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Based on observation, document review, and interview, the facility failed to maintain the fire rated door assemblies and egress paths. This was evidenced by the absence of an annual inspection and certification, and equipment obstructing an exit door. This affected four of four smoke compartments at the Main Hospital, and could result in the malfunction of the doors to contain fire to a compartment, and a potential delay in egress.

NFPA 101. Life Safety Code, 2012 Edition
Chapter 19 Existing Health Care Occupancies
19.1 General Requirements.
19.1.1 Application.
19.1.1.1 General.
19.1.1.1.3 General. The provisions of Chapter 4, General,
shall apply.
19.1.1.4.1.1 Communicating openings in dividing fire barriers
required by 19.1.1.4.1 shall be permitted only in corridors
and shall be protected by approved self-closing fire door assemblies.
(See also Section 8.3.)

4.5.3 Means of Egress.
4.5.7 System Design/Installation. Any fire protection system,
building service equipment, feature of protection, or safeguard
provided to achieve the goals of this Code shall be designed,
installed, and approved in accordance with applicable
NFPA standards.

4.5.8 Maintenance. Whenever or wherever any device, equipment,
system, condition, arrangement, level of protection, or any
other feature is required for compliance with the provisions of
this Code, such device, equipment, system, condition, arrangement,
level of protection, or other feature shall thereafter be
maintained, unless the Code exempts such maintenance.

8.3.3 Fire Doors and Windows.
8.3.3.1 Openings required to have a fire protection rating by
Table 8.3.4.2 shall be protected by approved, listed, labeled
fire door assemblies and fire window assemblies and their accompanying
hardware, including all frames, closing devices,
anchorage, and sills in accordance with the requirements of
NFPA 80, Standard for Fire Doors and Other Opening Protective's,
except as otherwise specified in this Code.

NFPA 80, Standard for Fire Doors and Other Opening Protective's, 2010 edition.
Chapter 5 Care and Maintenance
5.1* General.
5.1.1 Application.
5.1.1.1 This chapter shall cover the care and maintenance of
fire doors and fire windows.
5.2.14 Maintenance of Closing Mechanisms
5.2.14.1 Self-closing devices shall be kept in working condition at all times.
5.2* Inspections.
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.

Findings:

During a facility tour, document review, and interview with staff, inspection and testing for fire/exit doors was requested, and exits and paths of egress were observed.

Main Hospital:

1. On 4/18/18 at 5:35 p.m., the facility was observed with four sets of 90 minute fire rated cross-corridor doors, located in the fire wall openings in the four corridors. No certification for annual testing and inspection was available for review. Upon interview, Staff 2 confirmed that no annual testing/inspection was performed on the doors.

2. On 4/19/18 at 9:20 a.m., the cross-corridor exit doors to Wing 2, were observed. The right door leaf, traveling West from the Nursing Station, was obstructed by a medication cart that was stationed directly in front of the door. Upon interview, Nursing Staff 4 confirmed that the cart was stored at that location.

Based on observation and interview, the facility failed to maintain self-closing doors in the exit passageways and hazardous areas. This was evidenced by doors secured in the open position without self-closing and/or automatic Fire Alarm System (FAS) activation releasing devices. This affected two of four smoke compartments at the Main Hospital, and could potentially allow the spread of smoke into adjoining compartments.

NFPA 101, Life Safety Code, 2012 Edition.
19.2.2.2.7* Any door in an exit passageway, stairway enclosure,
horizontal exit, smoke barrier, or hazardous area enclosure
shall be permitted to be held open only by an automatic release
device that complies with 7.2.1.8.2. The automatic sprinkler
system, if provided, and the fire alarm system, and the
systems required by 7.2.1.8.2, shall be arranged to initiate the
closing action of all such doors throughout the smoke compartment
or throughout the entire facility.

