code training for staff.


Reference: NFPA 101 (2000 edition)

8.3.4.1* Doors in smoke barriers shall close the opening leaving
only the minimum clearance necessary for proper operation
and shall be without undercuts, louvers, or grilles.

Reference: NFPA 80 (1999 Edition)
Standard for Fire Doors 2-3.1.7
The clearance between the edge of the door on the pull side shall be 1/8 in. (+/-) 1/16 in. (3.18 mm (+/-) 1.59 mm) for steel doors and shall not exceed 1/8 in. (3.18mm) for wood doors.

Based on observation and interview, it was determined the facility failed to ensure exits were equipped with lighting in accordance with NFPA standards. The deficiency had the potential to affect seven (7) of eight (8) smoke compartments, residents, staff and visitors. The facility has seventy five (75) certified beds with a census of nineteen (19) on the day of the survey.

The findings include:

Observation, on 10/23/12 between 9:30 AM and 4:30 PM, with the Director of Engineering revealed the exterior exits throughout the facility had a light outside with only one bulb to light the egress path. Some areas did have a second light fixture mounted high on the wall; however, it could not be determined if all exterior lighting was connected to the generator.

Interview, on 10/23/12 between 9:30 AM and 4:30 PM, with the Director of Engineering revealed he was not aware the lighting outside of exterior exits were required to have more than one bulb.

Interview, on 10/24/12 at 6:05 PM, with the Director of Quality and Risk Management revealed she was not aware of the requirement for egress lighting. Further interview revealed the facility did not provide Life Safety Code training for staff.


Reference: NFPA 101 (2000 edition)
7.8.1.4* Required illumination shall be arranged so that the
failure of any single lighting unit does not result in an illumination
level of less than 0.2 ft-candle (2 lux) in any designated
area.

Based on staff interview and observation, it was determined the facility failed to provide emergency lighting in accordance with NFPA standards. The deficiency had the potential to affect eight (8) of eight (8) smoke compartments, residents, staff and visitors. The facility has seventy five (75) certified beds with a census of nineteen (19) on the day of the survey.

The findings include:

Observation, on 10/23/12 at 1:27 PM, with the Director of Engineering revealed an emergency battery light located inside the generator enclosure did not function when tested.

Interview, on 10/23/12 at 1:27 PM, with the Director of Engineering revealed he was unaware the light was not functioning properly.

Interview, on 10/24/12 at 6:16 PM, with the Director of Quality and Risk Management revealed she was not aware there was an issue with the battery light inside the generator enclosure. She relied on the Maintenance Staff to inform her of any concerns regarding battery lights.


Reference: NFPA 101 (2000 edition)
7.9.2.1* Emergency illumination shall be provided for not less than 11/2 hours in the event of failure of normal lighting. Emergency lighting facilities shall be arranged to provide initial illumination that is not less than an average of 1 ft-candle (10 lux) and, at any point, not less than 0.1 ft-candle (1 lux), measured along the path of egress at floor level. Illumination levels shall be permitted to decline to not less than an average of 0.6 ft-candle (6 lux) and, at any point, not less than 0.06 ft-candle (0.6
lux) at the end of the 11/2 hours. A maximum-to-minimum illumination uniformity ratio of 40 to 1 shall not be exceeded.

7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than
11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed at 30-day intervals.

Based on interview and fire drill record review, it was determined the facility failed to ensure fire drills were conducted quarterly on each shift at unexpected times, in accordance with NFPA standards. The deficiency had the potential to affect eight (8) of eight (8) smoke compartments, residents, staff and visitors. The facility has seventy five (75) certified beds with a census of nineteen (19) on the day of the survey.

The findings include:

Fire Drill record review, on 10/23/12 at 10:28 AM, with the Director of Engineering revealed the facility failed to conduct fire drills at unexpected times on all shifts. Fire drills were conducted quarterly on each shift, but were not conducted at random times per shift, per quarter.


Interview, on 10/23/12 at 10:28 AM, with the Director of Engineering revealed he was not aware the fire drills were not being conducted as required.

Interview, on 10/24/12 at 6:00 PM, with the Director of Quality and Risk Management revealed she was not aware the fire drills were not being conducted in accordance with NFPA standards. Further interview revealed the facility did not provide Life Safety Code training for staff.



Reference: NFPA Standard NFPA 101 19.7.1.2.
Fire drills shall be conducted at least quarterly on each shift and at unexpected times under varied conditions on all shifts.

Reference: NFPA 101 Life Safety Code (2000 Edition).
18.7.1.2*
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.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.

Based on observation and interview it was determined the facility failed to ensure the building had a complete sprinkler system, in accordance with NFPA Standards. The deficiency had the potential to affect two (2) of eight (8) smoke compartments, residents, staff and visitors. The facility has seventy five (75) certified beds with a census of nineteen (19) on the day of the survey.


