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Based on observation, the facility failed to ensure that fire and smoke resistive properties of the structure were maintained. Failure to maintain fire protective coatings and seal penetrations between floors, could allow fires, smoke and dangerous gases to spread and also reduce structural integrity during a fire. This deficient practice affected patients, staff and visitors on the date of the survey. The facility is licensed for 150 hospital beds and had a census of 66 on the day of exit.

Findings include:

1.) During the facility tour conducted on November 28, 2016 from approximately 11:00 AM to 2:00 PM, observation of the ceiling and floor fire rated assemblies in the second floor Post-partum mechanical room, revealed conduit installations ranging in size from approximately 1-1/2 inches to four (4) inches housing data cabling, which were absent of sealant in the annular space, or were not fully sealed to 360 degrees of the conduit and installed cabling.

2.) During the facility tour conducted on November 28 and 29, 2016 from approximately 11:00 AM to 3:30 PM, observation of the steel beams supporting floors in the structure, revealed missing fire protective coatings due to bracing and conduit installations, ranging in size from approximately three inches by five inches to eight inches by four feet. This observation was determined to be systemic in nature on all three floors and further documentation was deemed to be unnecessary.

Actual NFPA standard:

19.1.6 Minimum Construction Requirements.
19.1.6.1 Health care occupancies shall be limited to the building construction types specified in Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7. (See 8.2.1.)

8.3.4 Opening Protective's.
8.3.4.1 Every opening in a fire barrier shall be protected to limit the spread of fire and restrict the movement of smoke
from one side of the fire barrier to the other.
8.3.4.2* The fire protection rating for opening protectives in fire barriers, fire-rated smoke barriers, and fire-rated smoke partitions shall be in accordance with Table 8.3.4.2, except as otherwise permitted in 8.3.4.3 or 8.3.4.4.

Based on record review, observation, operational testing and interview, the facility failed to ensure that fire rated assemblies were in accordance with NFPA 80. Failure to maintain self-closing devices on fire rated doors 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 150 hospital beds and had a census of 66 on the day of exit.

Findings include:

1.) During review of provided facility annual inspection records conducted on November 28, 2016 from approximately 9:00 AM to 11:00 AM and on November 29, 2016 from approximately 2:30 PM to 3:30 PM, records provided from the annual inspection conducted by facility staff in August, 2016 did not reveal any deficiencies found for the two-hour rated assembly entering Medical Records from the adjacent patient lobby office.

2.) During the facility tour conducted on November 28 and 29, 2016 from 9:00 AM to 3:30 PM on both days, observation of installed doors revealed doors installed in the facility were tagged with fire labels indicating fire protective ratings of doors ranging between twenty minutes (20 minutes) to an hour and a half (90 minutes) duration.

3.) During the facility tour conducted on November 29, 2016 from approximately 10:00 AM to 10:30 AM, observation of the door entering Medical Records from the adjacent office/lobby, revealed the door was rated as part of a two-hour fire rated assembly with a fire-resistive rating of ninety (90) minutes. Further observation revealed this door was equipped with a self-closing device which was inoperable.

4.) During the facility tour conducted on November 29, 2016 from approximately 10:00 AM to 10:30 AM, observation and operational testing of the fire rated door assembly from the corridor into CT revealed the self-closing device was not functional.

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.

NFPA 80
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.
5.2.14 Maintenance of Closing Mechanisms.
5.2.14.1 Self-closing devices shall be kept in working condition at all times.

Based on record review, observation, operational testing and interview, the facility failed to ensure automatically operated Alcohol Based Hand Rub Dispensers (ABHR) were maintained in accordance with NFPA 101. Failure to test and document operation of automatic dispensing ABHR dispensers during refilling procedures could result in inadvertently spilling flammable liquids increasing the risk of fires. This deficient practice affected patients, staff and visitors on the date of the survey. The facility is licensed for 150 hospital beds and had a census of 66 on the day of exit.

Findings include:

1.) During the review of facility inspection records conducted on November 28, 2016 from approximately 9:00 AM to 11:00 AM, 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 November 28 and 29, 2016 from approximately 10:00 AM to 3:30 PM each day, observation of all installed ABHR dispensers revealed installed dispensers were automatically activated with motion sensing. Random operational testing confirmed these dispensers activated with motion.

