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Based on observation and staff interview, the facility failed to provide exit access from the east dining room without the use of a special tool or knowledge from the egress side. This deficient practice of not providing the knowledge necessary to exit the facility will prevent speedy exiting, affecting all patients in two of five smoke zones. The facility has a capacity of 32 with a census of 17.

Findings include:

During the survey on November 14 and 15, 2017 between the hours of 9:00AM and 4:00PM the following is observed:

1. Large open room area in the egress corridor outside the physical therapy room is being used as equipment storage. There is no separation between the storage items and the corridor.

The Bio-Med Director was present and acknowledged the findings.


Review of the following NFPA Standard revealed: Approved, listed, delayed-egress locking systems shall be permitted to be installed on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6 or an approved, supervised automatic sprinkler system in accordance with Section 9.7, and where permitted in Chapters 11 through 43, provided that all of the following criteria are met:

(1) The door leaves shall unlock in the direction of egress upon actuation of one of the following:

(a) Approved, supervised automatic sprinkler system in accordance with Section 9.7

(b) Not more than one heat detector of an approved, supervised automatic fire detection system in accordance with Section 9.6

(c) Not more than two smoke detectors of an approved, supervised automatic fire detection system in accordance with Section 9.6

(2) The door leaves shall unlock in the direction of egress upon loss of power controlling the lock or locking mechanism.

(3)*An irreversible process shall release the lock in the direction of egress within 15 seconds, or 30 seconds where approved by the authority having jurisdiction, upon application of a force to the release device required in 7.2.1.5.10 under all of the following conditions:

(a) The force shall not be required to exceed 15 lbf (67 N).

(b) The force shall not be required to be continuously applied for more than 3 seconds.

(c) The initiation of the release process shall activate an audible signal in the vicinity of the door opening.

(d) Once the lock has been released by the application of force to the releasing device, relocking shall be by manual means only.

(4)*A readily visible, durable sign in letters not less than 1 in. (25 mm) high and not less than 1?8 in. (3.2 mm) in stroke width on a contrasting background that reads as follow shall be located on the door leaf adjacent to the release device in the direction of egress:

PUSH UNTILALARM SOUNDS
DOOR CAN BE OPENED IN 15 SECONDS

(5) The egress side of doors equipped with delayed-egress locks shall be provided with emergency lighting in accordance with Section 7.9. 2012 NFPA 101, 7.2.1.6.1.1

Based on records review and staff interview the facility failed to ensure that battery powered exit sign devices are tested and working properly. This deficient practice could result in the lack of lighting during an interruption of power and does not ensure that the light is tested as required, affecting 0 patients in one of five smoke zones. The facility has a capacity of 32 with a census of 17.

Findings include:

During the survey on November 14 and 15, 2017 between the hours of 9:00AM and 4:00PM the following is observed:

1. Exit sign located in the main mechanical room is only partially illuminated.


Review of the following NFPA Standard revealed: Means of egress shall have signs in accordance with Section 7.10, unless otherwise permitted by 19.2.10.2, 19.2.10.3, or 19.2.10.4. 2012 NFPA 101, 19.2.10.1

Review of the following NFPA Standard revealed: Power Source. Where emergency lighting facilities are required by the applicable provisions of Chapters 11 through 43 for individual occupancies, the signs, other than approved self-luminous signs and listed photoluminescent signs in accordance with 7.10.7.2, shall be illuminated by the emergency lighting facilities. The level of illumination of the signs shall be in accordance with 7.10.6.3 or 7.10.7 for the required emergency lighting duration as specified in 7.9.2.1. However, the level of illumination shall be permitted to decline to 60 percent at the end of the emergency lighting duration. 2012 NFPA 101, 7.10.4*

Based on observation and staff interview the facility failed to ensure proper separation of hazardous areas from other spaces. This deficient practice would allow for the spread of smoke and fire to travel into the adjacent area, affecting all patients in all five smoke zones. The facility has a capacity of 32 with a census of 17.

