HospitalInspections.org

Reference: National Fire Protection Association (NFPA) 101, 2012 Edition

7.2.1.15 Inspection of Door Openings.

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.

Reference NFPA 80, 2010 Edition

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.

5.2.3 Functional Testing.
5.2.3.1 Functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing.

5.2.3.2 Before testing, a visual inspection shall be performed to identify any damaged or missing parts that can create a hazard during testing or affect operation or resetting.

5.2.4 Swinging Doors with Builders Hardware or Fire Door Hardware.

5.2.4.1 Fire door assemblies shall be visually inspected from both sides to assess the overall condition of door assembly.

5.2.4.2 As a minimum, the following items shall be verified:
(1) No open holes or breaks exist in surfaces of either the door or frame.
(2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped.
(3) The door, frame, hinges, hardware, and noncombustible threshold are secured, aligned, and in working order with no visible signs of damage.
(4) No parts are missing or broken.
(5) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7.
(6) The self-closing device is operational; that is, the active door completely closes when operated from the full open position.
(7) If a coordinator is installed, the inactive leaf closes before the active leaf.
(8) Latching hardware operates and secures the door when it is in the closed position.
(9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame.
(10) No field modifications to the door assembly have been performed that void the label.
(11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity.

Based on record review and interview, the facility failed to ensure fire doors assemblies were inspected and tested at least every 12-months in accordance with NFPA 80 (Standard for Fire Doors and Other Opening Protectives). Not inspecting and testing fire doors at least annually can result in fire/smoke traveling to and from other areas of the facility including the egress corridors in the event of a fire, which presents the risk of potential harm to all Twenty (20) patients as identified by the patient Census List provided by the Chief Executive Officer on 08/21/18. The findings are:

A. Record review of the facility maintenance records revealed no evidence fire door inspections and testing were being conducted at least annually.

B. On 08/21/18 at 2:50 pm, during interview, the Maintenance Supervisor stated he was not aware of the inspection requirement.


Reference: NFPA 101, 2012 Edition


19.2 Means of Egress Requirements.

19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7, unless otherwise modified by 19.2.2 through 19.2.11.


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
(5)*Where the corridor width is at least 8 ft (2440 mm), projections into the required width shall be permitted for fixed furniture, provided that all of the following conditions
are met:
(a) The fixed furniture is securely attached to the floor or to the wall.
(b) The fixed furniture does not reduce the clear unobstructed corridor width to less than 6 ft (1830 mm),
except as permitted by 19.2.3.4(2).
(c) The fixed furniture is located only on one side of the corridor.
(d) The fixed furniture is grouped such that each grouping does not exceed an area of 50 ft2 (4.6 m2).
(e) The fixed furniture groupings addressed in 19.2.3.4(5)(d) are separated from each other by a distance
of at least 10 ft (3050 mm).
(f)*The fixed furniture is located so as to not obstruct access to building service and fire protection equipment.
(g) Corridors throughout the smoke compartment are protected by an electrically supervised automatic
smoke detection system in accordance with 19.3.4, or the fixed furniture spaces are arranged and located
to allow direct supervision by the facility staff from a nurses ' station or similar space.
(h) The smoke compartment is protected throughout by an approved, supervised automatic sprinkler system
in accordance with 19.3.5.8.

Based on observation and interview, the facility failed to ensure projections into the required width of the egress (the action or right of going or coming out) corridors were in accordance with Life Safety Code 101. Medical carts,Transport equipment, such as wheel chairs, gurneys, etc, shall not reduce the clear unobstructed corridor width of egress corridors to less than 48 inches. Not maintaining required corridor width is likely to result in staff or other emergency personnel being unable to safely and timely evacuate patients in case of fire or other emergency, which presents the risk of potential harm to all patients, staff and visitors of emergency department. The findings are:

A. On 08/22/18 at 09:40 am, during observation within the emergency department, two (2) medical carts were placed on one side of the egress corridor and adjacent to the exit/ambulance entrance The width of egress was reduced to three feet(ft) in this exit access.

B. On 08/22/18 at 09:44 am, during interview, the Maintenance Supervisor stated the facility is limited on space for equipment storage, and staff does not actively watch for obstructions.

NFPA (National Fire Protection Association) 101 Life Safety Code (2012 Edition)

19.3.2.5 Cooking Facilities.

19.3.2.5.1 Cooking facilities shall be protected in accordance with 9.2.3, unless otherwise permitted by 19.3.2.5.2, 19.3.2.5.3, or 19.3.2.5.4.

