HospitalInspections.org

Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10

FINDINGS INCLUDE:

On 07/19/2017 between 10:00 AM and 4:00 PM, observation revealed the fire extinguisher mounted on the wall in the Hospital Main Laboratory exceeds 5 feet from the floor.

This finding was confirmed with the chief building engineer.

Based on documentation review and interview, the Facility failed to ensure that the fire/smoke dampers were maintained according to 9.2 and in accordance with the manufacturer's specifications.

HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
18.5.2.1, 19.5.2.1, 9.2

FINDINGS INCLUDE:

On facility tour between 10:00 AM and 4:00 PM on 07/19/2017, documentation could not be provided that indicated the fire/smoke damper test had occurred within the past 5 years.

This deficient practice was verified by the Facility Maintenance Director.

Based on observation and interview, the Facility failed to comply with 5.1.3.3.2 (NFPA 99).


Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)


FINDINGS INCLUDE:

On facility tour between 10:00 AM and 4:00 PM on 07/19/2017, 4 oxygen cylinders were observed stored with the Emergency Room Clean Utility Storage Room. This room did not have a sign posted indicating that medical gas was being stored within this room. Also, this room was extremely cluttered with storage of items, the door would not open completely due to this clutter.

This deficient practice was verified by the Facility Maintenance Director.

Gas Equipment - Qualifications and Training of Personnel
Personnel concerned with the application, maintenance and handling of medical gases and cylinders are trained on the risk. Facilities provide continuing education, including safety guidelines and usage requirements. Equipment is serviced only by personnel trained in the maintenance and operation of equipment.
11.5.2.1 (NFPA 99)

FINDINGS INCLUDE:

On facility tour between 10:00 AM and 4:00 PM on 07/19/2017, documentation could not be located to show that staff that handle medical gas have been properly trained per NFPA 99.

This deficient practice was verified by the Facility Maintenance Director.