Findings include:

During the survey on November 14 and 15, 2017 between the hours of 9:00AM and 4:00PM the following is observed:

1. It is observed that a penetration is located in the 200 hall mechanical room.
2. It is observed that multiple penetrations are located in the main mechanical room wall.
3. It is observed that a 5 inch by 8 inch penetration is located in the MRI equipment room.
4. It is observed that multiple penetrations are located in the CT mechanical room.
5. It is observed that the door to the CT mechanical room is not equipped with an automatic closer.


The Bio-Med Director was present and acknowledged the findings.


Review of the following NFPA Standard revealed: Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.7.1. 2012 NFPA 101, 19.3.2.1

Review of the following NFPA Standard revealed: The doors shall be self-closing or automatic-closing. 2012 NFPA 101, 19.3.2.1.3

Based on record review and staff interview, the facility failed to maintain and test smoke detectors for sensitivity in accordance with NFPA 72. This deficient practice may prevent the prompt initiating of smoke detectors alerting the residents and staff to smoke products due to the devices being out of calibration, affecting all patients in all five smoke zones. The facility has a capacity of 32 with a census of 17.

Findings include:

During the survey on November 14 and 15, 2017 between the hours of 9:00AM and 4:00PM the following is observed:

1. Record review revealed that no smoke detector sensitivity testing documentation is available.

The Bio-Med Director was present and acknowledged the findings.

Review of the following NFPA Standard revealed: 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 and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use. 2012 NFPA 101, 9.6.1.3

Review of the following NFPA Standard revealed: Sensitivity shall be checked every alternate year thereafter unless otherwise permitted by compliance with 14.4.5.3.3. 2012 NFPA 72, 14.4.5.3.2

Based on record review and staff interview, the facility failed to assure that the sprinkler system is tested and installed in accordance with NFPA 13 and 25. This deficient practice fails to ensure that the sprinkler system will operate properly in the event of a fire, affecting all patients in all five smoke zones. The facility has a capacity of 32 with a census of 17.

Findings include:

During the survey on November 14 and 15, 2017 between the hours of 9:00AM and 4:00PM the following is observed:

1. No quarterly sprinkler testing documentation is available.
2. A sprinkler head located in the 200 hall mechanical room is painted.
3. A sprinkler head located in the café rooftop room is painted.


The Bio-Med Director was present and acknowledged the findings.

Review of the following NFPA Standard revealed: Each automatic sprinkler system required by another section of this Code shall be in accordance with one of the following:
(1) NFPA 13, Standard for the Installation of Sprinkler Systems
(2) NFPA 13D, Standard for the Installation of Sprinkler Systems in One- and Two-Family Dwellings and Manufactured Homes
(3) NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and Including Four Stories in Height
2012 NFPA 101, 9.7.1.1

Review of the following NFPA Standard revealed: All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard
for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. 2012 NFPA 101, 9.7.5

Based on observation and staff interview the facility is not ensuring that room doors latch properly. This deficient practice of not ensuring that room doors latch properly prevents the ability of the facility to properly confine fire and smoke products and to properly defend occupants in place, affecting all patients in three of five smoke zones. The facility has a capacity of 32 with a census of 17.

Findings include:

During the survey on November 14 and 15, 2017 between the hours of 9:00AM and 4:00PM the following is observed:

1. Fire door protecting mezzanine from main mechanical room below is wedged open.

2. Closet doors located in the corridor outside the MRI control room do not latch.

3. The corridor door to the OR manager's office is held open by a wedge.

4. The sterile supply storage room doors are being held open by wedges.


The Bio-Med Director was present and acknowledged the findings.


