HospitalInspections.org

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The inspector observed, while accompanied by the Maintenance Supervisor and the Quality Officer during the hours of the inspection from 8:30 am to 11:35 am on 7/25/2017 that there were the following issues. They were:
Annual inspection of doors in means of egress was not being conducted.

Fire-rated door assemblies and certain other doors in the means of egress shall be tested annually or per an accepted performance-based evaluation schedule approved by the AHJ per NFPA 80, 2010, Ch. 5.2. A written record of the inspections and testing shall be signed and kept for inspection by the AHJ. NFPA101, 7.2.1.15

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Fire doors near the front entry were being held open with door stops.

Fire doors shall be self-closing or automatic-closing. - NFPA 101, 2012, 8.3.3.3 & 7.2.1.8.
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The inspector observed, while accompanied by the Maintenance Supervisor and the Quality Officer during the hours of the inspection from 8:30 am to 11:35 am on 7/25/2017 that there were the following issues. They were:
Shelving it the gift shop storage room and at in the OR's Janitor's Closet was too close to the sprinkler heads.
"The clearance between the deflector and the top of storage shall be 18 inches or greater." - NFPA 13, 2010: 8.5.6.1.
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The inspector observed, while accompanied by the Maintenance Supervisor and the Quality Officer during the hours of the inspection from 8:30 am to 11:35 am on 7/25/2017 that there were the following issues. They were:
Flame Spread documentation for wall and ceiling finishes were not available for review during this inspection.
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The inspector observed, while accompanied by the Maintenance Supervisor and the Quality Officer during the hours of the inspection from 8:30 am to 11:35 am on 7/25/2017 that there were the following issues. They were:
Electrical Room near Gift Shop: Life Safety Panel: The fire alarm circuit breaker needs to be painted red to meet the following requirements.
"The circuit breaker at the electrical panel board for the fire alarm shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as "FIRE ALARM CIRCUIT CONTROL"" - NFPA 72, 2010: 10.5.5.2.2
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The inspector observed, while accompanied by the Maintenance Supervisor and the Quality Officer during the hours of the inspection from 8:30 am to 11:35 am on 7/25/2017 that there were the following issues. They were:
Please verify that the Class K fire extinguisher is within 30 feet of the hazardous cooking areas.

In Kitchens: "A placard shall be conspicuously placed near the extinguisher that states that the fire protection shall be activated prior to using the fire extinguisher." - NFPA 10, 2012: 5.5.5.3

"Class K fire extinguishers manufactured after January 1, 2002, shall not be equipped with "extended wand-type" discharge devices." - NFPA 10, 2012, 5.5.5.1 (Extended wand is a rigid black tube that was placed on the end of the typical hose attached to the extinguisher. It had a nozzle on the end of the extension. These are very rarely seen today.)

"Maximum travel distance shall not exceed 30 ft from the hazard to the extinguishers." - NFPA 10, 2012, 6.6.2
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The inspector observed, while accompanied by the Maintenance Supervisor and the Quality Officer during the hours of the inspection from 8:30 am to 11:35 am on 7/25/2017 that there were the following issues. They were:
Logs of air filter changes were not available for review at the time of inspection. And relative humidity logs for the operating rooms were not available for review.
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The inspector observed, while accompanied by the Maintenance Supervisor and the Quality Officer during the hours of the inspection from 8:30 am to 11:35 am on 7/25/2017 that there were the following issues. They were:
Fire drills were being conducted yearly. They are required to be conducted quarterly for each shift.
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The inspector observed, while accompanied by the Maintenance Supervisor and the Quality Officer during the hours of the inspection from 8:30 am to 11:35 am on 7/25/2017 that there were the following issues. They were:
Flame Spread documentation for draperies and curtains were not available for review during this inspection.
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The inspector observed, while accompanied by the Maintenance Supervisor and the Quality Officer during the hours of the inspection from 8:30 am to 11:35 am on 7/25/2017 that there were the following issues. They were:
Flame Spread documentation for furniture and mattresses were not available for review during this inspection.
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The inspector observed, while accompanied by the Maintenance Supervisor and the Quality Officer during the hours of the inspection from 8:30 am to 11:35 am on 7/25/2017 that there were the following issues. They were:
Pharmacy: The drug refrigerator was plugged into a white receptacle indicating that this receptacle is on the normal branch. The drug refrigerator must be plugged into the essential electrical system, which will be red receptacles.

"The critical branch of the emergency system shall supply power for task illumination, fixed equipment, selected receptacles, and selected power circuits serving the following areas and functions related to patient care: (3) Task illumination and selected receptacles in the following: (b) Medication preparation areas, (c) Pharmacy dispensing areas, (d) Nurses' stations (unless adequately lighted by corridor luminaires)." - NFPA 99, 2002, 4.4.2.2.2.3(3).
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The inspector observed, while accompanied by the Maintenance Supervisor and the Quality Officer during the hours of the inspection from 8:30 am to 11:35 am on 7/25/2017 that there were the following issues. They were:
Documents were not available for review showing that fire loss prevention protocol in operating rooms was being done.
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