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Based on observation, document review and interview, the facility failed to meet the requirements of the National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition for construction type and supporting construction for health care and/or other building occupancies. A 2-hour separation was not provided in accordance with section 8.2.1.3 in 2 of 3 fire walls inspected.

Finding include:

Observation(S), Interview(S), and review of construction documents during a facility tour on 11/13/19 between 8 am and 1:30 PM with the Director of Facilities Management, Director of Fire and Employee Safety and Environmental Health/Safety Officer the following was found:

1. The two-hour fire Barrier wall that separates East wing and West Wing, has penetrations above ceiling near door # ewi-fdr-001 had a 4" hole (approximately) with data cables penetrating the rated assembly and also located in the west wing above door # ww1-fdr-002 was penetrated by 6" hole (approximately) with 4 pieces of electrical conduit that was not protected by a fire-stop system or device in accordance with NFPA 221 (2012 edition), Standard for High Challenge Fire, section 4.9.2 Fire-stop Systems and Devices Required - Penetrations for cables, cable trays, conduit, pipes, tubes, combustible vents and exhaust vents, wires and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a fire stop system or device. This deficient practice could affect the west and business wings of the facility, patients, visitors, and members of facility staff in this location(S).



This finding was verified by the Director of Facilities Management, Director of Fire and Employee Safety and Environmental Health/Safety Officer at the time of observations and document review on 11/13/19.

Based on observation and interview, the facility failed to ensure that aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with NFPA 101, Life Safety Code, 2012 edition, Chapter 7, and that the means of egress is continuously maintained free of all obstructions to full use in case of emergency unless modified by NFPA 101, Life Safety Code, 2012 edition, sections 18/19.2.2 through 18/19.2.11, 18.2.1, 19.2.1, and 7.1.10.1.

Finding:

Observation(S) and Interview(S) during a facility tour on 11/13/19 from 8:00 am to 1:30 PM identified:

1) Soiled linen carts were being stored in ER entrance corridor located in the west wing.


These findings were verified by the Director of Facilities Management, Director of Fire and Employee Safety and Environmental Health/Safety Officer at the time of observations and interview.

Based on observation and interview the facility failed to ensure that doors in a required means of egress met the latching/locking requirements of NFPA 101, Life Safety Code (2012 edition). This failure occurred at one of three smoke compartments in the facility.

Finding:

Observation(S) on 11/13/19 between the hours of 8:00 am-1:30 PM during a tour of facility the surveyor accompanied by the Director of Facilities Management, Director of Fire and Employee Safety and Environmental Health/Safety Officer identified the following:

1. Approved, listed delayed locking systems are installed in a required means of egress located in East wing near room #8/9. Upon inspection the door failed to meet the requirements of NFPA 101, Life Safety Code (2012 Edition), 7.2.1.6.1. The delayed egress door requires a sign on the door, must meet the requirement of 1" minimum brush stroke size, and must indicate door would release in 15 seconds from time of activation.. This deficient practice could affect the residents and visitors that occupied the east wing of the facility.

These findings were verified by the Director of Facilities Management, Director of Fire and Employee Safety and Environmental Health/Safety Officer at the time of observations and interview.

Based on observation and interview, the facility failed to ensure that hazardous areas were safeguarded in accordance with NFPA 101, Life Safety Code, section 19.3.2.1 in two hazardous areas of seventeen hazardous areas inspected in the facility at the basement location and ground floor location. This deficient practice has the potential of allowing the passage of smoke and/or fire from the hazardous area(S) into adjacent areas.

Findings Include:

Observation(S) and Interview(S) during a facility tour) with the Director of Facilities Management, Director of Fire and Employee Safety and Environmental Health/Safety Officer on 11/13/2019 from 8:00 am to 1:30 PM:

1) The West wing boiler room did have an approved automatic fire extinguishing system and shall be separated from other spaces by smoke partitions in accordance with NFPA 101, Life Safety Code, 2012 edition, section 8.4 - Smoke Partitions:

a) Wall/ceiling areas were penetrated by pipes, wires and holes that were not protected by a fire-stop system in accordance with NFPA 101, Life Safety Code, 2012 edition, section 8.5.6 Penetrations and has the potential of allowing the passage of smoke and/or fire into adjacent areas.

