HospitalInspections.org

Based on observation, interview and record review, facility staff failed to inspect, test and maintain the fire egress doors in accordance with the 2010 Editions of NFPA 80 (Standard for Fire Doors and Other Opening Protectives) and NFPA 105 (Standard for Fire Doors and Other Opening Protectives). Facility staff failed to conduct an annual inspection of the fire egress doors. The facility census was 9.

1. Review of the facility's inspection, testing and maintenance records for the 2018/2019 year showed the records did not contain documentation of an annual inspection of the fire egress doors during the 12-month period.

During an interview on 10/22/19 at 3:07 P.M., the Environmental Services Director confirmed the record review.

Review of NFPA 101, 2012 Edition showed the following:
-7.1.10.2.1 showed no furnishings, decorations, or other objects shall obstruct exits or their access thereto, egress therefrom, or visibility thereof.
-19.2.2.2.1 Doors complying with 7.2.1 shall be permitted.
-7.2.1.15.1* Where required by Chapters 11 through 43, the following door assemblies shall be inspected and tested not less than annually in accordance with 7.2.1.15.2 through 7.2.1.15.8:
(1) Door leaves equipped with panic hardware or fire exit hardware in accordance with 7.2.1.7;
(2) Door assemblies in exit enclosures;
(3) Electrically controlled egress doors;
(4) Door assemblies with special locking arrangements subject to 7.2.1.6.
-7.2.1.15.2 Fire-rated door assemblies shall be inspected and tested in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Smoke door assemblies shall be inspected and tested in accordance with NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives.
-7.2.1.15.3 The inspection and testing interval for fire-rated and nonrated door assemblies shall be permitted to exceed 12 months under a written performance-based program in accordance with 5.2.2 of NFPA 80, Standard for Fire Doors and Other Opening Protectives.
-7.2.1.15.4 A written record of the inspections and testing shall be signed and kept for inspection by the authority having jurisdiction.

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 census was 9.

1. Observation on 10/22/19, during the facility tour, showed the following area did not have adequate smoke detector coverage:

- a 40 foot hallway in the emergency department did not have smoke detector coverage.

During an interview on 10/22/19 at 10:50 A.M., the Environmental Services Director confirmed the observation.

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 NAPA 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.

Refer to NFPA 72, National Fire Alarm and Signaling Code, 2010 edition, section:

10.5.5.2 Circuit Identification and Accessibility.

10.5.5.2.1 The location of the dedicated branch circuit disconnecting
means shall be permanently identified at the control
unit.

10.5.5.2.2 For fire alarm systems the circuit disconnecting
means shall be identified as "FIRE ALARM CIRCUIT."

10.5.5.2.3 For fire alarm systems the circuit disconnecting
means shall have a red marking.

10.5.5.2.4 The circuit disconnecting means shall be accessible

Based on observation and facility staff interview, facility staff failed to ensure areas open to the corridor contain smoke detection per NFPA 72, National Fire Alarm and Signaling Code. The facility census was 9 .

Observations on 10/22/19, during the facility tour, showed the following room/areas open to the corridor open to the designated exit corridor. Observation showed the rooms/areas did not have smoke detector coverage:

- Outpatient registration;

- Outpatient clinic;

- E.R. registration.

During an interview on 10/22/19 at 10:30 A.M., the Environment Services Director confirmed the observations.

NFPA 101, 2012 edition states "Smoke detection systems are provided in spaces open to the corridors as required by 19.3.6.1".

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 staff interview and record review, facility staff failed to inspect the wet sprinkler systems per NFPA 25, Standard for the Inspection, Testing, and maintenance of Water-Based Fire Protection Systems, 2011 edition. The facility census was 9 .

Record review on 10/22/19 did not show the following inspections:


-5 year internal pipe inspection.

During an interview on 10/22/19 at 2:28 P.M., the Environmental Services Director said that a five year internal pipe inspection was never conducted on any of the sprinkler systems.

Refer to NFPA 25, Standard for the Inspection, Testing, and maintenance of Water-Based Fire Protection Systems, 2011 edition, Chapters 5, 13 and 14 for additional information.