The findings include:


Observation, on 10/23/12 between 9:30 AM and 4:30 PM, with the Director of Engineering revealed a sprinkler head located in the Business Office Closet was installed against a light fixture that was mounted below the deflector of the sprinkler head and would obstruct the spray pattern from fully developing. Further observation revealed two (2) tall windows that extended above the ceiling with a box built around the window without sprinkler protection below the ceiling that was installed at the top of the box. One (1) window was located in the OB Directors Office, and the second window was located in room #1081 next to the OB Directors Office.

Interview, on 10/23/12 between 9:30 AM and 4:30 PM, with the Director of Engineering revealed he was aware the boxes had been built to preserve the windows, but not aware they did not have sprinkler protection.


Interview, on 10/24/12 at 6:24 PM, with the Director of Quality and Risk Management revealed she was not aware of the missing sprinkler heads or the sprinkler was installed next to a light fixture. Further interview revealed she relied on the Department Directors to identify problems within their department and report them to the monthly Quality Meeting.




Reference: NFPA 13 (1999 Edition) 5-13 8.1

Actual NFPA Standard: NFPA 101, Table 19.1.6.2 and 19.3.5.1. Existing healthcare facilities with construction Type V (111) require complete sprinkler coverage for all parts of a facility.
Actual NFPA Standard: NFPA 101, 19.3.5.1. Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
Actual NFPA Standard: NFPA 101, 9.7.1.1. Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.
Actual NFPA Standard: NFPA 13, 5-1.1. The requirements for spacing, location, and position of sprinklers shall be based on the following principles:
(1) Sprinklers installed throughout the premises
(2) Sprinklers located so as not to exceed maximum protection area per sprinkler
(3) Sprinklers positioned and located so as to provide satisfactory performance with respect to activation time and distribution.


Reference: NFPA 13 (1999 ed.)
5-5.5.2.2 Sprinklers shall be positioned in accordance with
the minimum distances and special exceptions of Sections 5-6
through 5-11 so that they are located sufficiently away from
obstructions such as truss webs and chords, pipes, columns,
and fixtures.
Table 5-6.5.1.2 Positioning of Sprinklers to Avoid Obstructions to Discharge (SSU/SSP)

Maximum Allowable Distance
Distance from Sprinklers to of Deflector above Bottom of
Side of Obstruction (A) Obstruction (in.) (B
Less than 1 ft 0
1 ft to less than 1 ft 6 in. 21/2
1 ft 6 in. to less than 2 ft 31/2
2 ft to less than 2 ft 6 in. 51/2
2 ft 6 in. to less than 3 ft 71/2
3 ft to less than 3 ft 6 in. 91/2
3 ft 6 in. to less than 4 ft 12
4 ft to less than 4 ft 6 in. 14
4 ft 6 in. to less than 5 ft 161/2
5 ft and greater 18

For SI units, 1 in. = 25.4 mm; 1 ft = 0.3048 m.
Note: For (A) and (B), refer to Figure 5-6.5.1.2(a).
Reference: NFPA 13 (1999 ed.)
5-6.3.3 Minimum Distance from Walls. Sprinklers shall be located a minimum of 4 in. (102 mm) from a wall.

Based on observation and interview, it was determined the facility failed to ensure cooking facilities were protected in accordance with NFPA standards. The deficiency had the potential to affect one (1) of eight (8) smoke compartments, and kitchen staff. The facility has seventy five (75) certified beds with a census of nineteen (19) on the day of the survey.

The findings include:

Observation, on 10/23/12 between 9:30 AM and 4:30 PM, with the Director of Engineering revealed the exhaust fan for the appliance hood was turned off while a natural gas fired convection oven was in use. The gas fumes could not vent to the outside as required. The convection oven was the only appliance in use at the time of observation. Further observation revealed the manual pull station for the hood fire suppression system was not located in the path of egress but instead on a wall used to store carts.

Interview on 10/23/12 between 9:30 AM and 4:30 PM, with the Director of Engineering and Kitchen staff revealed the oven was left on between meals to keep warm and the hood was always turned off during this time. The Director of Engineering was not aware the hood was off while the equipment was in use.

Interview, on 10/24/12 at 6:22 PM, with the Director of Quality and Risk Management revealed she was not aware the hood was being turned off while cooking equipment was in use. Further interview revealed she was not aware the pull station for the hood fire suppression system was required to be located in the path of egress.

