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Based on observation, and interview, the facility failed to ensure hazardous areas of the building were protected in accordance with NFPA 101. Failure to ensure un-sprinklered hazardous areas are contained by a one-hour fire barrier has the potential to affect the means of egress and transfer of fires beyond the compartment of origin. This deficient practice affected patients utilizing the blood draw room and staff on the dates of the survey.

Findings include:

During the facility tour on May 16, 2019, from approximately 10:00 AM to 2:30 PM, observation of the laboratory on the main level revealed it was not sprinklered and had an approximately 36-inch opening between the laboratory and the blood draw room which was not protected by a 1-hour fire rated barrier. When asked, the Maintenance Supervisor stated the facility was not aware a 1-hour fire resistant fire barrier was required at the opening between the laboratory and the blood draw room.

Actual NFPA standard:

NFPA 101
19.3.2.1 Hazardous Areas.
Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating
or shall be provided with an automatic extinguishing system in accordance with 8.7.1.
19.3.2.1.3 The doors shall be self-closing or automatic-closing.
19.3.2.1.5 Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Rooms with soiled linen in volume exceeding 64 gal (242 L)
(6) Rooms with collected trash in volume exceeding 64 gal (242 L)
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by

Based on record review, observation and interview, the facility failed to ensure Alcohol Based Hand Rub Dispensers (ABHR) were maintained in accordance with NFPA 101. Failure to test and document the operation of ABHR dispensers in accordance with the manufacturer's care and use instructions each time a new refill is installed could result in inadvertently spilling flammable liquids, increasing the risk of fires. This deficient practice affected 11 patients and staff on the dates of the survey.

Findings include:

During the review of facility inspection records on May 15, 2019, from approximately 9:00 AM to 4:00 PM, no documentation could be produced to indicate ABHR dispensers were tested in accordance with manufacturer's care and use instructions when a new refill was installed. ABHR dispensers were observed throughout the facility and when asked, the Maintenance Supervisor stated the facility was unaware of the requirement to document the testing of ABHR dispensers each time they are refilled.

Actual NFPA standard:

NFPA 101

19.3.2.6% Alcohol-Based Hand-Rub Dispensers.
Alcohol-based hand-rub dispensers shall be protected in accordance with 8.7.3.1, unless all of the following conditions are met:
(1) Where dispensers are installed in a corridor, the corridor shall have a minimum width of 6 ft (1830 mm).
(2) The maximum individual dispenser fluid capacity shall be as follows:
(a) 0.32 gal (1.2 L) for dispensers in rooms, corridors, and areas open to corridors
(b) 0.53 gal (2.0 L) for dispensers in suites of rooms
(3) Where aerosol containers are used, the maximum capacity of the aerosol dispenser shall be 18 oz. (0.51 kg) and shall be limited to Level 1 aerosols as defined in NFPA30B, Code for the Manufacture and Storage of Aerosol Products.
(4) Dispen

Based on record review and interview, the facility failed to ensure fire suppression systems were maintained in accordance with NFPA 25. Failure to inspect suppression system components has the potential to hinder system performance during a fire event and/or render the facility not fully sprinklered after an activation or repair. This deficient practice affected 11 patients and staff on the dates of the survey.

Findings include:

During review of provided facility inspection and testing records conducted on May 15, 2019 from approximately 9:00 AM to 4:00 PM, no records were available indicating the wet system gauges were inspected monthly. When asked, the Maintenance Supervisor stated the facility was unaware wet sprinkler gauges were required to be inspected monthly.

Actual NFPA standard:

NFPA 25
5.24 gauges.
5.2.4.1 Gauges on wet pipe sprinkler systems shall be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained.

Based on observation, operational testing, and interview the facility failed to maintain doors that protect corridor openings. Failure to maintain corridor doors could allow smoke and dangerous gases to pass freely between smoke compartments, preventing defend in place. This deficient practice affected 11 patients and staff on the dates of the survey.

Findings include:

During the facility tour on May 16, 2019, from approximately 10:00 AM to 2:30 PM, observation and operational testing of the corridor door to resident room 12 revealed the door would not latch and had an approximately 5/8" gap between the face of the door and the frame of the door when fully closed. When asked, the Maintenance Supervisor stated the facility was unaware the door was not functioning properly.

Actual NFPA Standards:

19.3.6.3% Corridor Doors.
19.3.6.3.1% Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be doors constructed to resist the passage of smoke and shall be constructed of materials such as the following:
(1) 1-3/4 in. (44 mm) thick, solid-bonded core wood
(2) Material that resists fire for a minimum of 20 minutes
19.3.6.3.5% Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction, and the following requirements also shall apply:
(1) The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door.
(2) Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.7.

Based on record review and interview, the facility failed to ensure the generator for the EES (Essential Electrical System) was maintained in accordance with NFPA 110. Failure to inspect generators could result in a lack of system reliability during a power loss. This deficient practice affected 11 patients and staff on the dates of the survey.

Findings include:

During review of the facility generator inspection and testing records on May 15, 2019, from approximately 9:00 AM to 4:00 PM, the facility failed to provide weekly generator inspection records for the following weeks:
1.) 12/9/18 - 12/15/18
2.) 10/14/18 - 10/20/18
3.) 8/19/18 - 8/25/18
4.) 7/29/18 - 8/4/18
When asked, the Maintenance Supervisor stated the facility was unaware the weekly inspections were not completed during those time frames.

Actual NFPA standard:

NFPA 110
8.4 Operational Inspection and Testing.
8.4.1% EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly.