HospitalInspections.org

Based on observation, record review and facility staff interview, the building does not meet the building construction type to be a hospital, the building is a Type II (000) unprotected construction without complete sprinkler coverage, which is not allowed to be used as a hospital. This type of construction puts all patients, staff and visitors at a higher risk of injury or death from a fire. Additionally, facility staff constructed an attached overhang to the building with a construction type of V (000) unprotected wood frame, a prohibited construction type for hospitals. Constructing an attached type V (000) unprotected wood frame overhang to a type II (000) puts all patients,staff and visitors at a higher risk of injury or death from a fire. The facility census was 10.

1. Observation on 8/23/17, during the facility tour, showed an overhang attached to the building outside of the kitchen exit. Observation showed the exit designated for patients, staff and visitors. Observation showed the overhang constructed of wood (type V (000) with no protection. Observation showed the overhang attached to a biohazard shed.

During an interview on 8/24/17 at 12:10 P.M., The Director of Facility Services said that he did not know the overhang presented a hazard.

2. Observations during the facility tour showed the following:

Observations during the facility tour showed the building did not have sprinkler coverage for approximately 11,668 square feet of the building.

Observations showed the building had partial sprinkler coverage for approximately 36,673 square feet of the building.

Observation showed the building had complete sprinkler coverage for approximately 8,413 square feet of the building.

3. Record review of the facility supplied sprinkler coverage map showed the following zones size and designations:

-Zone HB-01 Business and other uses, no sprinkler coverage 14,231 square feet
-Zone HB-02 Existing Healthcare, partial sprinkler coverage 20,861 square feet
-Zone HB-03 Existing Healthcare, partial sprinkler coverage 2,683 square feet
-Zone HB-04 Existing Healthcare, no sprinkler coverage 3,062 square feet
-Zone HB-05 Existing Healthcare, partial sprinkler coverage 15,812 square feet
-Zone HB-06 Existing Healthcare, partial sprinkler coverage 5,923 square feet


Record review of National Fire Protection Association 101, 2012 edition, Table 19.1.6.1 Construction Type Limitations shows Type II (000) one story construction requires complete sprinkler coverage.

Based on observation and staff interview facility staff failed to provide two exits without passing through an intervening room. The facility census was 10.

1. Observation on 8/23/17, during the facility tour, showed one of two exits on the administrative hall required patients, staff and visitors to pass through an intervening room to exit the building. Observation showed a room labeled "Receiving" that patients, staff and visitors would have to pass through to exit the building.

During an interview on 8/24/17 at 12:15 P.M., The Director of Facility Services said that he did not know that passing through a intervening room presented a hazard.

National Fire Protection Association 101, 2012 edition, section 19.2.5.4 Intervening Rooms or Spaces states: "Every corridor shall provide access to not less than two approved exits in accordance with Sections 7.4 and 7.5 without passing through any intervening rooms or spaces other than corridors or lobbies."

Based on observation and facility staff interview, facility staff failed to ensure all designated exit corridors are illuminated with emergency egress lights not controlled by a light switch. Six of ten designated exit corridors contained switches controlling the emergency egress lighting fixtures. Failure to provide emergency egress lighting not controlled by a light switch has the potential to effect all facility occupants. This deficient practice could delay the safe evacuation of patients, staff and visitors in the event of an emergency. The facility census was 10.

1. Observation on 8/23/17, during the facility tour, showed the following designated exit corridors contained switches that controlled the emergency egress lighting fixtures:

- Front entrance corridor;
- Physical therapy corridor;
- Emergency Department corridor;
- Intensive Care Unit corridor;
- Swing Bed corridor;
- West Hall corridor.

During an interview on 8/24/17 at 11:10 A.M.. the Director of Facility Services said that he did not know that switches could not control emergency egress lighting.

National Fire Protection Association 101, 2012 edition, section 19.2.8 states:

"19.2.8 Illumination of Means of egress. Means of egress shall be illuminated in accordance with Section 7.8

7.8.1.2 Illumination of means of egress shall be continuous during the time that the conditions of occupancy that the means of egress be available for use, unless otherwise provided in 7.8.1.2.2"

Based on observation, record review and facility staff interview, facility staff failed to ensure emergency lighting inside one of one operating room functioned and was tested for 1 1/2 hours annually and 30 seconds a month per NFPA 101 requirements. Additionally, the operating room suite and pre/post operative alcove lights were controlled by light switches. These deficient practices have the potential to affect all patients, staff and visitors. Failure to provide and test emergency lighting could prevent proper illumination of required areas in the event of power loss. The facility census was 10.

1. Observations on 03/23/17, during the Life Safety Code (LCS) tour, showed the emergency battery powered light fixtures in the operating room ran for approximately 30 seconds then dimmed and turned off when tested.

2. Record review did not show 30 second monthly test logs or 1 1/2 hour annual test logs for the operating room emergency battery powered lights.

