HospitalInspections.org

Based on document review and staff interview, the facility failed to maintain the the weekly testing of the fire pump test as evidenced by four weekly tests not performed in the past two months. This deficient condition affected all building occupants and could result in the failure of the fire pump in the event of a fire.

Fire Pump
5-3 Testing.
5-3.1 Purpose. The purpose of testing the pump assembly is to ensure automatic or manual operation upon demand and continuous delivery of the required system output. An additional purpose is to detect deficiencies of the pump assembly not evident by inspection.
5-3.2 Weekly Tests. Qualified operating personnel shall be in attendance during the weekly pump operation.
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.

Findings

During document review with a staff member on 4/30/12, the documents for the weekly fire pump testing were requested. When the documents provided there was one week in March missing and three weeks in April were missing. Staff stated that the staff brought in during the strike were not trained to perform the weekly fire pump tests and the fire pump tests were not completed during that time. Staff stated that the facility performed a fire watch for the four weeks that the fire pump was not test.

Based on document review and staff interview, the facility failed to maintain the fire watch plan as evidenced by not performing the hourly checks as stated in the policy plan. This deficient condition affected all facility occupants and could result in the spread of fire without staff knowledge.

NFPA 101 Life Safety Code, 2000 edition
9.6.1.8 - When a required automatic sprinkler system is out of service for more than four hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated, or an approved Fire Watch shall be provided for all parties left unprotected by the shutdown until the automatic sprinkler system has been returned to service.

Findings:

During document review with staff members on 4/30/12, the fire watch plan for the sprinkler system was requested. The facility performed a Fire Watch while not performing the weekly checks of the fire pump. The authority having jurisdiction was not contacted and the plan was not followed.

There was no consistency in the times that staff performed the fire watch walk thru. There were gaps of time from three hours and up to nine hours between rounds.

The facility was on fire watch from 4/4/12 to 4/20/12, the documents provided were missing the records from 4/4/12 to 4/10/12. This condition exited for one week that the hospital was on fire watch.

Based on document review and staff interview, the facility failed to maintain the elevators as evidenced by failing to maintain the required monthly testing for the elevators in Building 1. This deficient condition affected all facility occupants and could result in failure of the elevator system.

NFPA 101, 2000 Edition,
9.4.6 Elevator Testing. Elevators shall be subject to routine
and periodic inspections and tests as specified in ASME/ANSI
A17.1, Safety Code for Elevators and Escalators. All elevators
equipped with fire fighter service in accordance with 9.4.4 and
9.4.5 shall be subject to a monthly operation with a written
record of the findings made and kept on the premises as
required by ASME/ANSI A17.1, Safety Code for Elevators and
Escalators.

9.4.4 Number of Cars. The number of elevator cars permitted
in a hoistway shall be in accordance with 8.2.5.9.

8.2.5.9 Where there are three or fewer elevator cars in a building,
they shall be permitted to be located within the same
hoistway enclosure. Where there are four elevator cars, they
shall be divided in such a manner that not less than two separate
hoistway enclosures are provided. Where there are more
than four elevator cars, the number of elevator cars located
within a single hoistway enclosure shall not exceed four.
Exception: This requirement shall not apply to existing hoistways in
existing buildings.

9.4.5* Elevator Machine Rooms. Elevator machine rooms
that contain solid-state equipment for elevators, other than
existing elevators, having a travel distance exceeding 50 ft (15
m) above the level of exit discharge or exceeding 30 ft (9.1 m)
below the level of exit discharge shall be provided with independent
ventilation or air conditioning systems required to
maintain temperature during fire fighters ' service operation
for elevator operation (see 9.4.4 and 9.4.5). The operating temperature
shall be established by the elevator equipment manufacturer ' s
specifications. When standby power is connected
to the elevator, the machine room ventilation or air conditioning
shall be connected to standby power.

Findings

During document review on 5/15/12, the documents for the monthly testing of the elevators were requested.

The documents provided did not have test records for April 2012. The last inspection was performed on 3/18/12.

In an interview with maintenance Staff, Staff confirmed that the testing was not completed in April, 2012 for Building 1.

