HospitalInspections.org

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The facility failed to provide a building construction type per code. Findings include:

During the survey, the following is an example of what was observed:
The surveyor observed what appeared to be a Type II (000) construction type in a single story part of the building, but connected to the six story part of the building without a two hour fire barrier separating these construction types in the following locations:
1. In corridor at the Imaging Director's Office
2. In the Reading Room
3. In the Clinical Coordinator's Office

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2000 NFPA 101, 19.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)Table 19.1.6.2 Construction Type Limitations
Construction Stories
Type
1 2 3 4 or
More
I(443) X X X X
I(332) X X X X
II(222) X X X X
II(111) X X* X* NP
II(000) X* X* NP NP
III(211) X* X* NP NP
III(200) X* NP NP NP
IV(2HH) X* X* NP NP
V(111) X* X* NP NP
V(000) X* NP NP NP
X: Permitted type of construction.
NP: Not permitted.
*Building requires automatic sprinkler protection. (See 19.3.5.1.)
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The facility failed to maintain the interior finish for rooms per code. Findings include:

During the survey, the following is an example of what was observed:

First Floor
Enviromental Services/Linen Storage Room - the facility could not provide the flame spread rating of the styrofoam that was observed on the walls and the ceiling in this room

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2000 NFPA 101, 19.3.3.2 Interior wall and ceiling finish materials complying with 10.2.3 shall be permitted as follows:
(1) Existing materials - Class A or Class B
Exception: In rooms protected by an approved, supervised automatic sprinkler system, existing Class C interior finish shall be permitted to be continued to be used on walls and ceilings within rooms separated from the exit access corridors in accordance with 19.3.6.
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The facility failed to provide corridor doors that would close and resist the passage of smoke. Findings include: During the survey, the following are examples of what was observed:

1. The door to ISU Office had holes at the top left side of the door.

2. The Office across from the Nurses Station on the Six Floor had holes above the door handle.

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NFPA 101, 19.3.6.3.1 Exception No.2. In the smoke compartments protected throughout by an approved, supervised automatic sprinkler system, doors in corridor walls shall be constructed to resist the passage of smoke and be provided with suitable means of keeping the doors closed.

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The facility failed to maintain the corridor openings per code. Findings include:

During the survey, the following are examples of what was observed:
Second Floor
1. The corridor door to PACU had four holes in it at the door knob
Fourth Floor
2. The Case Manager's Office across from room 424 had four holes in it at the door knob

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2000 NFPA 101, 19.3.6.3.1 Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.
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The facility failed to provide smoke barriers that would provide at least a half hour fire resistance rating. Findings include: During the survey, the following are examples of what was observed:

1. Unsealed penetrations around a sprinkler line, and flex conduit, in the Smoke Barrier at PT Entrance.

2. Unsealed penetrations around conduit at the deck, in the Smoke Barrier, by Patient room 618.

3. Unsealed penetrations around a sprinkler line, in the Smoke Barrier, by Patient Room 621.

4. Unsealed penetrations around conduit at the deck, in the Smoke Barrier, by Control Room Sleep Disorders Center.


27382


Second Floor
5. The smoke barrier at room 210 a group of conduits were not sealed around at the deck, on both sides of the barrier
Third Floor
6. The smoke barrier at the Pixis/Dictation Area - conduit with a blue and a white wire, the end of the conduit was not sealed

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2000 NFPA 101, 8.2.4.4.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through smoke partitions shall be protected as follows: (1) The space between the penetrating item and the smoke partition shall meet one of the following conditions: a. It shall be filled with a material that is capable of limiting the transfer of smoke. b. It shall be protected by an approved device that is designed for the specific purpose. (2) Where the penetrating item uses a sleeve to penetrate the smoke partition, the sleeve shall be solidly set in the smoke partition, and the space between the item and the sleeve shall meet one of the following conditions: a. It shall be filled with a material that is capable of limiting the transfer of smoke. b. It shall be protected by an approved device that is designed for the specific purpose. (3) Where designs take transmission of vibrations into consideration, any vibration isolation shall meet one of the following conditions: a It shall be made on either side of the smoke partitions. b. It shall be made by an approved device that is designed for the specific purpose.
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The facility failed to maintain the smoke barrier to restrict the passage of smoke. Findings include: During the survey, the following is an example of what was observed:

The doors in the smoke barrier by the elevators on the First floor, failed to close tight.
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NFPA 101, 19.3.7.6., 8.3.4 Doors in smoke barriers to be self-closing. Doors in smoke barriers shall close the opening in the wall leaving only a minimum clearance to allow door(s) to function properly.


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The facility failed to maintain separation of hazardous areas. Findings include: During the survey, the following is an example of what was observed:

The combustible storage room located outside, under the Educational Bldg, had two area were the ceiling was missing.
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NFPA 101, 19.3.2.1 Hazardous areas shall be safeguarded by a fire barrier of a one-hour fire resistance rating or provided with an automatic sprinkler system.