3. Observations on 03/23/17, during the Life Safety Code (LCS) tour, showed all of the operating room suite lights controlled by light switches.

During an interview on 3/24/17 at 11:59 A.M., the Director of Facility Services said the medication room lights always had light switches and were installed during the building construction.

NFPA 101, 2012 edition, Section 7.9.2.7 states: "7.9.2.7 The emergency lighting system shall be either continuously in operation or shall be capable of repeated automatic
operation without manual intervention."

NFPA 99, 2012 edition, section 6.4.2.2.4.2 states:

"6.4.2.2.4.2 The critical branch shall supply power for task illumination,
fixed equipment, select receptacles, and select power
circuits serving the following areas and functions related to patient
care:
(1) Critical care areas that utilize anesthetizing gases, task illumination,
select receptacles, and fixed equipment
(2) Isolated power systems in special environments
(3) Task illumination and select receptacles in the following:
(a) Patient care rooms, including infant nurseries, selected
acute nursing areas, psychiatric bed areas (omit receptacles),
and ward treatment rooms
(b) Medication preparation areas
(c) Pharmacy dispensing areas
(d) Nurses ' stations (unless adequately lighted by corridor
luminaires)
(4) Additional specialized patient care task illumination and
receptacles, where needed
(5) Nurse call systems
(6) Blood, bone, and tissue banks
(7)*Telephone equipment rooms and closets
(8) Task illumination, select receptacles, and select power circuits
for the following areas:
(a) General care beds with at least one duplex receptacle
per patient bedroom, and task illumination as required
by the governing body of the health care facility
(b) Angiographic labs
(c) Cardiac catheterization labs
(d) Coronary care units
(e) Hemodialysis rooms or areas
(f) Emergency room treatment areas (select)
(g) Human physiology labs
(h) Intensive care units
(i) Postoperative recovery rooms (select)
(9) Additional task illumination, receptacles, and select power
circuits needed for effective facility operation, including
single-phase fractional horsepower motors, which are permitted
to be connected to the critical branch"



7.9.2.6* Existing battery-operated emergency lights shall use
only reliable types of rechargeable batteries provided with suitable
facilities for maintaining them in properly charged condition.
Batteries used in such lights or units shall be approved
for their intended use and shall comply with NFPA 70, National
Electrical Code.

7.9.2.7 The emergency lighting system shall be either continuously
in operation or shall be capable of repeated automatic
operation without manual intervention.

7.9.3 Periodic Testing of Emergency Lighting Equipment.

7.9.3.1 Required emergency lighting systems shall be tested in
accordance with one of the three options offered by 7.9.3.1.1,
7.9.3.1.2, or 7.9.3.1.3.

7.9.3.1.1 Testing of required emergency lighting systems
shall be permitted to be conducted as follows:
(1) Functional testing shall be conducted monthly, with a
minimum of 3 weeks and a maximum of 5 weeks between
tests, for not less than 30 seconds, except as otherwise
permitted by 7.9.3.1.1(2).
(2)*The test interval shall be permitted to be extended beyond
30 days with the approval of the authority having
jurisdiction.
(3) Functional testing shall be conducted annually for a minimum
of 11.2 hours if the emergency lighting system is battery
powered.
(4) The emergency lighting equipment shall be fully operational
for the duration of the tests required by 7.9.3.1.1(1)
and (3).
(5) Written records of visual inspections and tests shall be
kept by the owner for inspection by the authority having
jurisdiction.

7.9.3.1.2 Testing of required emergency lighting systems
shall be permitted to be conducted as follows:
(1) Self-testing/self-diagnostic battery-operated emergency
lighting equipment shall be provided.
(2) Not less than once every 30 days, self-testing/self-diagnostic
battery-operated emergency lighting equipment shall automatically
perform a test with a duration of a minimum of
30 seconds and a diagnostic routine.
(3) Self-testing/self-diagnostic battery-operated emergency
lighting equipment shall indicate failures by a status indicator.
(4) A visual inspection shall be performed at intervals not exceeding
30 days.
(5) Functional testing shall be conducted annually for a minimum
of 11.2 hours.
(6) Self-testing/self-diagnostic battery-operated emergency
lighting equipment shall be fully operational for the duration
of the 11.2-hour test.
(7) Written records of visual inspections and tests shall be
kept by the owner for inspection by the authority having
jurisdiction."

Based on observation and facility staff interview, the facility failed to ensure a fire resistance rating of at least one hour between floors. The facility census was 10.

1. Observation on 8/23/17, during the facility tour, showed two, four inch in diameter holes in the concrete floor of the sterilizer room on the administrative hall. Observation showed the two holes led to the basement which contained an excessive amount of paper files. Observation showed the room contained two sterilizer that emitted excessive amounts of heat. Observation showed the double doors to the sterilizer room did not have a rating, was not equipped with self closing devices and had manual flush bolts.

