HospitalInspections.org

Based on observation and staff interview, the facility failed to provide separation of hazardous areas from other compartments. This condition had the potential to spread into the egress corridors. Facility census was 12 of 25.

Findings are:
Observations during the facility tour on 11/16/11, from 9:38 am to 9:42 am revealed:
1. The Lower Level IT Server Room failed to have a self-closure installed on the door, which separated the exit corridor from the room that contained a clean agent suppression system.
2. The Lower Level Pharmacy IV Storage Room Door failed to have a self-closure installed on the door.
In an interview conducted at the time of observation, (11/16/11, at 9:42 am), Maintenance A acknowledged the findings.

Based on observation and staff interview, the facility failed to provide illumination in the path of egress so that failure of one bulb would not leave the area in darkness. Facility census was 12 of 25.

Findings are:
Observation during the facility tour on 11/16/11, at 10:01 am revealed all lights were extinguished when the light switch was turned off in 2 of 2 exit stairwells.
In an interview conducted at the time of observation, (11/16/11, at 10:01 am), Maintenance A acknowledged that the stairwells were left in darkness when the light switch was turned off.

Based on record review and staff interview, the facility failed to maintain battery backup emergency lighting throughout the facility. This condition had the potential to leave occupants in darkness during a loss of power. Facility census was 12 of 25.

Findings are:
Record review revealed the facility failed to test battery backup emergency lights annually based on the documentation reviewed. The last recorded annual inspection occurred on 3/11.
In an interview conducted at the time of record review (11/15/11, at 12:41 pm), Maintenance A acknowledged that the test had not been completed within a year.

Actual NFPA Standard:
NFPA 101, 7.9.3, Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 ? hours. Equipment shall be fully operation for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Based on record review and staff interview, the facility failed to maintain the fire alarm system in accordance with the National Fire Protection Association, 72. This condition increased the potential that the fire alarm would fail to detect smoke. Facility census was 12 of 25.

Findings are:
Record review of fire alarm inspection reports revealed a calibration test failed to be conducted within the last two years from the date of the survey. The last documented calibration test occurred on 10/09.
In an interview conducted at the time of record review, (11/15/11, at 3:28 pm), Maintenance A confirmed the calibration failed to be completed.

Actual NFPA Standard:
NFPA 72, 7-3.2.1*
Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer ' s calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.

Based on observation and staff interview, the fully sprinkler protected facility failed to install a sprinkler head in all areas. This condition would allow a fire to grow and spread beyond the capability of the sprinkler system to suppress a fire. Facility census was 12 of 25.

Findings are:
Observation during the facility tour on 11/15/11, at 3:28 pm revealed the North Kitchen Entrance failed to have a sprinkler head installed in the enclosed vestibule.
In an interview conducted at the time of observation, Maintenance A confirmed that a sprinkler head failed to be installed in this area.

Actual NFPA Standard:
NFPA 13, 1-6.1
A building, where protected by an automatic sprinkler system installation, shall be provided with sprinklers in all areas.

Based on observation and staff interview, the facility failed to protect natural gas lines from unintentionally being disconnected by not providing a means of anchoring cooking appliances in the Kitchen. This condition had the potential to allow a wheeled appliance to be rolled out from the main gas supply, and potentially break the flexible natural gas hose. Facility census was 12 of 25.

Findings are:
Observations during the facility tour on 11/15/11, at 3:26 pm revealed the oven, convection oven and grill were on wheels in the Kitchen and failed to be restrained by a chain or another approved method to prevent the appliances from being rolled out too far to protect the natural gas hose.
In an interview conducted at the time of observation, (11/15/11, at 3:26 pm), Maintenance A acknowledged that the appliances failed to be restrained.

Actual NFPA Standard:

NFPA 54, 5.1.16 Avoiding Strain on Gas Piping.
Gas utilization equipment shall be supported and so connected to the piping as not to exert undue strain on the connections.

NFPA 54, 5.5.3 Connection of Portable and Mobile Industrial Gas Equipment.
(d) Where flexible connections are used, they shall be of the minimum practical length and shall not extend from one room to another or pass through any walls, partitions, ceilings, or floors. Flexible connections shall not be used in any concealed location. They shall be protected against physical or thermal damage and shall be provided with gas shutoff valves in readily accessible locations in rigid piping upstream from the flexible connections.

Based on observation and staff interview, the facility failed to label a piped oxygen shutoff valve to designate which area the valves controlled. This condition had the potential for oxygen to be shut off during a fire in the wrong area. Facility census was 12 of 25.

Findings are:
Observation during the facility tour on 11/15/11, at 2:00 pm revealed the OB Department piped oxygen shutoff valve failed to be labeled with the area it served.
In an interview conducted at the time of observation, (11/15/11, at 2:00 pm), Maintenance A confirmed the valve failed to be labeled.

