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Based on observation, it was determined that the facility failed to ensure that all doors in the smoke barrier were arranged as such that they will automatically close by activation of Fire Alarm/Sinkler system.

Findings include:

On 01/24/11 at 3:00 PM during the survey of the basement it was noted that the one leaf of the fire/smoke double door by the Central Sterile supply room was held open in such a manner that in case of fire it will not close automatically but will require manual intervention.
On observing the door, it was misaligned and the bottom of the door was scaping the floor, not allowing the door to swing freely, and so it would remain open.

It was noted that there was a sign on the door alerting everyone that these doors need to be closed at all times however both leaves were found propped open and without the capability to close automatically in case of fire.

Findings were observed with Staff #23, Staff #24 and Staff #25.

Based on observation it was noted that the facility did not ensure that soiled linen room which is considered as a hazardous area is safeguarded from other spaces, by smoke/fire resisting partitions and doors which are self-closing/ automatic-closing, and/or are provided with the positive latching devices to protect from fire/smoke, as detailed in 19.3.2.1.

Findings include:

During the survey of the Main Soiled Linen room in the basement on 01/28/11 at 12:45 PM, it was noted that the Soiled Linen room was not separated from the Decontamination room of the Central Sterile. The arrangement is such that it is one big room with Decontamination supplies/arrangement at one end of the room and the soiled linen machines/hampers/containers on the other end of the room.

Furthermore, it was noted that the door from this Soiled Linen room/area opening to the corridor did not latch positively.

Findings were verified with Staff #23 and Staff #25.

Based on observation, it was determined that the facility did not ensure that the exit signs installed at the exit discharge/ passageways were maintained continuously illuminated. This was noted at three sites.

The findings include:
1. On 01/28/11 at 2:45 PM, it was noted that the EXIT sign light in the Radiology waiting room was not lit completely and half of the sign was blown out/not lit.
2. On 01/27/11 at 12:45 PM, one of the exit directional signs in the Critical Care Unit was not working/illuminated.
3. On 01/24/11 at 3:00 PM, the exit directional sign over the exit door in the Main bulk storage room was not working.

Section -7-3.2.1* NFPA 72 requires that
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 to indicate if 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 re-calibrated or be replaced.

Based on record review and interview, the hospital did not ensure that the fire alarm system is maintained in accordance with NFPA 72.

Findings include

On 01/28/11 at 12:30 PM, during document review of the fire alarm test reports, Staff #23 was requested to indicate/provide the reports for the sensitivity test of the smoke detectors. Staff #23 was unsure where to find the specific information in the reports. Staff #24 called the vendor who stated that this service/test needs to be added to the facility's contract .
Therefore, based on feedback by Staff #24 the facility did not have the sensitivity test reports for all the smoke detectors as required by NFPA 72, 7-3.2.1.

Based on document review and interview, the hospital did not ensure that the sprinkler system is maintained in accordance with NFPA 25 1998 Table 2-1 and Table 9-1

Findings include:

On 01/28/11 at 12:30 PM, during documentation review and staff interview with Staff #23 it was revealed that, no documentation was available to show that five (5) year internal inspections for obstructions on the sprinkler piping, alarm valves and associated trim and check valves were conducted. The documentation was requested but not provided.

A. Based on observation, it was determined that the facility failed to ensure that all its portable fire extinguishers are installed such that the top of the fire extinguisher is not more than 5 feet (60 inches) above the floor (see reference NFPA 10, 1-6.10).

Findings include:

During survey of the Decontamination room on 01/24/11 at 1:00 PM, it was noted that a fire extinguisher by the entrance door was installed on the wall with its topmost portion approximately 5 feet 8 inches above the floor. This is greater than the required 5 ft. (60 inches).

Findings were verified with Staff #23 and Staff #25.

B. Section 1-6.3 of NFPA 10 states that
Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas.

Based on observation, it was determined that the facility failed to ensure that all its portable fire extinguishers are installed in such a manner that they are conspicuously located.

Findings include:

1. During the tour of the Operating Suite on 01/27/11 at 2:45 PM, it was noted that two portable fire extinguisher in the OR area were located/ installed in such a manner that they were not conspicuous with any signs for identification.

Furthermore, one out of the two fire extinguishers was not installed in the normal path of travel. It was installed in an alcove/middle part of the room which was opposite the 4 scrub sinks. Staff #28 who works there was not even aware of the presence of this extinguisher.

Findings were verified with Staff #23 and Staff #25.

2. During the tour of the Maintenance shop in the basement on 01/24/11 at 1:15 PM, it was noted that the fire extinguisher was not installed on the wall but was kept unsecure on the floor. No reason was provided for the fire extinguisher being stored on the floor in this manner.

