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Tag No.: K0111
Based on record review, observation and interview, the facility failed to ensure rehabilitation work was conducted in accordance with NFPA 101. Failure to provide interim life safety measures and required fire separation during construction or renovation projects could expose patients to increased risks associated with the project such as fires and infections. This deficient practice affected patients, staff and visitors on the date of the survey. The facility is licensed for 20 CAH beds and had a census of 13 on the day of the survey.
Findings include:
1) During review of facility maintenance and inspection records conducted on April 5, 2017 from approximately 9:45 AM to 12:00 PM, no records were provided for any alternative life safety measures which might be needed during a renovation being conducted in the northeast patient rooms: 14, 15, 16, 17.
2) During the facility tour conducted on April 5, 2017 from approximately 2:00 PM to 2:45 PM, observation of the renovation project in the northeast patient rooms revealed the temporary wall constructed between the area of rehabilitation an the occupied portion of the hospital, did not provide one-hour separation.
3) Interview of the Maintenance Manager conducted on April 5, 2017 from approximately 2:00 PM to 2:45 PM revealed the local fire authority had not been made aware of the project's initiation or duration and the facility had not conducted any alternative life safety measures evaluation for the project's impact to patient safety.
Actual NFPA standard:
NFPA 101
Chapter 3 Definitions
3.3.21.4* Hazardous Area. An area of a structure or building
that poses a degree of hazard greater than that normal
to the general occupancy of the building or structure.
19.7.9 Construction, Repair, and Improvement Operations.
19.7.9.1 Construction, repair, and improvement operations shall comply with 4.6.10.
4.6.10 Construction, Repair, and Improvement Operations.
4.6.10.1* Buildings, or portions of buildings, shall be permitted to be occupied during construction, repair, alterations, or additions only where required means of egress and required
fire protection features are in place and continuously maintained for the portion occupied or where alternative life safety measures acceptable to the authority having jurisdiction are in place.
43.1.2.1 Any building undergoing repair, renovation, modification, or reconstruction (see 43.2.2.1.1 through 43.2.2.1.4) shall comply with both of the following:
(1) Requirements of the applicable existing occupancy chapters (see Chapters 13, 15, 17, 19, 21, 23, 24, 26, 29, 31, 33, 37, 39, 40, and 42)
(2) Requirements of the applicable section of this chapter (see Sections 43.3, 43.4, 43.5, and 43.6)
Chapter 8 Features of Fire Protection
8.7 Special Hazard Protection.
8.7.1 General.
8.7.1.1* Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means:
(1) Enclosing the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.3
(2) Protecting the area with automatic extinguishing systems in accordance with Section 9.7
(3) Applying both 8.7.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 11 through 43
Tag No.: K0211
Based on record review, observation and interview, the facility failed to ensure that smoke and fire rated assemblies were inspected in accordance with NFPA 80 or NFPA 105, as applicable. Failure to inspect and test rated assemblies could result in a lack of system performance as designed. This deficient practice affected patients, staff and visitors on the date of the survey. The facility is licensed for 20 CAH beds and had a census of 13 on the day of the survey.
Findings include:
1) During review of provided facility annual inspection records conducted on April 5, 2017 from approximately 9:45 AM to 12:00 PM, no record was available demonstrating an initial or annual inspection and testing of rated assemblies had been conducted. When asked about the missing documentation, the Maintenance Manager stated he was not fully aware of the methods for being in compliance with the requirement.
2) During the facility tour conducted on April 5, 2017 from approximately 12:30 PM to 2:30 PM, observation of installed doors revealed doors throughout the facility were labeled with both fire and smoke resistive ratings, ranging from 20 minutes to one hour resistance.
Actual NFPA standard:
NFPA 101
19.2 Means of Egress Requirements
19.2.2.2 Doors.
19.2.2.2.1 Doors complying with 7.2.1 shall be permitted.
7.2.1 Door Openings.
7.2.1.15 Inspection of Door Openings.
7.2.1.15.1* Where required by Chapters 11 through 43, the following door assemblies shall be inspected and tested not less than annually in accordance with 7.2.1.15.2 through 7.2.1.15.8:
(1) Door leaves equipped with panic hardware or fire exit hardware in accordance with 7.2.1.7
(2) Door assemblies in exit enclosures
(3) Electrically controlled egress doors
(4) Door assemblies with special locking arrangements subject to 7.2.1.6
7.2.1.15.2 Fire-rated door assemblies shall be inspected and tested in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Smoke door assemblies shall be inspected and tested in accordance with NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives.
