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Based on observation, the facility failed to ensure hazardous rooms/areas had doors which were able to close, and latch under the power of a self-closing device, in accordance with NFPA 101, 2012 Edition, Sections 19.3.2.1 and 19.3.2.1.3.

Findings include:

1. During an observation on 2/21/24 at 2:33 p.m., the central supply room was inspected. The room is a storage room and thus considered a hazardous room. The corridor door to the room was also inspected. It was found to be lacking an automatic latching system that would latch the door under the power of the self-closer. It was fitted with a manual thumb-latch mechanism that latches the door.

Based on interview and record review, the facility failed to ensure smoke detector sensitivities were completed in accordance with NFPA 72 National Fire Alarm and Signaling Code, 2010 Edition, 14.4.5.3.2-14.5.3.3 These deficiencies affect all of the smoke compartments.

Findings include:

1. During record review on 2/21/24, records for the fire alarm and smoke detection systems were reviewed. There was no documentation of when smoke detector sensitivities were completed.

In an interview on 2/21/24 at 2:30 p.m., staff member B stated the panel is old and it does not monitor the sensitivities, they have to be done manually.

Based on observation the facility failed to sprinkle the entire facility in accordance with NFPA 101, Life Safety Code, 2012 Edition, Section 19.3.5.1., and failed to ensure sprinkler heads were installed clear of ceiling mounted fixtures in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.6.5.2 and Table 8.6.5.1.2.

Findings include:

1. During an observation on 2/21/24 at 1:59 p.m., the ER vestibule was inspected. It was found to be lacking any sprinkler coverage. It contained some combustible items as well.

2. During an observation on 2/21/24 at 2:28 p.m., the back room of central supply was inspected. A sprinkler head within the room was observed, blocked by a ceiling mounted light fixture.

Based on record review and observation, the facility failed to:

a) maintain the sprinkler system in accordance with NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition, Section 14.2,

b) test or replace gauges on the sprinkler system every five years, in accordance with NFPA 25, Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Sections 13.2.7.1 and 13.2.7.2,

c) ensure sprinkler heads over 50 years old had been tested or replace in accordance with NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protections Systems, Table 5.1.1.2, Sections 5.3.1.1.1, 5.3.1.2, and 5.3.1.3,

d) document weekly standpipe gauge readings per NFPA 25 Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 13.2.7.1.,

e) ensure sprinkler systems maintained satisfactory performance with respect to activation time in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.1.1(3).

Findings include:

1. During a review of facility records on 2/21/24, it was found that the 5 year internal pipe inspection for the sprinkler system had not been completed. The last time the internal inspection had been completed was in 2012.

2. Review of the facility's sprinkler reports and through observation on 2/21/24 at 2:05 p.m., there was no evidence the gauges had been calibrated or replaced in the last five years.

3. During a review of facility sprinkler reports on 2/21/24, it was found the vendor stated the sprinkler heads in the hospital were over 50 years old. This was on a report from December of 2023. The facility had not had any of the heads sampled and tested at the time of the survey. Sampling must include a minimum of 4 heads or 1% of the total in the space, whichever is greater.

4. During a review of facility sprinkler reports on 2/21/24 it was determined the facility is not monitoring or documenting standpipe gauge readings on a monthly basis for a wet system.

5. During an observation on 2/21/24 at 1:45 p.m., the server room was inspected, it was found to be missing a ceiling tile.

Based on observation, the facility failed to maintain a corridor door resistant to the passage of smoke in accordance with NFPA 101, 2012 Edition, Section 19.3.6.3.1 and 19.3.6.3.2.

Findings include:

1. During an observation on 2/21/24 at 1:28 p.m., The dirty side of the laundry corridor door was inspected. The door was found to have a large gap about 1/2" at the top, this is not resistant to the passage of smoke.

This door was also found to have a flip latch and a padlock on the outside of the door. It is not accessible from the egress side and could get an occupant locked inside the room.

2. During an observation on 2/21/24 at 1:28 p.m., the clean side of the laundry corridor door was found to be equipped with a two-step locking mechanism.

Based on observations, the facility failed to assure that a fire-rated door, protecting the linen chute, closed and latched with the efforts of the self-closing device per NFPA 101 2012 Edition, Sections 19.5.4.4.
The findings include:

1. During an observation on 2/21/24 at 1:27 p.m., the chute room was inspected. The lower linen chute door was found to be lacking the necessary latches to keep it closed.

Based on record review, the facility failed to test the fire doors in fire assemblies annually in accordance with NFPA 101-2012, Sections 7.2.1.15.1, 4.6.12 and in accordance with NFPA 80-2010, Section 5.2 (written report).

Findings include:

1. Review of the fire safety maintenance records on 2/21/24., reflected the lack of the annual fire door assembly testing documentation. The facility must identify the required fire/smoke barriers, as well as electronically controlled doors and doors with special locking arrangement in the building and show inspections of all components of the doors in those barriers.

Based on record review, the facility failed to ensure piped oxygen shutoff valves were accessible in accordance with NFPA 99 Healthcare Facilities Code 2012 Edition, Section 5.1.4.8.4.

Findings include:

1. During an observation on 2/21/24 at 2:02 p.m., the zone valve box in ER OB was identified. It was found to be partially obstructed from view and instant access by stored items in the room.

Based on record review, the facility failed to maintain the receptacles in patient areas.

Findings include:

Record review on 2/21/24 revealed non-hospital grade receptacles located in patient care rooms in the facility did not have annual retention testing as required by sections 6.3.4.1.2 and 6.3.4.1.3 in NFPA 99, Health Care Facilities Code, 2012 Edition.

Actual NFPA Standard: NFPA 99 (2012), 6.3.4.1 Maintenance and Testing of Electrical System.
6.3.4.1.2 Additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data.
6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months.
6.3.3.2 Receptacle Testing in Patient Care Rooms.
6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection.
6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified.
6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).

Based on observation, the facility failed to ensure a labeled remote manual stop station for the generator was installed in accordance with NFPA 110-2010, Section 5.6.5.6 and 5.6.5.6.1.

Findings include:

1. During an observation on 2/21/24 at 2:15 p.m., the generator was inspected. The generator lacked a labeled manual stop station at a remote location on the outside of the prime mover, of a type in order to prevent inadvertent or unintentional operation of the generator in an emergency.