Reference: NFPA 96 (1998 edition)
7-5.1 A readily accessible means for manual activation shall be located between 42 in. and 60 in. (1067 mm and 1524 mm) above the floor, located in a path of exit or egress, and clearly identify the hazard protected. The automatic and manual means of system activation external to the control head or releasing device shall be separate and independent of each other so that failure of one will not impair the operation of the other.
Exception No. 1: The manual means of system activation shall be permitted to be common with the automatic means if the manual activation device is located between the control head or releasing device and the first fusible link.
Exception No. 2: An automatic sprinkler system.

Based on observation and interview it was determined the facility failed to ensure portable space heaters used in the facility were in accordance with NFPA standards. The deficiency had the potential to affect five (5) of eight (8) smoke compartments, residents, staff and visitors. The facility has seventy five (75) certified beds with a census of nineteen (19) on the day of the survey.

The findings include:

Observation, on 10/23/12 between 9:30 AM and 4:30 PM, with the Director of Engineering revealed portable space heaters located in the following locations:

1) Two (2) located in the Business Office.
2) Two (2) located in the HR Directors Office.
3) Admissions Desk
4) Marketing Directors Office
5) Insurance Verification Office
6) Risk Management Office
7) Medical Records Office
8) HIM Office
9) Controller Office
10) Chief Financial Officer Office
11) Chief Nursing Office
12) Director of Emergency Office
13) Outpatient Registration

Interview, on 10/23/12 between 9:30 AM and 4:30 PM, with the Director of Engineering revealed he was aware the heaters could not exceed 212°F in non-sleeping, staff, and employee areas. However, he thought that the code was referring to the housing of the heater and not the element. Further interview revealed the facility did have a policy on the use of portable heaters and they were to be unplugged at night.

Interview, on 10/24/12 at 6:24 PM, with the Director of Quality and Risk Management revealed she was not aware the temperature of the heating element could not exceed 212F degrees, but thought it was the housing of the heater that could not exceed 212F degrees.


Reference: NFPA 101 (2000 edition)
19.7.8 Portable Space-Heating Devices. Portable space-heating
devices shall be prohibited in all health care occupancies.
Exception: Portable space-heating devices shall be permitted to be used
in non-sleeping staff and employee areas where the heating elements of
such devices do not exceed 212°F (100°C).

Based on observation and interview, it was determined the facility failed to maintain exit access in accordance with NFPA standards. The deficiency had the potential to affect four (4) of eight (8) smoke compartments, residents, staff and visitors. The facility has seventy five (75) beds with a census of nineteen (19) on the day of the survey.

The findings include:

Observation, on 10/23/12 between 9:30 AM and 4:30 PM, with the Director of Engineering revealed trash carts, computers on wheels, med carts, soiled linen carts, and biohazard carts stored in the corridors on the second floor, and by the Kitchen. Further observation on the second floor revealed a hand wipe warmer being stored and plugged into the wall in the corridor. Also, on the second floor were charting boxes mounted on the wall that would not close completely and extended off the wall greater than four (4) inches. Further observation revealed the storage of computer on wheels charging, soiled linen carts, metal carts, biohazard carts, forms and copy paper holder cabinet, and wheel chairs located in the ER egress path.

Interview, on 10/23/12 between 9:30 AM and 4:30 PM, with the Director of Engineering revealed he was aware of the requirement for storage in the corridor. However, other surveyors or inspectors had informed them they could store items as long as they were on one side of the corridor.

Interview, on 10/24/12 at 6:30 PM, with the Director of Engineering revealed she was aware of the requirement but depended on the Department Directors to monitor their areas.

Reference: NFPA 101 (2000 Edition)
Means of Egress Reliability 7.1.10.1
Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Based on observation and interview, it was determined the facility failed to ensure trash collection receptacles with capacities greater than 32 gallon were stored in accordance with NFPA standards. The deficiency had the potential to affect one (1) of eight (8) smoke compartments, residents, staff and visitors. The facility has seventy five (75) certified beds with a census of nineteen (19) on the day of the survey.

The findings include:

Observation, on 10/23/12 at 1:38 PM, with the Director of Engineering revealed an unattended trash cart in the corridor outside the Kitchen. The trash cart exceeded 32 gallons and was full of trash.

Interview, on 10/23/12 at 1:38 PM, with the Director of Engineering revealed he was unaware the Housekeeping Staff would leave the trash cart in the corridor unattended.

Interview, on 10/24/12 at 6:18 PM, with the Director of Quality and Risk Management revealed she was aware trash receptacles that exceed 32 gallon must be kept in a room that was rated for hazards. She was not aware the Housekeeping staff would leave the trash cart in the corridor outside the Kitchen. Further interview revealed the facility did not provide Life Safety Code training for staff.


19.7.5.5
Soiled linen or trash collection receptacles shall not exceed 32 gal (121 L) in capacity. The average density of container capacity in a room or space shall not exceed 0.5 gal/ft2 (20.4 L/m2). A capacity of 32 gal (121 L) shall not be exceeded within any 64-ft2 (5.9-m2) area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) shall be located in a room protected as a hazardous area when not attended.
Exception: Container size and density shall not be limited in hazardous areas.