2) The East wing boiler room did have an approved automatic fire extinguishing system and shall be separated from other spaces by smoke partitions in accordance with NFPA 101, Life Safety Code, 2012 edition, section 8.4 - Smoke Partitions:

a) The door was not self closing. This did not meet the requirements of NFPA 101, Life Safety Code, 2012 edition, section 19.3.2.1.3 and has the potential of allowing the passage of smoke and/or fire into adjacent areas.

b) Walls were penetrated by pipes that was not protected by a fire-stop system in accordance with NFPA 101, Life Safety Code, 2012 edition, section 8.5.6 Penetrations and has the potential of allowing the passage of smoke and/or fire into adjacent areas.

These findings were verified by the Director of Facilities Management, Director of Fire and Employee Safety and Environmental Health/Safety Officer at the time of observations and document review on 11/13/19. .




39983

Based on observation and interview, the facility failed to ensure that interior finish in 2 of 3 smoke compartments was in accordance with the Life Safety Code 2012 edition sections 10.2 and 19.3.3.2. This deficient practice could affect the area near the east wing corridor, patients/residents, visitors, and members of facility staff in this location(S).

Findings:

Observations and Interview during the facility Survey tour on 11/13/19 from 8:00 am to 1:30 PM identified:

1. The area/room outside of the east wing boiler room had wood paneling on the walls and no documentation could be provided to indicate it meets the requirements for interior finish in a healthcare occupancy.

2. Oil tank and Generator rooms located in rooms attached to the building on the west wing of the facility had exposed foam board insulation with no thermal barrier. No documentation could be provided to indicate it meets the requirements for interior finish in a healthcare occupancy.


These findings were verified by the Director of Facilities Management, Director of Fire and Employee Safety and Environmental Health/Safety Officer at the time of observations and document review on 11/13/19.

Based on observations and interview, the facility failed to ensure that Sprinkler System was inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. This deficient practice could affect the entire facility, patients/residents, visitors, and members of facility staff in this location(S).

Findings:

Document Review and Interview(S) during a facility tour on 11/13/19 from 1:00 PM to 4:30 PM identified:

1. Sprinkler escutcheon plates/rings were missing in the following locations: east corridor between rooms 8/9, Social worker office, east wing clean utility room, and occupational therapy room in rehab wing/hall, leaving unprotected penetrations (gaps) that have the potential of allowing passage of fire and/or smoke beyond this barrier.
These penetrations were not protected in accordance with NFPA 101, Life Safety Code, 2012 edition, section 8.5.6.

2. One sprinkler head located in the laundry room was painted. This could affect the operation of the sprinkler head. This deficiency does not meet the minimum requirements of maintaining a sprinkler system in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-based Fire Protection Systems, 2011 edition, Chapter 5, section 5.2.1.1.1

These findings were verified by the Director of Facilities Management, Director of Fire and Employee Safety and Environmental Health/Safety Officer at the time of observations and document review on 11/13/19.

Based on observation and interview, the facility failed to ensure that doors in 2 of 4 smoke compartments were protecting corridor openings in accordance with NFPA 101, Life Safety Code, section 19.3.6.3 - Corridor Doors.

Findings:

Observation, documentation review and Interview(S) during a facility tour) on 11/13/19 from 8:00 am to 1:30 PM identified:

1. Patient room # 10 located in the east wing, had a gap between the door and frame that exceeded ½" inch. This is not in accordance with CMS S&C-07-18. In a smoke compartment that is fully sprinkler, a gap between the face of a corridor door and the door stop should not exceed ½-inch, provided that the door latch mechanism is functioning. This deficient practice could affect the residents, visitors and staff located in these smoke compartment of the facility.

