HospitalInspections.org

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The inspector observed, while accompanied by the Maintenance Supervisor during the hours of the inspection from 1:00 pm to 4:30 pm on 7/24/2017 that there were the following issues. They were:
The File Room has a bookshelf that is too (tall) close to a sprinkler head.

"The clearance between the deflector and the top of storage shall be 18 inches or greater." - NFPA 13, 2010: 8.5.6.1.
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The inspector observed, while accompanied by the Maintenance Supervisor during the hours of the inspection from 1:00 pm to 4:30 pm on 7/24/2017 that there were the following issues. They were:
Flame spread documentation for wall and ceiling finishes were not available for review at the time of the inspection.
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The inspector observed, while accompanied by the Maintenance Supervisor during the hours of the inspection from 1:00 pm to 4:30 pm on 7/24/2017 that there were the following issues. They were:
There was a Class ABC fire extinguisher that too close (within 25') to the cooking area per the following requirements.

"Class K Cooking Media Fires. Fire extinguishers provided for the protection of cooking appliances that use combustible cooking media (vegetable or animal oils and fats) shall be listed and labeled for Class K fires." - NFPA 10, 2012: 5.5.5
"Fire extinguishers installed specifically for the protection of cooking appliances that use combustible cooking media (vegetable or animal oils and fats) without a Class K rating shall be remove from service."- NFPA 10, 2012: 5.5.5.2.
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The inspector observed, while accompanied by the Maintenance Supervisor during the hours of the inspection from 1:00 pm to 4:30 pm on 7/24/2017 that there were the following issues. They were:
Flame spread documentation for draperies, curtains and loosely hanging fabrics were not available for review at the time of the inspection.
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The inspector observed, while accompanied by the Maintenance Supervisor during the hours of the inspection from 1:00 pm to 4:30 pm on 7/24/2017 that there were the following issues. They were:
Flame spread documentation for furniture and mattresses were not available for review at the time of the inspection.
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The inspector observed, while accompanied by the Maintenance Supervisor during the hours of the inspection from 1:00 pm to 4:30 pm on 7/24/2017 that there were the following issues. They were:
Above the patient lounge door there was a non-illuminated simple exit sigh. This exit sign must be illuminated and on the Life Safety branch of the emergency electrical system.

6.4.2.2.3.2 "The life safety branch shall supply power for lighting, receptacles, and equipment as follows:
(1) Illumination of means of egress in accordance with 101, Life Safety Code,
(2) Exit signs and exit directional signs in accordance with NFPA 101, Life Safety Code,
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Electrical room had items stored in front of electrical panels.
No Storage Allowed Electrical Room:
"Dedicated Equipment Space: All switchboards, panelboards, distribution boards, and motor control centers shall be located in dedicated spaces and protected from damage." - NFPA 70, 2012, 110.26(E)

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The inspector observed, while accompanied by the Maintenance Supervisor during the hours of the inspection from 1:00 pm to 4:30 pm on 7/24/2017 that there were the following issues. They were:
Logs for testing, repairs or modifications to the patient care receptacles were not available for review.
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The inspector observed, while accompanied by the Maintenance Supervisor during the hours of the inspection from 1:00 pm to 4:30 pm on 7/24/2017 that there were the following issues. They were:
Documents for the four-hour load bank test were not available for review during this inspection.
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The inspector observed, while accompanied by the Maintenance Supervisor during the hours of the inspection from 1:00 pm to 4:30 pm on 7/24/2017 that there were the following issues. They were:
There were too many small medical gas bottles stored in an unprotected maintenance room. The limit is 300 cubic feet per the following requirements.

Storage ? 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. (Min. 1 hour enclosure)
> 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.
? 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of ? 300 cubic feet are not required to be stored in an enclosure.
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