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Based on record review and interview, the facility failed to ensure fire drills were conducted at least quarterly on the third nursing shift to assure preparedness for emergency response (Federal regulations require that fire drills shall not exceed 90-day spacing between drills on each shift). This failed practice could likely result in staff not being adequately prepared to exercise their duties in accordance to the facility's fire preparedness plan in the event of fire, which presents a risk of potential harm to all patients, staff and visitors of the facility. The findings are:


A. Record review of the fire drill log indicated the facility had three (3) nursing shifts.

First Shift (7:00 am - 3:00 pm)
Second Shift (3:00 pm - 11:00 pm)
Third Shift (11:00 pm - 7:00 am)

B. Record review of the fire drill log revealed a fire drill was conducted on 03/16/16 for the third shift. There was no record a fire drill was conducted on this shift since that time. This exceeds the 90-day spacing between drills on this shift.

C. On 08/02/16 at 2:30 pm, during interview, the Director of Plant Operations stated he was unaware the fire drills conducted on the third nursing shift had exceeded their time frames.

NFPA 72 1999 Edition
2-3.5.1*
In spaces served by air-handling systems, detectors shall not be located where airflow prevents operation of the detectors.

A-2-3.5.1 (Used for Guidance only)
Detectors should not be located in a direct airflow no closer than 3 ft (1 m) from an air supply diffuser or return air opening. Supply or return sources larger than those commonly found in residential and small commercial establishments can require greater clearance to smoke detectors. Similarly, smoke detectors should be located farther away from high velocity air supplies.


Based on observation and interview, the facility failed to ensure smoke detectors are located no closer than 3 ft from direct airflow components such as air supply diffusers or return air openings as required by NFPA 72 (National Fire Alarm Code). In the event of fire, this failed practice is likely to result in airflow preventing smoke detectors from detecting smoke, which presents a risk of potential harm to all patients, staff and visitors of the facility. The findings are:


A. On 08/03/16 at 7:05 am, during observation, a smoke detector located in the south main corridor, near the fire doors, was within 3-feet from the supply air diffuser.

B. On 08/03/16 at 7:10 am, during interview, the Director of Plant Operations stated the smoke detector was indeed installed to close to supply air diffuser.

Reference NFPA 72, 1999 Edition
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.

7-5.2.2
A permanent record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 7-5.2.2.
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business address, and telephone number
(6) Name, address, and representative of approving agency(ies)
(7) Designation of the detector(s) tested, for example, tests performed in accordance with Section 7-2 and 7-3
(8) Functional test of detectors
(9) * Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type heat detectors
(12) Other tests as required by equipment manufacturers
(13) Other tests as required by the authority having jurisdiction
(14) Signatures of tester and approved authority representative
(15) Disposition of problems identified during test (for example, owner notified, problem corrected/successfully retested, device abandoned in place)


Based on record review and interview, the facility failed to ensure smoke detectors were tested for sensitivity at least every two years as required by NFPA 72 (National Fire Alarm Code). Without this testing, the facility has no assurance the smoke detectors would detect smoke within their listed sensitivity, which in the event of fire, presents a risk of potential harm to all patients, staff and visitors of the hospital facility. The findings are:


A. Record review revealed no evidence the smoke detectors were being tested for sensitivity.

B. On 08/02/16 at 1:00 pm, during interview, the Director of Plant Operations stated sensitivity testing hasn't been conducted since he started working at the facility nine months ago. He stated he had not seen any records of sensitivity testing.

Reference NFPA 13

Section 1-5.1 Maintenance:
A sprinkler system installed under this standard shall be properly maintained for efficient service. The owner is responsible for the condition of the sprinkler system and shall use due diligence in keeping the system in good operating condition.

Reference: NFPA 13, Sect. 1-6.1 states that a building, where protected by an automatic sprinkler system installation, shall be provided with sprinklers in all areas.


NFPA 25, 1-4.4
The owner or occupant promptly shall correct or repair deficiencies, damaged parts, or impairments found while performing the inspection, test, and maintenance requirements of this standard. Corrections and repairs shall be performed by qualified maintenance personnel or a qualified contractor.