7.2.1.8 Self-Closing Devices.
7.2.1.8.1* A door leaf normally required to be kept closed
shall not be secured in the open position at any time and shall
be self-closing or automatic-closing in accordance with
7.2.1.8.2, unless otherwise permitted by 7.2.1.8.3.
7.2.1.8.2 In any building of low or ordinary hazard contents,
as defined in 6.2.2.2 and 6.2.2.3, or where approved by the
authority having jurisdiction, door leaves shall be permitted to
be automatic-closing, provided that all of the following criteria
are met:
(1) Upon release of the hold-open mechanism, the leaf becomes
self-closing.
(2) The release device is designed so that the leaf instantly
releases manually and, upon release, becomes selfclosing,
or the leaf can be readily closed.
(3) The automatic releasing mechanism or medium is activated
by the operation of approved smoke detectors installed
in accordance with the requirements for smoke
detectors for door leaf release service in NFPA 72, National
Fire Alarm and Signaling Code.
(4) Upon loss of power to the hold-open device, the holdopen
mechanism is released and the door leaf becomes
self-closing.

Findings:

During a facility tour, fire alarm testing, and interview with staff, the self-closing doors in the exit passageway and hazardous areas, were observed.

Main Hospital:

1. On 4/18/18 at 4:30 p.m., the metal, single-leaf cross corridor fire door leading into the Business Corridor, was observed. The door was in the full-open position, not equipped with a self-closing device. Upon interview, Staff 2 confirmed the finding.

2. On 4/19/18 at 8:30 a.m., the corridor door to the Laboratory, was observed. The door was secured in the full open position, equipped with self-closing and friction hold-open devices. The door did not release with activation of the FAS. Upon interview, Staff 2 confirmed the finding, stated that the hold-open device was not connected to the FAS for automatic release.

Based on observation and interview, the facility failed to maintain the laboratory. This was evidenced by not having a current fume hood inspection. This affected one of four smoke compartments at the Main Hospital, and could result in the increased risk of a hazardous condition.

NFPA 99 Health Care Facilities Code, 2012 Edition.
15.4 Laboratories. Laboratories using chemicals shall comply
with NFPA 45, Standard on Fire Protection for Laboratories Using
Chemicals, unless otherwise modified by other provisions of this
code.

NFPA 45, Standard on Fire Protection for Laboratories Using Chemicals, 2011 edition
8.12 Identification of Chemical Fume Hood Systems.
8.12.1* Special-use chemical fume hoods and special-use local
exhaust systems shall be identified to indicate their intended use.
8.12.2 Asign containing the following information from the last
inspection shall be affixed to each hood, or a properly maintained
log of all hoods providing the following information shall
be maintained:
(1) Inspection interval
(2) Last inspection date
(3) Average face velocity
(4) Location of fan that serves hood
(5) Inspector's name

8.13 Inspection, Testing, and Maintenance.
8.13.1* When installed or modified and at least annually thereafter,
chemical fume hoods, chemical fume hood exhaust systems,
and laboratory special exhaust systems shall be inspected
and tested as applicable, as follows:
(1) Visual inspection of the physical condition of the hood
interior, sash, and ductwork (see 7.5.3)
(2) Measuring device for hood airflow
(3) Low airflow and loss-of-airflow alarms at each alarm location
(4) Face velocity
(5) Verification of inward airflow over the entire hood face
(6) Changes in work area conditions that might affect hood
performance
8.13.2 Deficiencies in hood performance shall be corrected,
or one of the following shall apply:
(1) The activity within the hood shall be restricted to the capability
of the hood.
(2) The hood shall not be used.
8.13.3 Chemical fume hood face velocity profile or hood exhaust
air quantity shall be checked after any adjustment to the
ventilation system balance.

Findings:

During a facility tour and interview with staff, the laboratory and equipment were observed.

Main Hospital

On 4/18/18 at 5:30 p.m., the Laboratory fume hood had an outdated inspection tag date of 1/21/16. No current annual inspection was available for review. Upon interview, Staff 3 confirmed the finding.

Based on observation and interview, the facility failed to maintain the fire alarm notification devices. This was evidenced by an audible device that failed to sound when tested. This affected one of four smoke compartments at the Main Hospital, and could delay in notifying occupants of an imminent fire danger.

