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NFPA 72 National Fire Alarm Code 1999 Edition
Chapter 7 Inspection, Testing, and Maintenance
7-3 Inspection and Testing Frequency.
7-3.2.1*
Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer ' s calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

This Standard is not met as evidenced by:

Based on record review and staff interview, it was determined that the facility failed to maintain the fire alarm system in accordance with NFPA ( National Fire Protection Association) 72.

Findings include:

1. Upon review of testing records for the fire alarm system on 04/12/11 at approximately 1:45 p.m., there was no documentation of any current or complete sensitivity testing of all smoke detectors.

2. During interview with the Medical Services and Marketing Manager on 04/12/11 at approximately 2:45 p.m., it was revealed that the hospital had no current record that sensitivity testing of all smoke detectors had been conducted.

NFPA 25 - Standard for the Inspection, Testing, and Maintenance of Water-based Protection Systems
2-2 Inspection.
2-2.1 Sprinklers.
2-2.1.1*
Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

This Standard is not met as evidenced by:

Based on review of facility documentation and observation, it was determined the hospital failed to continuously maintain the sprinkler system in reliable operating condition with inspections, testing periodically and in accordance with NFPA (National Fire Protection Association) 25.

Findings include:

1. On 04/11/11 at approximately 2:00 p.m., the hospital sprinkler inspection reports for the previous twelve (12) month period were reviewed. The reports prepared by Simplex Grinnell recommended:
a. Nineteen (19) upright one half (1/2) one hundred sixty-five (165) degree sprinkler heads were out dated.
b. Thirty-five (35) one half (1/2) pendent one hundred sixty-five (165) degree sprinkler heads were out dated.
c. Three (3) vertical side wall sprinkler heads were out dated.

2. On 04/11/11 at approximately 10:30 a.m., an inspection of the second floor was conducted. At this time there was observed a broken ceiling tile around the sprinkler head located in the ice machine closet. This would not allow the proper operation of the sprinkler head.

NFPA 10 Standard for Portable Fire Extinguishers
3-7 Fire Extinguisher Size and Placement for Class K Fires.
3-7.1
Fire extinguishers shall be provided for hazards where there is a potential for fires involving combustible cooking media (vegetable or animal oils and fats).
This Standard is not met as evidenced by:

Based on observation, it was determined the hospital failed to maintain fire extinguishers in accordance with NFPA 10.
Findings include:

1. During a tour of the hospital kitchen area on 04/13/11 at approximately 9:45 a.m., there was no evidenance of a K type fire extinguisher.

American Institute of Architects (AIA) Guidelines for Design and Construction of Health Care Facilities.

This Standard is not met:

Based on observations, it was determined the hospital is not completely maintained in a manner as to ensure that all patient care equipment is maintained in a safe operating condition.

Findings include:

1. During the survey conducted from 04/11/11 through 04/14/11 there were six (6) of six (6) patient rooms with PTAC (Package Terminal Air Condition) heating and cooling units. This unit is designed with a single pass washable type filter. At this time the hospital could not assure the required air changes per hour in patient rooms. The HVAC (heating ventilating air condition) units were not properly balanced and adjusted to assure required pressure relationships and air exchange rates for patient rooms. This could create a potential for the spread of infection and cross contamination.

2. During the survey conducted from 04/11/11 through 04/14/11 the lab was not being maintained under a negative air pressure. This would create a potential source for cross contamination.