Actual NFPA Standard:
Actual NFPA Standard: 4-3.5.4.2
The shutoff valves described in 4-3.1.2.3, 4-3.1.2.3(m), and 4-3.1.2.3(n) shall be labeled to reflect the rooms that are controlled by such valves. Labeling shall be kept current from initial construction through acceptance. Valves shall be labeled in substance as follows:
CAUTION:
(NAME OF MEDICAL GAS) VALVE DO NOT CLOSE EXCEPT IN EMERGENCY THIS VALVE CONTROLS SUPPLY TO . . . .

A.

Based on record review and staff interview, the facility failed to provide documentation of final acceptance testing for the FM 200 Clean Agent Suppression System. This condition had the potential for the system to not activate as designed during a fire. Facility census was 12 of 25.

Findings are:
Record review during the facility tour revealed the facility failed to provide a report of acceptance testing for the Hospital Lower Level IT Server Room FM 200 Clean Agent Suppression System.
In an interview conducted at the time of record review, (11/16/11, at 9:39 am), Maintenance A confirmed that the reports failed to be available for review.

B.

Based on record review and staff interview, the facility failed to provide documentation of final acceptance testing for the FM 200 Clean Agent Suppression System. This condition had the potential for the system to not activate as designed during a fire. Facility census was 12 of 25.

Findings are:
Record review during the facility tour revealed the facility failed to provide a report of acceptance testing for the Physical Therapy FM 200 Clean Agent Suppression System.
In an interview conducted at the time of record review, (11/16/11, at 10:34 am), Maintenance A confirmed that the reports failed to be available for review.

Based on observation and staff interview, the facility failed to use electrical wiring in accordance with the National Fire Protection Association, 70. This condition had the potential to cause an electrical fire. Facility census was 12 of 25.

Findings are:
Observation during the facility tour on 11/15/11, from 3:54 pm to 11/16/11, at 9:54 pm revealed:
1. The facility failed to cover two open junction boxes at the ceiling in the Tractor Storage Room. The findings were corrected during the survey.
2. The facility failed to cover an open junction box in the Lower Level Air Handler Room above the AHU 15 Electrical Panel.
3. The facility failed to cover an open junction box above ceiling at the exit light near the Ground Level South Wing smoke doors.
In an interview conducted at the time of observation (11/15/11, from 3:54 pm to 11/16/11, at 9:54 pm), Maintenance A acknowledged the use of the electrical equipment.

Based on observation and staff interview, the facility failed to provide separation of hazardous areas from other compartments. This condition had the potential to spread into the egress corridors. Facility census was 12 of 25.

Findings are:
Observations during the facility tour on 11/16/11, from 9:38 am to 9:42 am revealed:
1. The Lower Level IT Server Room failed to have a self-closure installed on the door, which separated the exit corridor from the room that contained a clean agent suppression system.
2. The Lower Level Pharmacy IV Storage Room Door failed to have a self-closure installed on the door.
In an interview conducted at the time of observation, (11/16/11, at 9:42 am), Maintenance A acknowledged the findings.

Based on observation and staff interview, the facility failed to provide illumination in the path of egress so that failure of one bulb would not leave the area in darkness. Facility census was 12 of 25.

Findings are:
Observation during the facility tour on 11/16/11, at 10:01 am revealed all lights were extinguished when the light switch was turned off in 2 of 2 exit stairwells.
In an interview conducted at the time of observation, (11/16/11, at 10:01 am), Maintenance A acknowledged that the stairwells were left in darkness when the light switch was turned off.

Based on record review and staff interview, the facility failed to maintain battery backup emergency lighting throughout the facility. This condition had the potential to leave occupants in darkness during a loss of power. Facility census was 12 of 25.

Findings are:
Record review revealed the facility failed to test battery backup emergency lights annually based on the documentation reviewed. The last recorded annual inspection occurred on 3/11.
In an interview conducted at the time of record review (11/15/11, at 12:41 pm), Maintenance A acknowledged that the test had not been completed within a year.

Actual NFPA Standard:
NFPA 101, 7.9.3, Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 ? hours. Equipment shall be fully operation for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Based on record review and staff interview, the facility failed to maintain the fire alarm system in accordance with the National Fire Protection Association, 72. This condition increased the potential that the fire alarm would fail to detect smoke. Facility census was 12 of 25.

Findings are:
Record review of fire alarm inspection reports revealed a calibration test failed to be conducted within the last two years from the date of the survey. The last documented calibration test occurred on 10/09.
In an interview conducted at the time of record review, (11/15/11, at 3:28 pm), Maintenance A confirmed the calibration failed to be completed.

Actual NFPA Standard:
NFPA 72, 7-3.2.1*
Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer ' s calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.

