HospitalInspections.org

Reference NFPA 101, 2000 Edition

7.2.1.5 Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for the operation from the egress side.

Reference NFPA 101, 2000 Edition
Section 19.2.2.2.4 Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side.

Based on observation and interview, the facility failed to ensure the two set of sliding glass doors located at the main entrance were not equipped with a latch that does not require special knowledge or effort to operate from the exit side. With these latches in the "latched mode" staff and/or patients could likely not be able to exit freely through these doors in an emergency, which presents the risk of potential harm to all twenty-four (24) patients within the facility as identified by the Daily Census List provided by the Director of Facilities Management on 09/01/15. The findings are:

A. On 09/02/15 at 7:45 am, during observation, the main entry doors were provided with two sets of double sliding glass doors, which form a vestibule. Both sets of these sliding glass doors are break-away doors, which are designed to "break-away" from their frames in order to provide required or additional clear exit width in the event of emergency egress. Both sets of these sliding glass break-away doors were equipped with a dead-bolt style latching mechanism that when in the latched position, these doors would not break-away as designed. Also, if these latches were in the latched position and someone was to approach the doors with force to break them away in an emergency situation, the latch and/or the door frame is likely to bend, not allowing the latch to release thus not allowing the doors to break-away as designed or may cause great effort to release the latch to break the doors away.

B. On 09/02/15 at 7:50 am, during interview, the the Director of Facilities Management stated he was unaware the installation could pose a problem with exiting during an emergency.

Reference NFPA 101, 2000 Edition

9.6.2.9 Where a partial smoke detection system is required by another section of this Code, automatic detection of smoke in accordance with NFPA 72, National Fire Alarm Code, shall be provided in all common areas and work spaces, such as corridors, lobbies, storage rooms, equipment rooms, and other tenantless spaces in those environments suitable for proper smoke detector operation. Selective smoke detection unique to other sections of this Code shall be provided as required by those sections.

Reference NFPA 72, 1999 Edition

2-3.4.5 Smooth Ceiling Spacing.
2-3.4.5.1 Spot-Type Detectors.
2-3.4.5.1.1
On smooth ceilings, spacing of 30 ft (9.1 m) shall be permitted to be used as a guide. In all cases, the manufacturer's documented instructions shall be followed. Other spacing shall be permitted to be used depending on ceiling height, different conditions, or response requirements.


Based on observation and interview, the facility failed to ensure the enclosed vestibule, located at the main entrance to the building was provided with automatic smoke detection as required by NFPA 72 (National Fire Alarm Code). Not providing automatic smoke detection within this vestibule could result in an undetected fire at this location, which would render this required exit as unavailable in the event of fire, which presents the risk of potential harm to all twenty-four (24) patients within the facility as identified by the Daily Census List provided by the Director of Facilities Management on 09/01/15. The findings are:

A. On 09/02/15 at 8:00 am, during observation, an automatic smoke detection device was not provided within the vestibule located at the main entrance of the building.

B. On 09/02/15 at 8:05 am, during interview, the Director of Facilities Management stated he never noticed the space was not protected by a smoke detector.

Reference NFPA 25, 1998 Edition

NFPA 25, Sect. 1-4.2 states the responsibility for properly maintaining a water-based fire protection system shall be that of the owner(s) of the property. By means of periodic inspections, tests, and maintenance, the equipment shall be shown to be in good operating condition, or any defects or impairments shall be revealed.

Inspection, testing, and maintenance shall be implemented in accordance with procedures meeting or exceeding those established in this document and in accordance with the manufacturer's instructions. These tasks shall be performed by personnel who have developed competence through training and experience.

NFPA 25, Sect. 1-4.4 states 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.

NFPA 25, Table 2-1 lists periodic testing and inspections required for automatic sprinkler systems. These include monthly inspection of gauges and valves on wet systems.

NFPA 25, Sect. 1-8 states that records of inspections, tests, and maintenance of the system and its components shall be made available to the authority having jurisdiction upon request. Typical records include, but are not limited to, valve inspections; flow, drain, and pump tests; and trip tests of dry pipe, deluge, and preaction valves.

NFPA 25, Sect.1-8.1 states that records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.

NFPA 25, Sect.1-8.2 states that records shall be maintained by the owner. Original records shall be retained for the life of the system. Subsequent records shall be retained for a period of one year after the next inspection, test, or maintenance required by the standard.