Based on observation and interview, it was determined the facility failed to ensure electrical wiring was maintained in accordance with NFPA standards. The deficiency had the potential to affect five (5) of eight (8) smoke compartments, residents, staff, and visitors. The facility has seventy five (75) certified beds with a census of nineteen (19) on the day of the survey.

The findings include:

Observations, on 10/23/12 between 11:00 AM and 4:30 PM, with the Director of Engineering revealed:

1) An open electrical junction box located above the ceiling by the fire door next to the Engineering Office.
2) An open electrical junction box located above the ceiling at doors #1033, #1035, and door to Out Patient Surgery.
3) A power strip was plugged into another power strip located in the IS Director's Office.
4) A microwave was plugged into an extension cord located in the ER Lounge.
5) A crock pot, toaster, and a tea maker were plugged into an extension cord in the ER Lounge.
6) A toaster and coffee maker were plugged into a power strip located in Radiology.
7) Two (2) refrigerators were plugged into a power strip located in the Women's Center Clean Utility.
8) An open electrical junction box located in the electrical room in the Women's Center.
9) A refrigerator was plugged into a power strip located in the Cardiac Rehabilitation Room.

Interview, on 10/23/12 between 11:00 AM and 4:30 PM, with the Director of Engineering revealed he was not aware of the open electrical junction boxes above the ceiling. Further interview revealed he was aware of the proper use of power strips and extension cords, but not aware they had been installed and misused.


Observations, on 10/24/12 between 9:30 AM and 10:30 AM, with the Director of Engineering revealed:

1) Medical equipment was plugged into a power strip located in the FCU storage room on the 2nd Floor.
2) Medical equipment was plugged into a power strip that was plugged into a power strip that was plugged into a 3rd power strip located in the Doctor Dictation Room on the 2nd Floor.
3) Medical equipment was plugged into a power strip located in the Clean Utility Room on the 2nd Floor.
4) A refrigerator and a coffee maker were plugged into a power strip located in the Case Management Office.


Interview, on 10/24/12 between 9:30 AM and 10:30 AM, with the Director of Engineering revealed he was not aware medical equipment could not be plugged into a power strip.

Interview, on 10/24/12 at 6:10 PM, with the Director of Quality and Risk Management revealed she was aware of the proper use of power strips and extension cords, but was not aware they were installed and being misused. She also stated that she relied on Department Directors to report any concerns at the monthly Quality Meetings. Further interview revealed the facility did not provide Life Safety Code training for staff.




Reference: NFPA 70 400-8
( Extensions Cords) Uses Not Permitted.
Unless specifically permitted in 400.7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces


Reference: NFPA 99 (1999 edition)

3-3.2.1.2 D

Minimum Number of Receptacles. The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.


Reference: NFPA 70 (1999 edition)

370.28(c) Covers.

All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Section 250-110. An extension from the cover of an exposed box shall comply with Section 370-22, Exception.

Based on observations and interview, it was determined the facility failed to maintain smoke barriers that would resist the passage of smoke between smoke compartments in accordance with NFPA standards. The deficiency had the potential to affect three (3) of eight (8) smoke compartments, residents, staff and visitors. The facility has seventy five (75) certified beds with a census of nineteen (19) on the day of the survey.


The findings include:

Observation, on 10/23/12 at 11:26 AM, with the Director of Engineering revealed the smoke partition, extending above the ceiling located at door #1012 had been penetrated by data lines and sealed with unrated quick foam.

Interview, on 10/23/12 at 11:26 AM, with the Director of Engineering revealed new data lines had been installed recently and was not aware the data lines had been sealed with quick foam.

Observation, on 10/23/12 between 9:30 AM and 4:30 PM, with the Director of Engineering revealed a ceiling tile missing located above computer equipment located in the Server Room, and the Computer Room.

Interview, on 10/23/12 between 9:30 PM and 4:30 PM, with the Director of Engineering revealed the IT department had been running new data lines, as well as an outside contractor and they did not replace the ceiling tiles.

Interview, on 10/24/12 at 6:14 PM, with the Director of Quality and Risk Management revealed she thought the Maintenance Staff was checking work that was being performed over the ceiling and not aware quick foam could not be used to seal penetrations. She depends on the Maintenance Staff to report any concerns to the monthly Quality Meeting. Further interview revealed the facility did not provide Life Safety Code training for staff.



Reference: NFPA 101 (2000 Edition).