Note:The fire extinguisher needs to be installed on the wall or in a recessed cabinet to be conspicuously identified for use in case of emergencies.

Findings were verified with Staff #23 and Staff #25.

Based on observation and staff interview, it was determined that the facility failed to ensure that the artificial decorative plants displayed in the facility are not constructed of combustible material, unless otherwise rendered flame retardant.

The findings include:

On 01/28/11 at 2:45 PM, it was observed that the facility had provided at least 3 decorative artificial plants (4.0-5.0 feet tall) in the Radiology Department waiting room and on 01/28/11 at 2:15 PM, it was noted that at least 3 decorative artificial plants were placed in the waiting area of the Emergency Department. An interview with Staff #23 at that time revealed that he could not confirm the non-combustible nature or the flame-retardant properties of these artificial trees. He stated that he did not think that those plants were rendered flame retardant by any chemical treatment.

Based on observation, the facility did not ensure that all trash collection receptacles with capabilities greater than 32 gallons are located in a room protected as a hazardous area when not attended. The carts used to store and transport garbage were noted stored in the alcove near elevators.

Findings include:

On 01/27/11 0 at 3:00 PM, at least two large garbage container greater than 32 gallon were noted stored unattended on the 2nd floor elevator alcove/corridor in proximity of the Surgical suite. These two receptacles were noted to be still parked there at 4:00 PM.
Staff #23 stated that all soiled linen/trash bags/containers, when not attended, are to be stored in soiled utility room of the respective floors or in the main soiled holding room in the basement which are enclosed with a minimum of 1 hour fire resistance rated construction

Section 8.3.6.1 of NFPA 101 states that:
Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:

(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:

a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.

Based on observation and staff interview, it was determined that the facility did not ensure and were unaware that the penetrations of fire/smoke barrier walls were to be protected/sealed with a material capable of maintaining the smoke resistance of the barrier as per NFPA 101, 2000, 8.3.6

Findings include:

During the tour of the facility between 01/24/11 to 01/28/11, the fire/smoke barriers above the drop ceiling of the double doors and other smoke barriers were inspected to assess the integrity of smoke barriers. It was noted that the smoke barriers were penetrated by ducts, pipes, conduits, cables, and wires for light fixtures. Some of the penetrations were not sealed completely with an approved fire retardant material to prevent passage of smoke from one compartment to the other. For some of the penetrations that were sealed, facility could not provide information regarding the material's UL rating/ capability to resist fire.

Examples include but are not limited to:
a) On 01/24/11 at 3:30 PM, it was noted that a silver conduit was through the fire barrier wall (above the double door near the Central Sterilize Supply) and was missing fire retardant around it. Furthermore, there was a hole in the barrier around 4 x 5 inch that was covered by a piece of ceiling tile. There were other penetrations that had white material sealed around them. The UL rating/ fire resistive capacity for these white material could not be provided by the staff.

Similar 'fire retardant' kind material used to seal penetrations in colors, brown, gray and white were noted all around the facility. Apart from the conventional 'red' colored retardant material facility could not verify the UL rating/ or fire resistive capability of these different colored materials.

b) On 01/24/11 at 3:30 PM, it was noted that the fire wall by the Kitchen in the basement was missing fire retardant around some of the penetrations and a brown colored fire retardant material (as per staff) was noted falling off the conduit/wires.

c) On 01/25/11 at 3:40 PM, during the survey of the Behavior Health unit, and the above-the-ceiling inspection of the fire barrier, it was revealed that the HVAC passing through this wall did not have fire retardant completely around it. Furthermore, other penetrations were filled by white material whose UL rating could not be verified at the time of survey.

d) On 01/25/11 at 3:50 PM, during the survey of the fire door by the Radiology waiting room, it was noted that the HVAC duct did not have fire retardant completely around it. Furthermore, there were orange cables and wires passing through that did not have fire retardant around them.

e) On 01/28/10 at 2:30 PM, the above-ceiling-inspection of the wall in the alcove of Emergency Department (that was previously the Ambulance Entrance, but now closed via a wall) was conducted. It was noted that the wall had a square shape hole not sealed and other similar openings through which air draft from outside could be felt.

Findings were verified with Staff #23, Staff #24 and Staff #25.

Based on lack of document review, it could not be verified if all four elevator banks in the facility are equipped with fire fighter recall.

Findings include:

Staff #23 was requested to provide information regarding the fire fighter recall feature on all the elevators in the facility. During documentation review on 01/28/11 at 12:30 PM, it was noted that the vendor, 'Simplex,' did not indicate anything regarding fire fighter recall on the elevators. Furthermore, no documentation was provided to verify that all elevators are equipped with fire fighter recall phase I and phase II and that they are working appropriately.

