HospitalInspections.org

Based on observation and staff interview, the facility failed to protect hazardous areas in 1 of 6 smoke compartments. The findings were:

Observation on 5/1/12 at 12:30 PM revealed the door to the human resources storage room did not have a self closure device attached. The storage area contained over 20 boxes of paper and was greater than 50 square feet measuring 7ft x 8ft. In addition, observation on 5/1/12 at 12:48 pm revealed the door to the janitor's closet (room 128) and the door to the janitor's closet opposite the human resources office did not have a self closure devices attached. Maintenance staff acknowledged the finding at the time of the observations.

Ref: 2000 NFPA 101 Section 18.3.2.1, 8.4.1.2, 8.2.4.3.5

Based on observation and staff interview the facility failed to ensure sprinkler heads in 2 of 6 smoke compartments were installed as required. The findings were:

Observation on 5/1/12 between 11 AM and 3:30 PM revealed the following concerns:
a. The laboratory electric room #120 did not have sprinkler coverage. The room was greater than 50 square feet and had a heat detector installed in the ceiling.
b. The telephone equipment room in the basement did not have sprinkler coverage. The room was greater than 50 square feet and had a smoke detector installed in the ceiling.
Interview with the maintenance staff at the time of the observations confirmed the findings.

Reference: NFPA 101, Life Safety Code, 2000 edition. Sections 9.7.1.1; 19.3.5.1; 1999 NFPA 5-6.5.3.

Based on observation and staff interview the facility failed to ensure the fire suppression (sprinkler) system was properly maintained in 2 of 6 smoke compartments. The findings were:

Observation on 5/1/12 at 2:48 PM revealed a gap greater than one-half inch existed between the sprinkler head escutcheons and the ceiling in the mail room, in the soiled utility room in the surgical suite and in the purchasing supply room in the basement. In addition, a storage shelf in the housekeeping storage room by the mens' locker room had supplies stored less than 8 inches from the sprinkler head. Interview with maintenance staff at the time of the observation confirmed the findings.

Ref: 2000 NFPA 101 Section 19.3.5.1 (existing).
Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with section 9.7.
9.7.5 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 the Water-Based Fire Protection systems, 1992 edition.

Based upon observation and staff interview the facility failed to maintain 1 portable fire extinguisher in 1 of 6 smoke compartments as required. The findings were:

Observation on 5/1/12 at 11:48 AM revealed an AC water mist type of fire extinguisher attached to the wall in the cardiac therapy room (old education section). The top of the fire extinguisher was approximately six feet from the floor exceeding the maximal 5 ft requirement for extinguishers weighing less than 40 pounds. The fire extinguisher weighed 21 lbs. Interview with maintenance staff at the time of the observation confirmed the above findings.

Reference: NFPA 101, Life Safety Code, 2000 edition.
Sections 19.3.5.6 Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1.
9.7.4.1 Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected and maintained in accordance with NFPA 10.
NFPA 10, Standard for the Installation of Portable Fire Extinguishers, 1990 ed.
1-6.9. Extinguishers having a gross weight not exceeding 40 lb shall be installed so that the top of the extinguisher is not more than 5 ft above the floor. Extinguishers having a gross weight greater than 40 lb shall be installed so installed that the top of the extinguisher is not more than 3.5 ft above the floor. In no case shall the clearance between the bottom of the extinguisher and the floor be less than 4 in.

Based on observation and staff interview, the facility failed to ensure medical gas cylinders were securely fastened in 1 of 6 smoke compartments. The findings were:

Observation on 5/1/12 at 1:23 PM showed two unsecured "E" sized oxygen tanks lying horizontally on the floor in the medical/surgical Pixus room. Interview with maintenance staff at the time of the observation confirmed the tanks needed to be secured.

Reference: NFPA 101, Life Safety Code, 2000 edition.
Section 19.3.2.4 Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.
NFPA 99 Standard for Health Care Facilities, Chapters 4 and 8.
Stand Alone Cylinders and Containers Storage areas: General Considerations. Cylinders must be secured from falling or mechanical shock.

Based on observation and staff interview, the facility failed to ensure compliance with the National Electric Code in 1 of 6 smoke compartments. The findings were:

Observation on 5/1/12 at 10:30 AM revealed a desk in the medical records section had an electrical cover plate that had come away from the wall. The electrical cord was still plugged into the outlet. In addition, a light switch cover plate in the soiled utility room was chipped. Interview with maintenance staff at the time of the observations confirmed the above findings.

Reference: NFPA 70, National Electrical Code, 1999 Edition.