8.3.6.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(a) The space between the penetrating item and the smoke barrier shall
1. Be filled with a material capable of maintaining the smoke resistance of the smoke barrier, or
2. Be protected by an approved device designed for the specific purpose.
(b) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall
1. Be filled with a material capable of maintaining the smoke resistance of the smoke barrier, or
2. Be protected by an approved device designed for the specific purpose.
(c) Where designs take transmission of vibration into consideration, any vibration isolation shall
1. Be made on either side of the smoke barrier, or
2. Be made by an approved device designed for the specific purpose.

Based on observation and interview, it was determined the facility failed to ensure cross -corridor doors located in a smoke barrier would resist the passage of smoke in accordance with NFPA standards. The deficiency had the potential to affect four (4) of eight (8) smoke compartments, residents, staff and visitors. The facility has seventy five (75) certified beds with a census of nineteen (19) on the day of the survey.

The findings include:

Observation, on 10/23/12 between 9:00 AM and 4:30 PM, with the Director of Engineering revealed the cross-corridor doors located in the two (2) smoke barriers would not close completely when tested, and would not resist the passage of smoke. The doors were held open with unbalanced air pressure that would cause a draft when the doors tried to close and the draft was strong enough to force the door open when manually pushed shut. The doors are identified on the facility map as door #1033, and #1035.

Interview, on 10/23/12 between 9:00 AM and 4:30 PM, with the Director of Engineering revealed he was aware of the unbalanced air problem and was in the process of having a contractor rebalance the facility. He was also aware the doors would not close due to the air pressure problem, but thought that since the HVAC units would shut down with the activation of the Fire Alarm system that they would still be in compliance.

Interview, on 10/24/12 at 6:12 PM, with the Director of Quality and Risk Management revealed she was aware the facility air was not balanced, but not aware it was causing a problem with the smoke barrier doors. Further interview revealed the facility did not provide Life Safety Code training for staff.


Reference: NFPA 101 (2000 edition)

8.3.4.1* Doors in smoke barriers shall close the opening leaving
only the minimum clearance necessary for proper operation
and shall be without undercuts, louvers, or grilles.

Reference: NFPA 80 (1999 Edition)
Standard for Fire Doors 2-3.1.7
The clearance between the edge of the door on the pull side shall be 1/8 in. (+/-) 1/16 in. (3.18 mm (+/-) 1.59 mm) for steel doors and shall not exceed 1/8 in. (3.18mm) for wood doors.

Based on observation and interview, it was determined the facility failed to ensure exits were equipped with lighting in accordance with NFPA standards. The deficiency had the potential to affect seven (7) of eight (8) smoke compartments, residents, staff and visitors. The facility has seventy five (75) certified beds with a census of nineteen (19) on the day of the survey.

The findings include:

Observation, on 10/23/12 between 9:30 AM and 4:30 PM, with the Director of Engineering revealed the exterior exits throughout the facility had a light outside with only one bulb to light the egress path. Some areas did have a second light fixture mounted high on the wall; however, it could not be determined if all exterior lighting was connected to the generator.

Interview, on 10/23/12 between 9:30 AM and 4:30 PM, with the Director of Engineering revealed he was not aware the lighting outside of exterior exits were required to have more than one bulb.

Interview, on 10/24/12 at 6:05 PM, with the Director of Quality and Risk Management revealed she was not aware of the requirement for egress lighting. Further interview revealed the facility did not provide Life Safety Code training for staff.


Reference: NFPA 101 (2000 edition)
7.8.1.4* Required illumination shall be arranged so that the
failure of any single lighting unit does not result in an illumination
level of less than 0.2 ft-candle (2 lux) in any designated
area.

Based on staff interview and observation, it was determined the facility failed to provide emergency lighting in accordance with NFPA standards. The deficiency had the potential to affect eight (8) of eight (8) smoke compartments, residents, staff and visitors. The facility has seventy five (75) certified beds with a census of nineteen (19) on the day of the survey.

The findings include:

Observation, on 10/23/12 at 1:27 PM, with the Director of Engineering revealed an emergency battery light located inside the generator enclosure did not function when tested.

Interview, on 10/23/12 at 1:27 PM, with the Director of Engineering revealed he was unaware the light was not functioning properly.

Interview, on 10/24/12 at 6:16 PM, with the Director of Quality and Risk Management revealed she was not aware there was an issue with the battery light inside the generator enclosure. She relied on the Maintenance Staff to inform her of any concerns regarding battery lights.


Reference: NFPA 101 (2000 edition)
7.9.2.1* Emergency illumination shall be provided for not less than 11/2 hours in the event of failure of normal lighting. Emergency lighting facilities shall be arranged to provide initial illumination that is not less than an average of 1 ft-candle (10 lux) and, at any point, not less than 0.1 ft-candle (1 lux), measured along the path of egress at floor level. Illumination levels shall be permitted to decline to not less than an average of 0.6 ft-candle (6 lux) and, at any point, not less than 0.06 ft-candle (0.6
lux) at the end of the 11/2 hours. A maximum-to-minimum illumination uniformity ratio of 40 to 1 shall not be exceeded.

