HospitalInspections.org

Based on observation, the facility failed to maintain the integrity of the building construction. This was evidenced by unsealed penetrations in the walls and ceilings. This affected five of nine smoke compartments and could result in the increased potential for the spread of fire and smoke to other areas of the facility.

Findings:

During a tour of the facility with staff on 9/16/14, the walls and ceilings were observed.

1. At 12:23 p.m. in the IT office, there was an approximately 1/4 inch penetration around a blue and gray wire in the right wall, three approximately 1/2 inch penetrations in the left wall, and an approximately two inch penetration in the right corner of the wall.

2. At 12:40 p.m. in the Kitchen two door there were two approximately 1/2 inch penetrations in the wall near a metal rack.

3. At 12:41 p.m., there were two approximately 1/4 inch penetrations in the wall near a sink in the Kitchen.

4. At 12:42 p.m., there was an approximately 1/4 inch penetration in the left wall in the Food Service Manager's Office.

5. At 12:46 p.m., there were two approximately 1/4 inch penetrations in the left wall on top of a sink, in the Housekeeping Closet near Room 116.

6. At 12:58 p.m., there were 11 approximately 1/4 inch to 1/2 inch penetrations in the right wall in the Room 201.

7. At 1:17 p.m., there was an approximately two inch penetration around two blues cords and one black cord in the ceiling, at the Nurse Station in the Emergency Department.

Based on observation, the facility failed to maintain the corridor doors. This was evidenced by doors that were obstructed and/or failed to latch. This affected five of nine smoke compartments and could result in the inability to contain a fire to a room.

NFPA 101, 2000
19.3.6.3.3* Hold-open devices that release when the door is pushed or pulled shall be permitted.

Findings:

During a tour of the facility with staff on 9/16/14, the corridor doors were observed.

1. At 12:33 p.m., the self closing door to the Kitchen Dish Wash area was held open by a rubber wedge.

2. At 12:35 p.m., the self closing door to Kitchen Door two was held open by a wooden wedge.

3. At 12:40 p.m., the self closing door to the Linen Closet across from the Kitchen was held open by a wooden wedge.

4. At 12:51 p.m., the self closing door to the Staff Locker failed to latch.

5. At 12:57 p.m., the self closing door to the Utility Room across from Room 207 was held open by a plastic bag that was used to tie the door handle to keep the door open.

6. At 12:59 p.m., the self closing door to Room 201 was held open by a rubber wedge.

7. At 1 p.m., the door to Room 207 was obstructed by a bed that prevented the door from closing.

8. At 1:18 p.m., the self closing door to the Emergency Doctor Office was obstructed by a bedside table.

Based on observation, the facility failed to maintain its fire doors. This was evidenced by a fire door that was held open and by a set of fire doors that failed to operate freely.

NFPA 101, 2000
7.2.1.5.5 Where pairs of doors are required in a means of egress, each leaf of the pair shall be provided with its own releasing device. Devices that depend on the release of one door before the other shall not be used.
Exception: Where exit doors are used in pairs and approved automatic
flush bolts are used, the door leaf equipped with the automatic flush
bolts shall have no doorknob or surface-mounted hardware. The unlatching of any leaf shall not require more than one operation.
8.2.3.2.1 Doors assemblies in fire barriers shall be if an approved type with the apporiate fire protection rating for the location in which they are installed and shall comply with the following: (a) Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows.

NFPA 80, 1999
15-1 This chapter covers the care and maintenance of fire doors and fire windows.
15-2.3 Prevention of Door Blockage.
15-2.3.1 Door openings and the surrounding areas shall be kept clear of anything that could obstruct or interfere with the free operation of the door.
15-2.3.3 Blocking or wedging of doors in the open position shall be prohibited.

Findings:

During a tour of the facility with staff on 9/16/14, the fire doors were observed.

1. At 1 p.m., the left leaf fire door near the Lab was held open by a wooden wedge.

2. At 1:44 p.m., the fire door near the Med Surge Nurse Station was observed. In order to open the fire door, the left leaf fire door needed to be operate first and then the right leaf fire door. Both sides of the fire doors were equipped with a push handle.

Based on observation and interview, the facility failed to maintain the emergency exit. This was evidenced by items that were stored in front of the emergency exit door. This affected one of nine smoke compartments, and could result in a delay in egress in the event of an emergency.

NFPA 101, 2000
19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7.
7.1.10 Mean of Egress Reliability.
7.1.10.1 Mean of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.
7.1.10.2 Furnishings and Decorations in Mean of Egress.
7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof.

Findings:

During a tour and interview with staff on 9/16/14, the emergency fire exit doors were observed.

At 12:15 p.m., the emergency fire exit door in the Storage Room adjacent to the Chief Executive Officer (CEO) office had five large boxes of supplies that were stationed in front of the fire exit door. Staff 1 confirmed the supplies should not be there.