NFPA 101, Life Safety Code, 2012 Edition
19.3.4.3 Notification. Positive alarm sequence in accordance with 9.6.3.4 shall be permitted in health care occupancies protected throughout by an approved, supervised automatic sprinkler system in accordance with 9.7.1.1(1).

9.6.3.4 Where permitted by Chapters 11 through 43, a positive alarm sequence shall be permitted, provided that it is in accordance with NFPA 72, National Fire Alarm and Signaling Code.

NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition
18.2 Purpose. Notification appliances shall provide stimuli for initiating emergency action and provide information to users, emergency response personnel, and occupants.

18.4.1.4 Audible notification appliances for alert and evacuation signal tones shall meet the requirements of 18.4.3 (Public Mode Audible Requirements), 18.4.4 (Private Mode Audible Requirements), 18.4.5 (Sleeping Area Requirements), or 18.4.6 (Narrow Band Tone Signaling for Exceeding Masked Thresholds), as applicable.

Findings:

During a facility tour and interview with staff, the fire alarm system was tested and observed.

Main Hospital:

On 4/19/18 at 8:00 a.m., the chime/fire alarm located in the Lobby, was not sounding when tested. Upon interview, Staff 2 confirmed the finding.

Based on document review, and interview, the facility failed to maintain the fire alarm system. This was evidenced by the failure to repair a listed deficiency on the Semi-Annual Fire Alarm Inspection. This affected one of four smoke compartments at the Main Hospital, and could result in a system malfunction, or delay in notification in the event of a fire.

NFPA 101, Life Safety Code, 2012 Edition
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with section 9.6
9.6.1.3 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use.

NFPA 72, National Fire Alarm Code, 2010 Edition
14.2.1.2.2 System defects and malfunctions shall be corrected.
14.2.1.2.3 If a defect or malfunction is not corrected at the conclusion of system inspection, testing, or maintenance, the system owner or the owner ' s designated representative shall be informed of the impairment in writing within 24 hours.
14.2.2 Responsibilities.
14.2.2.1 The property or building or system owner or the owner ' s designated representative shall be responsible for inspection, testing, and maintenance of the system and for alterations or additions to this system.

Findings:

During document review and interview with staff, the fire alarm system was observed and records were requested for review.

Main Hospital:

On 4/18/18 at 3:30 p.m., the Semi-Annual Fire Alarm Report dated 2/1/18, was reviewed. The report indicated that the Lobby chime/strobe still had no audible. No documentation was available for follow-up repair. Upon interview, Staff 2 confirmed the finding, stated that the parts are on order.

Based on observation and interview, the facility failed to maintain the portable fire extinguishers. This was evidenced by a fire extinguisher that was mounted higher than the maximum allowed height of sixty inches. This affected one of four smoke compartments at the Main Hospital, and could result in the inability of staff to readily access the fire extinguisher in the event of a fire.

NFPA 101 Life Safety Code, 2012 edition
19.3.5.12 Portable fire extinguishers shall be provided in all
health care occupancies in accordance with 9.7.4.1.
9.7.4.1* Where required by the provisions of another section
of this Code, portable fire extinguishers shall be selected, installed,
inspected, and maintained in accordance with
NFPA 10, Standard for Portable Fire Extinguishers.

NFPA 10, Standard for Portable Fire Extinguishers, 2010 edition.
6.1.3.8 Installation Height.
6.1.3.8.1 Fire extinguishers having a gross weight not exceeding
40 lb (18.14 kg) shall be installed so that the top of the fire
extinguisher is not more than 5 ft (1.53 m) above the floor.
6.1.3.8.2 Fire extinguishers having a gross weight greater
than 40 lb (18.14 kg) (except wheeled types) shall be installed
so that the top of the fire extinguisher is not more than 3 1/2 ft
(1.07 m) above the floor.
6.1.3.8.3 In no case shall the clearance between the bottom
of the hand portable fire extinguisher and the floor be less
than 4 in. (102 mm).

Findings:

During a tour of the facility and interview with staff, the portable fire extinguishers were observed.