During an interview on 8/24/17, at 12:14 P.M., The Director of Facility Services, said that he did not know the holes in the floor presented a hazard.

National Fire Protection Association 101, 2012 edition, section 19.3 states:

"19.3 Protection.

19.3.1 Protection of Vertical Openings. Any vertical opening
shall be enclosed or protected in accordance with Section 8.6,
unless otherwise modified by 19.3.1.1 through 19.3.1.8."

Based on observation and facility staff interview, facility staff failed to provide a one hour separation between a hazardous area (areas that pose a degree of hazard greater than normal to the general occupancy of the building such as areas used for storage or use of combustibles or flammables, toxic, noxious, or corrosive materials, or heat producing appliances). Failure to separate the designated exit corridors and provide the the one hour rated doors with self closures puts all patients, staff and visitors at risk of injury or death from a fire by not containing the fire and smoke within the hazardous area. The facility census was 10.

1. Observation on 8/23/17, during the facility tour, showed the following;

- The clean linen room on the administrative hall contained an excessive amount of linens (considered a heavy fuel load). Further observation showed the room did not have sprinkler coverage. Observation showed an unrated door on the room that separated the room from the exit corridor. Observation showed the room exceeded 50 square feet.

- The emergency room soiled linen/trash collection room did not have separation from the room and exit corridor. Further observation showed the room did not have sprinkler coverage. Observation showed the room contained excessive amounts of soiled linen and trash that exceeded 64 gallons.

- The purchasing room contained an excessive amount of combustible materials. Further observation showed the room did not have sprinkler coverage. Observation showed an unrated door on the room that separated the room from the exit corridor. Observation showed the room exceeded 50 square feet.

- The Medical records store room contained an excessive amount of combustible materials. Further observation showed the room did not have sprinkler coverage. Observation showed no door to the room. Observation showed the room exceeded 50 square feet.

During an interview on 8/24/17 at 11:50 P.M., the Director of Facility Services said that he did not know the doors were unrated. The Director of Facility Services said that he did not know the emergency room soiled linen/trash collection room was considered hazardous.

National Fire Protection Association 101, 2012 edition, section 19.32.1.5 states:

"19.3.2.1.5 Hazardous areas shall include, but shall not be restricted to the following:

(1) Boiler and fuel fired heater rooms
(2) Central bulk laundries larger than 100 ft2
(3) Paint Shops
(4) Repair Shops
(5) Rooms with soiled linen in volume exceeding 64 gallons
(6) Rooms with collected trash in volume exceeding 64 gallons
(7) Rooms or spaces larger than 50 ft2, including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the AHJ."

Based on observation and facility staff interview, facility staff failed to secure oxygen valves. This deficient practice has the potential to affect the health and welfare of any patient undergoing surgery in that operating room. The facility census was 10.

1. Observation on 8/23/17, during the facility tour, showed an unsecured oxygen valve on the physical therapy hall. Observation showed the physical therapy hallway accessible to patients, staff and visitors.

During an interview on 8/24/17 at 10:43 A.M., The Director of Facility Services said that the oxygen valve controls oxygen that serves the emergency room. The Director of Facility Services said that if the valve is closed the emergency room will lose the oxygen supply.

NFPA 99, 2012 edition, section 5.1.4.2 states: "Accessibility. All valves, except valves in zone valve assemblies, shall be located in secured areas such as locked piped chases, or be locked or latched in their operating position, and be labeled as to gas supplied and the areas controlled."

Based on observation and facility staff interview, the facility staff failed to provide and maintain one of one kitchen range hood in accordance with National Fire Protection Association (NFPA) 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 edition requirements. These deficient practices have the potential to effect all facility residents. Failure to maintain the range hood could effect the range hood's ability to contain grease fires. This deficient practice effects one of one kitchen range hood systems. The facility census was 10.

1. Observation on 8/23/17, during the facility tour, showed the range hood did not have a an enclosed metal container to collect grease from the drip tray.

During an interview on 8/23/17 at 11:30 A.M., The Director of Facility Services said he did not know the range hood required a grease collection container.

NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 edition, section 6.2.4.1 states: "Grease filters shall be equipped with a grease drip-tray beneath their lower edges.

2. Observation on 8/24/2017, during the facility tour, showed the kitchen range hood did not have an adequate supply air intake for make up air. Observation showed the range hood exhaust fan pulling make up air from the HVAC system and corridor air through kitchen doorways preventing the doors to self close.

During an interview on 8/24/17 at 11:30 A.M., The Director of Facility Services said he did not know the range hood pulled make up air from the HVAC system and corridor air.

NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 edition, section 8.3 states:

"8.3* Replacement Air.

8.3.1 Replacement air quantity shall be adequate to prevent
negative pressures in the commercial cooking area(s) from
exceeding 4.98 Pa (0.02 in. water column).