NFPA (National Fire Protection Association) 99 Standard for Health Care Facilities 1999 Edition
Chapter 8 Gas Equipment
8-3.1.11 Storage Requirements.
8-3.1.11.2
Storage for nonflammable gases less than 3000 ft3 (85 m3).
(a) 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.
(b) Oxidizing gases, such as oxygen and nitrous oxide, shall not be stored with any flammable gas, liquid, or vapor.
(c) Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by either:
1. A minimum distance of 20 ft (6.1 m), or
2. A minimum distance of 5 ft (1.5 m) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, or
3. An enclosed cabinet of noncombustible construction having a minimum fire protection rating of one-half hour for cylinder storage. An approved flammable liquid storage cabinet shall be permitted to be used for cylinder storage.
d) Liquefied gas container storage shall comply with 4-3.1.1.2(b)4.
(e) Cylinder and container storage locations shall meet 4-3.1.1.2(a)11e with respect to temperature limitations.
(f) Electrical fixtures in storage locations shall meet 4-3.1.1.2(a)11d.
(g) Cylinder protection from mechanical shock shall meet 4-3.5.2.1(b)13.
(h) Cylinder or container restraint shall meet 4-3.5.2.1(b)27.
(i) Smoking, open flames, electric heating elements, and other sources of ignition shall be prohibited within storage locations and within 20 ft (6.1 m) of outside storage locations.
(j) Cylinder valve protection caps shall meet 4-3.5.2.1(b)14.
8-3.1.11.3 Signs.
A precautionary sign, readable from a distance of 5 ft (1.5 m), shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum:
CAUTION
OXIDIZING GAS(ES) STORED WITHIN
NO SMOKING

This Standard is not met as evidenced by:

Based on observation, it was determined the hospital failed to store all oxygen cylinders in accordance with NFPA 99. This has the potential to adversely affect the safety of all hospital staff, patients and visitors.


Findings include:

1. During a tour of the 2nd floor chapel on 04/11/11 at approximately 11:15 a.m., one (1) large oxygen cylinder was observed stored in a closet and was not identified with proper sign

2. During a tour of room 204 lounge on 04/11/11 at approximately 11:30 a.m., two (2) large oxygen cylinders were observed stored in a closet and was not identified with proper sign.

3. During a tour of the CT area on 04/11/11 at approximately 11:35 a.m., two (2) small oxygen cylinders were observed stored and was not identified by proper sign.

4. During an inspection of the hospital oxygen storage building on 04/12/11 at approximately 2:00 p.m., fifteen (15) oxygen cylinders were observed freestanding and not secured by chain or stand.

5. During an inspection of the hospital oxygen storage building on 04/12/11 at approximately 2.00 p.m., combustible material was found stored within three (3) feet of oxygen cylinders.

6. During an inspection of the hospital outpatient physical therapy on 04/14/11 at approximately 9:40 am two (2) oxygen cylinders were found stored within ten (10) inches of combustiable material.

NFPA 72 National Fire Alarm Code 1999 Edition
Chapter 7 Inspection, Testing, and Maintenance
7-3 Inspection and Testing Frequency.
7-3.2.1*
Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer ' s calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

This Standard is not met as evidenced by:

Based on record review and staff interview, it was determined that the facility failed to maintain the fire alarm system in accordance with NFPA ( National Fire Protection Association) 72.

Findings include:

1. Upon review of testing records for the fire alarm system on 04/12/11 at approximately 1:45 p.m., there was no documentation of any current or complete sensitivity testing of all smoke detectors.

2. During interview with the Medical Services and Marketing Manager on 04/12/11 at approximately 2:45 p.m., it was revealed that the hospital had no current record that sensitivity testing of all smoke detectors had been conducted.

NFPA 25 - Standard for the Inspection, Testing, and Maintenance of Water-based Protection Systems
2-2 Inspection.
2-2.1 Sprinklers.
2-2.1.1*
Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

This Standard is not met as evidenced by:

Based on review of facility documentation and observation, it was determined the hospital failed to continuously maintain the sprinkler system in reliable operating condition with inspections, testing periodically and in accordance with NFPA (National Fire Protection Association) 25.

Findings include:

1. On 04/11/11 at approximately 2:00 p.m., the hospital sprinkler inspection reports for the previous twelve (12) month period were reviewed. The reports prepared by Simplex Grinnell recommended:
a. Nineteen (19) upright one half (1/2) one hundred sixty-five (165) degree sprinkler heads were out dated.
b. Thirty-five (35) one half (1/2) pendent one hundred sixty-five (165) degree sprinkler heads were out dated.
c. Three (3) vertical side wall sprinkler heads were out dated.

2. On 04/11/11 at approximately 10:30 a.m., an inspection of the second floor was conducted. At this time there was observed a broken ceiling tile around the sprinkler head located in the ice machine closet. This would not allow the proper operation of the sprinkler head.