Review of the following NFPA Standard revealed: Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be doors constructed to resist the passage of smoke and shall be constructed of materials such as the following:
(1) 13?4 in. (44 mm) thick, solid-bonded core wood
(2) Material that resists fire for a minimum of 20 minutes
2012 NFPA 101, 19.3.6.3.1

Review of the following NFPA Standard revealed: 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.
2012 NFPA 101, 19.3.6.3.5

Review of the following NFPA Standard revealed: Doors shall not be held open by devices other
than those that release when the door is pushed or pulled. 2012 NFPA 101, 19.3.6.3.10

Based on observation and staff interview the facility fails to maintain the smoke barriers to at least one half hour fire resistance. This deficient practice would not allow containment of fire and smoke, affecting all patients in all five smoke zones. The facility has a capacity of 32 with a census of 17.

Findings include:


During the survey on November 14 and 15, 2017 between the hours of 9:00AM and 4:00PM the following is observed:


1. Smoke barrier located by the main mechanical room has multiple penetrations where conduit goes through.

2. Smoke barrier located by the MRI/CT suite has multiple penetrations where conduit goes through.

3. Smoke barrier located in the West inpatient area has multiple penetrations where pipes go through.

4. Smoke barrier located in the East inpatient area has multiple penetrations where pipes go through.


The Bio-Med Director was present and acknowledged the findings.


Review of the following NFPA Standard revealed: Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier, or by use of a combination thereof. 2012 NFPA 101, 8.5.2.1

Based on observation and staff interview, the facility did not ensure that electrical wiring and equipment is installed and maintained in accordance with NFPA 70, National Electrical Code. This deficient practice does not ensure prevention of an electrical fire or electric shock hazard, affecting all patients in all five smoke zones. The facility has a capacity of 32 with a census of 17.

Findings include:

During the survey on November 14 and 15, 2017 between the hours of 9:00AM and 4:00PM the following is observed:

1. Multiple open junction boxes are located in the 200 hall mechanical room.
2. Multiple open junction boxes are located in the main mechanical room.
3. Multiple open junction boxes are located in the main mechanical room.
4. An open junction box is located in the MRI mechanical room.
5. A freezer is plugged into a power strip in the physical therapy room.


The Bio-Med Director was present and acknowledged the findings.

Review of the following NFPA Standard revealed: Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service. 2012 NFPA 101, 9.1.2

Based on observation and record review, the facility fails to maintain fire dampers in heating, ventilation and air conditioning assemblies as required. This deficient practice of not identifying, testing and maintaining fire dampers as required increases the risk fire, affecting all patients in all five smoke zones. The facility has a capacity of 32 with a census of 17.

Findings include:

During the survey on November 14 and 15, 2017 between the hours of 9:00AM and 4:00PM the following is observed:


1. The following deficiencies are noted on the 2017 fire damper report:

a. The damper located on the hall side of the men's locker room did not close

b. The other damper located on the hall side of the men's locker room did not close

c. The damper located in the new corridor to OR has a broken rod.

d. The damper located in the light scan Ex-fan1 was not reachable to test.

e. The damper located in the RTU-1 patient wing supply was not accessible.

No documentation is available to show that these have been corrected.


The Bio-Med Director was present and acknowledged the findings.


Review of the following NFPA Standard revealed: 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 such installations are approved existing installations, which shall be permitted to be continued in service. 2012 NFPA 101, 9.2.1
Review of the following NFPA Standard revealed: Fire dampers and ceiling dampers shall be maintained in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. 2012 NFPA 90A, 5.4.8.1
Review of the following NFPA Standard revealed: The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years. 2010 NFPA 80, 19.4.1.1
Review of the following NFPA Standard revealed: If the link is damaged or painted, it shall be replaced with a link of the same size, temperature, and load rating. 2010 NFPA 80, 19.4.8.1

Based on record review and staff interview, the facility is not conducting fire drills as required and properly recording the results and facts relating to the fire drills. This deficient practice affects the ability of the staff to properly respond in the event of an actual emergency, affecting all patients in all five smoke zones. The facility has a capacity of 32 with a census of 17.