(A) NFPA 80 (reference)
5.2* Inspections.
5.2.1* Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ.
OR
(B) NFPA 105 reference
5.2 Specific Requirements.
5.2.1* Inspections.
5.2.1.1 Smoke door assemblies shall be inspected annually.
5.2.1.2 Doors shall be operated to confirm full closure.
5.2.1.3 Hardware and gaskets shall be inspected annually, and any parts found to be damaged or inoperative shall be replaced.
Tag No.: K0232
Based on observation and interview, the facility failed to ensure that means of egress were maintained in accordance with NFPA 101. Failure to plan and provide training for the relocation of wheeled equipment during an emergency could result in confusion and delay in evacuating patients. This deficient practice affected patients, staff and visitors on the date of the survey. The facility is licensed for 20 CAH beds and had a census of 13 on the day of the survey.
Findings include:
1) During review of facility emergency preparedness records conducted on April 5, 2017 from approximately 9:45 AM to 12:00 PM, no records were provided indicating a specified location for and staff training of, the relocation of wheeled equipment during an emergency.
2) During the facility tour conducted on April 5, 2017 from approximately 1:00 PM to 2:00 PM, observation of the occupied patient wing on the northeast side revealed three (3) wheeled computer stations; one (1) dietary cart and one nurse's cart parked outside the nurse's station. When measured, the remaining space between the computer station across from room 7B and the dietary cart, only forty-two (42) inches remained in clear width.
3) Interview of three (3) staff present at the nurse's station from approximately 2:00 PM to 2:45 PM revealed the staff were not aware of any training having been conducted for the specified location of the relocation of wheeled equipment as directed by the emergency plan.
Actual NFPA standard:
19.2.3.4* Any required aisle, corridor, or ramp shall be not less than 48 in. (1220 mm) in clear width where serving as means of egress from patient sleeping rooms, unless otherwise permitted by one of the following:
(1) Aisles, corridors, and ramps in adjunct areas not intended for the housing, treatment, or use of inpatients shall be not less than 44 in. (1120 mm) in clear and unobstructed width.
(2)*Where corridor width is at least 6 ft (1830 mm), noncontinuous projections not more than 6 in. (150 mm) from the corridor wall, above the handrail height, shall be permitted.
(3) Exit access within a room or suite of rooms complying with the requirements of 19.2.5 shall be permitted.
(4) Projections into the required width shall be permitted for wheeled equipment, provided that all of the following conditions are met:
(a) The wheeled equipment does not reduce the clear unobstructed corridor width to less than 60 in.(1525 mm).
(b) The health care occupancy fire safety plan and training program address the relocation of the wheeled equipment during a fire or similar emergency.
(c)*The wheeled equipment is limited to the following:
i. Equipment in use and carts in use
ii. Medical emergency equipment not in use
iii. Patient lift and transport equipment
Tag No.: K0300
Based on record review, observation and interview, the facility failed to ensure installed fire dampers were tested in accordance with NFPA 80. Failure to test fire dampers as required could result in a lack of system performance during a fire. This deficient practice affected patients, staff and visitors on the date of the survey. The facility is licensed for 20 CAH beds and had a census of 13 on the day of the survey.
Findings include:
During review of facility maintenance and inspection records conducted on April 5, 2017 from approximately 9:45 AM to 12:00 PM, no recods were provided indicating installed fire dampers had been tested. When asked, the Maintenance Manager stated the facility was equipped with fire dampers and he tested them, but was not aware of the requirement for the documentation and testing.
Actual NFPA standard:
NFPA 80
Chapter 19 Installation, Testing, and Maintenance of Fire Dampers
19.4* Periodic Inspection and Testing.