Main Hospital:

On 4/18/18 at 4:48 p.m., the portable ABC fire extinguisher located in the Phone Room, was observed. The extinguisher was mounted to the wall with the top of the operative handle at 68 inches above the floor. The extinguisher weighed less than 40 pounds. Upon interview, Staff 2 confirmed the finding.

Based on observation and interview, the facility failed to maintain the corridor doors. This was evidenced by a door that failed to positive latch. This affected one of four smoke compartments at the Main Hospital, and could result in the inability to contain smoke and/or fire to a room.

Findings:

During a tour of the facility and interview with staff, the corridor doors, were observed.

On 4/18/18 at 5:00 p.m., the corridor door to Room 3-8, was observed. The door was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to positive latch when closed. Upon interview, Staff 2 confirmed the finding.

Based on document review and interview, the facility failed to maintain the fire drills. This was evidenced by the failure to activate the alarm system during drills conducted between the hours of 6:00 a.m. and 9:00 p.m. This affected four of four smoke compartments at the Main Hospital, and could result in staff being untrained and unaware of shift-specific roles and responsibilities during an emergency.

19.7.1 Evacuation and Relocation Plan and Fire Drills.
19.7.1.4* Fire drills in health care occupancies shall include
the transmission of a fire alarm signal and simulation of emergency
fire conditions.
19.7.1.7 When drills are conducted between 9:00 p.m. and
6:00 a.m. (2100 hours and 0600 hours), a coded announcement
shall be permitted to be used instead of audible alarms.
19.7.2 Procedure in Case of Fire.
19.7.2.2 Fire Safety Plan. A written health care occupancy fire
safety plan shall provide for all of the following:


Findings:

During document review and interview with Staff, the fire drill records were requested and reviewed.

Main Hospital:

On 4/18/18 at 3:15 p.m., fire drill records indicated that no alarm device was activated during a Night Shift drill dated 12/27/17, at 9:30 a.m. Upon interview, Staff 2 confirmed the finding.

Based on observation and interview, the facility failed to maintain the emergency power supply (EPS). This was evidenced by combustible storage in the EPS Enclosure Room. This affected one of four smoke compartments at the Main Hospital, and could result in the malfunction of the generator due to a fire hazard.

NFPA 101 Life Safety Code, 2012 edition
19.5.1 Utilities, Utilities shall comply with the provisions of section 9.1
19.5.1.1 Utilities shall comply with the provisions of section 9.1
9.1.3.1 Emergency Generators and standby power systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems.

NFPA 110, Standard for Emergency and Standby Power Systems, 2010 edition.
7.11 Protection.
7.11.1 The room in which the EPS equipment is located shall not be used for other purposes that are not directly related to the EPS. Parts, tools, and manuals for routine maintenance and repair shall be permitted to be stored in the EPS room.


Findings:

During a tour of the facility and interview with staff, the EPS Enclosure Room, was observed.

Main Hospital:

On 4/18/18 at 4:59 p.m., the EPS Enclosure Room for the 125 kilowatt permanent diesel generator, was observed. Approximately 38, fifty pound plastic bags containing a salt-blend mixture, were stored along side the diesel generator. Upon interview, Staff 1 confirmed the finding.

Based on observation, the facility failed to maintain oxygen storage. This was evidenced by an oxygen storage room door that did not have the minimal required signage. This affected one of four smoke compartments at the Main Hospital, and could result in the unsafe storage of oxygen.

NFPA 99, Health Care Facilities Code, 2012 Edition.
11.3.2.1 Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry.

11.3.4 Signs.
11.3.4.1 A precautionary sign, readable from a distance of 1.5 m (5 ft), shall be displayed on each door or gate of the storage room or enclosure.
11.3.4.2 The sign shall include the following wording as a minimum:
CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING

Findings:

During a tour of the facility with staff, the oxygen storage was observed.

Main Hospital:

On 4/18/18 at 5:10 p.m., the Inside Oxygen Storage Room, was observed. The room contained approximately 1000 cubic feet of stored oxygen. The room door was not equipped with a No Smoking sign.