HospitalInspections.org

Based on observation and staff interview, the facility failed to ensure the fire barrier was continuous from floor to ceiling. The findings were:

Observation of the fire barrier on 3/12/13 at 8:15 AM showed two unsealed cable penetrations. The largest gap measured 2 inches across. At the time of observation the plant operations superintendent could not explain why the holes were not filled after the new computer cables were installed.

Based on observation and staff interview, the facility failed to ensure the smoke barrier wall was smoke resistant. The findings were:

Observation of the smoke barrier wall above the central double doors on 3/11/13 at 6:52 PM showed two unsealed conduit penetrations. The largest gap measured ? inch across. At the time of observation the plant operations superintendent could not explain why the holes had not been noticed and filled during the quarterly safety inspections.

Based on observation and staff interview, the facility failed to ensure hazardous areas were separated from use areas in 1 of 3 smoke compartments. The findings were:

Observation of the oxygen manifold room on 3/11/13 at 5:09 PM showed one of the double doors was unable to be fully latched into the door frame with the force from the self-closing device, with three attempts. At the time of the observation maintenance technician #1 could not explain why the closure force had not been noticed and modified during the weekly safety inspection.

Based on observation, record review, and staff interview, the facility failed to ensure sprinkler heads were unobstructed in 2 of 3 smoke compartments and failed to ensure 2 of 7 sprinkler system tests were performed. The findings were:

1. Observation of the gift shop storeroom on 3/11/13 at 4:52 PM showed a cardboard box was stored closer than 18 inches below the sprinkler deflector. The box was 10 inches from the deflector. At the time of the observation maintenance technician #1 was unable to explain why the box had not been noticed and removed during the quarterly safety inspections.

2. Observation of the north nurses storeroom on 3/11/13 at 5:32 PM showed a piece of sheetrock had been secured to the ceiling less than one inch from the sprinkler head. Further observation showed the bottom of the sprinkler deflector was not 1 inch below the sheetrock. The sprinkler deflector was level with the bottom of the sheetrock. At the time of the observation the plant operations superintendent reported the sheetrock was installed to cover a hole after a water pipe burst. He could not explain why the sheetrock was not modified to ensure the sprinkler head was not obstructed.

3. Observation of the OR recovery office on 3/11/13 at 6:21 PM showed one of three sprinkler head was flush with the ceiling sheetrock. At the time of the observation the plant operations superintendent could not explain why the sprinkler head had not been noticed and lowered to 1 inch or more from the ceiling during the annual sprinkler system inspection.

4. Review of the sprinkler system testing records showed the facility did not have record of the last time a full discharge fire pump test had been performed. Further review showed a fire pump churn test without flow was being performed on a monthly basis, not weekly. On 3/12/13 at 8:05 AM the plant operations superintendent reported he was unaware of the annual fire pump discharge test. He also reported that he was unaware the churn test without flow was required on a weekly basis.

Reference NFPA 101, 2000 Edition 19.3.5.1, 9.7.1.1, NFPA 13, 1999 Edition;
5-5.6 Clearance to storage. The clearance between the deflector and the top of storage shall be 18 in. or greater.
5-6.4.1.1 Under unobstructed construction, the distance between the sprinkler deflector and the ceiling shall be a minimum of 1 in. and a maximum of 12 in.
Reference NFPA 101, 2000 Edition 19.3.5.1, 9.7.5, NFPA 25, 1998 Edition;
2-2.1.1* Sprinklers shall be visually inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged or loaded, or in the improper orientation.
5-3.2.1 A weekly test of electric motor-driven pump assemblies shall be conducted without flowing water. This test shall be conducted by starting the pump automatically. The pump shall run a minimum of 10 minutes.
Exception: A valve installed to open as a safety feature shall be permitted to discharge water.
5-3.3 Annual Tests.
5-3.3.1 An annual test of each pump assembly shall be conducted under minimum, rated, and peak flows of the fire pump by controlling the quantity of water discharge through approved test devices. This test shall be conducted as described in 5-3.3.1 (a), (b), or (c).
Exception: If available suction supplies do not allow flowing of 150 percent of the rated pump capacity, the fire pump shall be operated at maximum allowable discharge. The reduced capacity shall not constitute a noncompliant test.

Based on observation and staff interview, the facility failed to ensure portable fire extinguishers were maintained in 1 of 3 smoke compartments. The findings were:

Observation of the lab on 3/11/13 at 6:07 PM showed the installed fire extinguisher did not have a record of the last annual inspection. At the time of the observation the plant operations superintendent reported he was unaware a fire extinguisher was located in the lab.