Based on observation and interview, the facility failed to ensure the soiled linen storage room located at the old loading dock, was protected from fire by the automatic fire sprinkler system in accordance with NFPA 13, (Standard for the Installation of Sprinkler Systems). Not providing sprinklers in all required areas could result in spread of fire from this soiled linen room to other areas of the facility, which presents the risk of potential harm to all patients, staff and visitors of the facility. The findings are:

A. On 08/03/16 at 8:40 am, during observation, the soiled linen room located at the old loading dock was not protected from fire by the facility's automatic fire sprinkler system. This room is connected via the roof structure of the hospital.

B. On 08/03/16 at 8:45 am, during interview, the Director of Plant Operations stated that it would be a good idea to sprinkler the room.

Reference NFPA 10, Standard for Portable Fire Extinguishers, 1998 Edition

2-3.2.1 A placard shall be conspicuously placed near the extinguisher that states that the fire protection system shall be activated prior to using the fire extinguisher.

Based on observation and interview, the facility failed to ensure a placard was posted at the Type K fire extinguisher to inform staff that the fire protection system (range hood) must be activated prior to using the fire extinguisher to extinguish fire. The commercial range hood system is pre-engineered to extinguish high energy and high auto-ignition temperatures. Therefore, the Type K fire extinguisher is used for follow-up in the event it is needed and to extinguish any fire that is displaced outside of the kitchen range hood fire protection system. In the event of fire underneath the range hood, this presents the risk of potential harm to all all patients, staff and visitors within the hospital facility. The findings are:


A. On 08/03/16 at 8:00 am, observation of the Type K fire extinguisher located in the kitchen revealed it was not posted with a placard to inform staff to not use the fire extinguisher prior to activation of the range hood fire protection system.

B. On 08/03/16 at 8:05 am, during interview, the Director of Plant Operations stated he didn't notice the placard wasn't in place.

Based on record review and interview, the facility failed to ensure fire drills were conducted at least quarterly on the third nursing shift to assure preparedness for emergency response (Federal regulations require that fire drills shall not exceed 90-day spacing between drills on each shift). This failed practice could likely result in staff not being adequately prepared to exercise their duties in accordance to the facility's fire preparedness plan in the event of fire, which presents a risk of potential harm to all patients, staff and visitors of the facility. The findings are:


A. Record review of the fire drill log indicated the facility had three (3) nursing shifts.

First Shift (7:00 am - 3:00 pm)
Second Shift (3:00 pm - 11:00 pm)
Third Shift (11:00 pm - 7:00 am)

B. Record review of the fire drill log revealed a fire drill was conducted on 03/16/16 for the third shift. There was no record a fire drill was conducted on this shift since that time. This exceeds the 90-day spacing between drills on this shift.

C. On 08/02/16 at 2:30 pm, during interview, the Director of Plant Operations stated he was unaware the fire drills conducted on the third nursing shift had exceeded their time frames.

NFPA 72 1999 Edition
2-3.5.1*
In spaces served by air-handling systems, detectors shall not be located where airflow prevents operation of the detectors.

A-2-3.5.1 (Used for Guidance only)
Detectors should not be located in a direct airflow no closer than 3 ft (1 m) from an air supply diffuser or return air opening. Supply or return sources larger than those commonly found in residential and small commercial establishments can require greater clearance to smoke detectors. Similarly, smoke detectors should be located farther away from high velocity air supplies.


Based on observation and interview, the facility failed to ensure smoke detectors are located no closer than 3 ft from direct airflow components such as air supply diffusers or return air openings as required by NFPA 72 (National Fire Alarm Code). In the event of fire, this failed practice is likely to result in airflow preventing smoke detectors from detecting smoke, which presents a risk of potential harm to all patients, staff and visitors of the facility. The findings are:


A. On 08/03/16 at 7:05 am, during observation, a smoke detector located in the south main corridor, near the fire doors, was within 3-feet from the supply air diffuser.