Based on observation, it was determined that the facility failed to ensure that all doors in the smoke barrier were arranged as such that they will automatically close by activation of Fire Alarm/Sinkler system.

Findings include:

On 01/24/11 at 3:00 PM during the survey of the basement it was noted that the one leaf of the fire/smoke double door by the Central Sterile supply room was held open in such a manner that in case of fire it will not close automatically but will require manual intervention.
On observing the door, it was misaligned and the bottom of the door was scaping the floor, not allowing the door to swing freely, and so it would remain open.

It was noted that there was a sign on the door alerting everyone that these doors need to be closed at all times however both leaves were found propped open and without the capability to close automatically in case of fire.

Findings were observed with Staff #23, Staff #24 and Staff #25.

Based on observation it was noted that the facility did not ensure that soiled linen room which is considered as a hazardous area is safeguarded from other spaces, by smoke/fire resisting partitions and doors which are self-closing/ automatic-closing, and/or are provided with the positive latching devices to protect from fire/smoke, as detailed in 19.3.2.1.

Findings include:

During the survey of the Main Soiled Linen room in the basement on 01/28/11 at 12:45 PM, it was noted that the Soiled Linen room was not separated from the Decontamination room of the Central Sterile. The arrangement is such that it is one big room with Decontamination supplies/arrangement at one end of the room and the soiled linen machines/hampers/containers on the other end of the room.

Furthermore, it was noted that the door from this Soiled Linen room/area opening to the corridor did not latch positively.

Findings were verified with Staff #23 and Staff #25.

Based on observation, it was determined that the facility did not ensure that the exit signs installed at the exit discharge/ passageways were maintained continuously illuminated. This was noted at three sites.

The findings include:
1. On 01/28/11 at 2:45 PM, it was noted that the EXIT sign light in the Radiology waiting room was not lit completely and half of the sign was blown out/not lit.
2. On 01/27/11 at 12:45 PM, one of the exit directional signs in the Critical Care Unit was not working/illuminated.
3. On 01/24/11 at 3:00 PM, the exit directional sign over the exit door in the Main bulk storage room was not working.

Section -7-3.2.1* NFPA 72 requires that
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 to indicate if 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 re-calibrated or be replaced.

Based on record review and interview, the hospital did not ensure that the fire alarm system is maintained in accordance with NFPA 72.

Findings include

On 01/28/11 at 12:30 PM, during document review of the fire alarm test reports, Staff #23 was requested to indicate/provide the reports for the sensitivity test of the smoke detectors. Staff #23 was unsure where to find the specific information in the reports. Staff #24 called the vendor who stated that this service/test needs to be added to the facility's contract .
Therefore, based on feedback by Staff #24 the facility did not have the sensitivity test reports for all the smoke detectors as required by NFPA 72, 7-3.2.1.

Based on document review and interview, the hospital did not ensure that the sprinkler system is maintained in accordance with NFPA 25 1998 Table 2-1 and Table 9-1

Findings include:

On 01/28/11 at 12:30 PM, during documentation review and staff interview with Staff #23 it was revealed that, no documentation was available to show that five (5) year internal inspections for obstructions on the sprinkler piping, alarm valves and associated trim and check valves were conducted. The documentation was requested but not provided.

A. Based on observation, it was determined that the facility failed to ensure that all its portable fire extinguishers are installed such that the top of the fire extinguisher is not more than 5 feet (60 inches) above the floor (see reference NFPA 10, 1-6.10).

Findings include:

During survey of the Decontamination room on 01/24/11 at 1:00 PM, it was noted that a fire extinguisher by the entrance door was installed on the wall with its topmost portion approximately 5 feet 8 inches above the floor. This is greater than the required 5 ft. (60 inches).

Findings were verified with Staff #23 and Staff #25.

B. Section 1-6.3 of NFPA 10 states that
Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas.

Based on observation, it was determined that the facility failed to ensure that all its portable fire extinguishers are installed in such a manner that they are conspicuously located.

Findings include:

1. During the tour of the Operating Suite on 01/27/11 at 2:45 PM, it was noted that two portable fire extinguisher in the OR area were located/ installed in such a manner that they were not conspicuous with any signs for identification.

Furthermore, one out of the two fire extinguishers was not installed in the normal path of travel. It was installed in an alcove/middle part of the room which was opposite the 4 scrub sinks. Staff #28 who works there was not even aware of the presence of this extinguisher.

Findings were verified with Staff #23 and Staff #25.

2. During the tour of the Maintenance shop in the basement on 01/24/11 at 1:15 PM, it was noted that the fire extinguisher was not installed on the wall but was kept unsecure on the floor. No reason was provided for the fire extinguisher being stored on the floor in this manner.