19.4.1 Each damper shall be tested and inspected 1 year after installation.
19.4.1.1 The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years.
Tag No.: K0321
Based on observation and operational testing, the facility failed to ensure that hazardous areas open to the corridor were protected with self-closing doors. Failure to provide self-closing doors to hazardous areas could result in fire, smoke and dangerous gases entering corridors hindering egress of patients. This deficient practice affected patients staff and visitors on the date of the survey. The facility is licensed for 20 CAH beds and had a census of 13 on the day of the survey.
Findings include:
During the facility tour conducted on April 5, 2017 from approximately 1:00 PM to 2:45 PM, observation and operational testing of the corridor door which opened to the back of two new dryers in the newly created laundry space, revealed the door was not equipped to self-close. Further observation revealed the interior space of the laundry was clearly visible beyond these dryers, when viewed from the corridor.
Actual NFPA standard:
19.3.2 Protection from Hazards.
19.3.2.1 Hazardous Areas. Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.7.1.
19.3.2.1.1 An automatic extinguishing system, where used in hazardous areas, shall be permitted to be in accordance with 19.3.5.9.
19.3.2.1.2* Where the sprinkler option of 19.3.2.1 is used, the areas shall be separated from other spaces by smoke partitions in accordance with Section 8.4.
19.3.2.1.3 The doors shall be self-closing or automatic-closing.
19.3.2.1.5 Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Rooms with soiled linen in volume exceeding 64 gal (242 L)
(6) Rooms with collected trash in volume exceeding 64 gal
(242 L)
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard
Tag No.: K0325
Based on record review, observation and interview, the facility failed to ensure automatically activated Alcohol Based Hand Rub Dispensers (ABHR) were maintained in accordance with NFPA 101. Failure to test and document operation of automatic dispensing ABHR dispensers could result in excessive flammable liquids being dispensed, increasing the risk of fires. This deficient practice affected 13 patients, staff and visitors on the date of the survey. The facility is licensed for 20 CAH beds and had a census of 13 on the day of the survey.
Findings include:
1) During the review of facility inspection records conducted on April 5, 2017 from approximately 9:45 AM to 12:30 PM, no records were available indicating inspection and testing of ABHR dispensers was performed when refilling dispensers in accordance with manufacturer's care and use instructions.
2) During the facility tour conducted on April 5, 2017 from approximately 1:00 PM to 2:30 PM, observation of installed ABHR dispensers revealed automatic dispensers were installed throughout the facility.
When asked about refill testing and documentation, the Environmental Services Manager stated he was not aware of any testing requirement.
Actual NFPA standard:
NFPA 101
19.3.2.6* Alcohol-Based Hand-Rub Dispensers.
Alcohol-based hand-rub dispensers shall be protected in accordance with
8.7.3.1, unless all of the following conditions are met:
(1) Where dispensers are installed in a corridor, the corridor shall have a minimum width of 6 ft (1830 mm).
(2) The maximum individual dispenser fluid capacity shall be as follows:
(a) 0.32 gal (1.2 L) for dispensers in rooms, corridors, and areas open to corridors
(b) 0.53 gal (2.0 L) for dispensers in suites of rooms
(3) Where aerosol containers are used, the maximum capacity of the aerosol dispenser shall be 18 oz. (0.51 kg) and shall be limited to Level 1 aerosols as defined in NFPA30B, Code for the Manufacture and Storage of Aerosol Products.
(4) Dispensers shall be separated from each other by horizontal spacing of not less than 48 in. (1220 mm).
(5) Not more than an aggregate 10 gal (37.8 L) of alcohol-based hand-rub solution or 1135 oz (32.2 kg) of Level 1 aerosols, or a combination of liquids and Level 1 aerosols not to exceed, in total, the equivalent of 10 gal
(37.8 L) or 1135 oz (32.2 kg), shall be in use outside of a storage cabinet in a single smoke compartment, except as otherwise provided in 19.3.2.6(6).
(6) One dispenser complying with 19.3.2.6 (2) or (3) per room and located in that room shall not be included in the aggregated quantity addressed in 19.3.2.6(5).
(7) Storage of quantities greater than 5 gal (18.9 L) in a single smoke compartment shall meet the requirements of NFPA 30, Flammable and Combustible Liquids Code.