Based on document review and interview, the facility to insure that all staff are trained. This was evidenced by one fire drill that did not include staff signatures. This affected nine of nine smoke compartments and could result in staff members be untrained and unaware of their roles and responsibilities during an emergency.

Findings:

During document review and interview with staff on 9/16/14, the fire drills were reviewed.

At 3:15 p.m., a fire drill that was performed on 3/21/14 at 1:10 p.m. failed to include staff signatures. Staff 1 stated that they forgot to include the staff signatures.

Based on testing and interview, the facility failed to ensure that the sprinkler system had a supervised valve. This was evidenced by a outside stem and yoke (OS&Y) valve on the riser that did not produce an audible tamper alarm when tested. This affected nine of nine smoke compartment and could potentially result in staff being unaware that the sprinkler system water supply was shut off

NFPA 101, 2000
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 Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves. 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.

NFPA 72 National Fire Alarm Code 1999 Edition
1-5.4.4 Distinctive Signals. Fire alarms, supervisory signals, and trouble signals shall be distinctively and descriptively annunciated.
3-8.3.3.1 General. The provisions of 3-8.3.3 shall apply to the monitoring of sprinkler systems, other fire suppression systems, and other systems for the protection of life and property for the initiation of a supervisory signal indicating an off-normal condition that could adversely affect the performance of the system.

Findings:

During testing and interview with staff on 9/16/14, the tamper alarm was tested.

At 1:37 p.m., the OS&Y tamper alarm was located outside in a Riser room near the Emergency (ER) Department Entrance. When the valves were closed, there was no audible tamper alarm at the ER Admitting Area fire alarm panel or at the Med Surge Nurse Station sub-panel. At the ER Admitting Area, the panel indicated, "Fire Sprinkler Tamper." At the Med Surge Nurse Station sub-panel, a supervisory light was on. Staff 2 stated that a sound should be heard when the tamper alarm was activated. A reviewed of the remote monitoring station report indicated a supervisory trouble was signal received.

Based on document review and interview, the facility failed to maintain the fire alarm system. This was evidenced by incomplete testing records for the annual fire alarm inspection report. This affected one of nine smoke compartments and could result in a delay in notification in the event of a fire.

NFPA 101, 2000
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with section 9.6
9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

NFPA 72, 1999
1-6.3 Records. A complete, unalterable record of the tests and operations of each system shall be kept until the next test and for 1 year thereafter. The record shall be available for examination and, if required, reported to the authority having jurisdiction. Archiving of records by any means shall be permitted if hard copies of the records can be provided promptly when requested.
Exception: If off-premises monitoring is provided, records of all signals,
tests, and operations recorded at the supervising station shall be
maintained for not less than 1 year.
7-5.2.2 A permanent record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 7-5.2.2.
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business address, and telephone number
(6) Name, address, and representative of approving agency(ies)
(7) Designation of the detector(s) tested, for example, " Tests performed in accordance with Section __________. "
(8) Functional test of detectors
(9) *Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type heat detectors
(12) Other tests as required by equipment manufacturers
(13) Other tests as required by the authority having jurisdiction
(14) Signatures of tester and approved authority representative
(15)Disposition of problems identified during test (for example, owner notified, problem corrected/successfully retested, device abandoned in place)

Findings:

At 3:23 p.m., the documentation titled, "Fire Alarm Inspection and Testing Form," dated 12/6/13 was incomplete. On page six of six, the report stated that there were 21 chimes and strobes and that 21 were tested 21. The report also listed 20 chimes and strobes that passed and one that failed. Under the problem found and correction made section of the report, there was no indication that the chime/strobe that failed had been repaired. The facility was given the opportunity to fax the information by 5 p.m. on 9/16/14. There was no fax received.

Based on document review, the facility failed to maintain its smoke detectors. This was evidenced by incomplete testing for the smoke detector sensitivity test. This affected nine of nine smoke compartments and could result in delayed notification of a fire due to a malfunctioning or dirty smoke detector.

NFPA 101, 2000
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with section 9.6
9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

NFPA 72, 1999 edition
7-3.2.1 Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and table 7-2.2.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

Findings:

During document review with staff on 9/16/14, the smoke detector sensitivity test was reviewed.

At 3:20 p.m., the documentation titled, "Fire Alarm Inspection and Testing Form," dated 12/6/13 was incomplete. On page four of six of the report, there were no sensitivity ranges or outputs listed for the two smoke detectors identified in the report in the BR Hall and HIS M21. The facility was given the opportunity to fax the information by 5 p.m. on 9/16/14. There was no fax received.

Based on document review and interview, the facility failed to test its automatic fire sprinkler system. This was evidenced by the failure to provide documentation for the quarterly fire sprinkler system test. This affected nine of nine smoke compartments and could result in a malfunction of the automatic fire sprinkler system.

