HospitalInspections.org

Based on observations with the Facilities Management Director on 8/27/18, not all of the commercial cooking equipment was properly protected for the commercial cooking equipment in the kitchen under the exhaust hood. This in the event of fire under the hood could delay or deny extinguishment of a fire.

The findings included:

On 8/27/18 at 3:10 p.m. while on tour, in the kitchen it was observed on the cooking line the gas supplied a six (6) burners stove and a char grill on casters was not provided with a means to prevent strain on the gas connection when moving the device for cleaning or servicing operations. It was acknowledged by the Facilities Management Director and Kitchen Manager at time of observation that the six (6) burners stove and a char grill was not properly provided with means to secure the gas appliance from putting strain on the gas connection.

At 2:25 p.m., on 8/30/18, during the exit conference, the Vice President of Operations and Facilities Management Director acknowledged this finding.

NFPA 54 (2012) 10.12.6, NFPA 96 (2011) 13.2.3, NFPA 101 (2012) 4.5.7, 4.5.8, 4.6.12.1, 4.6.12.3, 4.6.12.4, 9.2.3, 19.3.2.5, 19.7.6.

10.12.6 Use with Casters. Floor-mounted appliances with casters
shall be listed for such construction and shall be installed
in accordance with the manufacturer ' s installation instructions
for limiting the movement of the appliance to prevent
strain on the connection.

Based on observations made with the facility staff during the Fire Life Safety survey it was determined that the facility failed to ensure that the automatic fire sprinkler systems were installed, tested and maintained in reliable operating condition and in accordance with NFPA 13 & 25. Failure to ensure proper installation, testing and maintenance of the supervised automatic fire sprinkler system can result in the failure to properly control and protect the facility and allow for the rapid increase in fire spread which will endanger the patients, staff and other building occupants.

The findings included:

During documentations review with staff on 8/29/18 at 11:20 a.m. revealed there was no documentation to indicate that the facility sprinkler system pipes had received the 5 year internal inspection for the facility as required.

At 2:25 p.m., on 8/30/18, during the exit conference, the Vice President of Operations and Facilities Management Director acknowledged this finding.

NFPA 25 (2011 edition) 14.2.1

Based on observation and staff interview the facility failed to maintain the facilities door opening assemblies. This deficient practice affects smoke compartments, staff, visitors and all patients.

The findings included:

During an observation tour on 8/29/18 between 1:00 p.m. and 2:00 p.m. accompanied by the Assistant Director of Facility, the following smoke/fire doors did not latch and close completely when tested.

1st floor pediatric speech rehab office,
MRI double door at nurse station.
1st floor outside engineering office.
Basement at doctor check in.
2nd floor E/W/N at elevators fire door.
3rd smoke door in Cardiovascular operating room area.

At 2:25 p.m., on 8/30/18, during the exit conference, the Vice President of Operations and Facilities Management Director acknowledged this finding.

NFPA 101 (2012 edition), 19.3.6.3,

Based on observation, staff interview, and record review, the facility failed to test batteries for the emergency generator in accordance with NFPA 99, NFPA 110, and in accordance with manufacturer's specifications. Failure to conduct these tests could result in loss of power to the facility. This could endanger the occupants of the building from the loss of power that provides life support and life safety features of the facility.

The findings included:


1. On 8/29/18 at 10:25 a.m. while reviewing the facility maintenance and testing documents and the generator log sheets, no records of monthly testing and recording of the generator battery specific gravity were found.

2. Documentation provided for the emergency generator at 10:30 a.m. was reviewed with the Facilities Management Director, the monthly load bank for unit 5, 2000 kW, failure to meet or exceed 30% of the nameplate of the unit. The facility failed to conducted the required annual (3) three hour load bank test for 2018

At 2:25 p.m., on 8/30/18, during the exit conference, the Vice President of Operations and Facilities Management Director acknowledged this finding.

NFPA 110 Chapter 8.