Reference NFPA 101, 2000 Edition, 19.3.5.6, 9.7.4.1, NFPA 10, 1998 Edition;
4-3 Inspection.
4-3.1 Frequency. Extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals ....
4-4 Maintenance.
4-4.1 Frequency. Fire Extinguishers shall be subjected to maintenance at intervals of not more than 1 year, and the time of hydrostatic test, of when the specifically indicated by an inspection.

Based on observation and staff interview, the facility failed to ensure oxygen cylinders were restrained in the manifold storeroom. The findings were:

Observation of the oxygen manifold room on 3/11/13 at 5:06 PM showed 15 "H" sized oxygen cylinders were not restrained or fastened. Further observation showed the area was equipped with a chain for a restraint, which was lying on the ground. At the time of the observation the plant operations superintendent could not explain why the chain was not re-attached after the cylinders were adjusted.

Reference NFPA 101, 2000 Edition, 19.3.2.4, NFPA 99, 1999 Edition;
4-3 Level 1 Piped Systems.
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 fastening to protect cylinders from accidental damage or dislocation.

Based on record review, observation, and staff interview, the facility failed to ensure facility entrance doors were posted with No Smoking signs on 1 of 4 exits. The findings were:

Review of the facility smoking policy showed the campus was non-smoking and No Smoking signs would be posted at all major entrances and oxygen storage locations. Observation of the main hospital entrance on 3/11/13 at 4:46 PM showed it was not posted with a No Smoking sign. At the time of the observation the plant operations superintendent could not explain why the entrance door was not posted with a No Smoking sign.

Reference NFPA 101, 2000 Edition;
19.7.4* Smoking. Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
Exception: In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.

Based on observation and staff interview, the facility failed to ensure electrical receptacles in wet locations were provided with ground fault circuit interruption (GFCI) protection in 1 of 3 smoke compartments. The findings were:

Observation of the nurses lounge on 3/11/13 at 5:46 PM showed an electrical outlet was located 26 inches from the sink. Further observation showed the outlet was not provided with GFCI protection. At the time of the observation the plant operations superintendent could not explain why the outlet had not been noticed and replaced with a GFCI outlet during the semi-annual electrical inspections.

Reference NFPA 101, 2000 Edition, 19.5.1, 9.1.2, NFPA 70, 1999 Edition;
517-20. Wet Locations.
(a) All receptacles and fixed equipment within the area of the wet location shall have ground-fault circuit-interrupter protection for personnel if interruption or power under fault conditions can be tolerated, or be served by an isolated power system if such interruption cannot be tolerated.

Based on observation and staff interview, the facility failed to ensure the fire barrier was continuous from floor to ceiling. The findings were:

Observation of the fire barrier on 3/12/13 at 8:15 AM showed two unsealed cable penetrations. The largest gap measured 2 inches across. At the time of observation the plant operations superintendent could not explain why the holes were not filled after the new computer cables were installed.

Based on observation and staff interview, the facility failed to ensure the smoke barrier wall was smoke resistant. The findings were:

Observation of the smoke barrier wall above the central double doors on 3/11/13 at 6:52 PM showed two unsealed conduit penetrations. The largest gap measured ? inch across. At the time of observation the plant operations superintendent could not explain why the holes had not been noticed and filled during the quarterly safety inspections.

Based on observation and staff interview, the facility failed to ensure hazardous areas were separated from use areas in 1 of 3 smoke compartments. The findings were:

Observation of the oxygen manifold room on 3/11/13 at 5:09 PM showed one of the double doors was unable to be fully latched into the door frame with the force from the self-closing device, with three attempts. At the time of the observation maintenance technician #1 could not explain why the closure force had not been noticed and modified during the weekly safety inspection.

Based on observation, record review, and staff interview, the facility failed to ensure sprinkler heads were unobstructed in 2 of 3 smoke compartments and failed to ensure 2 of 7 sprinkler system tests were performed. The findings were:

1. Observation of the gift shop storeroom on 3/11/13 at 4:52 PM showed a cardboard box was stored closer than 18 inches below the sprinkler deflector. The box was 10 inches from the deflector. At the time of the observation maintenance technician #1 was unable to explain why the box had not been noticed and removed during the quarterly safety inspections.

2. Observation of the north nurses storeroom on 3/11/13 at 5:32 PM showed a piece of sheetrock had been secured to the ceiling less than one inch from the sprinkler head. Further observation showed the bottom of the sprinkler deflector was not 1 inch below the sheetrock. The sprinkler deflector was level with the bottom of the sheetrock. At the time of the observation the plant operations superintendent reported the sheetrock was installed to cover a hole after a water pipe burst. He could not explain why the sheetrock was not modified to ensure the sprinkler head was not obstructed.

3. Observation of the OR recovery office on 3/11/13 at 6:21 PM showed one of three sprinkler head was flush with the ceiling sheetrock. At the time of the observation the plant operations superintendent could not explain why the sprinkler head had not been noticed and lowered to 1 inch or more from the ceiling during the annual sprinkler system inspection.