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The facility failed to maintain stairways with at least 2 hour fire resistance rating. During the survey, the following is an example of what was observed:

Unsealed penetrations around a sprinkler line, in the Stairwell by the Gift Shop First Floor.

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LSC 2000 Edition, 19.3.1.1 Any vertical openings shall be enclosed or protected in accordance with 8.2.5. Where enclosure is provided, the construction shall have not less than 2-hour fire resistance rating.


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The facility failed to provide protection of openings in fire barriers to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. During the survey, the following are examples of what was observed:

1. Unsealed penetrations at the end of a sleeve, in the two hour barrier, by Plant Operations.

2. Unsealed penetrations at the end of a sleeve, and around wiring, in the two hour barrier, at the Educational Department.

3. Unsealed penetrations at the deck, in the two hour barrier, above the doors at the Educational Department.


27382


Second Floor
4. The two hour fire barrier that separates the two story from the six story had the following unsealed penetrations:
a. HVAC pipe not sealed around it
b. Several conduit ends not sealed
c. A conduit was not sealed around it
d. Foam used to seal a penetration
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NFPA 101, 19.2.2.5 and 7.2.4.3 Openings in fire barriers shall be constructed to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other.

2000 NFPA 101, 8.2.3.2.4.2 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows: (1) The space between the penetrating item and the fire barrier shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier. b. It shall be protected by an approved device that is designed for the specific purpose. (2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier. b. It shall be protected by an approved device that is designed for the specific purpose. (3) * Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met: a. The material shall be capable of maintaining the fire resistance of the fire barrier. b. The material shall be protected by an approved device that is designed for the specific purpose. (4) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions: a. It shall be made on either side of the fire barrier. b. It shall be made by an approved device that is designed for the specific purpose.
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The facility failed to provide protection of openings in fire barriers to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. During the survey, the following is an example of what was observed:

1. Unsealed penetrations around conduit, and at the end of a sleeve, in the two hour barrier by the Elevators on the First Floor.


27382


First Floor
2. Cardiopulmonary Care "Alabama Office" - the fire barrier had an unsealed conduit end
3. Imaging Director's Office - the fire barrier had an unsealed conduit end

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NFPA 101, 19.2.2.5 and 7.2.4.3 Openings in fire barriers shall be constructed to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other.

2000 NFPA 101, 8.2.3.2.4.2 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows: (1) The space between the penetrating item and the fire barrier shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier. b. It shall be protected by an approved device that is designed for the specific purpose. (2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier. b. It shall be protected by an approved device that is designed for the specific purpose. (3) * Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met: a. The material shall be capable of maintaining the fire resistance of the fire barrier. b. The material shall be protected by an approved device that is designed for the specific purpose. (4) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions: a. It shall be made on either side of the fire barrier. b. It shall be made by an approved device that is designed for the specific purpose.
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The facility failed to document staff participation in the fire drills. Findings include:

During the survey, the following is an example of what was observed:
Per documentation and interview the facility was not getting all staff to sign the participation sheets

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2000 NFPA 101, 19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
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The facility failed to maintain the fire alarm system. Findings include: During the survey, the following are examples of what was observed:

1. The Waiting Room for the Ultrasound was not provided with Audible/Visual device.

2. The Visual devices failed to function upon activation of the fire alarm system in the PT Department.


27382

Fifth Floor
3. SCU - the two sets of double corridor doors did not release under the activation of the fire alarm

First Floor
4. Emergency Department double corridor doors for the entrance from the Waiting Room - the left leaf did not release under activation of the fire alarm

5. The Front Lobby Public Bathrooms - the fire alarm strobes did not activate under activation of the fire alarm

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2000 NFPA 101, 9.6.3.6 Notification signals for occupants to evacuate shall be by audible and visible signals in accordance with NFPA 72, National Fire Alarm Code, and CABO/ANSI A117.1, American National Standard for Accessible and Usable Buildings and Facilities, or other means of notification acceptable to the authority having jurisdiction shall be provided.
2000 NFPA 101, 9.6.3.7 The general evacuation alarm signal shall operate throughout the entire building.
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The facility failed to maintain the fire alarm system per code. Findings include:

During the survey, the following are examples of what was observed:
Second Floor
Lab - the audible/visual device did not activate when the fire alarm was activated

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2000 NFPA 101, 9.6.3.6 Notification signals for occupants to evacuate shall be by audible and visible signals in accordance with NFPA 72, National Fire Alarm Code, and CABO/ANSI A117.1, American National Standard for Accessible and Usable Buildings and Facilities, or other means of notification acceptable to the authority having jurisdiction shall be provided.
2000 NFPA 101, 9.6.3.7 The general evacuation alarm signal shall operate throughout the entire building.
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The facility failed to maintain the cooking facilities per code. Findings include:

During the survey, the following are examples of what was observed:

