HospitalInspections.org

NFPA 101, 39.3.3.2 Interior Wall and Ceiling Finish. Interior wall and ceiling finish complying with 10.2.3 shall be Class A, or Class B in exits and enclosed corridors furnishing access to exits; and Class A, Class B, or Class C in office areas.

10.2.3 Interior Wall or Ceiling Finish Testing and Classification. 10.2.3.1 Interior wall or ceiling finish that is required elsewhere in this Code to be Class A, Class B, or Class C, shall be classified based on test results from NFPA 255, Standard Method of Test of Surface Burning Characteristics of Building Materials.

Based on observation and document review, the facility failed to establish all wall coverings' interior finish flame spread rating to establish compliance.

Findings include:

On 6/13/13 at 11:00 AM in the Rawson-Neal's "Building 1", Administrative and Outpatient Clinic (West Charleston) - Rooms #6, #26, #28, and #41 had wood paneling. In room #32, carpet was applied 2.5 feet up a ten-foot high wall, on all sides. The facility did not have flame spread documentation to establish the flame spread rating values for the materials applied to these walls.

Based on observation the facility failed to ensure that self-closing doors opening onto a corridor did not have any impediment to closing.

Findings include:

On 6/12/13 at 10:10 AM a trash receptacle was holding the door to room C100 open, a restraint-type wheel chair was holding the door open to room C101. At 11:05 AM the door to room C164 was held open by a chair.

39.2.1.1 All means of egress shall be in accordance with Chapter 7 and this chapter.

Based on observation, the facility failed to ensure that all egress markings were properly installed.

Findings include:

On 6/13/13 in the East Las Vegas Clinic, at 4:00 PM a required exit sign was absent in the vicinity of the Pharmacy/Triage area.

Based on observation the facility failed to ensure that cross-corridor, smoke barrier doors were provided with astragals at the meeting edges.

Findings include:

On 6/11/13 at 10:15 AM the cross-corridor, smoke barrier doors between Rawson-Neal's building sections D and B had a 1/8th inch gap between the meeting edges.

Based on observation the facility failed to ensure that cross-corridor, smoke barrier doors were provided with astragals at the meeting edges.

Findings include:

On 6/11/13 at 10:30 AM the cross-corridor, smoke barrier doors between building sections G and F had a 1/8th inch gap between the meeting edges. The cross-corridor, smoke barrier doors between building sections E and F had a 1/8th inch gap between the meeting edges.

Based on observation the facility failed to ensure than a hazardous area was separated from a storage room with a smoke-resisting door.

Findings include:

The mechanical room in Building 3A was missing a door which at one time, separated the mechanical room from the storage room. The storage room did have a 20-minute fire-resistive, rated door, which opened onto the corridor.

Based on observation the facility failed to ensure that all soiled linen rooms were protected with a 3/4 hour, fire-rated door.

Findings include:

On 6/12/13 at 2:10 PM the rating plate on the door to soiled utility room E169, had a fire-resistive rating of 20 minutes.

On 6/12/13 at 2:48 PM the rating plate on the door to soiled utility room G169, had a fire-resistive rating of 20 minutes.

NFPA 13 (1996 ed.) 4-5.5 Obstructions to Sprinkler Discharge. 4-5.5.2 Obstructions to Sprinkler Discharge Pattern Development. 4-5.5.2.1 Continuous or noncontinuous obstructions less than 18 in. (457 mm) below the sprinkler deflector that prevent the pattern from fully developing shall comply with this section.

Based on observation the facility failed to insure that there were no obstructions 18 in. or less below the sprinkler deflector.

Findings include:

On 6/12/13 at 8:50 AM it was observed that suspended light fixtures were hung below sprinkler heads with a clearance of ten inches, or less. The rooms in which sprinkler patterns could have been affected were; B173, B178, B179, B169, B168, B167, B168b, B187, B164, B163.

Based on observation and record review, the facility failed to ensure that smokers utilized only designated smoking areas, used ashtrays of noncombustible material and safe design, and had access to metal containers with self-closing lids.