Based on observation and staff interview, the fully sprinkler protected facility failed to install a sprinkler head in all areas. This condition would allow a fire to grow and spread beyond the capability of the sprinkler system to suppress a fire. Facility census was 12 of 25.

Findings are:
Observation during the facility tour on 11/15/11, at 3:28 pm revealed the North Kitchen Entrance failed to have a sprinkler head installed in the enclosed vestibule.
In an interview conducted at the time of observation, Maintenance A confirmed that a sprinkler head failed to be installed in this area.

Actual NFPA Standard:
NFPA 13, 1-6.1
A building, where protected by an automatic sprinkler system installation, shall be provided with sprinklers in all areas.

Based on observation and staff interview, the facility failed to protect natural gas lines from unintentionally being disconnected by not providing a means of anchoring cooking appliances in the Kitchen. This condition had the potential to allow a wheeled appliance to be rolled out from the main gas supply, and potentially break the flexible natural gas hose. Facility census was 12 of 25.

Findings are:
Observations during the facility tour on 11/15/11, at 3:26 pm revealed the oven, convection oven and grill were on wheels in the Kitchen and failed to be restrained by a chain or another approved method to prevent the appliances from being rolled out too far to protect the natural gas hose.
In an interview conducted at the time of observation, (11/15/11, at 3:26 pm), Maintenance A acknowledged that the appliances failed to be restrained.

Actual NFPA Standard:

NFPA 54, 5.1.16 Avoiding Strain on Gas Piping.
Gas utilization equipment shall be supported and so connected to the piping as not to exert undue strain on the connections.

NFPA 54, 5.5.3 Connection of Portable and Mobile Industrial Gas Equipment.
(d) Where flexible connections are used, they shall be of the minimum practical length and shall not extend from one room to another or pass through any walls, partitions, ceilings, or floors. Flexible connections shall not be used in any concealed location. They shall be protected against physical or thermal damage and shall be provided with gas shutoff valves in readily accessible locations in rigid piping upstream from the flexible connections.

Based on observation and staff interview, the facility failed to label a piped oxygen shutoff valve to designate which area the valves controlled. This condition had the potential for oxygen to be shut off during a fire in the wrong area. Facility census was 12 of 25.

Findings are:
Observation during the facility tour on 11/15/11, at 2:00 pm revealed the OB Department piped oxygen shutoff valve failed to be labeled with the area it served.
In an interview conducted at the time of observation, (11/15/11, at 2:00 pm), Maintenance A confirmed the valve failed to be labeled.

Actual NFPA Standard:
Actual NFPA Standard: 4-3.5.4.2
The shutoff valves described in 4-3.1.2.3, 4-3.1.2.3(m), and 4-3.1.2.3(n) shall be labeled to reflect the rooms that are controlled by such valves. Labeling shall be kept current from initial construction through acceptance. Valves shall be labeled in substance as follows:
CAUTION:
(NAME OF MEDICAL GAS) VALVE DO NOT CLOSE EXCEPT IN EMERGENCY THIS VALVE CONTROLS SUPPLY TO . . . .

A.

Based on record review and staff interview, the facility failed to provide documentation of final acceptance testing for the FM 200 Clean Agent Suppression System. This condition had the potential for the system to not activate as designed during a fire. Facility census was 12 of 25.

Findings are:
Record review during the facility tour revealed the facility failed to provide a report of acceptance testing for the Hospital Lower Level IT Server Room FM 200 Clean Agent Suppression System.
In an interview conducted at the time of record review, (11/16/11, at 9:39 am), Maintenance A confirmed that the reports failed to be available for review.

B.

Based on record review and staff interview, the facility failed to provide documentation of final acceptance testing for the FM 200 Clean Agent Suppression System. This condition had the potential for the system to not activate as designed during a fire. Facility census was 12 of 25.

Findings are:
Record review during the facility tour revealed the facility failed to provide a report of acceptance testing for the Physical Therapy FM 200 Clean Agent Suppression System.
In an interview conducted at the time of record review, (11/16/11, at 10:34 am), Maintenance A confirmed that the reports failed to be available for review.

Based on observation and staff interview, the facility failed to use electrical wiring in accordance with the National Fire Protection Association, 70. This condition had the potential to cause an electrical fire. Facility census was 12 of 25.

Findings are:
Observation during the facility tour on 11/15/11, from 3:54 pm to 11/16/11, at 9:54 pm revealed:
1. The facility failed to cover two open junction boxes at the ceiling in the Tractor Storage Room. The findings were corrected during the survey.
2. The facility failed to cover an open junction box in the Lower Level Air Handler Room above the AHU 15 Electrical Panel.
3. The facility failed to cover an open junction box above ceiling at the exit light near the Ground Level South Wing smoke doors.
In an interview conducted at the time of observation (11/15/11, from 3:54 pm to 11/16/11, at 9:54 pm), Maintenance A acknowledged the use of the electrical equipment.