8.3.2 When the fire-extinguishing system activates, makeup
air supplied internally to a hood shall be shut off."

3. Observation on 8/24/2017, during the facility tour, showed the kitchen range hood did not have an electrical shut off device.

Record review of the range hood inspection reports dated 5/24/2016 and 7/26/2017 have notations stating: "No automatic electric shutoff".

NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 edition, section 10.4 states:

"10.4 Fuel and Electric Power Shutoff.

10.4.1 Upon activation of any fire-extinguishing system for a
cooking operation, all sources of fuel and electrical power that
produce heat to all equipment requiring protection by that
system shall automatically shut off.

10.4.2 Steam supplied from an external source shall not be
required to automatically shut off.

10.4.3 Any gas appliance not requiring protection but located
under the same ventilating equipment shall also automatically
shut off upon activation of any extinguishing system.

10.4.4 Shutoff devices shall require manual reset."

4. Record review of the range hood inspection report dated 7/26/2017 has a notation stating: "Microswitch not hooked up".

Record review of the annual fire alarm inspection dated 7/03/2017 did not show a connection test between the range hood extinguishing system and the fire alarm control panel.

NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 edition, section 10.6 states:

"10.6 System Annunciation.

10.6.1 Upon activation of an automatic fire-extinguishing system,
an audible alarm or visual indicator shall be provided to
show that the system has activated.

10.6.2 Where a fire alarm signaling system is serving the occupancy
where the extinguishing system is located, the activation
of the automatic fire-extinguishing system shall activate
the fire alarm signaling system."

5. Record review of the most recent range hood inspection reports dated 12/02/2016 and 7/26/2017 showed seven months and 26 days between the inspections.

NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 edition, section 11.2 states:

"11.2 Inspection, Testing, and Maintenance of Fire-Extinguishing
Systems.

11.2.1* Maintenance of the fire-extinguishing systems and
listed exhaust hoods containing a constant or fire-activated
water system that is listed to extinguish a fire in the grease
removal devices, hood exhaust plenums, and exhaust ducts
shall be made by properly trained, qualified, and certified person(
s) acceptable to the authority having jurisdiction at least
every 6 months."

Based on observation and facility staff interview, the facility staff failed to ensure interior ceiling and wall finishes met Class A or Class B flame spread requirements. The facility census was 10.

1. Observation on 8/23/17, during the facility tour, showed the business office wall contained wood board wainscoting on the walls. Observation showed the business office on an exit corridor.

During an interview on 8/23/17 at 4:00 P.M., The Director of Facility Services said that the wood board wainscoting is combustible.

Observation showed the building sprinkler system did not meet NFPA 13, Standard For the Installation of Sprinkler Systems, 2010 edition, installation requirements.

National Fire Protection Association 101, 2012 edition, section 19.3.3.2 states:


"19.3.3.2* Interior Wall and Ceiling Finishes. Existing interior wall and ceiling finish materials complying with Section 10.2 shall be permitted to be Class A or Class B."

Based on observation and facility staff interview, the facility failed to ensure that one of one fire alarm systems was installed per NFPA 72, National Fire Alarm and Signaling Code, 2010 edition. The deficient practice has the potential to effect all facility patients, staff and visitors. The deficient practice could delay fire and emergency personnel response in the event of a fire. The facility census was 10.

1. Observation on 8/23/17, during the facility tour, showed all exit corridors and areas where patients, staff and visitors congregate, did not have complete smoke detector coverage. Observation showed the following:

- Front Entrance Corridor did not have any smoke detectors to the barrier doors in the corridor to the barrier doors in the lobby area;

- Lobby Area did not have smoke detectors;

- Cafeteria did not have smoke detectors;

- Administrative Hall did not have smoke detector coverage to the barrier doors near the kitchen entrance. Observation showed the hall measured 90 feet;

- Administrative Hall after the smoke barrier doors only contained one smoke detector. Observation showed the smoke detector near the smoke barrier doors. Observation showed 63 feet of the hall did not have smoke detector coverage.

- Physical Therapy Hall did not have smoke detector coverage to the barrier doors leading to the emergency room corridor. Observation showed the corridor measured 55 feet;

- Emergency room corridor did not have smoke detector coverage. Observation showed the corridor measured 68 feet.

- X-Ray corridor only contained one smoke detector. Observation showed the smoke detector near the smoke barrier doors. Observation showed 70 feet of the hall did not have smoke detector coverage;

- Swing Bed corridor, to the barrier doors, only contained one smoke detector. Observation showed the detector near the smoke barrier doors. Observation showed 40 feet of the hall did not have smoke detector coverage;

- Swing Bed corridor, after the barrier doors, only contained one smoke detector. Observation showed the detector near the smoke barrier doors. Observation showed 56 feet of the hall did not have smoke detector coverage;

- West Hall, to the barrier doors, only contained one smoke detector. Observation showed the detector near the smoke barrier doors. Observation showed 44 feet of the hall did not have smoke detector coverage;

- South Hall, to the barrier doors, only contained one smoke detector. Observation showed the detector near the smoke barrier doors. Observation showed 82 feet of the hall did not have smoke detector coverage.