9.2.3 Commercial Cooking Equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations (2011 Edition)

11.7 Cooking Equipment Maintenance.

11.7.1 Inspection and servicing of the cooking equipment shall be made at least annually by properly trained and qualified persons.

Based on interview and record review of commercial cooking equipment (appliances), the facility failed to provide annual inspection and servicing of cooking equipment by a qualified source. The Failure to ensure commercial cooking equipment is serviced annually could result in a fire from possible failure of the equipment. This failed practice presents a risk of potential harm by fire to all Twenty (20) patients within the facility as identified by the daily census list provided by the Chief Executive Officer on 08/21/18. The findings are:

A. On 08/21/18 at 1:30 pm, during a record review of documentation for annual servicing of commercial cooking appliances. No evidence of annual commercial cooking appliance inspections or servicing could be located.

B. On 08/21/18 at 1:35 pm during interview, the Maintenance supervisor stated that he was not aware of the requirement for annual appliance inspections.

National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition

19.3.4 Detection, Alarm, and Communications Systems.

19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.

9.6.1.3 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use.


National Fire Protection Association (NFPA) 72 National Fire Alarm and Signaling Code, 2010 Edition
10.5.5.2 Circuit Identification and Accessibility.

10.5.5.2.1 The location of the dedicated branch circuit disconnecting means shall be permanently identified at the control unit.

10.5.5.2.2 For fire alarm systems the circuit disconnecting means shall be identified as "FIRE ALARM CIRCUIT."

10.5.5.2.3 For fire alarm systems the circuit disconnecting means shall have a red marking.

10.5.5.2.4 The circuit disconnecting means shall be accessible only to authorized personnel.

10.5.5.3 Mechanical Protection. The dedicated branch circuit(s) and connections shall be protected against physical damage.

Based on observation and interview, the facility failed to ensure the circuit breaker, which provides power to a Fire Alarm Notification Appliance Circuit (NAC) panel on the second floor, was not provided with mechanical protection (a lock out device preventing the circuit breaker from being switched of by unauthorized personnel) in accordance with NFPA 72 (National Fire Alarm and Signaling Code). This deficient practice presents risk of the power to the fire alarm system being shut down, and render the system inoperable in the event of fire or other emergency. This may prevent staff from responding to an incident in a timely manner. This deficient practice presents a risk of potential harm by fire to all twenty (20) patients as identified by the daily census report provided by the Chief Executive Officer on 08/21/18. The findings are:

A. On 08/22/18 at 09:45 am, during observation, the dedicated breaker supplying power to a Fire Alarm Notification Appliance Panel in electrical room # 480 on the second floor, was not protected by a Circuit Lockout Device.

B. On 05/30/18 at 12:05 pm, during interview, the Maintenance Supervisor stated that he was not aware that a circuit lockout device was missing for this part of the fire alarm system.

National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition

9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA (National Fire Protection Association) 25 Standard for the Inspection, Testing and Maintenance for Water Based Fire Protection Systems (2011 Edition)

13.3.2 Inspection

13.3.2.1 All valves shall be inspected weekly.

13.3.2.1.2 Valves secured with locks or supervising in accordance with applicable NFPA standards shall be permitted to be inspected monthly.

13.3.2.1.2 After any alterations or repairs, an inspection shall be made by the property owner or designated representative to ensure that the system is in service and all valves are in the normal position and properly sealed, locked, or electrically supervised.

13.3.2.2 The valve inspection shall verify that the valves are in the following condition:
(1) In the normal open or closed position
(2) Sealed, locked, or supervised
(3) Accessible
(4) Provided with correct wrenches
(5) Free from external leaks
(6) Provided with applicable identification


Based on record review and interview, the facility failed to conduct and document monthly visual sprinkler control valve inspections. Not visually inspecting and documenting sprinkler system control valves monthly could result in a control valve being moved from it's proper working position, which can result in the failure of the sprinkler system supplying water to extinguish a fire. This failed practice presents a potential risk of injury by fire to all Twenty (20) patients of the facility as identified by the census list provided by the Chief Executive Officer on 08/21/18. The findings are:

A. On 08/21/18 at. 1:11 pm, during a record review for monthly sprinkler valve inspections, no documentation could be located verifying the inspections have taken place.