3.) During the facility tour conducted on November 28, 2016 from approximately 11:00 AM to 1:00 PM, observation of the ABHR dispenser installed in the MHU nurse's station revealed the dispenser was installed approximately 1/2 inch from the light switch.

4.) During the facility tour conducted on November 29, 2016 from approximately 10:00 AM to 12:00 PM, observation and operational testing of the ABHR dispenser installed in Decon Soiled Utility holding area, revealed the dispenser would not activate and held a full refill.

When asked about refill testing and documentation, the Housekeeping Supervisor stated staff did not test dispensers each time a new refill was installed.

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.

Based on observation the facility failed to ensure the fire alarm system initiating devices were installed in accordance with NFPA 72. Failure to ensure initiating devices were installed correctly would inhibit early occupant notification and delay emergency response. This deficient practice affected patients, staff and visitors on the date of the survey. The facility is licensed for 150 hospital beds and had a census of 66 on the day of exit.

Findings Include:

During the facility tour on November 28 and November 29, 2016, observation revealed the manual alarm-initiating devices were installed above the maximum height of 48 inches throughout the facility in the following areas:
· First Floor Kitchen corridor near Director of Nutrition office
· First floor Maintenance Hallway near exit
· Second floor Nurse Station in Medical/Surgical Suite
· Second Floor Nurse Station in Post Partum Suite

This deficiency was acknowledged during the exit interview.

Actual NFPA Standard:

NFPA 72
17.14.4 The operable part of each manual fire alarm box
shall be not less than 42 in. (1.07 m) and not more than 48 in.
(1.22 m) above floor level.
17.14.5 Manual fire alarm boxes shall be installed so that they
are conspicuous, unobstructed, and accessible.

Based on observation, the facility failed to ensure fire suppression system pendants were maintained free of obstructions such as paint, corrosion or storage. Failure to maintain fire sprinkler pendants free of obstructions could hinder system performance during a fire event. This deficient practice affected patients, staff and visitors on the date of the survey. The facility is licensed for 150 hospital beds and had a census of 66 on the day of the survey.

Findings include:

During the facility tour conducted on November 29, 2016 from approximately 11:00 AM to 11:30 AM, observation of the installed fire sprinkler pendants revealed the following:

Existing Laundry room first floor: three (3) corroded heads
Kitchen: One (1) corroded head above the dishwashing station
First floor Com closet off Admin. Reception: sprinkler head blocked by
equipment rack with approximately twelve inches clearance from the
bottom of the pendant to the top of the racked equipment.

Actual NFPA standard:
NFPA 25
5.2.1 Sprinklers.
5.2.1.1* Sprinklers shall be inspected from the floor level
annually.
5.2.1.1.1* Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall).
5.2.1.1.2 Any sprinkler that shows signs of any of the following
shall be replaced:
(1) Leakage
(2) Corrosion
(3) Physical damage
(4) Loss of fluid in the glass bulb heat responsive element
(5)*Loading
(6) Painting unless painted by the sprinkler manufacturer
5.2.1.2* The minimum clearance required by the installation standard shall
be maintained below all sprinkler deflectors.

NFPA 13
8.5.6* Clearance to Storage.
8.5.6.1* Unless the requirements of 8.5.6.2, 8.5.6.3, 8.5.6.4, or 8.5.6.5 are met, the clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.

Based on observation the facility failed to ensure fire extinguishers were installed in accordance with NFPA 10. Failure to install fire extinguishers at the correct height could hinder access during a fire. This deficient practice affected staff and visitors on the date of the survey. The facility is licensed for 150 hospital beds and had a census of 66 on the day of exit.