During an interview on 8/24/17 at 11:00 A.M., The Director of Facility Services said that the facility did not have complete smoke detector coverage.

National Fire Protection Association 101, 2012 edition, section 19.3.4.1 states:


"19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6."

Refer to NFPA 72, National Fire Alarm and Signaling Code, 2010 edition, sections 17.6.3 Location and Spacing and 17.6.3.3.1 Spacing for additional information.

Based on observation and staff interview the facility failed to install manual fire alarm boxes near each required exit. The facility census was 10.

1. Observation on 8/23/17, during the facility tour, showed the exit that serves the administrative hall, off of the kitchen entrance, did not have a manual fire alarm box at or in the path of egress of the exit. Observation showed the exit could possibly serve patient's, staff and visitors in an emergency.

During an interview on 8/24/17 at 11:06 A.M., the Director of Facilities Services said that the exit did not have a pull station.

The National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, section 9.6.2.3 states,

"A manual fire alarm box shall be provided as follows, unless modified by another section of this code:

(1) For new alarm system installations, the manual fire alarm box shall be located within 60 in. (1525 mm) of exit doorways.

(2) For existing alarm system installations, the manual fire alarm box either shall be provided in the natural access path near each required exit or within 60 in. (1525 mm) of exit doorways."

Based on observation and facility staff interview, the facility failed to secure the fire alarm control panel against unauthorized use. The facility census was 10.

1. Observation on 8/23/17, during the facility tour, showed a key in the fire alarm control panel. Observation showed the fire alarm control panel in Swing Bed Corridor.

During an interview on 8/23/17 at 4:17 P.M., The Director of Facility Services said that fire alarm control panel key should be secured.

NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition, Section 10.11.5.2 states: " The means shall be key operated or located within a locked cabinet, or arranged to provide equivalent protection against unauthorized use.

Based on record review and facility staff interview, facility staff did not ensure all devices connected to the fire alarm system were inspected and tested per NFPA 72, National Fire Alarm and Signaling Code, 2010 edition. This deficient practice has the potential to affect all patients, staff and visitors. Failure to inspect/test all components connected to the fire alarm system could delay emergency services response and evacuation out of the building in the event of a fire or other emergency. The facility census was 10.

Record review of the annual fire alarm inspection dated 07/03/2017 did not show inspections and connection function tests for the following:


- 29 fire alarm audible/visual signaling devices
-sprinkler system tamper alarm
-sprinkler system flow alarm
-sprinkler system Post Indicator Valve (PIV)
-semi annual fire alarm testing
-kitchen range hood to fire alarm connection

During an interview on 8/24/2017, the Director of Facilities Services said he believed the fire alarm inspection company did the inspections per code requirements.

Refer to NFPA 72, National Fire Alarm and Signaling Code, 2010 edition, Table 14.3.1, Table 14.4.2.2, Table 14.4.5, sections 14.4.5, 14.4.5.3.1 through section 14.4.5.4 for additional testing information.

Based on observation and facility staff interview, facility staff failed to sprinkler the building in accordance with the National Fire Protection Association (NFPA) 13, Standard for the Installation of Sprinkler Systems, 2010 edition. The facility census was 10.

Observation on 8/23/17, during the facility tour showed the following:

1. Observation showed the building construction type as Type II (000). Type II (000) construction type requires complete sprinkler coverage.

2. Observation showed the facility did not have sprinkler coverage in corridors, resident rooms or in auxiliary spaces.

3. During an interview on 8/24/17 at 11:06 A.M., the Director of Facility Services said that the facility does not have sprinkler coverage.

Record review of National Fire Protection Association 101, 2012 edition, Table 19.1.6.1 Construction Type Limitations shows Type II (000) one story construction requires complete sprinkler coverage.

Based on record review and facility staff interview, the facility staff failed to ensure the sprinkler supervisory alarms were installed and monitored per NFPA 72, National Fire Alarm and Signaling Code, 2010 edition. The facility census was 10.

Observations during the facility tour showed the following devices connected to the facility sprinkler system:

-sprinkler system tamper alarm
-sprinkler system flow alarm
-sprinkler system Post Indicator Valve (PIV)

Record review of the annual fire alarm inspection dated 07/03/2017 did not show inspections and connection function tests for the following:

-sprinkler system tamper alarm
-sprinkler system flow alarm
-sprinkler system Post Indicator Valve (PIV)

During an interview on 8/24/2017, the Director of Facilities Services said he believed the fire alarm inspection company did the inspections per code requirements.

NFPA 101, 2012 edition, Section 9.7.2 states:

"9.7.2 Supervision.