Findings include:

During the survey on November 14 and 15, 2017 between the hours of 9:00AM and 4:00PM the following is observed:

1. No fire drill forms are available to review. The documentation presented shows the time, date, and signatures only.


The Bio-Med Director was present and acknowledged the findings.

Review of the following NFPA Standard revealed: The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan required by 19.7.1.1. A copy of the plan required by 19.7.1.1 shall be readily available at all times in the telephone operator's location or at the security center. Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building. 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. 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. Employees of health care occupancies shall be instructed in life safety procedures and devices. 2012 NFPA 101, 19.7.1.1-8

Review of the following NFPA Standard revealed: The basic response required of staff shall include the following:

(1) Removal of all occupants directly involved with the fire Emergency

(2) Transmission of an appropriate fire alarm signal to warn other building occupants and summon staff

(3) Confinement of the effects of the fire by closing doors to isolate the fire area

(4) Relocation of patients as detailed in the health care occupancy's fire safety plan

2012 NFPA 101, 19.7.2.1.2

Based on record review and staff interview the facility fails to provide for testing of the medical gas system. This deficient practice could adversely affect all persons using or receiving medical gases from the bulk medical gas system, affecting all patients in all five smoke zones. The facility has a capacity of 32 with a census of 17.

Findings include:

During the survey on November 14 and 15, 2017 between the hours of 9:00AM and 4:00PM the following is observed:

1. The med gas shut off panels located in the OR area are blocked by beds.

2. No annual report for the Med-gas is available since August of 2015.


The Bio-Med Director was present and acknowledged the findings.


Review of the following NFPA Standard revealed: Inspection Procedures. The facility shall be permitted to use any inspection procedure(s) or testing methods established through its own risk assessment.
Maintenance Schedules: Scheduled maintenance for equipment and procedures shall be established through the risk assessment of the facility and developed with consideration of the original equipment manufacturer recommendations and other recommendations as required by the authority having jurisdiction.
Qualifications: Persons maintaining these systems shall be qualified to perform these operations. Appropriate qualification shall be demonstrated by any of the following:

(1) Training and certification through the health care facility by which such persons are employed to work with specific
equipment as installed in that facility

(2) Credentialing to the requirements of ASSE 6040, Professional Qualification Standard for Medical Gas Maintenance Personnel

(3) Credentialing to the requirements of ASSE 6030, Professional Qualification Standard for Medical Gas Systems Verifiers
2012 NFPA 99, 5.1.14.2.2.3-5

Review of the following NFPA Standard revealed: An annual review of bulk system capacity shall be conducted to ensure the source system has sufficient capacity.

Central supply systems for nonflammable medical gases shall conform to the following:

(1) They shall be inspected annually.
(2) They shall be maintained by a qualified representative of the equipment owner.
(3) A record of the annual inspection shall be available for review by the authority having jurisdiction.
2012 NFPA 99, 5.1.14.4.3-4

Based on observation and staff interview the facility failed to provide a remote emergency shut off for the emergency generator power supply as required. The deficient practice may prevent the emergency power supply from being shut down in the event of an emergency, affecting all patients in all five smoke zones. The facility has a capacity of 32 with a census of 17.

Findings include:

During the survey on November 14 and 15, 2017 between the hours of 9:00AM and 4:00PM the following is observed:

1. No weekly generator check documentation is available.

2. No generator malfunction policy is available.


The Bio-Med Director was present and acknowledged the findings.

Review of the following NFPA Standard revealed: All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building. The remote manual stop station shall be labeled. 2010 NFPA 110, 5.6.5.6

Review of the following NFPA Standard revealed: For a diesel-powered EPS, loading shall be not less than 30 percent of the nameplate kW rating of the EPS.A supplemental load bank shall be permitted to be used to meet or exceed the 30 percent requirement. 2010 NFPA 110, 8.4.9.5.1

Review of the following NFPA Standard revealed: EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly. 2010 NFPA 110, 8.4.1*