Based on observation and staff interview, the facility failed to protect hazardous areas in 1 of 6 smoke compartments. The findings were:

Observation on 5/1/12 at 12:30 PM revealed the door to the human resources storage room did not have a self closure device attached. The storage area contained over 20 boxes of paper and was greater than 50 square feet measuring 7ft x 8ft. In addition, observation on 5/1/12 at 12:48 pm revealed the door to the janitor's closet (room 128) and the door to the janitor's closet opposite the human resources office did not have a self closure devices attached. Maintenance staff acknowledged the finding at the time of the observations.

Ref: 2000 NFPA 101 Section 18.3.2.1, 8.4.1.2, 8.2.4.3.5

Based on observation and staff interview the facility failed to ensure sprinkler heads in 2 of 6 smoke compartments were installed as required. The findings were:

Observation on 5/1/12 between 11 AM and 3:30 PM revealed the following concerns:
a. The laboratory electric room #120 did not have sprinkler coverage. The room was greater than 50 square feet and had a heat detector installed in the ceiling.
b. The telephone equipment room in the basement did not have sprinkler coverage. The room was greater than 50 square feet and had a smoke detector installed in the ceiling.
Interview with the maintenance staff at the time of the observations confirmed the findings.

Reference: NFPA 101, Life Safety Code, 2000 edition. Sections 9.7.1.1; 19.3.5.1; 1999 NFPA 5-6.5.3.

Based on observation and staff interview the facility failed to ensure the fire suppression (sprinkler) system was properly maintained in 2 of 6 smoke compartments. The findings were:

Observation on 5/1/12 at 2:48 PM revealed a gap greater than one-half inch existed between the sprinkler head escutcheons and the ceiling in the mail room, in the soiled utility room in the surgical suite and in the purchasing supply room in the basement. In addition, a storage shelf in the housekeeping storage room by the mens' locker room had supplies stored less than 8 inches from the sprinkler head. Interview with maintenance staff at the time of the observation confirmed the findings.

Ref: 2000 NFPA 101 Section 19.3.5.1 (existing).
Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with section 9.7.
9.7.5 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 the Water-Based Fire Protection systems, 1992 edition.

Based upon observation and staff interview the facility failed to maintain 1 portable fire extinguisher in 1 of 6 smoke compartments as required. The findings were:

Observation on 5/1/12 at 11:48 AM revealed an AC water mist type of fire extinguisher attached to the wall in the cardiac therapy room (old education section). The top of the fire extinguisher was approximately six feet from the floor exceeding the maximal 5 ft requirement for extinguishers weighing less than 40 pounds. The fire extinguisher weighed 21 lbs. Interview with maintenance staff at the time of the observation confirmed the above findings.

Reference: NFPA 101, Life Safety Code, 2000 edition.
Sections 19.3.5.6 Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1.
9.7.4.1 Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected and maintained in accordance with NFPA 10.
NFPA 10, Standard for the Installation of Portable Fire Extinguishers, 1990 ed.
1-6.9. Extinguishers having a gross weight not exceeding 40 lb shall be installed so that the top of the extinguisher is not more than 5 ft above the floor. Extinguishers having a gross weight greater than 40 lb shall be installed so installed that the top of the extinguisher is not more than 3.5 ft above the floor. In no case shall the clearance between the bottom of the extinguisher and the floor be less than 4 in.

Based on observation and staff interview, the facility failed to ensure medical gas cylinders were securely fastened in 1 of 6 smoke compartments. The findings were:

Observation on 5/1/12 at 1:23 PM showed two unsecured "E" sized oxygen tanks lying horizontally on the floor in the medical/surgical Pixus room. Interview with maintenance staff at the time of the observation confirmed the tanks needed to be secured.

Reference: NFPA 101, Life Safety Code, 2000 edition.
Section 19.3.2.4 Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.
NFPA 99 Standard for Health Care Facilities, Chapters 4 and 8.
Stand Alone Cylinders and Containers Storage areas: General Considerations. Cylinders must be secured from falling or mechanical shock.

Based on observation and staff interview, the facility failed to ensure compliance with the National Electric Code in 1 of 6 smoke compartments. The findings were:

Observation on 5/1/12 at 10:30 AM revealed a desk in the medical records section had an electrical cover plate that had come away from the wall. The electrical cord was still plugged into the outlet. In addition, a light switch cover plate in the soiled utility room was chipped. Interview with maintenance staff at the time of the observations confirmed the above findings.

Reference: NFPA 70, National Electrical Code, 1999 Edition.