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NFPA 10 Standard for Portable Fire Extinguishers 2010 Edition

6.1.3.1 Fire extinguishers shall be conspicuously located where they are readily accessible and immediately available in the event of fire.

7.2.1.2* Fire extinguishers shall be inspected either manually or by means of an electronic monitoring device/system at a minimum of 30-day intervals.

7.2.2 Procedures. Periodic inspection or electronic monitoring of fire extinguishers shall include a check of at least the following items:
(1) Location in designated place
(2) No obstruction to access or visibility
(3) Pressure gauge reading or indicator in the operable range or position
(4) Fullness determined by weighing or hefting for self expelling-type extinguishers, cartridge-operated extinguishers, and pump tanks
(5) Condition of tires, wheels, carriage, hose, and nozzle for wheeled extinguishers
(6) Indicator for non-rechargeable extinguishers using push to-test pressure indicators

This Standard was not met as evidenced by:

Based on observation and interview, the facility failed to ensure that a fire extinguisher was immediately available, accessible and unobstructed, and failed to ensure that carbon dioxide fire extinguishers fullness was determined by weighing or hefting.

Portable fire extinguishers are intended as a first line of defense to cope with fires of limited size. For fire extinguisher to do their job they must be full and accessible. The deficient did not ensure that the fire extinguisher would be available and immediately accessible when needed.

Findings:

2nd Floor Surgery

1. During the LSC survey on 5/23/18 between 9 a.m. and 9:27 a.m., the evaluator noted that there were carbon dioxide extinguishers in operating rooms (ORs).

During an interview at the same time as the observation, the Maintenance Journey Man stated that the CO2 fire extinguishers were checked by weight one time a year during the annual service. He further stated that although he conducted monthly inspections of the fire extinguishers, he did not determine the fullness of the CO2 extinguishers by weighing at 30 day intervals.

During an interview on 5/24/18 at 3 p.m., the Supervisor Maintenance Engineer stated that 10 of 10 ORs had CO2 extinguishers.

Per NFPA 10: Standard for Portable Fire Extinguishers 2010 Edition; Table D.1.2.2 Extinguisher Operation and Methods of Expelling, the expelling method of a carbon dioxide extinguisher is Self-Expelling (a fire extinguisher in
which the agents have sufficient vapor pressure at normal operating
temperatures to expel themselves).

2. During the LSC survey on 5/23/18 at 9:20 a.m., the evaluator noted that there was a soiled linen cart placed in front of a fire extinguisher cabinet in operating room 6.

During an interview at the same time as the observation, the Supervisor Maintenance Engineer acknowledged the cart was obstructing the fire extinguisher in the cabinet.

Based on observation and interview the facility staff failed to ensure that corridor doors were able to be held in the closed position.

The deficiency had a potential to create a condition conducive to the potential transfer of smoke, heat, gases, and fire during a fire emergency.

Findings:

4th Floor North Tower

1. During the LSC survey on 5/22/18 at 2:15 p.m., the evaluator noted that the 4th floor corridor door to room N450 could not be held in the closed position.

During an interview at the same time as the observation, the Supervisor Maintenance Engineer stated that the door did not hold in the closed position because the strike plate had moved, and that the strike plate needed to be filed on its side.

2nd Floor Berger Tower

2. During the LSC survey on 5/23/18 at 2:14 p.m., the evaluator noted that the 2nd floor corridor door to room 223 could not be held in the closed position.

During an interview at the same time as the observation, the Supervisor Maintenance Engineer stated that staff was on their way to fix it.

1st Floor Perinatal

3. During the LSC survey on 5/23/18 at 2:29 p.m., the evaluator noted that the 1st floor corridor door to room 122 could not be held in the closed position.

NFPA 70 National Electrical Code 2011 Edition

110.12 Mechanical Execution of Work. Electrical equipment shall be installed in a workmanlike manner.

406.5 Receptacle Mounting. Receptacles shall be mounted in boxes or assemblies designed for the purpose, and such boxes or assemblies shall be securely fastened in place unless otherwise permitted elsewhere in Code.

This Code was not met as evidenced by:

Based on observation and interview, the facility failed to ensure that electrical wiring and equipment were in accordance with NFPA 70 as evidenced by a loose electrical receptacles.

The deficiencies had the potential risk of electrical shock and fire.

Findings:

5th Floor North Tower

1. During the LSC survey on 5/22/18 at 1:50 p.m., the evaluator noted a loose electrical receptacle in the equipment room.

2. At 2 p.m., the evaluator noted a loose electrical receptacle in the corridor by the soiled linen room.

During interviews at the same time as the observations the Supervisor Maintenance Engineering acknowledged the observation of the loose receptacles.