9.7.2.1* Supervisory Signals. Where supervised automatic
sprinkler systems are required by another section of this Code,
supervisory attachments shall be installed and monitored for
integrity in accordance with NFPA 72, National Fire Alarm and
Signaling Code, and a distinctive supervisory signal shall be provided
to indicate a condition that would impair the satisfactory
operation of the sprinkler system. Supervisory signals shall
sound and shall be displayed either at a location within the
protected building that is constantly attended by qualified personnel
or at an approved, remotely located receiving facility."

Based on observation and interview, facility staff failed to ensure that all corridor doors are capable of resisting the passage of smoke. The facility census was 10.

1. Observation on 8/23/17, during the facility tour showed door kickdowns on the following corridor doors:

- Cafeteria door in lobby area;
- Kitchen door on administrative hall;
- Emergency Room trauma room door;
- Cat Scan Room door on X-ray corridor;
- Volunteer Storeroom door;
- Ultrasound Room door.

National Fire Protection Association 101, 2012 edition, section 19.3.6.3.10 states:

"19.3.6.3.10* Doors shall not be held open by devices other
than those that release when the door is pushed or pulled."

2. Observation on 8/31/17, during the facility tour, showed the following doors did not positively latch:

- Scope Room door on ;
- Emergency Room door;
- X-Ray Room #1 door;
- X-Ray Room #2 door;
- Cat Scan Room door;
- Empty Oxygen Tank room door on Swing Bed corridor;
- Empty Oxygen/Full Oxygen tank room door on Swing Bed corridor;
- Marketing Office room door


NFPA 101, 2012 edition, Section 19.3.6.3.5 states:

"19.3.6.3.5* Doors shall be provided with a means for keeping
the door closed that is acceptable to the authority having jurisdiction,
and the following requirements also shall apply:
(1) The device used shall be capable of keeping the door fully
closed if a force of 5 lbf (22 N) is applied at the latch edge
of the door.
(2) Roller latches shall be prohibited on corridor doors in
buildings not fully protected by an approved automatic
sprinkler system in accordance with 19.3.5.7."


3. During an interview on 8/24/17 at 11:27 A.M., The Director of Facility Services said that he did not know that the doors may not resist the passage of smoke.

19172

Based on observation and facility staff interview, the facility failed to ensure three soiled utility rooms was adequately vented and kept under negative pressure. This deficient practice has the potential to effect all residents, staff and visitors. Failure to provide adequate ventilation could increase the concentration of smoke, products of combustion and noxious fumes. The facility census was 10.

1. Observation on 8/23/17, during the facility tour, showed the following soiled utility rooms did not have functioning exhaust ventilation:

- emergency room soiled linen room;
- intensive care unit soiled linen room;
- south hall soiled linen room.
- Operating room suite soiled/biohazard room

During an interview on 8/24/17 at 12:08 P.M., The Director of Facility Services said that he did not know the exhaust ventilation did not work.

19172

Based on observation and facility staff interview, the facility failed to provide a means of egress without suspended unit heaters. The facility census was 10.

1. Observation on 8/23/17, during the facility tour, showed a suspended unit heater in a room labeled "Receiving" on the Administration hallway. Observation showed the room labeled "Receiving" on the Administration hallway was used as an intervening room in the path of egress used to get to the designated exit.

During an interview on 8/24/17 at 10:43 A.M., The Director of Facility Services said that he did not know the suspended heater was a hazard.

National Fire Protection Association 101, 2012 edition, section 19.5.2.3 states:


"19.5.2.3 The requirements of 19.5.2.2 shall not apply where
otherwise permitted by the following:
(1) Approved, suspended unit heaters shall be permitted in
locations other than means of egress and patient sleeping
areas, provided that both of the following criteria are met:
(a) Such heaters are located high enough to be out of the
reach of persons using the area.
(b) Such heaters are equipped with the safety features
required by 19.5.2.2(2).
(2) Direct-vent gas fireplaces, as defined in NFPA 54, National
Fuel Gas Code, shall be permitted inside of smoke compartments
containing patient sleeping areas, provided that all
of the following criteria are met:
(a) All such devices shall be installed, maintained, and
used in accordance with 9.2.2.
(b) No such device shall be located inside of a patient
sleeping room.
(c) The smoke compartment in which the direct-vent gas
fireplace is located shall be protected throughout by
an approved, supervised automatic sprinkler system
in accordance with 9.7.1.1(1) with listed quickresponse
or listed residential sprinklers.
(d)*The direct-vent fireplace shall include a sealed glass
front with a wire mesh panel or screen.
(e)*The controls for the direct-vent gas fireplace shall be
locked or located in a restricted location.
(f) Electrically supervised carbon monoxide detection in
accordance with Section 9.8 shall be provided in the
room where the fireplace is located.
(3) Solid fuel-burning fireplaces shall be permitted and used
only in areas other than patient sleeping areas, provided
that all of the following criteria are met:
(a) Such areas are separated from patient sleeping spaces
by construction having not less than a 1-hour fire resistance
rating.
(b) The fireplace complies with the provisions of 9.2.2.
(c) The fireplace is equipped with a fireplace enclosure
guaranteed against breakage up to a temperature of
650°F (343°C) and constructed of heat-tempered
glass or other approved material.
(d) Electrically supervised carbon monoxide detection in
accordance with Section 9.8 is provided in the room
where the fireplace is located.
(4) If, in the opinion of the authority having jurisdiction, special
hazards are present, a lock on the enclosure specified
in 19.5.2.3(3)(c) and other safety precautions shall be
permitted to be required."