Based on document review and staff interview, the facility failed to maintain the elevators as evidenced by failing to maintain the required monthly testing for the elevators in Building 2. This deficient condition affected all facility occupants and could result in failure of the elevator system.

NFPA 101, 2000 Edition,
9.4.6 Elevator Testing. Elevators shall be subject to routine
and periodic inspections and tests as specified in ASME/ANSI
A17.1, Safety Code for Elevators and Escalators. All elevators
equipped with fire fighter service in accordance with 9.4.4 and
9.4.5 shall be subject to a monthly operation with a written
record of the findings made and kept on the premises as
required by ASME/ANSI A17.1, Safety Code for Elevators and
Escalators.

9.4.4 Number of Cars. The number of elevator cars permitted
in a hoistway shall be in accordance with 8.2.5.9.

8.2.5.9 Where there are three or fewer elevator cars in a building,
they shall be permitted to be located within the same
hoistway enclosure. Where there are four elevator cars, they
shall be divided in such a manner that not less than two separate
hoistway enclosures are provided. Where there are more
than four elevator cars, the number of elevator cars located
within a single hoistway enclosure shall not exceed four.
Exception: This requirement shall not apply to existing hoistways in
existing buildings.

9.4.5* Elevator Machine Rooms. Elevator machine rooms
that contain solid-state equipment for elevators, other than
existing elevators, having a travel distance exceeding 50 ft (15
m) above the level of exit discharge or exceeding 30 ft (9.1 m)
below the level of exit discharge shall be provided with independent
ventilation or air conditioning systems required to
maintain temperature during fire fighters ' service operation
for elevator operation (see 9.4.4 and 9.4.5). The operating temperature
shall be established by the elevator equipment manufacturer ' s
specifications. When standby power is connected
to the elevator, the machine room ventilation or air conditioning
shall be connected to standby power.

Findings

During document review on 5/15/12, the documents for the monthly testing of the elevators were requested.

The documents provided indicated that the last monthly inspection was performed on 2/28/12. There were no inspection records for March or April, 2012.

In an interview with Maintenance staff, Staff confirmed that the testing was not completed in March and April, 2012 for Building 2.

Based on document review and staff interview, the facility failed to maintain the the weekly testing of the fire pump test as evidenced by four weekly tests not performed in the past two months. This deficient condition affected all building occupants and could result in the failure of the fire pump in the event of a fire.

Fire Pump
5-3 Testing.
5-3.1 Purpose. The purpose of testing the pump assembly is to ensure automatic or manual operation upon demand and continuous delivery of the required system output. An additional purpose is to detect deficiencies of the pump assembly not evident by inspection.
5-3.2 Weekly Tests. Qualified operating personnel shall be in attendance during the weekly pump operation.
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.

Findings

During document review with a staff member on 4/30/12, the documents for the weekly fire pump testing were requested. When the documents provided there was one week in March missing and three weeks in April were missing. Staff stated that the staff brought in during the strike were not trained to perform the weekly fire pump tests and the fire pump tests were not completed during that time. Staff stated that the facility performed a fire watch for the four weeks that the fire pump was not test.

Based on document review and staff interview, the facility failed to maintain the fire watch plan as evidenced by not performing the hourly checks as stated in the policy plan. This deficient condition affected all facility occupants and could result in the spread of fire without staff knowledge.

NFPA 101 Life Safety Code, 2000 edition
9.6.1.8 - When a required automatic sprinkler system is out of service for more than four hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated, or an approved Fire Watch shall be provided for all parties left unprotected by the shutdown until the automatic sprinkler system has been returned to service.

Findings:

During document review with staff members on 4/30/12, the fire watch plan for the sprinkler system was requested. The facility performed a Fire Watch while not performing the weekly checks of the fire pump. The authority having jurisdiction was not contacted and the plan was not followed.

There was no consistency in the times that staff performed the fire watch walk thru. There were gaps of time from three hours and up to nine hours between rounds.

The facility was on fire watch from 4/4/12 to 4/20/12, the documents provided were missing the records from 4/4/12 to 4/10/12. This condition exited for one week that the hospital was on fire watch.