(8) Dispensers shall not be installed in the following locations:
(a) Above an ignition source within a 1 in. (25 mm) horizontal distance from each side of the ignition source
(b) To the side of an ignition source within a 1 in. (25mm) horizontal distance from the ignition source
(c) Beneath an ignition source within a 1 in. (25 mm) vertical distance from the ignition source
(9) Dispensers installed directly over carpeted floors shall be permitted only in sprinklered smoke compartments.
(10) The alcohol-based hand-rub solution shall not exceed 95 percent alcohol content by volume.
(11) Operation of the dispenser shall comply with the following criteria:
(a) The dispenser shall not release its contents except when the dispenser is activated, either manually or automatically by touch-free activation.
(b) Any activation of the dispenser shall occur only when an object is placed within 4 in. (100 mm) of the sensing device.
(c) An object placed within the activation zone and left in place shall not cause more than one activation.
(d) The dispenser shall not dispense more solution than the amount required for hand hygiene consistent with label instructions.
(e) The dispenser shall be designed, constructed, and operated in a manner that ensures that accidental or malicious activation of the dispensing device is minimized.
(f) The dispenser shall be tested in accordance with the manufacturer's care and use instructions each time a new refill is installed.
Tag No.: K0353
Based on observation and interview, the facility failed to ensure fire suppression systems were maintained in accordance with NFPA 25. Failure to maintain fire sprinkler systems could hinder system performance during a fire. This deficient practice affected patients, staff and visitors on the date of the survey. The facility is licensed for 20 CAH beds and had a census of 13 on the day of the survey.
Findings include:
1) During review of provided fire suppression system maintenance and testing records conducted on April 5, 2017 from approximately 9:45 AM to 12:30 PM, no records were provided indicating the five-year internal piping inspection had been conducted since 2009.
2) During review of provided fire suppression system maintenance and testing records conducted on April 5, 2017 from approximately 9:45 AM to 12:30 PM, records indicated that the anti-freeze concentration in the propylene glycol loop was above the allowable concentration at 55.3 percent.
3) During the facility tour conducted on April 5, 2017 from approximately 1:00 PM to 1:30 PM, observation of the Medical Specialties section revealed the pendant in the staff closet was blocked by a cabinet with only thirteen (13) inches clearance from the deflector to the obstruction and the pendant in the closet behind reception was blocked by a cabinet with sixteen (16) inches clearance from the deflector.
Actual NFPA standard:
NFPA 25
Finding 1
14.2 Internal Inspection of Piping.
14.2.1 Except as discussed in 14.2.1.1 and 14.2.1.4 an inspection of piping and branch line conditions shall be conducted every 5 years by opening a flushing connection at the end of one main and by removing a sprinkler toward the end of one branch line for the purpose of inspecting for the presence of foreign organic and inorganic material.
Finding 2
NFPA 25 TIA 11-1
5.3.4.2* Antifreeze solutions shall comply with one of the following:
(3) The concentration of a propylene glycol solution measured in an existing system shall be limited to 40% by volume.
Finding 3
5.2.1 Sprinklers.
5.2.1.1* Sprinklers shall be inspected from the floor level annually.
5.2.1.2* The minimum clearance required by the installation standard shall be maintained below all sprinkler deflectors.
Tag No.: K0511
Based on observation, the facility failed to ensure safe electrical installations in accordance with NFPA 70. Substituting flexible cords and cables for the fixed wiring of the facility could result in fires by arcing or electrocution. This deficient practice affected staff and visitors in the main Kitchen and data/comms room on the date of the survey. The facility is licensed for 20 CAH beds and had a census of 13 on the day of the survey.
Findings include:
1) During the facility tour conducted on April 5, 2017 from approximately 1:00 PM to 2:30 PM, observation of the Kitchen revealed the water softener was supplied power by an extension cord fed behind a rack of styrofoam cups.
2) During the facility tour conducted on April 5, 2017 from approximately 1:00 PM to 2:30 PM, observation of the data/comms room revealed data equipment being supplied power by a 3-1 multiple plug adapter plugged into an extension cord.