Based on staff interview and record review, facility staff failed to conduct fire drills for three of four quarters reviewed. This deficient practice has the potential to effect all facility residents. Failure to hold drills could effect facility staff response in a fire or other emergency. The facility census was 10.

1. Record review on 08/24/17 of the facility fire drill records for 2017, showed the following:

Missing drills on all shifts for the following months of 2017: January, February, April and May.
No second or third shift drills during the first quarter of 2017
No third shift fire drill during the second quarter of 2017

During an interview on 8/24/2017, the Director of Facilities Services said he believed the fire drills were conducted per code requirements.

The National Fire Protection Association 101 Life Safety Code, 2012 edition, Section 19.7.1 states:

"19.7.1 Evacuation and Relocation Plan and Fire Drills.

19.7.1.4* Fire drills in health care occupancies shall include
the transmission of a fire alarm signal and simulation of emergency
fire conditions.

19.7.1.5 Infirm or bedridden patients shall not be required
to be moved during drills to safe areas or to the exterior of the
building.

19.7.1.6 Drills shall be conducted quarterly on each shift to
familiarize facility personnel (nurses, interns, maintenance
engineers, and administrative staff) with the signals and emergency
action required under varied conditions.

19.7.1.7 When drills are conducted between 9:00 p.m. and
6:00 a.m. (2100 hours and 0600 hours), a coded announcement
shall be permitted to be used instead of audible alarms."

Based on record review and facility staff interview, the facility failed to ensure that all building systems had been assigned a risk assessment category and documented. The census was 10.

1. Review of the facility documents for fire safety, building system tests, and policies did not show categorical risk assessments for the building systems.

2. During an interview on 08/24/17 at 12:25 P.M., the Director of Facility Services said the facility departments started the process of doing the risk assessments but do not have categorical risk assessments for building systems.

The National Fire Protection Association 99 Health Care Facilities Code, 2012 edition, Chapter 4 states:

"Chapter 4 Fundamentals

4.1* Building System Categories. Building systems in health
care facilities shall be designed to meet system Category 1
through Category 4 requirements as detailed in this code.

4.1.1* Category 1. Facility systems in which failure of such equipment
or system is likely to cause major injury or death of patients
or caregivers shall be designed to meet system Category 1 requirements
as defined in this code.

4.1.2* Category 2. Facility systems in which failure of such equipment
is likely to cause minor injury to patients or caregivers shall
be designed to meet system Category 2 requirements as defined
in this code.

4.1.3 Category 3. Facility systems in which failure of such equipment
is not likely to cause injury to patients or caregivers, but can
cause patient discomfort, shall be designed to meet system Category
3 requirements as defined in this code.

4.1.4 Category 4. Facility systems in which failure of such equipment
would have no impact on patient care shall be designed to
meet system Category 4 requirements as defined in this code.

4.2* Risk Assessment. Categories shall be determined by following
and documenting a defined risk assessment procedure.

4.3 Application. The Category definitions in Chapter 4 shall
apply to Chapters 5 through 11."

Based on observation and facility staff interview the facility failed to provide a remote annunciator panel (a panel providing information on the condition and problems with the emergency generator) for one of one emergency generators at a constantly attended location. The facility census was 10.

1. Observation on 8/23/17, during the facility tour, did not show a remote annunciator panel for the emergency generator in a constantly attended location.

During an interview on 8/24/17 at 12:09 A.M., The Director of Facility Services said the facility did not have an annunciator panel.

The National Fire Protection Association 99 Health Care Facilities Code, 2012 edition, Section 6.4.1.1.17 states:

"6.4.1.1.17 Alarm Annunciator. A remote annunciator that is
storage battery powered shall be provided to operate outside of
the generating room in a location readily observed by operating
personnel at a regular work station (see 700.12 of NFPA 70, National
Electrical Code). The annunciator shall be hard-wired to indicate
alarm conditions of the emergency or auxiliary power
source as follows:
(1) Individual visual signals shall indicate the following:
(a) When the emergency or auxiliary power source is operating
to supply power to load
(b) When the battery charger is malfunctioning
(2) Individual visual signals plus a common audible signal to
warn of an engine-generator alarm condition shall indicate
the following:
(a) Low lubricating oil pressure
(b) Low water temperature (below that required in
6.4.1.1.11)
(c) Excessive water temperature
(d) Low fuel when the main fuel storage tank contains
less than a 4-hour operating supply
(e) Overcrank (failed to start)
(f) Overspeed