B. On 08/03/16 at 7:10 am, during interview, the Director of Plant Operations stated the smoke detector was indeed installed to close to supply air diffuser.

Reference NFPA 72, 1999 Edition
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.

7-5.2.2
A permanent record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 7-5.2.2.
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business address, and telephone number
(6) Name, address, and representative of approving agency(ies)
(7) Designation of the detector(s) tested, for example, tests performed in accordance with Section 7-2 and 7-3
(8) Functional test of detectors
(9) * Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type heat detectors
(12) Other tests as required by equipment manufacturers
(13) Other tests as required by the authority having jurisdiction
(14) Signatures of tester and approved authority representative
(15) Disposition of problems identified during test (for example, owner notified, problem corrected/successfully retested, device abandoned in place)


Based on record review and interview, the facility failed to ensure smoke detectors were tested for sensitivity at least every two years as required by NFPA 72 (National Fire Alarm Code). Without this testing, the facility has no assurance the smoke detectors would detect smoke within their listed sensitivity, which in the event of fire, presents a risk of potential harm to all patients, staff and visitors of the hospital facility. The findings are:


A. Record review revealed no evidence the smoke detectors were being tested for sensitivity.

B. On 08/02/16 at 1:00 pm, during interview, the Director of Plant Operations stated sensitivity testing hasn't been conducted since he started working at the facility nine months ago. He stated he had not seen any records of sensitivity testing.

Reference NFPA 13

Section 1-5.1 Maintenance:
A sprinkler system installed under this standard shall be properly maintained for efficient service. The owner is responsible for the condition of the sprinkler system and shall use due diligence in keeping the system in good operating condition.

Reference: NFPA 13, Sect. 1-6.1 states that a building, where protected by an automatic sprinkler system installation, shall be provided with sprinklers in all areas.


NFPA 25, 1-4.4
The owner or occupant promptly shall correct or repair deficiencies, damaged parts, or impairments found while performing the inspection, test, and maintenance requirements of this standard. Corrections and repairs shall be performed by qualified maintenance personnel or a qualified contractor.


Based on observation and interview, the facility failed to ensure the soiled linen storage room located at the old loading dock, was protected from fire by the automatic fire sprinkler system in accordance with NFPA 13, (Standard for the Installation of Sprinkler Systems). Not providing sprinklers in all required areas could result in spread of fire from this soiled linen room to other areas of the facility, which presents the risk of potential harm to all patients, staff and visitors of the facility. The findings are:

A. On 08/03/16 at 8:40 am, during observation, the soiled linen room located at the old loading dock was not protected from fire by the facility's automatic fire sprinkler system. This room is connected via the roof structure of the hospital.

B. On 08/03/16 at 8:45 am, during interview, the Director of Plant Operations stated that it would be a good idea to sprinkler the room.

Reference NFPA 10, Standard for Portable Fire Extinguishers, 1998 Edition

2-3.2.1 A placard shall be conspicuously placed near the extinguisher that states that the fire protection system shall be activated prior to using the fire extinguisher.

Based on observation and interview, the facility failed to ensure a placard was posted at the Type K fire extinguisher to inform staff that the fire protection system (range hood) must be activated prior to using the fire extinguisher to extinguish fire. The commercial range hood system is pre-engineered to extinguish high energy and high auto-ignition temperatures. Therefore, the Type K fire extinguisher is used for follow-up in the event it is needed and to extinguish any fire that is displaced outside of the kitchen range hood fire protection system. In the event of fire underneath the range hood, this presents the risk of potential harm to all all patients, staff and visitors within the hospital facility. The findings are:


A. On 08/03/16 at 8:00 am, observation of the Type K fire extinguisher located in the kitchen revealed it was not posted with a placard to inform staff to not use the fire extinguisher prior to activation of the range hood fire protection system.

B. On 08/03/16 at 8:05 am, during interview, the Director of Plant Operations stated he didn't notice the placard wasn't in place.