Actual NFPA standard:
NFPA 70
Chapter 4
Equipment for General Use
ARTICLE 400
Flexible Cords and Cables
400.8 Uses Not Permitted.
Unless specifically permitted in 400.7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
Exception to (4): Flexible cord and cable shall be permitted
to be attached to building surfaces in accordance with the
provisions of 368.56(B)
(5) Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings
(6) Where installed in raceways, except as otherwise permitted in this Code
(7) Where subject to physical damage
Tag No.: K0712
Based on record review, the facility failed to ensure fire drills were conducted quarterly for each shift. Failure to conduct quarterly fire drills could result in a lack of staff preparedness during a fire or other emergency. This deficient practice affected patients, staff and visitors on the date of the survey. The facility is licensed for 20 CAH beds and had a census of 13 on the day of the survey.
Findings include:
During review of facility fire drill records conducted on April 5, 2017 from approximately 9:45 AM to 12:30 PM, no records were provided demonstrating a fire drill was performed for the evening shift in the fourth quarter of 2016.
Actual NFPA standard:
19.7* Operating Features.
19.7.1 Evacuation and Relocation Plan and Fire Drills.
19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.
Tag No.: K0914
Based on record review, observation and interview, the facility failed to ensure outlets were tested in accordance with NFPA 99. Failure to perform maintenance and testing on electrical systems could result in failures affecting the safety and health of patients. This deficient practice affected patients, staff and visitors on the date of the survey. The facility is licensed for 20 CAH beds and had a census of 13 on the day of the survey.
Findings include:
1) During review of facility maintenance and inspection records provided on April 5, 2017 from approximately 9:45 AM to 12:30 PM, no records were provided indicating outlets were inspected and tested. When asked what method was used for maintenance and testing of outlets in the hospital, the Maintenance Manager stated he was not aware of the requirement.
2) During the facility tour conducted on April 5, 2017 from approximately 1:00 PM to 2:45 PM, observation of facility electrical installations revealed the facility was equipped with hospital grade outlets.
Actual NFPA standard:
NFPA 99
6.3.4.1 Maintenance and Testing of Electrical Systems
6.3.4.1.1 Where hospital-grade receptacles are required at patient bed locations and in locations where deep sedation or general anesthesia is administered, testing shall be performed after initial installation, replacement, or servicing of the device.
6.3.4.1.2 Additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data.
6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months.
Tag No.: K0923
Based on observation, the facility failed to ensure medical gas cylinders were secured in accordance with NFPA 99. Failure to secure oxygen cylinders could result in cylinder damages, increasing the potential for fires and explosions. This deficient practice affected patients, staff and visitors on the date of the survey. The facility is licensed for 20 CAH beds and had a census of 13 on the day of the survey.
Findings include:
During the facility tour conducted on April 5, 2017 from approximately 1:00 PM to 2:30 PM, observation of the Lab Storage closet revealed four (4) oxygen cylinders which were not secured either by a chain or in a rack.
Actual NFPA standard:
NFPA 99
11.6.2.3 Cylinders shall be protected from damage by means
of the following specific procedures:
(1) Oxygen cylinders shall be protected from abnormal mechanical shock, which is liable to damage the cylinder, valve, or safety device.
(2) Oxygen cylinders shall not be stored near elevators or gangways or in locations where heavy moving objects will strike them or fall on them.
(3) Cylinders shall be protected from tampering by unauthorized individuals.
(4) Cylinders or cylinder valves shall not be repaired, painted, or altered.
(5) Safety relief devices in valves or cylinders shall not be tampered with.
(6) Valve outlets clogged with ice shall be thawed with warm - not boiling - water.
(7) A torch flame shall not be permitted, under any circumstances, to come in contact with a cylinder, cylinder valve, or safety device.
(8) Sparks and flame shall be kept away from cylinders.
(9) Even if they are considered to be empty, cylinders shall not be used as rollers, supports, or for any purpose other than that for which the supplier intended them.
(10) Large cylinders (exceeding size E) and containers larger than 45 kg (100 lb) weight shall be transported on a proper hand truck or cart complying with 11.4.3.1.
(11) Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.
(12) Cylinders shall not be supported by radiators, steam pipes, or heat ducts.