Findings include:

On 6/11/13 at 11:40 AM a covered area with a picnic table, east of Rawson-Neal's "Building D", was being used as a smoking area. Dozens of cigarette butts were observed scattered on the ground. Empty packages of cigarettes were found in the trash container. The trash container was made of combustible material. According to the facility's smoking policy, there is only one designated smoking area, and it was located north of the main entrance. On top of the resin trash container, there was an open, metal bowl for the disposal of extinguished, smoking material.

NFPA 110, 3-5.6.1 A remote, audible alarm powered by the storage battery shall be provided as specified in 3-5.5.2(d). This remote alarm shall be located outside of the Emergency Power Supply (EPS) service room at a work site readily observable by personnel.

Based on observation and staff interview, the facility failed to ensure that a remote, emergency generator annunciator panel was located where it could be readily observable by personnel.

Findings include:

On 6/12/13 at 2:48 PM the Facility Supervisor and this surveyor entered the storeroom containing the main fire alarm control panel, and searched for the remote annunciator for the emergency generator. The panel was discovered behind three boxes in the store room. The Facility Supervisor indicated that he was unaware that the annunciator panel had to be in a place which was readily observable.

NFPA 101
Chapter 39-5.1 Utilities shall comply with the provisions of Section 9-1
Chapter 9-1.2 Electrical wiring and equipment installed shall be in accordance with NFPA 70, National Electric Code.
Exception: Existing installations may be continued in service subject to approval by the authority having jurisdiction

NFPA 70, Section 400-8 Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(a) As a substitute for fixed wiring of a structure

Based on observation the facility failed to ensure that flexible cords were not used in lieu of fixed, permanent wiring.

Findings include:

On 6/11/13 at 4:30 PM a coffee maker was observed to be plugged into a power strip in room F115.

NFPA 101
Chapter 39-5.1 Utilities shall comply with the provisions of Section 9-1
Chapter 9-1.2 Electrical wiring and equipment installed shall be in accordance with NFPA 70, National Electric Code.
Exception: Existing installations may be continued in service subject to approval by the authority having jurisdiction

NFPA 70, Section 400-8 Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(a) As a substitute for fixed wiring of a structure

Based on observation the facility failed to ensure that flexible cords were not used in lieu of fixed, permanent wiring.

Findings include:

On 6/12/13 at 3:20 PM in room H157 a refrigerator was observed to be plugged into a power strip. At 3:40 PM a coffee pot was observed to be plugged into a power strip in room H101.

NFPA 101
Chapter 39-5.1 Utilities shall comply with the provisions of Section 9-1
Chapter 9-1.2 Electrical wiring and equipment installed shall be in accordance with NFPA 70, National Electric Code.
Exception: Existing installations may be continued in service subject to approval by the authority having jurisdiction

NFPA 70, Section 400-8 Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(a) As a substitute for fixed wiring of a structure

Based on observation the facility failed to ensure that flexible cords were not used in lieu of fixed, permanent wiring.

Findings include:

On 6/13/13 in the Human Resource building at 1321 South Jones, at 2:45 PM, a microwave and refrigerator were plugged into a power strip in an office near the south exit door. Also, a refrigerator was plugged into a power strip in the conference room.

NFPA 101
Chapter 39-5.1 Utilities shall comply with the provisions of Section 9-1
Chapter 9-1.2 Electrical wiring and equipment installed shall be in accordance with NFPA 70, National Electric Code.
Exception: Existing installations may be continued in service subject to approval by the authority having jurisdiction.

NFPA 70, Section 400-8 Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(a) As a substitute for fixed wiring of a structure

Based on observation the facility failed to ensure that flexible cords were not used in lieu of fixed, permanent wiring.

Findings include:

On 6/12/13 at 11:05 AM in room C164 a refrigerator was observed to be plugged into a power strip.

Based on observation the facility failed to ensure that alcohol-based hand rub dispensers were not located over ignition sources.

