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Tag No.: K0018
Based on observation and interview it was determined that the facility did not ensure that corridor doors were constructed to resist the passage of smoke and did not have any impediment to closing. Corridor doors that are not able to be closed and do not resist the passage of smoke can allow smoke and fire gases to enter the corridor in the event of a fire.
Findings include:
1. During the tour of the facility on August 22, 2012, at 2:15 PM, observation of the dutch door to the Central Sterilizing room revealed that there was not an astragal, rabbet or bevel between the upper and lower leafs. When questioned about the door the Maintenance Supervisor stated the he was unaware of the requirement for dutch door to be smoke resisting.
2. During the tour of the facility on August 22, 2012, at 1:45 PM, observation of the door to the computer server room revealed a transfer grill in the lower half of the door. When questioned about the transfer grill in the door the Maintenance Supervisor stated the he was unaware that corridor doors can not have transfer grills.
3. During the tour of the facility on August 22, 2012, at 2:05 PM, observation room #201 revealed a patient bed protruding into the doorway preventing the door from fully closing. When questioned about the bed in the doorway the Maintenance Supervisor stated that beds being moved into doorways has been on ongoing problem with the nursing staff.
Actual NFPA Standard:
19.3.6.3.6
Dutch doors shall be permitted where they conform to 19.3.6.3. In addition, both the upper leaf and lower leaf shall be equipped with a latching device, and the meeting edges of the upper and lower leaves shall be equipped with an astragal, a rabbet, or a bevel.
19.3.6.4 Transfer Grilles.
Transfer grilles, regardless of whether they are protected by fusible link-operated dampers, shall not be used in these walls or doors.
19.3.6.3
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas are substantial doors, such as those constructed of 1? inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in sprinklered buildings are only required to resist the passage of smoke. There is no impediment to the closing of the doors. Doors are provided with a means suitable for keeping the door closed. Dutch doors meeting 19.3.6.3.6 are permitted.
19.3.6.4 Transfer Grilles.
Transfer grilles, regardless of whether they are protected by fusible link-operated dampers, shall not be used in these walls or doors.
Tag No.: K0048
Based on record review and interview it was determined that the facility did not ensure that the fire safety plan included the required eight components. This deficiency can endanger patients and slow an emergency response.
Findings include:
During record review on August 22, 2012, at 12:50 PM, it was determined that the facility's fire safety plan did not include the transmission of an alarm to the fire department, evacuation of the immediate area and the smoke compartment in the event of a fire. When questioned about the fire safety plan the Maintenance Supervisor stated the he was unaware that the plan did not include the required components of a fire safety plan.
Actual NFPA Standard:
19.7.1 Evacuation and Relocation Plan and Fire Drills.
19.7.1.1
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. A copy of the plan shall be readily available at all times in the telephone operator ' s position or at the security center.
19.7.2.2
A written health care occupancy fire safety plan shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment
(7) Preparation of floors and building for evacuation
(8) Extinguishment of fire
Tag No.: K0056
Based on observation the facility did not ensure that the sprinkler system was installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. This deficiency could render the sprinkler system so that the appropriate sprinkler head may not activate as designed.
Findings include:
During the facility tour on August 22, 2012 at 2:35 PM, observation of the sprinkler heads in the stairwell revealed one ordinary response sprinkler head located at the bottom of the stairwell mixed with one quick response sprinkler head located at the top of the stairwell. When questioned about the sprinkler heads the Maintenance Supervisor stated the he had not noticed the different types of sprinkler heads in the stairwell.
Actual NFPA Standard:
NFPA 13 1999 Edition
5-4.5.3
Where residential sprinklers are installed in a compartment as defined in 1-4.2, all sprinklers within the compartment shall be of the fast-response type that meets the criteria of 1-4.5.1(a)1.
Tag No.: K0062
Based on record review and interview it was determined that the facility did not ensure that the sprinkler system was being maintained in accordance NFPA 25. Properly maintaining the sprinkler system helps to ensure system reliability.
Findings include:
During record review on August 22, 2012 at 11:42 AM, the facility was unable to provide documented quarterly sprinkler system inspections for the previous twelve month period. When questioned about the inspections the maintenance Supervisor stated that he was unaware of the requirement for quarterly sprinkler system inspections.
Actual NFPA Standard:
9.7.5 Maintenance and Testing.
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.
NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 1998 Edition
2-2.6 Alarm Devices.
Alarm devices shall be inspected quarterly to verify that they are free of physical damage.
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.
Tag No.: K0130
Based on observation and interview it was determined that the facility did not ensure that required means of egress doors were not equipped with a lock that requires the use of a key from the egress side. This deficiency can slow the evacuation of the room in an emergency and has the potential to prevent an individual in the room from evacuating if the door is locked from the corridor side of the door.