Based on observation and interview the facility failed to provide window blinds that were flame resistant in accordance with provisions of NFPA 101, 10.3. The facility census was 9.

1. Observations on 10/22/19, during the Life Safety Code tour, showed window blinds throughout the east wing resident rooms without identification that showed them as being flame retardant.

During an interview on 10/22/19 at 11:45 A.M., the Environmental Services Director said that he did not know if the blinds had a rating.


NFPA Standard: Draperies, curtains, and other similar loosely hanging furnishings and decorations shall be flame resistant as /demonstrated by testing in accordance with NFPA 701. 2012 NFPA 101.

Based on observation and facility staff interview, the facility did not ensure containers in excess of 32 gallons in size are stored in a room protected as a hazardous area. Two containers exceeded 32 gallons in size and were stored in a corridor that was not protected as a hazardous area. This deficient practice affects all occupants in the building. The census was 9 .

1. Observation on 10/22/19 showed the emergency department eight feet wide corridor contained one soiled linen barrel and one trash barrel. Observation showed each container exceeded 32 gallons capacity.

During an interview on 10/22/19 at 1:09 P.M., the Environmental Services Director said for the most part the barrels are stored in the corridor.

NFPA 101, 2012 edition, Section 19.7.5.7 states:

"19.7.5.7 Soiled Linen and Trash Receptacles.

19.7.5.7.1 Soiled linen or trash collection receptacles shall
not exceed 32 gal (121 L) in capacity and shall meet all of the
following requirements:
(1) The average density of container capacity in a room or
space shall not exceed 0.5 gal/ft2 (20.4 L/m2).
(2) A capacity of 32 gal (121 L) shall not be exceeded within
any 64 ft2 (6 m2) area.
(3)*Mobile soiled linen or trash collection receptacles with
capacities greater than 32 gal (121 L) shall be located in a
room protected as a hazardous area when not attended.
(4) Container size and density shall not be limited in hazardous
areas.

19.7.5.7.2* Containers used solely for recycling clean waste or
for patient records awaiting destruction shall be permitted to
be excluded from the requirements of 19.7.5.7.1 where all the
following conditions are met:
(1) Each container shall be limited to a maximum capacity of
96 gal (363 L), except as permitted by 19.7.5.7.2(2) or (3).
(2)*Containers with capacities greater than 96 gal (363 L)
shall be located in a room protected as a hazardous area
when not attended.
(3) Container size shall not be limited in hazardous areas.
(4) Containers for combustibles shall be labeled and listed as
meeting the requirements of FMApproval Standard 6921,
Containers for Combustible Waste; however, such testing, listing,
and labeling shall not be limited to FM Approvals.

A.19.7.5.7.2 It is the intent that this provision permits recycling
of bottles, cans, paper, and similar clean items that do
not contain grease, oil, flammable liquids, or significant plastic
materials, using larger containers or several adjacent containers,
and not require locating such containers in a room
protected as a hazardous area. Containers for medical records
awaiting shredding are often larger than 32 gal (121 L). These
containers are not to be included in the calculations and limitations
of 19.7.5.7.1. There is no limit on the number of these
containers, as FM Approval Standard 6921, Containers for Combustible
Waste, ensures that the fire will not spread outside of
the container. FM approval standards are written for use with
FM Approvals. The tests can be conducted by any approved
laboratory. The portions of the standard referring to FM Approvals

Based on observation and staff interview facility staff failed to provide an emergency stop switch away from the generator set location. The facility census was 9.

1. Observation on 10/22/19, during the facility tour, showed the generator for the original building did not have an emergency stop switch.

During an interview on 10/22/19 at 11:27 A.M., the Environmental Services Director confirmed the observation.


NFPA 110, Standard for Emergency and Standby Power Systems, 2010 edition states:

5.6.5.6* 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.

5.6.5.6.1 The remote manual stop station shall be labeled.

8.4.2* Diesel generator sets in service shall be exercised at
least once monthly, for a minimum of 30 minutes, using one
of the following methods:
(1) Loading that maintains the minimum exhaust gas temperatures
as recommended by the manufacturer
(2) Under operating temperature conditions and at not less
than 30 percent of the EPS nameplate kW rating

8.4.2.1 The date and time of day for required testing shall be
decided by the owner, based on facility operations.

8.4.2.2 Equivalent loads used for testing shall be automatically
replaced with the emergency loads in case of failure of
the primary source.