Based on observation, record review and interview, the facility failed to ensure the automatic fire sprinkler system was inspected internally for obstructions in the sprinkler piping at least every 5-years in accordance with NFPA 25, (Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems). Without this maintenance, the inside of the sprinkler system piping may contain foreign matter (ie: sand, gravel, etc.) which is likely to result in restricted water flow and/or unreliable sprinkler performance in the event of fire, which presents the risk of potential harm to all twenty-four (24) patients within the facility as identified by the Daily Census List provided by the Director of Facilities Management 09/01/15. The findings are:


A. Record review of the fire sprinkler system maintenance records revealed no evidence the wet fire sprinkler system was inspected for obstructions since the building was built [2007].

B. On 09/01/15 at 2:30 pm, observation of the maintenance tags attached to the sprinkler riser revealed no 5-year obstruction inspection tag.

C. On 09/01/15 at 2:35 pm, during interview, the the Director of Facilities Management stated he wasn't aware a 5-year inspection had not been conducted on the sprinkler system.

NFPA 99 (1999 Edition)

4-3.5.2.2 Facility authorities, in consultation with medical staff and other trained personnel, shall provide and enforce regulations for the storage and handling of cylinders and containers of oxygen and nitrous oxide in storage rooms of approved construction, and for the safe handling of these agents in anesthetizing locations. Storage locations for flammable inhalation anesthetic agents, established in any operating or delivery suite, shall be limited by space allocation and regulations to not more than a 48-hour normal requirement for any such suite. In storage locations, cylinders shall be properly secured in racks or adequately fastened. No cylinders containing oxygen or nitrous oxide, other than those connected to anesthetic apparatus, shall be kept or stored in anesthetizing locations.

1. Storage shall be planned so that cylinders can be used in the order in which they are received from the supplier.

2. If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder needed hurriedly.

3. Cylinders stored in the open shall be protected against extremes of weather and from the ground beneath to prevent rusting. During winter, cylinders stored in the open shall be protected against accumulations of ice or snow. In summer, cylinders stored in the open shall be screened against continuous exposure to direct rays of the sun in those localities where extreme temperatures prevail.


Based on observation, the facility failed to ensure oxygen cascade system located at west exterior side of complex was protected from extreme weather conditions, (direct sunlight/freezing temperatures). By not having proper protection from the elements, the backup system could fail, leaving the facility with out a backup oxygen system in the event of an emergency, which has the potential to harm all twenty four (24) patients of the facility as identified by the daily census list provided by the Director of Facilities Management on 09/01/15. The findings are:

A. On 09/01/15, at 1:40 pm, observation of backup oxygen storage (cascade system), located at west exterior portion of complex was not properly protected from direct sunlight/snow and ice.

B. On 09/02/15, during interview, Director of Facilities Management stated the permanent cover over cascade system was insufficient, and required a larger canopy for adequate protection.





NFPA 50 (1999 EDITION)

3.5 Equipment Assembly and Installation

3.5.6 Storage containers, piping, valves, regulating equipment, and other accessories shall be protected against physical damage and against tampering by the general public. A shutoff valve shall be located in liquid product withdrawal lines as close to the container as practical.


Based on observation, the facility failed to ensure exterior Bulk Oxygen Storage (BOS) located in the west parking lot, was protected from physical damage by not installing protective vehicle bollards. Not properly protecting the (BOS) could result in oxygen not being supplied to the entire hospital which presents a risk of potential harm to all twenty four (24) patients as identified by the daily census list provided by the Director of Facilities Management on 09/01/15. The findings are:

A. On 09/01/15, at 1:45 pm, observation of Bulk Oxygen Storage (BOS) located in the west parking lot was not properly protected against physical damage.

B. On 09/01/15 at 1:50 pm, during interview, the Director of Facilities Management stated additional vehicle bollards should be installed at the parking lot side of (BOS) to ensure protection against physical damage from vehicles.

NFPA 2001, 2000 Edition

4-1 Inspection and Tests.

4-1.1 At least annually, all systems shall be thoroughly inspected and tested for proper operation by competent personnel. Discharge tests are not required.

4-1.2 The inspection report with recommendations shall be filed with the owner.

4-1.3 At least semiannually, the agent quantity and pressure of refillable containers shall be checked.

4-1.3.1 For halocarbon clean agents, if a container shows a loss in agent quantity of more than 5 percent or a loss in pressure (adjusted for temperature) of more than 10 percent, it shall be refilled or replaced.



Based observation and interview, the facility failed to ensure the FM-200 fire extinguishing system installed in the catherization laboratory was being inspected and tested at least once a year as required by NFPA 2001 (Standard on Clean-Agent Fire Extinguishing Systems). Not maintaining clean agent fire extinguishing systems as required could result in the system failing to extinguish fire, which presents a risk of potential harm by fire to all patients who require treatment in the catherization laboratory. The findings are:


A. On 09/02/15 at 9:50 am, during observation, the FM-200 fire extinguishing system located in the catherization laboratory had an inspection and testing tag dated February, 2014. There were no current inspection and testing tags for the year 2015.