Based on document review and staff interview, the facility failed to maintain the elevators as evidenced by failing to maintain the required monthly testing for the elevators in Building 1. This deficient condition affected all facility occupants and could result in failure of the elevator system.

NFPA 101, 2000 Edition,
9.4.6 Elevator Testing. Elevators shall be subject to routine
and periodic inspections and tests as specified in ASME/ANSI
A17.1, Safety Code for Elevators and Escalators. All elevators
equipped with fire fighter service in accordance with 9.4.4 and
9.4.5 shall be subject to a monthly operation with a written
record of the findings made and kept on the premises as
required by ASME/ANSI A17.1, Safety Code for Elevators and
Escalators.

9.4.4 Number of Cars. The number of elevator cars permitted
in a hoistway shall be in accordance with 8.2.5.9.

8.2.5.9 Where there are three or fewer elevator cars in a building,
they shall be permitted to be located within the same
hoistway enclosure. Where there are four elevator cars, they
shall be divided in such a manner that not less than two separate
hoistway enclosures are provided. Where there are more
than four elevator cars, the number of elevator cars located
within a single hoistway enclosure shall not exceed four.
Exception: This requirement shall not apply to existing hoistways in
existing buildings.

9.4.5* Elevator Machine Rooms. Elevator machine rooms
that contain solid-state equipment for elevators, other than
existing elevators, having a travel distance exceeding 50 ft (15
m) above the level of exit discharge or exceeding 30 ft (9.1 m)
below the level of exit discharge shall be provided with independent
ventilation or air conditioning systems required to
maintain temperature during fire fighters ' service operation
for elevator operation (see 9.4.4 and 9.4.5). The operating temperature
shall be established by the elevator equipment manufacturer ' s
specifications. When standby power is connected
to the elevator, the machine room ventilation or air conditioning
shall be connected to standby power.

Findings

During document review on 5/15/12, the documents for the monthly testing of the elevators were requested.

The documents provided did not have test records for April 2012. The last inspection was performed on 3/18/12.

In an interview with maintenance Staff, Staff confirmed that the testing was not completed in April, 2012 for Building 1.

Based on document review and staff interview, the facility failed to maintain the elevators as evidenced by failing to maintain the required monthly testing for the elevators in Building 2. This deficient condition affected all facility occupants and could result in failure of the elevator system.

NFPA 101, 2000 Edition,
9.4.6 Elevator Testing. Elevators shall be subject to routine
and periodic inspections and tests as specified in ASME/ANSI
A17.1, Safety Code for Elevators and Escalators. All elevators
equipped with fire fighter service in accordance with 9.4.4 and
9.4.5 shall be subject to a monthly operation with a written
record of the findings made and kept on the premises as
required by ASME/ANSI A17.1, Safety Code for Elevators and
Escalators.

9.4.4 Number of Cars. The number of elevator cars permitted
in a hoistway shall be in accordance with 8.2.5.9.

8.2.5.9 Where there are three or fewer elevator cars in a building,
they shall be permitted to be located within the same
hoistway enclosure. Where there are four elevator cars, they
shall be divided in such a manner that not less than two separate
hoistway enclosures are provided. Where there are more
than four elevator cars, the number of elevator cars located
within a single hoistway enclosure shall not exceed four.
Exception: This requirement shall not apply to existing hoistways in
existing buildings.

9.4.5* Elevator Machine Rooms. Elevator machine rooms
that contain solid-state equipment for elevators, other than
existing elevators, having a travel distance exceeding 50 ft (15
m) above the level of exit discharge or exceeding 30 ft (9.1 m)
below the level of exit discharge shall be provided with independent
ventilation or air conditioning systems required to
maintain temperature during fire fighters ' service operation
for elevator operation (see 9.4.4 and 9.4.5). The operating temperature
shall be established by the elevator equipment manufacturer ' s
specifications. When standby power is connected
to the elevator, the machine room ventilation or air conditioning
shall be connected to standby power.

Findings

During document review on 5/15/12, the documents for the monthly testing of the elevators were requested.

The documents provided indicated that the last monthly inspection was performed on 2/28/12. There were no inspection records for March or April, 2012.

In an interview with Maintenance staff, Staff confirmed that the testing was not completed in March and April, 2012 for Building 2.