7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than
11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed at 30-day intervals.

Based on interview and fire drill record review, it was determined the facility failed to ensure fire drills were conducted quarterly on each shift at unexpected times, in accordance with NFPA standards. The deficiency had the potential to affect eight (8) of eight (8) smoke compartments, residents, staff and visitors. The facility has seventy five (75) certified beds with a census of nineteen (19) on the day of the survey.

The findings include:

Fire Drill record review, on 10/23/12 at 10:28 AM, with the Director of Engineering revealed the facility failed to conduct fire drills at unexpected times on all shifts. Fire drills were conducted quarterly on each shift, but were not conducted at random times per shift, per quarter.


Interview, on 10/23/12 at 10:28 AM, with the Director of Engineering revealed he was not aware the fire drills were not being conducted as required.

Interview, on 10/24/12 at 6:00 PM, with the Director of Quality and Risk Management revealed she was not aware the fire drills were not being conducted in accordance with NFPA standards. Further interview revealed the facility did not provide Life Safety Code training for staff.



Reference: NFPA Standard NFPA 101 19.7.1.2.
Fire drills shall be conducted at least quarterly on each shift and at unexpected times under varied conditions on all shifts.

Reference: NFPA 101 Life Safety Code (2000 Edition).
18.7.1.2*
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.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.

Based on observation and interview it was determined the facility failed to ensure the building had a complete sprinkler system, in accordance with NFPA Standards. The deficiency had the potential to affect two (2) of eight (8) smoke compartments, residents, staff and visitors. The facility has seventy five (75) certified beds with a census of nineteen (19) on the day of the survey.


The findings include:


Observation, on 10/23/12 between 9:30 AM and 4:30 PM, with the Director of Engineering revealed a sprinkler head located in the Business Office Closet was installed against a light fixture that was mounted below the deflector of the sprinkler head and would obstruct the spray pattern from fully developing. Further observation revealed two (2) tall windows that extended above the ceiling with a box built around the window without sprinkler protection below the ceiling that was installed at the top of the box. One (1) window was located in the OB Directors Office, and the second window was located in room #1081 next to the OB Directors Office.

Interview, on 10/23/12 between 9:30 AM and 4:30 PM, with the Director of Engineering revealed he was aware the boxes had been built to preserve the windows, but not aware they did not have sprinkler protection.


Interview, on 10/24/12 at 6:24 PM, with the Director of Quality and Risk Management revealed she was not aware of the missing sprinkler heads or the sprinkler was installed next to a light fixture. Further interview revealed she relied on the Department Directors to identify problems within their department and report them to the monthly Quality Meeting.




Reference: NFPA 13 (1999 Edition) 5-13 8.1

Actual NFPA Standard: NFPA 101, Table 19.1.6.2 and 19.3.5.1. Existing healthcare facilities with construction Type V (111) require complete sprinkler coverage for all parts of a facility.
Actual NFPA Standard: NFPA 101, 19.3.5.1. Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
Actual NFPA Standard: NFPA 101, 9.7.1.1. Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.
Actual NFPA Standard: NFPA 13, 5-1.1. The requirements for spacing, location, and position of sprinklers shall be based on the following principles:
(1) Sprinklers installed throughout the premises
(2) Sprinklers located so as not to exceed maximum protection area per sprinkler
(3) Sprinklers positioned and located so as to provide satisfactory performance with respect to activation time and distribution.


Reference: NFPA 13 (1999 ed.)
5-5.5.2.2 Sprinklers shall be positioned in accordance with
the minimum distances and special exceptions of Sections 5-6
through 5-11 so that they are located sufficiently away from
obstructions such as truss webs and chords, pipes, columns,
and fixtures.
Table 5-6.5.1.2 Positioning of Sprinklers to Avoid Obstructions to Discharge (SSU/SSP)

Maximum Allowable Distance
Distance from Sprinklers to of Deflector above Bottom of
Side of Obstruction (A) Obstruction (in.) (B
Less than 1 ft 0
1 ft to less than 1 ft 6 in. 21/2
1 ft 6 in. to less than 2 ft 31/2
2 ft to less than 2 ft 6 in. 51/2
2 ft 6 in. to less than 3 ft 71/2
3 ft to less than 3 ft 6 in. 91/2
3 ft 6 in. to less than 4 ft 12
4 ft to less than 4 ft 6 in. 14
4 ft 6 in. to less than 5 ft 161/2
5 ft and greater 18

For SI units, 1 in. = 25.4 mm; 1 ft = 0.3048 m.
Note: For (A) and (B), refer to Figure 5-6.5.1.2(a).
Reference: NFPA 13 (1999 ed.)
5-6.3.3 Minimum Distance from Walls. Sprinklers shall be located a minimum of 4 in. (102 mm) from a wall.