Findings include:

During the facility tour conducted on November 28 and November 29, 2016 from approximately 9:00 AM to 12:00 PM, observation of the installed portable fire extinguishers revealed the following extinguishers were installed over the maximum height of 60 inches to the top of the extinguisher when measured from the finished floor:

· Mental Health Unit Nurse Station: 63 1/2 inches above floor
· Generator Room: 67 inches above floor
· Lab Room: 63 inches above floor

Upon further evaluation of the installed fire extinguisher on the 2nd floor mechanical room revealed an improper orientated arrow/sign directed towards an HVAC unit

When asked, the Maintenance Supervisor stated the facility was unaware of the height and orientation of the extinguishers

Actual NFPA standard:
NFPA 10
6.1.3.8 Installation Height.
6.1.3.8.1 Fire extinguishers having a gross weight not exceeding 40 l (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor.
6.1.3.3 Visual Obstructions.
6.1.3.3.1 Fire extinguishers shall not be obstructed or obscured
from view.
6.1.3.3.2* In large rooms and in certain locations where visual
obstructions cannot be completely avoided, means shall be
provided to indicate the extinguisher location.

Based on observation, operational testing, and interview the facility failed to maintain doors that protect corridor openings. Failure to maintain corridor doors could allow smoke and dangerous gases to pass freely between smoke compartments. This deficient practice affected patients, staff and visitors on the date of the survey. The facility is licensed for 150 hospital beds and had a census of 66 on the day of exit.

Findings include:

1.) During the facility tour on November 28, 2016 at approximately 1:00 PM observation and operational testing of the corridor door to room 328 on the third floor revealed the door would not latch when closed.

2.) During the facility tour on November 28, 2016 at approximately 1:00 PM observation and operational testing of the corridor door to room 331 on the third floor revealed the door would not latch when closed.

3.) During the facility tour on November 28, 2016 at approximately 2:30 PM observation and operational testing of the corridor door to room 234 on the second floor revealed the door would close due to a screw impeding the progress of the door.

When asked, the Maintenance Supervisor stated the facility was unaware the two room doors would not latch and a screw was impeding the door from closing.

*This deficiency was corrected by the end of survey

Actual NFPA Standards:
19.3.6.3* Corridor Doors.
19.3.6.3.1* Doors protecting corridor openings in other than
required enclosures of vertical openings, exits, or hazardous
areas shall be doors constructed to resist the passage of smoke
and shall be constructed of materials such as the following:
(1) 13/4 in. (44 mm) thick, solid-bonded core wood
(2) Material that resists fire for a minimum of 20 minutes

Based on observation, operational testing and interview, the facility failed to ensure smoke barrier doors would close properly when activated by the smoke detection system. Failure to ensure that smoke compartment doors closed completely could allow the spread of fire and allow the movement of smoke from one side of the barrier to the other. This deficient practice affected patients, staff and visitors on the date of the survey. The facility is licensed for 150 hospital beds and had a census of 66 on the day of exit.

Findings include:

1.) During the facility tour on November 28, 2016, at approximately 11:30 AM, operational testing of the cross corridor doors on the third floor entering Critical Care Unit revealed the doors would not close and seal properly.

2.) During the facility tour on November 28, 2016, at approximately 11:30 AM, operational testing of the cross corridor doors on the third floor in the Critical Care Unit on the North West side of Nursing station revealed would not close and seal properly.

3.) During the facility tour on November 29, 2016, at approximately 10:00 AM, operational testing of the 45 minute fire rated doors on the first floor entering the Emergency Department from the Imaging revealed a 3/4 inch gap between the doors when closed.

When asked, the Maintenance Supervisor stated the facility was unaware of the doors not closing properly and the gap between the two doors.

Actual NFPA standard:

NFPA 101
19.3.7.6 Openings in smoke barriers shall be protected using
one of the following methods:
(1) Fire-rated glazing
(2) Wired glass panels in steel frames
(3) Doors, such as 13/4 in. (44 mm) thick, solid-bonded woodcore
doors
(4) Construction that resists fire for a minimum of 20 minutes.
19.3.7.8* Doors in smoke barriers shall comply with 8.5.4 and
all of the following:
(1) The doors shall be self-closing or automatic-closing in accordance
with 19.2.2.2.7.
(2) Latching hardware shall not be required
(3) The doors shall not be required to swing in the direction
of egress travel.
19.3.7.6*
Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 19.2.2.2.6. Such doors in smoke barriers shall not be required to swing with egress travel. Positive latching hardware shall not be required.