Findings include:
During the tour of the facility on August 22, 2012, at 2:07 PM, observation of the door to the soiled utility room revealed a deadbolt lock installed on the door with the key side on the egress side and the hand operated locking mechanism on the corridor side of the door. When questioned about the lock on the door the Maintenance Supervisor stated that he was unaware that a deadbolt had been installed backwards on the door.
Actual NFPA Standard:
19.2.2 Means of Egress Components.
19.2.2.2.4
Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side.
Tag No.: K0144
Based on record review and interview the facility did not ensure that the emergency generator was being load tested on a monthly basis in accordance with NFPA 110. Failure to load test the generator monthly and inspect the generator on a weekly basis could result in the generator not starting or functioning properly in the event of a power outage.
Findings include:
During record review on August 22, 2012 at 1:10 PM, the facility was unable to provide documented thirty minute monthly load tests for the previous twelve month period. When questioned about the monthly load tests the Maintenance Supervisor's assistant stated that he was unaware of the requirement for thirty minute monthly load tests.
This deficiency was cited during the fire/life safety survey conducted on October 6, 2009.
Actual NFPA Standard:
NFPA 110 Standard for Emergency and Standby Power Systems 1999 Edition.
6-3.4
A written record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained on the premises. The written record shall include the following:
(a) The date of the maintenance report
(b) Identification of the servicing personnel
(c) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced
(d) Testing of any repair for the appropriate time as recommended by the manufacturer
6-4.1*
Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
6-4.2*
Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
The date and time of day for required testing shall be decided by the owner, based on facility operations.
Tag No.: K0147
Based on observation and interview the facility did not ensure that electrical wiring and equipment usage was in accordance with NFPA 70. Utilizing relocatable power taps and multiple adapters can lead to overloaded wiring and start a fire.
Findings include:
1. During the tour of the facility on August 22, 2012 at 1:37 PM, observation of the kitchen revealed a freezer plugged into a multiple electrical adapter. When questioned about the multiple adapter usage the Maintenance Supervisor stated he was unaware that multiple electrical adapters can not be utilized in the facility.
2. During the tour of the facility on August 22, 2012 at 1:39 PM, observation of the staff break room revealed a bread toaster plugged into a relocateable power tap. When questioned about the relocateable power tap usage the Maintenance Supervisor stated that he was unaware of the usage in the break room.
Actual NFPA Standard:
NFPA 70 National Electrical Code 1999 Edition
110-3. Examination, Identification, Installation, and Use of Equipment
(a) Examination. In judging equipment, considerations such as the following shall be evaluated:
1. Suitability for installation and use in conformity with the provisions of this Code
FPN: Suitability of equipment use may be identified by a description marked on or provided with a product to identify the suitability of the product for a specific purpose, environment, or application. Suitability of equipment may be evidenced by listing or labeling.
2. Mechanical strength and durability, including, for parts designed to enclose and protect other equipment, the adequacy of the protection thus provided
3. Wire-bending and connection space
4. Electrical insulation
5. Heating effects under normal conditions of use and also under abnormal conditions likely to arise in service
6. Arcing effects
7. Classification by type, size, voltage, current capacity, and specific use
8. Other factors that contribute to the practical safeguarding of persons using or likely to come in contact with the equipment
(b) Installation and Use. Listed or labeled equipment shall be installed and used in accordance with any instructions included in the listing or labeling.
UL 1363
RELOCATABLE POWER TAPS (XBYS)
Relocatable Power TapsXBYSUSE AND INSTALLATION
This category covers relocatable power taps rated 250 V ac or less, 20 A or less. They are intended for indoor use as relocatable multiple outlet extensions of a single branch circuit to supply laboratory equipment, home workshops, home movie lighting controls, musical instrumentation, and to provide outlet receptacles for computers, audio and video equipment, and other equipment. They consist of one attachment plug and a single length of flexible cord terminated in a single enclosure in which one or more receptacles are mounted. They may, in addition, be provided with fuses or other supplementary overcurrent protection, switches, suppression components and/or indicator lights in any combination, or connections for cable, communications, telephone and/or antenna.
Relocatable power taps are intended to be directly connected to a permanently installed branch circuit receptacle. Relocatable power taps are not intended to be series connected (daisy chained) to other relocatable power taps or to extension cords.
Relocatable power taps are not intended for use at construction sites and similar locations.
Relocatable power taps are not intended to be permanently secured to building structures, tables, work benches or similar structures, nor are they intended to be used as a substitute for fixed wiring. The cords of relocatable power taps are not intended to be routed through walls, windows, ceilings, floors or similar openings.
Relocatable power taps have not been investigated and are not intended for use with general patient care areas or critical patient care areas of health care facilities as defined in Article 517 of ANSI/NFPA 70, "National Electrical Code."