B. On 08/21/18 at 1:15 pm, during an Interview, the Maintenance Supervisor advised that monthly sprinkler valve inspections had not been conducted.



Reference National Fire Protection Association (NFPA) 25 Testing of Water Based Fire Protection Systems, 2011 Edition

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.

14.2.1.1 Alternative nondestructive examination methods shall be permitted.

14.2.1.2 Tubercules or slime, if found, shall be tested for indications of microbiologically influenced corrosion (MIC).

14.2.1.3* If the presence of sufficient foreign organic or inorganic material is found to obstruct pipe or sprinklers, an obstruction investigation shall be conducted as described in Section 14.3.
.
14.2.1.4 Non-metallic pipe shall not be required to be inspected internally.


Based on record review and interview, the facility failed to ensure an internal piping investigation inspection had been conducted at least every 5 years as required by NFPA 25 (Standard for the Inspection, Testing and Maintenance of Water-Based fire Protection Systems). Not internally inspecting sprinkler piping is likely to result in the presence of foreign organic material (i.e. micro-biologically influenced corrosion) and inorganic material (i.e. rust and scale, gravel, sand) in the piping that is likely to cause obstructions to water flow during a fire, which presents a risk of potential harm to all Twenty (20) Patients as identified by the daily Census List provided by the Chief Executive Officer on 08/21/18. The findings are:

A. On 08/21/18 at 12:03 pm, during a record review of the sprinkler maintenance records, no evidence of an internal piping investigation was conducted within the last five years.

B. On 08/21/18 at 12:05 pm, during interview, the Maintenance Supervisor stated that an internal piping inspections had not been conducted.



Reference National Fire Protection Association (NFPA) 13 Standard for the Installation of Sprinkler Systems, 2010 Edition.

6.2.7 Escutcheons and Cover Plates.

6.2.7.1 Plates, escutcheons, or other devices used to cover the annular space around a sprinkler shall be metallic or shall be listed for use around a sprinkler.


National Fire Protection Association (NFPA 25) Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition

5.2.1.1.4 Any Sprinkler shall be replaced that has signs of leakage, is painted other than by the sprinkler manufacturer, corroded, damaged or loaded; or is in the improper orientation.

Annex E Table E.1 (For Guidance Purposes Only) Examples of Classifications of Needed Corrections and Repairs.

E.1 Table: E.1 is an example of classifications (e.g., impairment, critical deficiency, or noncritical deficiency) of some of the needed corrections and repairs that are identified during the inspection, testing, and maintenance of some systems. This table is not all-inclusive but is included in this annex to provide some guidance in responding to needed corrections and repairs. The table does not take into account the nature of
the hazard or the life safety exposure of the occupancy and should be used with good judgment.

Escutcheons- Missing, Painted, or Rusted (Section # 5.2.1.1.4)

Based on Observation and Interview the facility failed to ensure all escutcheon plates (a protective or ornamental plate or flange) were properly secured and located on all sprinkler heads within the Sterilizer Room of the sterile processing area. Failure to maintain all sprinkler escutcheons may disrupt the spray patterns of an activated sprinkler during fire conditions. This failed practice presents a potential risk of fire to spread, injury to hospital staff and patients located within the operating suite. The findings are;

A. On 08/21/18 at 3:21 pm, during an observation of the sterile processing room, a sprinkler located above the steris washers (appliance utilized to sterilze surgical instruments) was located without the proper escutcheon plate for the sprinkler head.

B. On 08/21/18 at 3:25 pm, during an interview, the Maintenance Supervisor stated he was not aware of the missing escutcheon plate.

Reference: National Fire Protection Association (NFPA) 101 (Life Safety Code), 2012 Edition

19.3.7.3. Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a fire resistance rating of not less than 1/2 hour.

Section 8.5.6 Penetrations.

8.5.6.1 The provisions of 8.5.6 shall govern the materials and methods of construction used to protect through-penetrations and membrane penetrations of smoke barriers.

8.5.6.2 Penetrations for cables, cable trays, conduits, pipes, tubes, vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a smoke barrier, or through the ceiling membrane of the roof/ceiling of a smoke barrier assembly, shall be protected by a system or material capable of restricting the transfer of smoke.