8.4.2.3 Diesel-powered EPS installations that do not meet the
requirements of 8.4.2 shall be exercised monthly with the available
EPSS load and shall be exercised annually with supplemental
loads at not less than 50 percent of the EPS nameplate kW
rating for 30 continuous minutes and at not less than 75 percent
of the EPS nameplate kWrating for 1 continuous hour for a total
test duration of not less than 1.5 continuous hours.

8.3 Maintenance and Operational Testing.

8.3.1* The EPSS shall be maintained to ensure to a reasonable
degree that the system is capable of supplying service within the
time specified for the type and for the time duration specified for
the class.

8.3.2 A routine maintenance and operational testing program
shall be initiated immediately after the EPSS has passed
acceptance tests or after completion of repairs that impact the
operational reliability of the system.

8.3.2.1 The operational test shall be initiated at an ATS and
shall include testing of each EPSS component on which maintenance
or repair has been performed, including the transfer of
each automatic and manual transfer switch to the alternate
power source, for a period of not less than 30 minutes under
operating temperature.

8.3.3 A written schedule for routine maintenance and operational
testing of the EPSS shall be established.

8.3.4 A permanent record of the EPSS inspections, tests, exercising,
operation, and repairs shall be maintained and readily
available.

8.3.4.1 The permanent record shall include the following:
(1) The date of the maintenance report
(2) Identification of the servicing personnel
(3) Notation of any unsatisfactory condition and the corrective
action taken, including parts replaced
(4) Testing of any repair for the time as recommended by the
manufacturer

8.3.5* Transfer switches shall be subjected to a maintenance and
testing program that includes all of the following operations:
(1) Checking of connections
(2) Inspection or testing for evidence of overheating and excessive
contact erosion
(3) Removal of dust and dirt
(4) Replacement of contacts when required

8.3.6 Paralleling gear shall be subject to an inspection, testing,
and maintenance program that includes all of the following
operations:
(1) Checking of connections
(2) Inspection or testing for evidence of overheating and excessive
contact erosion
(3) Removal of dust and dirt
(4) Replacement of contacts when required

8.3.7* Storage batteries, including electrolyte levels or battery
voltage, used in connection with systems shall be inspected
weekly and maintained in full compliance with manufacturer ' s
specifications.

8.3.7.1 Maintenance of lead-acid batteries shall include the
monthly testing and recording of electrolyte specific gravity. Battery
conductance testing shall be permitted in lieu of the testing
of specific gravity when applicable or warranted.

8.3.7.2 Defective batteries shall be replaced immediately
upon discovery of defects.

8.3.8 A fuel quality test shall be performed at least annually
using tests approved by ASTM standards.

8.4 Operational Inspection and Testing.

8.4.1* EPSSs, including all appurtenant components, shall be
inspected weekly and exercised under load at least monthly.

8.4.6 Transfer switches shall be operated monthly.

8.4.6.1 The monthly test of a transfer switch shall consist of
electrically operating the transfer switch from the standard position
to the alternate position and then a return to the standard
position.

7.2.4* Minimizing the possibility of damage resulting from interruptions
of the emergency source shall be a design consideration
for EPSS equipment.

A.7.2.4 When installing the EPSS equipment and related
auxiliaries, environmental considerations should be given,
particularly with regard to the installation of the fuel tanks
and exhaust lines, or the EPS building, or both.
To protect against disruption of power in the facility, it is recommended
that the transfer switch be located as close to the load
as possible. The following are examples of external influences:
(1) Natural conditions
(a) Storms
(b) Floods
(c) Earthquakes
(d) Tornadoes
(e) Hurricanes
(f) Lightning
(g) Ice storms
(h) Wind
(i) Fire
(2) Human-caused conditions
(a) Vandalism
(b) Sabotage
(c) Other similar occurrences
(3) Material and equipment failures