2. Patient room door # 6 located in the west wing would not latch upon closure of the door, which could not prevent the passage of smoke/fire.

3. Soiled and Clean Utility doors located in the west wing did not have latching devices on the doors and no documentation was provided to indicate that the closing devices on the doors would keep them closed if 5 lbf was applied on the leading edge of the door (section 19.3.6.3.5)



These findings were verified by the Director of Facilities Management, Director of Fire and Employee Safety and Environmental Health/Safety Officer at the time of observations and interview on 11/13/19.

Based on document review, observation and interview, the facility failed to inspect and test fire door assemblies in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protection. This affected 1 of 3 smoke compartments.

Findings:

Review of documentation and interview with the Director of Facilities Management, Director of Fire and Employee Safety and Environmental Health/Safety Officer on 11/13/19 identified the following deficiencies:

1. 13 of 15 fire door(S)(approximately) located on in the east wing did not have a record of annual inspection for calendar year 2018/2019 in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protection, 2010 edition, 5.2.1. Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ. This deficient practice could affect the east wing of the facility, patients, visitors, and members of facility staff in this location(S).

1.1 The facility had a procedure for decommissioning doors that were not required to be fire rated and this procedure was reviewed and approved by this office, however the doors that were cited had not been decommissioned and were required to be inspected until such time the approved process for decommissioning was completed.

These findings were verified by the Director of Facilities Management, Director of Fire and Employee Safety and Environmental Health/Safety Officer at the time of observations and document review on 11/13/19.

Based on document review and interview with the Director of Facilities on 11-13-19, the Medical Gas testing and evaluation testing completed May 8, 2019, by W.G. Frank Medical Gas Testing & Consulting, LLC. Indicated that the facility failed to meet the requirements of NFPA 2012 health care Facilities Code 99 Chapter 5.

Findings:

Review of the Medical Gas Report this surveyor found 18 deficiencies listed in the summary of compliance deficiencies.; (i.e.) to include area alarms, zone vales, WAGD inlet not installed, master alarm source valve, final line gauge,central supply systems door labeled, vacuum pump exhaust.

1. 2 out of 18 deficiencies include, No Area alarms in Emergency Department or Procedure.

2. Zone Valves missing in 7 out of 18 areas.
a. Emergency Department
b. Procedure.
c. Acute Care.

3. WAGD inlet not installed, 1 of of 18 area.
a. Procedure Room.

4. Master Alarms and Source- Oxygen Manifold.
a. No Master Alarm to monitor operation or condition.
b. No Source Valve installed- required to isolate central supply from facility.
c. No Final Line Gauge.
d. No automatic means to alternate between headers.
e. Central Supply door not labeled.
f. No pressure relief valve piping.
g. Braided oxygen lines required to be replaced with compliant material.


5. Vacuum Pump,
a. Vacuum exhaust air intake located less than 25 feet from door, window, air intake, or other openings in the facility.


All deficiencies were confirmed with the Director of facilities during record review.

Based on document review and interview, the facility failed to ensure that power strips were use in accordance with 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5 . This deficient practice could affect the entire facility, patients/residents, visitors, and members of facility staff in this location(S).

Findings:

Observation and Interview during a facility tour on 11/13/19 from 1:00 PM to 4:30 PM identified:

1. Staff break room located in the east wing, was using a multi outlet power strip to power appliance (microwave/toaster) and no documentation could be provided to indicate if the if the appliances exceeded the capacity of the multi outlet device and/or if the manufactures of the appliances allow this practice.

2. On the West wing corridor near the nursing station there was a multi outlet power strip plugged into a hospital grade multi outlet device that was attached to the wall. The multi outlet power strip did not have any markings to indicate that it was approved for healthcare, no documentation could be provided and the Director of Fire and Employee Safety agreed it was not likely a approved device. The power strip was being used to power a battery charging device and wheeled blood pressure stands.



These findings were verified by the Director of Facilities Management, Director of Fire and Employee Safety and Environmental Health/Safety Officer at the time of observations and document review on 11/13/19.