HospitalInspections.org

Based upon observations made in the presence of the facility managers on 06-28-2022, it was determined that the facility did not maintain the Fire/smoke control doors so that they shut to resist the passage of Fire/smoke in accordance with NFPA101 19.2.2.2.6.

This deficiency affected 1 of several rated doors

Findings include:
1-The rated door in the "bowling alley" storage room was blocked open with a wedge and could not shut to prevent the passage of fire/smoke at the time of this survey in accordance with NFPA 19.2.2.2.2, 19.2.2.2.8

Based upon observations made in the presence of the facility managers on 06-28-2022, it was determined that the facility did not maintain the fire alarm system in accordance with NFPA 101 19.3.4.4. & 9.6.1.3.; and NFPA 72.


This deficiency affected 1 of two requirements.

Findings include:
1-During the record review the facility failed to provide documentation that the fire alarm control panel batteries had been tested under load two times in the last year. There was documentation of one test. Batteries need to be tested semiannually in accordance with NFPA 101 19.3.4.1, 9.6.1.3 and NFPA 72 table 7.3.2. The plant manager confirmed these findings.

Based upon observations made in the presence of the facility managers on 06-28-2022, it was determined that the facility did not maintain the fire barrier wall rating in accordance with NFPA 101 19.3.7., 8.5.3

The deficiency affected 3 of the rated compartments.

Findings include:
1-During the tour of the facility it was observed that the fire/smoke barrier wall in the basement data room had 2 holes approximately 4"x4" in the rated wall. Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a minimum 1?2-hour fire resistance rating in accordance with NFPA 101 19.3.7.3.
2- During the tour of the facility it was observed that the fire/smoke barrier wall in the main lobby by the soda machines had penetrations in the rated wall. Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a minimum 1?2-hour fire resistance rating in accordance with NFPA 101 19.3.7.3.

Based upon observations made in the presence of the facility managers on 06-28-2022, it was determined that the facility did not maintain electrical equipment in accordance with NFPA 101 19.5.1 and 9.1.2.

This deficiency affected 6 GFIC outlets.

Findings include
1-During the facility tour it was observed that the 2 outlets at the dirty CP sink was not GFIC protected and was observed to be within 6ft of the sink and not GFCI protected. The facility manager confirmed these findings. GFCI outlets are required where the receptacles are installed to serve the countertop surfaces and are located within 6 ft. (1.83 m) of the outside edge of the sink. NFPA 101 Section 19.5.1, 9.1.2; 1999 NFPA 70 Article 210-8(7)
2- During the facility tour it was observed that there was 2 emergency power outlets and 1 normal power outlets in the pharmacy room at the sink was not GFIC protected and was observed to be within 6ft of the sink and not GFCI protected. The facility manager confirmed these findings. GFCI outlets are required where the receptacles are installed to serve the countertop surfaces and are located within 6 ft. (1.83 m) of the outside edge of the sink. NFPA 101 Section 19.5.1, 9.1.2; 1999 NFPA 70 Article 210-8(7)
3-During the facility tour it was observed that the 1 normal power outlet at the laundry room sink was not GFIC protected and was observed to be within 6ft of the sink and not GFCI protected. The facility manager confirmed these findings. GFCI outlets are required where the receptacles are installed to serve the countertop surfaces and are located within 6 ft. (1.83 m) of the outside edge of the sink. NFPA 101 Section 19.5.1, 9.1.2; 1999 NFPA 70 Article 210-8(7)

During the record review made in the presence of the facility managers on 06-28-2022, it was determined that the facility did not inspect or complete the functional testing of the roll up fire door window assemblies in accordance with NFPA 101 19.7.6, 8.3.3.1, NFPA 80 5.2, 5.2.3

This deficiency affected all required testing of 2 roll up fire doors.

Findings include:
1- During the facility tour and documentation review made in the presence of the facility managers on 06-28-2022 it was discovered that there was no documentation of the inspection and or testing of the roll up fire doors assemblies located in the hospital dietary serving line wall and the dirty tray return wall. The doors have been deactivated and do not automatically close per the facility manager NFPA 101 19.7.6, 8.3.3.1, NFPA 80 5.2, 5.2.3 These finding was verified with the facility manager.

Based upon observations made in the presence of the facility managers on 06-28-2022, it was determined that the facility did not test the Line Isolation Monitors in accordance with NFPA 99 6.3.4.1.4, 6.3.3.3.2

The deficiency affected 2 of 2 isolation monitor.

Findings include:
1-During the facility tour it was discovered that the line isolation monitor in the operating room had not been tested at the correct intervals. Line Isolation Monitors shall be tested at intervals of not more than 1 month by actuating the LIM test switch (see 6.3.2.6.3.6).
For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators, the system was not in accordance with NFPA 99 6.3.4.1.4, 6.3.2.6.3
2- During the facility tour it was discovered that the line isolation monitor in the Emergency Department had not been tested. Line Isolation Monitors shall be tested at intervals of not more than 1 month by actuating the LIM test switch (see 6.3.2.6.3.6).
For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators, the system was not in accordance with NFPA 99 6.3.4.1.4, 6.3.2.6.3