Based on observation and interview, it was determined the facility failed to ensure cooking facilities were protected in accordance with NFPA standards. The deficiency had the potential to affect one (1) of eight (8) smoke compartments, and kitchen staff. The facility has seventy five (75) certified beds with a census of nineteen (19) on the day of the survey.

The findings include:

Observation, on 10/23/12 between 9:30 AM and 4:30 PM, with the Director of Engineering revealed the exhaust fan for the appliance hood was turned off while a natural gas fired convection oven was in use. The gas fumes could not vent to the outside as required. The convection oven was the only appliance in use at the time of observation. Further observation revealed the manual pull station for the hood fire suppression system was not located in the path of egress but instead on a wall used to store carts.

Interview on 10/23/12 between 9:30 AM and 4:30 PM, with the Director of Engineering and Kitchen staff revealed the oven was left on between meals to keep warm and the hood was always turned off during this time. The Director of Engineering was not aware the hood was off while the equipment was in use.

Interview, on 10/24/12 at 6:22 PM, with the Director of Quality and Risk Management revealed she was not aware the hood was being turned off while cooking equipment was in use. Further interview revealed she was not aware the pull station for the hood fire suppression system was required to be located in the path of egress.

Reference: NFPA 96 (1998 edition)
7-5.1 A readily accessible means for manual activation shall be located between 42 in. and 60 in. (1067 mm and 1524 mm) above the floor, located in a path of exit or egress, and clearly identify the hazard protected. The automatic and manual means of system activation external to the control head or releasing device shall be separate and independent of each other so that failure of one will not impair the operation of the other.
Exception No. 1: The manual means of system activation shall be permitted to be common with the automatic means if the manual activation device is located between the control head or releasing device and the first fusible link.
Exception No. 2: An automatic sprinkler system.

Based on observation and interview it was determined the facility failed to ensure portable space heaters used in the facility were in accordance with NFPA standards. The deficiency had the potential to affect five (5) of eight (8) smoke compartments, residents, staff and visitors. The facility has seventy five (75) certified beds with a census of nineteen (19) on the day of the survey.

The findings include:

Observation, on 10/23/12 between 9:30 AM and 4:30 PM, with the Director of Engineering revealed portable space heaters located in the following locations:

1) Two (2) located in the Business Office.
2) Two (2) located in the HR Directors Office.
3) Admissions Desk
4) Marketing Directors Office
5) Insurance Verification Office
6) Risk Management Office
7) Medical Records Office
8) HIM Office
9) Controller Office
10) Chief Financial Officer Office
11) Chief Nursing Office
12) Director of Emergency Office
13) Outpatient Registration

Interview, on 10/23/12 between 9:30 AM and 4:30 PM, with the Director of Engineering revealed he was aware the heaters could not exceed 212°F in non-sleeping, staff, and employee areas. However, he thought that the code was referring to the housing of the heater and not the element. Further interview revealed the facility did have a policy on the use of portable heaters and they were to be unplugged at night.

Interview, on 10/24/12 at 6:24 PM, with the Director of Quality and Risk Management revealed she was not aware the temperature of the heating element could not exceed 212F degrees, but thought it was the housing of the heater that could not exceed 212F degrees.


Reference: NFPA 101 (2000 edition)
19.7.8 Portable Space-Heating Devices. Portable space-heating
devices shall be prohibited in all health care occupancies.
Exception: Portable space-heating devices shall be permitted to be used
in non-sleeping staff and employee areas where the heating elements of
such devices do not exceed 212°F (100°C).

Based on observation and interview, it was determined the facility failed to maintain exit access in accordance with NFPA standards. The deficiency had the potential to affect four (4) of eight (8) smoke compartments, residents, staff and visitors. The facility has seventy five (75) beds with a census of nineteen (19) on the day of the survey.

The findings include:

Observation, on 10/23/12 between 9:30 AM and 4:30 PM, with the Director of Engineering revealed trash carts, computers on wheels, med carts, soiled linen carts, and biohazard carts stored in the corridors on the second floor, and by the Kitchen. Further observation on the second floor revealed a hand wipe warmer being stored and plugged into the wall in the corridor. Also, on the second floor were charting boxes mounted on the wall that would not close completely and extended off the wall greater than four (4) inches. Further observation revealed the storage of computer on wheels charging, soiled linen carts, metal carts, biohazard carts, forms and copy paper holder cabinet, and wheel chairs located in the ER egress path.

Interview, on 10/23/12 between 9:30 AM and 4:30 PM, with the Director of Engineering revealed he was aware of the requirement for storage in the corridor. However, other surveyors or inspectors had informed them they could store items as long as they were on one side of the corridor.