NFPA 101, 2000
19.7.6 Maintenance and Testing (see 4.6.12)
4.6.12 Maintenance and Testing. Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provision of this code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

NFPA 25, 1998
2-3.3 Alarm Devices. Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.
9-2.7 Waterflow Alarm. All waterflow alarms shall be tested quarterly in accordance with the manufacturer's instructions.

Findings:

During document review and interview with staff on 9/16/14, the quarterly sprinkler test were requested.

At 3:45 p.m., the facility was unable to provide documentation for the quarterly sprinkler tests and inspections. Staff 1 stated that he could not locate the quarterly sprinkler test documents. The facility was given the opportunity to fax the information by 5 p.m. on 9/16/14. No fax was received.

Based on observation, the facility failed to maintain its portable fire extinguishers. This was evidenced by one portable fire extinguisher that was obstructed and two fire extinguishers that were recessed into the wall with no identification signs. This affected three of nine smoke compartments, and could result a delay in access in the event of a fire.

NFPA 101, 2000
19.3.5.6 Portable Fire Extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1
9.7.4 Manual Extinguishing Equipment
9.7.4.1 Where required by the provision of another section of this code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguisher.

NFPA 10, 1998
1-6.6* Fire extinguishers shall not be obstructed or obscured from view. Exception: In large rooms, and in certain locations where visual obstruction cannot be completely avoided, means all be provided to indicate the location.

Findings:

During a tour of the facility with staff on 9/16/14, the portable fire extinguishers were observed.

1. At 12:16 p.m., a portable fire extinguisher was located behind an open fire door in the Administration Hallway. The door had a glass panel in it so the fire extinguisher was visible. In order to access the fire extinguisher, the occupant would need to release and close the fire door to gain access to it.

2. At 12:50 p.m., the portable fire extinguisher located near Room 116 was recessed into the wall. There was no identification sign posted indicating that a fire extinguisher was available at that location.

3. At 1:10 p.m., the portable fire extinguisher located across from Emergency Room 1 was recessed into the wall. There was no identification sign posted indicating that a fire extinguisher was available at that location.

Based on document review, the facility failed to maintain its smoke/fire dampers. This was evidenced by the failure to provide documentation that the smoke/fire dampers had been inspected within the past 4 years. This affected nine of nine smoke compartments and could result in the spread of smoke or fire to other locations of the facility due to a malfunctioning damper.

NFPA 101, 2000
19.5.2.1 Heating, ventilating, and air conditioning shall comply with the provisions of section 9.2 and shall be installed in accordance with the manufacturer's specifications.
9.2.1 Air conditioning, Heating, Ventilating Ductwork, and Related Equipment. Air conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, as applicable, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 90A, 1999 edition
Section 3-4.7 At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.

Findings:

During document review with staff on 9/16/14, the fire/smoke damper inspection documentation was requested.

At 3:30 p.m., the facility was unable to provide fire/smoke damper testing documentation during survey. The facility was given the opportunity to fax the information by 5 p.m. on 9/16/14. There was no fax received.

Based on observation, document review, and interview, the facility failed to maintain the kitchen exhaust system. This was evidenced by an accumulation of grease on the pipes inside the exhaust hood, failure to have the hood cleaned semi-annually, and the failure to service the kitchen suppression system semi-annually. This affected one of nine smoke compartments, and could result in an increased risk of a grease fire to ignite in the kitchen.

NFPA 101, 2000
19.3.2.6 Cooking Facilities. Cooking facilities shall be protected in accordance with 9.2.3
9.2.3 Commercial Cooking Equipment. Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operation, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 96, 1998
8-2 Inspection
An inspection and servicing of the fire-extinguishing system and listed exhaust hoods containing a constant or fire-actuated water system shell be made at least every 6 months by properly trained and qualified persons.
8-3.1 Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. the entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Table 8-3.1.

Findings:

During a tour, document review, and interview with staff on 9/16/14, the kitchen fire suppression system was observed and documents were requested.

1. At 3:18 p.m., the kitchen exhaust hood was observed. There was a thick accumulation of grease on the pipes running through the interior of the kitchen exhaust hood. The facility was unable to provide any hood cleaning records at the time of survey. Staff 4 stated that the facility cleaned the exhaust hood in-house but could not produce the cleaning documents. Staff 3 stated that they thought that a vendor came out to serviced the hood exhaust system. Staff 2 stated that he did not think that a vendor came out to service the exhaust hood. The facility was given the opportunity to fax the information by 5 p.m. on 9/16/14. There was no fax received.

2. At 3:25 p.m., the facility was not able to provide the previous Kitchen suppression system report at the time of survey. The last kitchen suppression system was serviced on 7/25/14. The facility was given the opportunity to fax the information by 5 p.m. on 9/16/14. There was no fax received. On 9/18/14, a telephone called to the facility regarding if any fax information was sent, Staff 1 stated he was not sure because Staff 2 was not here today.