Findings include:

On 6/12/13 at 2:27 PM an alcohol-based hand rub (ABHR) dispenser was found located over a speaker, volume-control device at the nurses station in Rawson-Neal's "D-Pod". This ABHR dispenser was removed during the survey.

NFPA 101, 39.3.3.2 Interior Wall and Ceiling Finish. Interior wall and ceiling finish complying with 10.2.3 shall be Class A, or Class B in exits and enclosed corridors furnishing access to exits; and Class A, Class B, or Class C in office areas.

10.2.3 Interior Wall or Ceiling Finish Testing and Classification. 10.2.3.1 Interior wall or ceiling finish that is required elsewhere in this Code to be Class A, Class B, or Class C, shall be classified based on test results from NFPA 255, Standard Method of Test of Surface Burning Characteristics of Building Materials.

Based on observation and document review, the facility failed to establish all wall coverings' interior finish flame spread rating to establish compliance.

Findings include:

On 6/13/13 at 11:00 AM in the Rawson-Neal's "Building 1", Administrative and Outpatient Clinic (West Charleston) - Rooms #6, #26, #28, and #41 had wood paneling. In room #32, carpet was applied 2.5 feet up a ten-foot high wall, on all sides. The facility did not have flame spread documentation to establish the flame spread rating values for the materials applied to these walls.

Based on observation the facility failed to ensure that self-closing doors opening onto a corridor did not have any impediment to closing.

Findings include:

On 6/12/13 at 10:10 AM a trash receptacle was holding the door to room C100 open, a restraint-type wheel chair was holding the door open to room C101. At 11:05 AM the door to room C164 was held open by a chair.

39.2.1.1 All means of egress shall be in accordance with Chapter 7 and this chapter.

Based on observation, the facility failed to ensure that all egress markings were properly installed.

Findings include:

On 6/13/13 in the East Las Vegas Clinic, at 4:00 PM a required exit sign was absent in the vicinity of the Pharmacy/Triage area.

Based on observation the facility failed to ensure that cross-corridor, smoke barrier doors were provided with astragals at the meeting edges.

Findings include:

On 6/11/13 at 10:15 AM the cross-corridor, smoke barrier doors between Rawson-Neal's building sections D and B had a 1/8th inch gap between the meeting edges.

Based on observation the facility failed to ensure that cross-corridor, smoke barrier doors were provided with astragals at the meeting edges.

Findings include:

On 6/11/13 at 10:30 AM the cross-corridor, smoke barrier doors between building sections G and F had a 1/8th inch gap between the meeting edges. The cross-corridor, smoke barrier doors between building sections E and F had a 1/8th inch gap between the meeting edges.

Based on observation the facility failed to ensure than a hazardous area was separated from a storage room with a smoke-resisting door.

Findings include:

The mechanical room in Building 3A was missing a door which at one time, separated the mechanical room from the storage room. The storage room did have a 20-minute fire-resistive, rated door, which opened onto the corridor.

Based on observation the facility failed to ensure that all soiled linen rooms were protected with a 3/4 hour, fire-rated door.

Findings include:

On 6/12/13 at 2:10 PM the rating plate on the door to soiled utility room E169, had a fire-resistive rating of 20 minutes.

On 6/12/13 at 2:48 PM the rating plate on the door to soiled utility room G169, had a fire-resistive rating of 20 minutes.

NFPA 13 (1996 ed.) 4-5.5 Obstructions to Sprinkler Discharge. 4-5.5.2 Obstructions to Sprinkler Discharge Pattern Development. 4-5.5.2.1 Continuous or noncontinuous obstructions less than 18 in. (457 mm) below the sprinkler deflector that prevent the pattern from fully developing shall comply with this section.

Based on observation the facility failed to insure that there were no obstructions 18 in. or less below the sprinkler deflector.

Findings include:

On 6/12/13 at 8:50 AM it was observed that suspended light fixtures were hung below sprinkler heads with a clearance of ten inches, or less. The rooms in which sprinkler patterns could have been affected were; B173, B178, B179, B169, B168, B167, B168b, B187, B164, B163.