6.4.1.1.17.1* A remote, common audible alarm shall be provided
as specified in 6.4.1.1.17.4 that is powered by the storage
battery and located outside of the EPS service room at a work
site observable by personnel. [110:5.6.6]

6.4.1.1.17.2 An alarm-silencing means shall be provided, and
the panel shall include repetitive alarm circuitry so that, after
the audible alarm has been silenced, it reactivates after the
fault condition has been cleared and has to be restored to its
normal position to be silenced again. [110:5.6.6.1]

6.4.1.1.17.3 In lieu of the requirement of 5.6.6.1 of NFPA110, a
manual alarm-silencing means shall be permitted that silences
the audible alarm after the occurrence of the alarm condition,
provided such means do not inhibit any subsequent alarms from
sounding the audible alarm again without further manual action.
[110:5.6.6.2]

6.4.1.1.17.4 Individual alarm indication to annunciate any of
the conditions listed in Table 6.4.1.1.16.2 shall have the following
characteristics:
(1) It shall be battery powered.
(2) It shall be visually indicated.
(3) It shall have additional contacts or circuits for a common
audible alarm that signals locally and remotely when any
of the itemized conditions occurs.
(4) It shall have a lamp test switch(es) to test the operation of
all alarm lamps.

6.4.1.1.17.5 Acentralized computer system (e.g., building automation
system) shall not be permitted to be substituted for
the alarm annunciator in 6.4.1.1.17 but shall be permitted to
be used to supplement the alarm annunciator.

6.4.1.2 Battery. Battery systems shall meet all requirements of
Article 700 of NFPA 70, National Electrical Code.


Table 6.4.1.1.16.2 Safety Indications and Shutdowns
Level 1
Indicator Function (at Battery Voltage) CV S RA
(a) Overcrank X X X
(b) Low water temperature X - X
(c) High engine temperature pre-alarm X - X
(d) High engine temperature X X X
(e) Low lube oil pressure pre-alarm X - X
(f) Low lube oil pressure X X X
(g) Overspeed X X X
(h) Low fuel main tank X - X
(i) Low coolant level X O X
(j) EPS supplying load X - -
(k) Control switch not in automatic
position
X - X
(l) High battery voltage X - -
(m) Low cranking voltage X - X
(n) Low voltage in battery X - -
(o) Battery charger ac failure X - -
(p) Lamp test X - -
(q) Contacts for local and remote
common alarm
X - X
(r) Audible alarm-silencing switch - - X
(s) Low starting air pressure X - -
(t) Low starting hydraulic pressure X - -
(u) Air shutdown damper when used X X X
(v) Remote emergency stop - X -
CV: Control panel-mounted visual. S: Shutdown of EPS indication.
RA: Remote audible. X: Required. O: Optional.
Notes:
(1) Item (p) shall be provided, but a separate remote audible signal shall
not be required when the regular work site in 5.6.6 of NFPA110, Standard
for Emergency and Standby Power Systems, is staffed 24 hours a day.
(2) Item (b) is not required for combustion turbines.
(3) Item (r) or (s) is required only where used as a starting method.
(4) Item (j): EPS ac ammeter shall be permitted for this function.
(5) All required CV functions shall be visually annunciated by a remote,
common visual indicator.
(6) All required functions indicated in the RAcolumn shall be annunciated
by a remote, common audible alarm as required in 5.6.5.2(4) of
NFPA 110.
(7) Item (i) requires a low gas pressure alarm on gaseous systems.
(8) Item (b) must be set at 11°C (20°F) below the regulated temperature
determined by the EPS manufacturer, as required in 5.3.1 of
NFPA 110."

Based on observation and facility staff interview, the facility staff failed to ensure extension cords were not used permanently and multi plug adaptor was connected to a duplex receptacle. The facility census was 10.

Observation on 8/23/2017, during the facility tour, showed an extension cord running through a wood column of a half wall with wood surround in the emergency department nurse's station connected to a monitor.

Observation on 8/23/2017 at 3:47 P.M., of the office in the operating room suite, showed an unrated power tap with an orange colored extension cord connected to a second orange extension cord with a multi plug end and a black cord connected to it. Observation showed the black cord connected to a microwave. Additional observation showed a yellow extension cord connected to a refrigerator.

Observation on 8/23/2017 at 3:38 P.M., of the pre/post operation recovery room showed a multi plug adaptor connected to a duplex receptacle. Observation showed a patient warming device and a patient medical monitor connected to the multi plug adaptor.

During an interview on 8/24/2017 the Director of Facilities Services said he did not know staff used non rated power taps, extension cords and multi plug adaptors.

Refer to NFPA 70, National Electrical Code, 2011 edition, Article 400.8 for additional information.