B. On 09/02/15 at 9:55 am, during interview, the Director of Facilities Management stated he had no documentation demonstrating the FM-200 fire extinguishing system had been serviced since the date of installation [February, 2014].

Reference NFPA 110, 1999 Edition

6-4 Operational Inspection and Testing.
6-4.1*
Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.


Based on record review and interview, the facility failed to ensure their emergency generator, used to protect residents during the times of primary power failure, was being inspected weekly in accordance with NFPA 110 (Standard for Emergency and Standby Power System). Not performing weekly inspections could result in an undetected problem with the generator. In the event of primary power failure, this failed practice could leave the facility without a source of emergency power and emergency illumination, which presents the risk of potential harm to all twenty-four (24) patients within the facility as identified by the Daily Census List provided by the the Director of Facilities Management on 09/01/15. The findings are:


A. Record review of the generator's maintenance log revealed no record the emergency generator was being inspected at least once a week.

B. On 09/01/15 at 2:00 pm, during interview, the Director of Facilities Management stated his maintenance staff were visually inspecting the generator but they were not documenting the inspection.

Based on observation and interview, the facility's practice failed to ensure electrical outlets within 6 feet of a water supply were equipped with Ground Fault Circuit Interrupters (GFCI) as required by NFPA 70 (National Electrical Code), which resulted in a hydrocollator (a liquid heating device that is used to heat and store hot packs for therapeutic use)plugged into a standard regular electrical outlet within the physical therapy room. In the event moisture from the hydrocollator comes into contact with a standard electrical outlet, this outlet is not designed to cut off the electrical supply to the hydrocollator, which presents the risk of potential harm to eight (8) residents that received physical therapy as identified by a physical therapy list provided by the Director of Facilities Management on 09/02/15. The findings are:


A. On 09/02/15 at 10:30 am, based on observation, the hydrocollator located in the physical therapy room was plugged into a standard electrical outlet instead of the required GFCI outlet.

B. On 09/02/15 at 10:35 am, during interview, the Director of Facilities Management stated he was unaware the hydrocollator was not on an outlet that was GFCI protected.

Reference NFPA 101, 2000 Edition

7.2.1.5 Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for the operation from the egress side.

Reference NFPA 101, 2000 Edition
Section 19.2.2.2.4 Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side.

Based on observation and interview, the facility failed to ensure the two set of sliding glass doors located at the main entrance were not equipped with a latch that does not require special knowledge or effort to operate from the exit side. With these latches in the "latched mode" staff and/or patients could likely not be able to exit freely through these doors in an emergency, which presents the risk of potential harm to all twenty-four (24) patients within the facility as identified by the Daily Census List provided by the Director of Facilities Management on 09/01/15. The findings are:

A. On 09/02/15 at 7:45 am, during observation, the main entry doors were provided with two sets of double sliding glass doors, which form a vestibule. Both sets of these sliding glass doors are break-away doors, which are designed to "break-away" from their frames in order to provide required or additional clear exit width in the event of emergency egress. Both sets of these sliding glass break-away doors were equipped with a dead-bolt style latching mechanism that when in the latched position, these doors would not break-away as designed. Also, if these latches were in the latched position and someone was to approach the doors with force to break them away in an emergency situation, the latch and/or the door frame is likely to bend, not allowing the latch to release thus not allowing the doors to break-away as designed or may cause great effort to release the latch to break the doors away.

B. On 09/02/15 at 7:50 am, during interview, the the Director of Facilities Management stated he was unaware the installation could pose a problem with exiting during an emergency.

Reference NFPA 101, 2000 Edition

9.6.2.9 Where a partial smoke detection system is required by another section of this Code, automatic detection of smoke in accordance with NFPA 72, National Fire Alarm Code, shall be provided in all common areas and work spaces, such as corridors, lobbies, storage rooms, equipment rooms, and other tenantless spaces in those environments suitable for proper smoke detector operation. Selective smoke detection unique to other sections of this Code shall be provided as required by those sections.

Reference NFPA 72, 1999 Edition

2-3.4.5 Smooth Ceiling Spacing.
2-3.4.5.1 Spot-Type Detectors.
2-3.4.5.1.1
On smooth ceilings, spacing of 30 ft (9.1 m) shall be permitted to be used as a guide. In all cases, the manufacturer's documented instructions shall be followed. Other spacing shall be permitted to be used depending on ceiling height, different conditions, or response requirements.