Based on observation and record review, the facility failed to ensure that smokers utilized only designated smoking areas, used ashtrays of noncombustible material and safe design, and had access to metal containers with self-closing lids.

Findings include:

On 6/11/13 at 11:40 AM a covered area with a picnic table, east of Rawson-Neal's "Building D", was being used as a smoking area. Dozens of cigarette butts were observed scattered on the ground. Empty packages of cigarettes were found in the trash container. The trash container was made of combustible material. According to the facility's smoking policy, there is only one designated smoking area, and it was located north of the main entrance. On top of the resin trash container, there was an open, metal bowl for the disposal of extinguished, smoking material.

NFPA 110, 3-5.6.1 A remote, audible alarm powered by the storage battery shall be provided as specified in 3-5.5.2(d). This remote alarm shall be located outside of the Emergency Power Supply (EPS) service room at a work site readily observable by personnel.

Based on observation and staff interview, the facility failed to ensure that a remote, emergency generator annunciator panel was located where it could be readily observable by personnel.

Findings include:

On 6/12/13 at 2:48 PM the Facility Supervisor and this surveyor entered the storeroom containing the main fire alarm control panel, and searched for the remote annunciator for the emergency generator. The panel was discovered behind three boxes in the store room. The Facility Supervisor indicated that he was unaware that the annunciator panel had to be in a place which was readily observable.

NFPA 101
Chapter 39-5.1 Utilities shall comply with the provisions of Section 9-1
Chapter 9-1.2 Electrical wiring and equipment installed shall be in accordance with NFPA 70, National Electric Code.
Exception: Existing installations may be continued in service subject to approval by the authority having jurisdiction

NFPA 70, Section 400-8 Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(a) As a substitute for fixed wiring of a structure

Based on observation the facility failed to ensure that flexible cords were not used in lieu of fixed, permanent wiring.

Findings include:

On 6/11/13 at 4:30 PM a coffee maker was observed to be plugged into a power strip in room F115.

NFPA 101
Chapter 39-5.1 Utilities shall comply with the provisions of Section 9-1
Chapter 9-1.2 Electrical wiring and equipment installed shall be in accordance with NFPA 70, National Electric Code.
Exception: Existing installations may be continued in service subject to approval by the authority having jurisdiction

NFPA 70, Section 400-8 Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(a) As a substitute for fixed wiring of a structure

Based on observation the facility failed to ensure that flexible cords were not used in lieu of fixed, permanent wiring.

Findings include:

On 6/12/13 at 3:20 PM in room H157 a refrigerator was observed to be plugged into a power strip. At 3:40 PM a coffee pot was observed to be plugged into a power strip in room H101.

NFPA 101
Chapter 39-5.1 Utilities shall comply with the provisions of Section 9-1
Chapter 9-1.2 Electrical wiring and equipment installed shall be in accordance with NFPA 70, National Electric Code.
Exception: Existing installations may be continued in service subject to approval by the authority having jurisdiction

NFPA 70, Section 400-8 Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(a) As a substitute for fixed wiring of a structure

Based on observation the facility failed to ensure that flexible cords were not used in lieu of fixed, permanent wiring.

Findings include:

On 6/13/13 in the Human Resource building at 1321 South Jones, at 2:45 PM, a microwave and refrigerator were plugged into a power strip in an office near the south exit door. Also, a refrigerator was plugged into a power strip in the conference room.

NFPA 101
Chapter 39-5.1 Utilities shall comply with the provisions of Section 9-1
Chapter 9-1.2 Electrical wiring and equipment installed shall be in accordance with NFPA 70, National Electric Code.
Exception: Existing installations may be continued in service subject to approval by the authority having jurisdiction.

NFPA 70, Section 400-8 Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(a) As a substitute for fixed wiring of a structure

Based on observation the facility failed to ensure that flexible cords were not used in lieu of fixed, permanent wiring.

Findings include:

On 6/12/13 at 11:05 AM in room C164 a refrigerator was observed to be plugged into a power strip.