NFPA 10 Standard for Portable Fire Extinguishers
3-7 Fire Extinguisher Size and Placement for Class K Fires.
3-7.1
Fire extinguishers shall be provided for hazards where there is a potential for fires involving combustible cooking media (vegetable or animal oils and fats).
This Standard is not met as evidenced by:

Based on observation, it was determined the hospital failed to maintain fire extinguishers in accordance with NFPA 10.
Findings include:

1. During a tour of the hospital kitchen area on 04/13/11 at approximately 9:45 a.m., there was no evidenance of a K type fire extinguisher.

American Institute of Architects (AIA) Guidelines for Design and Construction of Health Care Facilities.

This Standard is not met:

Based on observations, it was determined the hospital is not completely maintained in a manner as to ensure that all patient care equipment is maintained in a safe operating condition.

Findings include:

1. During the survey conducted from 04/11/11 through 04/14/11 there were six (6) of six (6) patient rooms with PTAC (Package Terminal Air Condition) heating and cooling units. This unit is designed with a single pass washable type filter. At this time the hospital could not assure the required air changes per hour in patient rooms. The HVAC (heating ventilating air condition) units were not properly balanced and adjusted to assure required pressure relationships and air exchange rates for patient rooms. This could create a potential for the spread of infection and cross contamination.

2. During the survey conducted from 04/11/11 through 04/14/11 the lab was not being maintained under a negative air pressure. This would create a potential source for cross contamination.

NFPA (National Fire Protection Association) 99 Standard for Health Care Facilities 1999 Edition
Chapter 8 Gas Equipment
8-3.1.11 Storage Requirements.
8-3.1.11.2
Storage for nonflammable gases less than 3000 ft3 (85 m3).
(a) 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.
(b) Oxidizing gases, such as oxygen and nitrous oxide, shall not be stored with any flammable gas, liquid, or vapor.
(c) Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by either:
1. A minimum distance of 20 ft (6.1 m), or
2. A minimum distance of 5 ft (1.5 m) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, or
3. An enclosed cabinet of noncombustible construction having a minimum fire protection rating of one-half hour for cylinder storage. An approved flammable liquid storage cabinet shall be permitted to be used for cylinder storage.
d) Liquefied gas container storage shall comply with 4-3.1.1.2(b)4.
(e) Cylinder and container storage locations shall meet 4-3.1.1.2(a)11e with respect to temperature limitations.
(f) Electrical fixtures in storage locations shall meet 4-3.1.1.2(a)11d.
(g) Cylinder protection from mechanical shock shall meet 4-3.5.2.1(b)13.
(h) Cylinder or container restraint shall meet 4-3.5.2.1(b)27.
(i) Smoking, open flames, electric heating elements, and other sources of ignition shall be prohibited within storage locations and within 20 ft (6.1 m) of outside storage locations.
(j) Cylinder valve protection caps shall meet 4-3.5.2.1(b)14.
8-3.1.11.3 Signs.
A precautionary sign, readable from a distance of 5 ft (1.5 m), shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum:
CAUTION
OXIDIZING GAS(ES) STORED WITHIN
NO SMOKING

This Standard is not met as evidenced by:

Based on observation, it was determined the hospital failed to store all oxygen cylinders in accordance with NFPA 99. This has the potential to adversely affect the safety of all hospital staff, patients and visitors.


Findings include:

1. During a tour of the 2nd floor chapel on 04/11/11 at approximately 11:15 a.m., one (1) large oxygen cylinder was observed stored in a closet and was not identified with proper sign

2. During a tour of room 204 lounge on 04/11/11 at approximately 11:30 a.m., two (2) large oxygen cylinders were observed stored in a closet and was not identified with proper sign.

3. During a tour of the CT area on 04/11/11 at approximately 11:35 a.m., two (2) small oxygen cylinders were observed stored and was not identified by proper sign.

4. During an inspection of the hospital oxygen storage building on 04/12/11 at approximately 2:00 p.m., fifteen (15) oxygen cylinders were observed freestanding and not secured by chain or stand.

5. During an inspection of the hospital oxygen storage building on 04/12/11 at approximately 2.00 p.m., combustible material was found stored within three (3) feet of oxygen cylinders.

6. During an inspection of the hospital outpatient physical therapy on 04/14/11 at approximately 9:40 am two (2) oxygen cylinders were found stored within ten (10) inches of combustiable material.