Based on document review, the facility failed to maintain the fume hood. This was evidenced by failure to provide documentation for an annual fume hood inspection report. This affected one of nine smoke compartments and could result in a exposure to hazardous or toxic fume.

Findings:

During document review with staff on 9/16/14, the fume hood inspections were requested.

At 4 p.m., the facility was unable to provide documentation for a current fume hood inspection report at the time of survey. The last fume hood inspection was performed on 9/25/12. The facility was given the opportunity to fax the information by 5 p.m. on 9/16/14. There was no fax received.

Based on observation, the facility failed to maintain its electrical wiring and connections. This was evidenced by the use of extension cords, power strips used for medical equipment, high power appliances plugged into power strips, a power strips chained together, and a power strip suspended off the floor. This affected seven of nine smoke compartments, and could result in an increased risk of an electrical fire resulting in potential harm to the patients.

NFPA 101, 2000
19.5.1 Utilities. Utilities shall comply with the provisions of section 9.1
9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 70, 1999
110-12 Mechanical Execution of Work. Electrical equipment shall be installed in a neat and workmanlike manner.
(c) Integrity of Electrical Equipment and Connections. Internal parts of electrical equipment, including busbars, wiring terminals, insulators, and other surfaces, shall not be damaged or contaminated by foreign materials such as paint, plaster, cleaners, abrasives, or corrosive residues. There shall be no damaged parts that may adversely affect safe operation or mechanical strength of the equipment such as parts that are broken; bent; cut; or deteriorated by corrosion, chemical action, or overheating.
210-23 In no case shall the load exceed the branch-circuit ampere rating. An individual branch circuit shall be permitted to supply any load for which it is rated. A branch circuit supplying two or more outlets or receptacles shall supply only the loads specified according to its size as specified in (a) through (d) and as summarized in Section 210-24. A 15 or 20-ampere branch circuit shall be permitted to supply lighting units or other utilization, or a combination of both. The rating of any one cord and plug-connected utilization equipment shall not exceed 80 percent of the branch-circuit ampere rating. The total rating of utilization equipment fastened in place, other than lighting fixtures, shall not exceed 50 percent of the branch circuit ampere rating where lighting units, cord and plug-connected utilization equipment not fastened in place, or both, are also supplied.
400-8 Unless specifically permitted in Section 400-7, flexible cord and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors.
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code.
400-10. Flexible cords and cables shall be connected to devices and to fittings so that tension will not be transmitted to joints or terminals.

Findings:

During a tour of the facility with staff on 9/16/14, the electrical wiring and connections were observed.

1. At 12:20 p.m., a coffee maker was plugged into a power strip that was connected to another power strip in Cubicle 2 of the Business Office.

2. At 12:21 p.m., a coffee maker was plugged into a power strip in Medical Record Office 1.

3. At 12:22 p.m., a refrigerator was plugged into a power strip, in Medical Record Office 2.

4. At 12:30 p.m., a portable air conditioner unit was plugged into a power strip in the Server Room.

5. At 12:43 p.m., a IV pump and a EKG machine were plugged into a overhead bed light outlet in Room 211.

6. At 12:56 p.m., a suction machine and two medical roller cart machines were plugged into a power strip in the Med Surge Nurse Station.

7. At 12:57 p.m., a wall air conditioner unit was plugged into a power strip that was suspended off the floor in the Utility Room across from Room 207.

8. At 12:59 p.m., an electric bed was plugged into a orange extension cord that was plugged into a overhead bed light outlet in Room 208.

9. At 1 p.m. in the Pharmacy Office, a coffee maker was plugged into a power strip that was suspended off the floor. A black refrigerator was plugged into a orange extension cord along with a power strip that was connected to a three plug adapter.

10. At 1:05 p.m. in the Lab Office, a portable oil heater was plugged into a power strip. A microwave machine, coffee maker, and a coffee grinder machine were plugged into a power strip.

11. At 1:10 p.m., a coffee maker and a toaster oven were plugged into a power strip in the X-Ray Office.

12. At 1:15 p.m. in the Recovery Operating Room, a criticare/poet plus 8100 machine was plugged into a power strip at the southeast wall. An air purifier machine, a medical monitor machine, and a force 2 machine were plugged into a power strip that was mounted on the wall at the southwest wall. A suction machine and a medical work station machine were plugged into a power strip that was mounted on the wall at the southwest wall. A defibrillator machine, a ventilation machine, and a glidescope machine were plugged into a power strip in the west wall.

13. At 1:19 p.m. in Room 209, an electric bed and a IV pump were plugged into a power strip that was mounted on the wall and was connected to a overhead bed light outlet.