Based on observation and interview, the facility failed to ensure the enclosed vestibule, located at the main entrance to the building was provided with automatic smoke detection as required by NFPA 72 (National Fire Alarm Code). Not providing automatic smoke detection within this vestibule could result in an undetected fire at this location, which would render this required exit as unavailable in the event of fire, which presents the risk of potential harm to all twenty-four (24) patients within the facility as identified by the Daily Census List provided by the Director of Facilities Management on 09/01/15. The findings are:

A. On 09/02/15 at 8:00 am, during observation, an automatic smoke detection device was not provided within the vestibule located at the main entrance of the building.

B. On 09/02/15 at 8:05 am, during interview, the Director of Facilities Management stated he never noticed the space was not protected by a smoke detector.

Reference NFPA 25, 1998 Edition

NFPA 25, Sect. 1-4.2 states the responsibility for properly maintaining a water-based fire protection system shall be that of the owner(s) of the property. By means of periodic inspections, tests, and maintenance, the equipment shall be shown to be in good operating condition, or any defects or impairments shall be revealed.

Inspection, testing, and maintenance shall be implemented in accordance with procedures meeting or exceeding those established in this document and in accordance with the manufacturer's instructions. These tasks shall be performed by personnel who have developed competence through training and experience.

NFPA 25, Sect. 1-4.4 states 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.

NFPA 25, Table 2-1 lists periodic testing and inspections required for automatic sprinkler systems. These include monthly inspection of gauges and valves on wet systems.

NFPA 25, Sect. 1-8 states that records of inspections, tests, and maintenance of the system and its components shall be made available to the authority having jurisdiction upon request. Typical records include, but are not limited to, valve inspections; flow, drain, and pump tests; and trip tests of dry pipe, deluge, and preaction valves.

NFPA 25, Sect.1-8.1 states that records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.

NFPA 25, Sect.1-8.2 states that records shall be maintained by the owner. Original records shall be retained for the life of the system. Subsequent records shall be retained for a period of one year after the next inspection, test, or maintenance required by the standard.



Based on observation, record review and interview, the facility failed to ensure the automatic fire sprinkler system was inspected internally for obstructions in the sprinkler piping at least every 5-years in accordance with NFPA 25, (Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems). Without this maintenance, the inside of the sprinkler system piping may contain foreign matter (ie: sand, gravel, etc.) which is likely to result in restricted water flow and/or unreliable sprinkler performance in the event of fire, which presents the risk of potential harm to all twenty-four (24) patients within the facility as identified by the Daily Census List provided by the Director of Facilities Management 09/01/15. The findings are:


A. Record review of the fire sprinkler system maintenance records revealed no evidence the wet fire sprinkler system was inspected for obstructions since the building was built [2007].

B. On 09/01/15 at 2:30 pm, observation of the maintenance tags attached to the sprinkler riser revealed no 5-year obstruction inspection tag.

C. On 09/01/15 at 2:35 pm, during interview, the the Director of Facilities Management stated he wasn't aware a 5-year inspection had not been conducted on the sprinkler system.

NFPA 99 (1999 Edition)

4-3.5.2.2 Facility authorities, in consultation with medical staff and other trained personnel, shall provide and enforce regulations for the storage and handling of cylinders and containers of oxygen and nitrous oxide in storage rooms of approved construction, and for the safe handling of these agents in anesthetizing locations. Storage locations for flammable inhalation anesthetic agents, established in any operating or delivery suite, shall be limited by space allocation and regulations to not more than a 48-hour normal requirement for any such suite. In storage locations, cylinders shall be properly secured in racks or adequately fastened. No cylinders containing oxygen or nitrous oxide, other than those connected to anesthetic apparatus, shall be kept or stored in anesthetizing locations.

1. Storage shall be planned so that cylinders can be used in the order in which they are received from the supplier.

2. If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder needed hurriedly.

3. Cylinders stored in the open shall be protected against extremes of weather and from the ground beneath to prevent rusting. During winter, cylinders stored in the open shall be protected against accumulations of ice or snow. In summer, cylinders stored in the open shall be screened against continuous exposure to direct rays of the sun in those localities where extreme temperatures prevail.


Based on observation, the facility failed to ensure oxygen cascade system located at west exterior side of complex was protected from extreme weather conditions, (direct sunlight/freezing temperatures). By not having proper protection from the elements, the backup system could fail, leaving the facility with out a backup oxygen system in the event of an emergency, which has the potential to harm all twenty four (24) patients of the facility as identified by the daily census list provided by the Director of Facilities Management on 09/01/15. The findings are:

A. On 09/01/15, at 1:40 pm, observation of backup oxygen storage (cascade system), located at west exterior portion of complex was not properly protected from direct sunlight/snow and ice.