8.5.6.3 Where a smoke barrier is also constructed as a fire barrier, the penetrations shall be protected in accordance with the requirements of 8.3.5 to limit the spread of fire for a time period equal to the fire resistance rating of the assembly and 8.5.6 to restrict the transfer of smoke, unless the requirements of 8.5.6.4 are met.


Based on observation and interview, the facility failed to ensure the smoke barriers in multiple locations in the facility identified below, were maintained and properly protected from openings in accordance with NFPA 101 (Life Safety Code) section 8.5. These unprotected openings would permit the passage of smoke from one smoke compartment to another, which presents a risk of harm to all Twenty (20) Patients in the facility as identified by the Daily Census provided by the Chief Executive Officer on 08/21/18. The findings are:


A. On 08/21/18 at 3:20 pm, during observation, the smoke barrier ceiling located in the sterile processing room had four (4) unsealed pipe penetrations (pipe, through which electrical wires or communication wires can pass) penetrating the smoke barrier wall.

B. On 08/21/18 at 3:21 pm, during observation, the smoke barrier ceiling located in the sterilizer room had unsealed pipe penetrations through the smoke barrier.

C. On 08/22/18 at 9:10 am, during observation, the smoke barrier ceiling located in Electrical room #480 on the second floor had ten (10) unsealed conduit penetrations through the smoke barrier ceiling.

D. On 08/22/18 at 10:40 am, during observation, the smoke barrier ceiling located in the materials management furnace closet #140 had multiple unsealed pipe and conduit penetration through the smoke barrier ceiling.

E. On 08/22/18 at 10:45 am, during observation of Mechanical room #6 of the administrative wing, one large 5" inch penetration and multiple small penetrations were located above the water heater.

F. On 08/22/18 at 10:47 am, during observation of Storage Room #7 Multiple penetrations were located in the ceiling and wall of this area.

G. On 02/27/18 at 10:52 pm, during interview, the Maintenance Supervisor stated that he would begin to properly seal the open penetrations.

National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition

9.1.3.1 Emergency generators and standby power systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems.


NFPA (National Fire Prevention Association), 110 (Standard for Emergency and Standby Power Systems), 2010 Edition

5.6.5.6* All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building.

5.6.5.6.1 The remote manual stop station shall be labeled.

(Appendix included for guidance only, not regulatory)
A.5.6.5.6 For systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified.


Based on observation and interview, the facility failed to ensure a remote manual stop switch (emergency stop) was provided remotely from the prime mover (engine) as required by NFPA 110 (Standard for Emergency and Standby Power Systems). Not providing a remote emergency stop located outside of the housing of the the prime mover can result in,physical harm to persons, fire, mechanical damage, and inadvertent or unintentional operation of the emergency generator. In the event the emergency generator can't be shut down quickly due to the above circumstances, it is likely to result in physical harm to service personnel as well as mechanical failure. Mechanical failure is likely to result in an unreliable source of secondary power in the event of primary power failure, which presents the risk of potential harm to all twenty (20) patients of the facility as identified by the census list provided by the Chief Executive Officer on 08/21/18. The findings are:

A. On 08/22/18 at 10:28 am, during observation of emergency generator #2, the shut off switch was installed inside the housing of the emergency generator, and is not remotely located outside the housing of the unit as required by code.

B. On 08/22/18 at 10:30 am, during an interview the Maintenance Supervisor, he advised he was not aware of the requirement of a remotely located emergency stop button.



Reference NFPA 110, 2010 Edition

8.3.8 A fuel quality test shall be performed at least annually using tests approved by ASTM standards (American Society for Testing Materials).

Based on record review and interview, the facility failed to ensure an annual fuel quality test was conducted for the diesel fuel source that serves the emergency generator. Not conducting a fuel quality test at least every 12 months is likely to allow water, sediment (matter that settles to the bottom of a liquid), and microbial (microorganisms) growth in the fuel tank, which breaks down or degrades fuel and plugs fuel filters, fuel lines, and fuel injectors. In the event of primary power failure, the emergency power source (generator) may not come on line, which is likely to leave the facility without a source of emergency power and emergency lighting, which presents a risk of potential harm to all Twenty (20) patients as identified by the daily Census List provided by the Chief Executive Officer on 08/21/18. The findings are:

A. Record review of facility's emergency generator log revealed no evidence a fuel quality test has been conducted in the past 12 months.

B. On 08/21/18 at 11:25 am, during interview, the Maintenance Supervisor stated he was unaware a fuel quality test was required.