Interview, on 10/24/12 at 6:30 PM, with the Director of Engineering revealed she was aware of the requirement but depended on the Department Directors to monitor their areas.

Reference: NFPA 101 (2000 Edition)
Means of Egress Reliability 7.1.10.1
Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Based on observation and interview, it was determined the facility failed to ensure trash collection receptacles with capacities greater than 32 gallon were stored in accordance with NFPA standards. The deficiency had the potential to affect one (1) of eight (8) smoke compartments, residents, staff and visitors. The facility has seventy five (75) certified beds with a census of nineteen (19) on the day of the survey.

The findings include:

Observation, on 10/23/12 at 1:38 PM, with the Director of Engineering revealed an unattended trash cart in the corridor outside the Kitchen. The trash cart exceeded 32 gallons and was full of trash.

Interview, on 10/23/12 at 1:38 PM, with the Director of Engineering revealed he was unaware the Housekeeping Staff would leave the trash cart in the corridor unattended.

Interview, on 10/24/12 at 6:18 PM, with the Director of Quality and Risk Management revealed she was aware trash receptacles that exceed 32 gallon must be kept in a room that was rated for hazards. She was not aware the Housekeeping staff would leave the trash cart in the corridor outside the Kitchen. Further interview revealed the facility did not provide Life Safety Code training for staff.


19.7.5.5
Soiled linen or trash collection receptacles shall not exceed 32 gal (121 L) in capacity. The average density of container capacity in a room or space shall not exceed 0.5 gal/ft2 (20.4 L/m2). A capacity of 32 gal (121 L) shall not be exceeded within any 64-ft2 (5.9-m2) area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) shall be located in a room protected as a hazardous area when not attended.
Exception: Container size and density shall not be limited in hazardous areas.

Based on observation and interview, it was determined the facility failed to ensure electrical wiring was maintained in accordance with NFPA standards. The deficiency had the potential to affect five (5) of eight (8) smoke compartments, residents, staff, and visitors. The facility has seventy five (75) certified beds with a census of nineteen (19) on the day of the survey.

The findings include:

Observations, on 10/23/12 between 11:00 AM and 4:30 PM, with the Director of Engineering revealed:

1) An open electrical junction box located above the ceiling by the fire door next to the Engineering Office.
2) An open electrical junction box located above the ceiling at doors #1033, #1035, and door to Out Patient Surgery.
3) A power strip was plugged into another power strip located in the IS Director's Office.
4) A microwave was plugged into an extension cord located in the ER Lounge.
5) A crock pot, toaster, and a tea maker were plugged into an extension cord in the ER Lounge.
6) A toaster and coffee maker were plugged into a power strip located in Radiology.
7) Two (2) refrigerators were plugged into a power strip located in the Women's Center Clean Utility.
8) An open electrical junction box located in the electrical room in the Women's Center.
9) A refrigerator was plugged into a power strip located in the Cardiac Rehabilitation Room.

Interview, on 10/23/12 between 11:00 AM and 4:30 PM, with the Director of Engineering revealed he was not aware of the open electrical junction boxes above the ceiling. Further interview revealed he was aware of the proper use of power strips and extension cords, but not aware they had been installed and misused.


Observations, on 10/24/12 between 9:30 AM and 10:30 AM, with the Director of Engineering revealed:

1) Medical equipment was plugged into a power strip located in the FCU storage room on the 2nd Floor.
2) Medical equipment was plugged into a power strip that was plugged into a power strip that was plugged into a 3rd power strip located in the Doctor Dictation Room on the 2nd Floor.
3) Medical equipment was plugged into a power strip located in the Clean Utility Room on the 2nd Floor.
4) A refrigerator and a coffee maker were plugged into a power strip located in the Case Management Office.


Interview, on 10/24/12 between 9:30 AM and 10:30 AM, with the Director of Engineering revealed he was not aware medical equipment could not be plugged into a power strip.

Interview, on 10/24/12 at 6:10 PM, with the Director of Quality and Risk Management revealed she was aware of the proper use of power strips and extension cords, but was not aware they were installed and being misused. She also stated that she relied on Department Directors to report any concerns at the monthly Quality Meetings. Further interview revealed the facility did not provide Life Safety Code training for staff.




Reference: NFPA 70 400-8
( Extensions Cords) Uses Not Permitted.
Unless specifically permitted in 400.7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces


Reference: NFPA 99 (1999 edition)

3-3.2.1.2 D

Minimum Number of Receptacles. The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.


Reference: NFPA 70 (1999 edition)

370.28(c) Covers.

All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Section 250-110. An extension from the cover of an exposed box shall comply with Section 370-22, Exception.