Note:The fire extinguisher needs to be installed on the wall or in a recessed cabinet to be conspicuously identified for use in case of emergencies.

Findings were verified with Staff #23 and Staff #25.

Based on observation and staff interview, it was determined that the facility failed to ensure that the artificial decorative plants displayed in the facility are not constructed of combustible material, unless otherwise rendered flame retardant.

The findings include:

On 01/28/11 at 2:45 PM, it was observed that the facility had provided at least 3 decorative artificial plants (4.0-5.0 feet tall) in the Radiology Department waiting room and on 01/28/11 at 2:15 PM, it was noted that at least 3 decorative artificial plants were placed in the waiting area of the Emergency Department. An interview with Staff #23 at that time revealed that he could not confirm the non-combustible nature or the flame-retardant properties of these artificial trees. He stated that he did not think that those plants were rendered flame retardant by any chemical treatment.

Based on observation, the facility did not ensure that all trash collection receptacles with capabilities greater than 32 gallons are located in a room protected as a hazardous area when not attended. The carts used to store and transport garbage were noted stored in the alcove near elevators.

Findings include:

On 01/27/11 0 at 3:00 PM, at least two large garbage container greater than 32 gallon were noted stored unattended on the 2nd floor elevator alcove/corridor in proximity of the Surgical suite. These two receptacles were noted to be still parked there at 4:00 PM.
Staff #23 stated that all soiled linen/trash bags/containers, when not attended, are to be stored in soiled utility room of the respective floors or in the main soiled holding room in the basement which are enclosed with a minimum of 1 hour fire resistance rated construction

Section 8.3.6.1 of NFPA 101 states that:
Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:

(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:

a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.

Based on observation and staff interview, it was determined that the facility did not ensure and were unaware that the penetrations of fire/smoke barrier walls were to be protected/sealed with a material capable of maintaining the smoke resistance of the barrier as per NFPA 101, 2000, 8.3.6

Findings include:

During the tour of the facility between 01/24/11 to 01/28/11, the fire/smoke barriers above the drop ceiling of the double doors and other smoke barriers were inspected to assess the integrity of smoke barriers. It was noted that the smoke barriers were penetrated by ducts, pipes, conduits, cables, and wires for light fixtures. Some of the penetrations were not sealed completely with an approved fire retardant material to prevent passage of smoke from one compartment to the other. For some of the penetrations that were sealed, facility could not provide information regarding the material's UL rating/ capability to resist fire.

Examples include but are not limited to:
a) On 01/24/11 at 3:30 PM, it was noted that a silver conduit was through the fire barrier wall (above the double door near the Central Sterilize Supply) and was missing fire retardant around it. Furthermore, there was a hole in the barrier around 4 x 5 inch that was covered by a piece of ceiling tile. There were other penetrations that had white material sealed around them. The UL rating/ fire resistive capacity for these white material could not be provided by the staff.

Similar 'fire retardant' kind material used to seal penetrations in colors, brown, gray and white were noted all around the facility. Apart from the conventional 'red' colored retardant material facility could not verify the UL rating/ or fire resistive capability of these different colored materials.

b) On 01/24/11 at 3:30 PM, it was noted that the fire wall by the Kitchen in the basement was missing fire retardant around some of the penetrations and a brown colored fire retardant material (as per staff) was noted falling off the conduit/wires.

c) On 01/25/11 at 3:40 PM, during the survey of the Behavior Health unit, and the above-the-ceiling inspection of the fire barrier, it was revealed that the HVAC passing through this wall did not have fire retardant completely around it. Furthermore, other penetrations were filled by white material whose UL rating could not be verified at the time of survey.

d) On 01/25/11 at 3:50 PM, during the survey of the fire door by the Radiology waiting room, it was noted that the HVAC duct did not have fire retardant completely around it. Furthermore, there were orange cables and wires passing through that did not have fire retardant around them.

e) On 01/28/10 at 2:30 PM, the above-ceiling-inspection of the wall in the alcove of Emergency Department (that was previously the Ambulance Entrance, but now closed via a wall) was conducted. It was noted that the wall had a square shape hole not sealed and other similar openings through which air draft from outside could be felt.

Findings were verified with Staff #23, Staff #24 and Staff #25.

Based on lack of document review, it could not be verified if all four elevator banks in the facility are equipped with fire fighter recall.

Findings include:

Staff #23 was requested to provide information regarding the fire fighter recall feature on all the elevators in the facility. During documentation review on 01/28/11 at 12:30 PM, it was noted that the vendor, 'Simplex,' did not indicate anything regarding fire fighter recall on the elevators. Furthermore, no documentation was provided to verify that all elevators are equipped with fire fighter recall phase I and phase II and that they are working appropriately.