4. Review of the sprinkler system testing records showed the facility did not have record of the last time a full discharge fire pump test had been performed. Further review showed a fire pump churn test without flow was being performed on a monthly basis, not weekly. On 3/12/13 at 8:05 AM the plant operations superintendent reported he was unaware of the annual fire pump discharge test. He also reported that he was unaware the churn test without flow was required on a weekly basis.

Reference NFPA 101, 2000 Edition 19.3.5.1, 9.7.1.1, NFPA 13, 1999 Edition;
5-5.6 Clearance to storage. The clearance between the deflector and the top of storage shall be 18 in. or greater.
5-6.4.1.1 Under unobstructed construction, the distance between the sprinkler deflector and the ceiling shall be a minimum of 1 in. and a maximum of 12 in.
Reference NFPA 101, 2000 Edition 19.3.5.1, 9.7.5, NFPA 25, 1998 Edition;
2-2.1.1* Sprinklers shall be visually inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged or loaded, or in the improper orientation.
5-3.2.1 A weekly test of electric motor-driven pump assemblies shall be conducted without flowing water. This test shall be conducted by starting the pump automatically. The pump shall run a minimum of 10 minutes.
Exception: A valve installed to open as a safety feature shall be permitted to discharge water.
5-3.3 Annual Tests.
5-3.3.1 An annual test of each pump assembly shall be conducted under minimum, rated, and peak flows of the fire pump by controlling the quantity of water discharge through approved test devices. This test shall be conducted as described in 5-3.3.1 (a), (b), or (c).
Exception: If available suction supplies do not allow flowing of 150 percent of the rated pump capacity, the fire pump shall be operated at maximum allowable discharge. The reduced capacity shall not constitute a noncompliant test.

Based on observation and staff interview, the facility failed to ensure portable fire extinguishers were maintained in 1 of 3 smoke compartments. The findings were:

Observation of the lab on 3/11/13 at 6:07 PM showed the installed fire extinguisher did not have a record of the last annual inspection. At the time of the observation the plant operations superintendent reported he was unaware a fire extinguisher was located in the lab.

Reference NFPA 101, 2000 Edition, 19.3.5.6, 9.7.4.1, NFPA 10, 1998 Edition;
4-3 Inspection.
4-3.1 Frequency. Extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals ....
4-4 Maintenance.
4-4.1 Frequency. Fire Extinguishers shall be subjected to maintenance at intervals of not more than 1 year, and the time of hydrostatic test, of when the specifically indicated by an inspection.

Based on observation and staff interview, the facility failed to ensure oxygen cylinders were restrained in the manifold storeroom. The findings were:

Observation of the oxygen manifold room on 3/11/13 at 5:06 PM showed 15 "H" sized oxygen cylinders were not restrained or fastened. Further observation showed the area was equipped with a chain for a restraint, which was lying on the ground. At the time of the observation the plant operations superintendent could not explain why the chain was not re-attached after the cylinders were adjusted.

Reference NFPA 101, 2000 Edition, 19.3.2.4, NFPA 99, 1999 Edition;
4-3 Level 1 Piped Systems.
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 fastening to protect cylinders from accidental damage or dislocation.

Based on record review, observation, and staff interview, the facility failed to ensure facility entrance doors were posted with No Smoking signs on 1 of 4 exits. The findings were:

Review of the facility smoking policy showed the campus was non-smoking and No Smoking signs would be posted at all major entrances and oxygen storage locations. Observation of the main hospital entrance on 3/11/13 at 4:46 PM showed it was not posted with a No Smoking sign. At the time of the observation the plant operations superintendent could not explain why the entrance door was not posted with a No Smoking sign.

Reference NFPA 101, 2000 Edition;
19.7.4* Smoking. Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
Exception: In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.

Based on observation and staff interview, the facility failed to ensure electrical receptacles in wet locations were provided with ground fault circuit interruption (GFCI) protection in 1 of 3 smoke compartments. The findings were:

Observation of the nurses lounge on 3/11/13 at 5:46 PM showed an electrical outlet was located 26 inches from the sink. Further observation showed the outlet was not provided with GFCI protection. At the time of the observation the plant operations superintendent could not explain why the outlet had not been noticed and replaced with a GFCI outlet during the semi-annual electrical inspections.

Reference NFPA 101, 2000 Edition, 19.5.1, 9.1.2, NFPA 70, 1999 Edition;
517-20. Wet Locations.
(a) All receptacles and fixed equipment within the area of the wet location shall have ground-fault circuit-interrupter protection for personnel if interruption or power under fault conditions can be tolerated, or be served by an isolated power system if such interruption cannot be tolerated.