B. On 09/02/15, during interview, Director of Facilities Management stated the permanent cover over cascade system was insufficient, and required a larger canopy for adequate protection.





NFPA 50 (1999 EDITION)

3.5 Equipment Assembly and Installation

3.5.6 Storage containers, piping, valves, regulating equipment, and other accessories shall be protected against physical damage and against tampering by the general public. A shutoff valve shall be located in liquid product withdrawal lines as close to the container as practical.


Based on observation, the facility failed to ensure exterior Bulk Oxygen Storage (BOS) located in the west parking lot, was protected from physical damage by not installing protective vehicle bollards. Not properly protecting the (BOS) could result in oxygen not being supplied to the entire hospital which presents a risk of potential harm to all twenty four (24) patients as identified by the daily census list provided by the Director of Facilities Management on 09/01/15. The findings are:

A. On 09/01/15, at 1:45 pm, observation of Bulk Oxygen Storage (BOS) located in the west parking lot was not properly protected against physical damage.

B. On 09/01/15 at 1:50 pm, during interview, the Director of Facilities Management stated additional vehicle bollards should be installed at the parking lot side of (BOS) to ensure protection against physical damage from vehicles.

NFPA 2001, 2000 Edition

4-1 Inspection and Tests.

4-1.1 At least annually, all systems shall be thoroughly inspected and tested for proper operation by competent personnel. Discharge tests are not required.

4-1.2 The inspection report with recommendations shall be filed with the owner.

4-1.3 At least semiannually, the agent quantity and pressure of refillable containers shall be checked.

4-1.3.1 For halocarbon clean agents, if a container shows a loss in agent quantity of more than 5 percent or a loss in pressure (adjusted for temperature) of more than 10 percent, it shall be refilled or replaced.



Based observation and interview, the facility failed to ensure the FM-200 fire extinguishing system installed in the catherization laboratory was being inspected and tested at least once a year as required by NFPA 2001 (Standard on Clean-Agent Fire Extinguishing Systems). Not maintaining clean agent fire extinguishing systems as required could result in the system failing to extinguish fire, which presents a risk of potential harm by fire to all patients who require treatment in the catherization laboratory. The findings are:


A. On 09/02/15 at 9:50 am, during observation, the FM-200 fire extinguishing system located in the catherization laboratory had an inspection and testing tag dated February, 2014. There were no current inspection and testing tags for the year 2015.

B. On 09/02/15 at 9:55 am, during interview, the Director of Facilities Management stated he had no documentation demonstrating the FM-200 fire extinguishing system had been serviced since the date of installation [February, 2014].

Reference NFPA 110, 1999 Edition

6-4 Operational Inspection and Testing.
6-4.1*
Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.


Based on record review and interview, the facility failed to ensure their emergency generator, used to protect residents during the times of primary power failure, was being inspected weekly in accordance with NFPA 110 (Standard for Emergency and Standby Power System). Not performing weekly inspections could result in an undetected problem with the generator. In the event of primary power failure, this failed practice could leave the facility without a source of emergency power and emergency illumination, which presents the risk of potential harm to all twenty-four (24) patients within the facility as identified by the Daily Census List provided by the the Director of Facilities Management on 09/01/15. The findings are:


A. Record review of the generator's maintenance log revealed no record the emergency generator was being inspected at least once a week.

B. On 09/01/15 at 2:00 pm, during interview, the Director of Facilities Management stated his maintenance staff were visually inspecting the generator but they were not documenting the inspection.

Based on observation and interview, the facility's practice failed to ensure electrical outlets within 6 feet of a water supply were equipped with Ground Fault Circuit Interrupters (GFCI) as required by NFPA 70 (National Electrical Code), which resulted in a hydrocollator (a liquid heating device that is used to heat and store hot packs for therapeutic use)plugged into a standard regular electrical outlet within the physical therapy room. In the event moisture from the hydrocollator comes into contact with a standard electrical outlet, this outlet is not designed to cut off the electrical supply to the hydrocollator, which presents the risk of potential harm to eight (8) residents that received physical therapy as identified by a physical therapy list provided by the Director of Facilities Management on 09/02/15. The findings are:


A. On 09/02/15 at 10:30 am, based on observation, the hydrocollator located in the physical therapy room was plugged into a standard electrical outlet instead of the required GFCI outlet.

B. On 09/02/15 at 10:35 am, during interview, the Director of Facilities Management stated he was unaware the hydrocollator was not on an outlet that was GFCI protected.