1. Per documentation and interview the facility was not doing monthly inspections on the kitchen hood
suppression system

2. The facility failed to provide a sign for the K-extinguisher

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1998 NFPA 17A, 5-2.1 Inspection shall be conducted on a monthly basis in accordance with the manufacturer ' s listed installation and maintenance manual or the owner ' s manual. As a minimum, this " quick check " or inspection shall include verification of the following: (a) The extinguishing system is in its proper location. (b) The manual actuators are unobstructed. (c) The tamper indicators and seals are intact. (d) The maintenance tag or certificate is in place. (e)No obvious physical damage or condition exists that might prevent operation. (f) The pressure gauge(s), if provided, is in operable range. (g) The nozzle blowoff caps are intact and undamaged. (h) The hood, duct, and protected cooking appliances have not been replaced, modified, or relocated.
1998 NFPA 96, 7-2.1.1 A placard identifying the use of the extinguisher as a secondary backup means to the automatic fire suppression system shall be conspicuously placed near each portable fire extinguisher in the cooking area. Placard States: " CAUTION - In case of appliance fire, actuate fixed suppression system before using this fire extinguisher "
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The facility failed to provide anesthetizing locations per code. Findings include:

During the survey, the following are examples of what was observed:
Second Floor
1. ORs 2 and 4 were observed without windows and without a smoke venting system
Third Floor
2. C-Section Room was observed without battery back-up lighting

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1999 NFPA 99, 5-4.1.2 Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically vent smoke and products of combustion.
1999 NFPA 99, 5-4.1.3 Ventilating systems for anesthetizing locations shall be provided that automatically (a) prevent recirculation of smoke originating within the surgical suite and (b) prevent the circulation of smoke entering the system intake, without in either case interfering with the exhaust function of the system.
1999 NFPA 99, 5-4.1.4 The electric supply to the ventilating system shall be served by the equipment system of the essential electrical system specified in Chapter 3, " Electrical Systems. "
1999 NFPA 99, 3-3.2.1.2 All Patient Care Areas. 5. Wiring in Anesthetizing Locations. e. Battery-Powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12(e).
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The facility failed to provide receptacles for appliances. Findings include: During the survey, the following is an example of what was observed:


1. A microwave was plugged into a overcurrent device in the office of the Nurse Manager on the 5th. Floor.


27382


First Floor
2. Cardiopulmonary Care Office - microwave plugged into a surge protector
3. ER Doctors' Sleep Room - microwave and refrigerator plugged into a surge protector
Second Floor

4. Nurses' Lounge -
a. T.V. plugged into an extension cord
b. microwave plugged into a surge protector
5. Blood Assurance 201-B - refrigerator plugged into a surge protector
6. OR Lounge - refrigerator plugged into a surge protector

Third Floor
7. Nurse Manager's Office - refrigerator plugged into a surge protector
8. Lactation Room - refrigerator plugged into a surge protector

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Appliances, such as air conditioners and refrigerators,microwaves, shall plug directly into a receptacle. 1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99.

1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip.

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The facility failed to maintain the electrical wiring and equipment per code. Findings include:

During the survey, the following are examples of what was observed:
Second Floor
1. Medical Records/Transcription Room -
a. the cubicles were plugged into surge protectors (piggy back)
b. microwave plugged into a surge protector
2. Pharmacy - refrigerator plugged into an extension cord
3. Night Stock Room -
a. refrigerator plugged into a surge protector
b. surge protector plugged into a surge protector

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1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip.
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The facility failed to provide a building construction type per code. Findings include:

During the survey, the following is an example of what was observed:
The surveyor observed what appeared to be a Type II (000) construction type in a single story part of the building, but connected to the six story part of the building without a two hour fire barrier separating these construction types in the following locations:
1. In corridor at the Imaging Director's Office
2. In the Reading Room
3. In the Clinical Coordinator's Office

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2000 NFPA 101, 19.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)Table 19.1.6.2 Construction Type Limitations
Construction Stories
Type
1 2 3 4 or
More
I(443) X X X X
I(332) X X X X
II(222) X X X X
II(111) X X* X* NP
II(000) X* X* NP NP
III(211) X* X* NP NP
III(200) X* NP NP NP
IV(2HH) X* X* NP NP
V(111) X* X* NP NP
V(000) X* NP NP NP
X: Permitted type of construction.
NP: Not permitted.
*Building requires automatic sprinkler protection. (See 19.3.5.1.)
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The facility failed to maintain the interior finish for rooms per code. Findings include:

During the survey, the following is an example of what was observed:

First Floor
Enviromental Services/Linen Storage Room - the facility could not provide the flame spread rating of the styrofoam that was observed on the walls and the ceiling in this room

_________________

2000 NFPA 101, 19.3.3.2 Interior wall and ceiling finish materials complying with 10.2.3 shall be permitted as follows:
(1) Existing materials - Class A or Class B
Exception: In rooms protected by an approved, supervised automatic sprinkler system, existing Class C interior finish shall be permitted to be continued to be used on walls and ceilings within rooms separated from the exit access corridors in accordance with 19.3.6.
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The facility failed to provide corridor doors that would close and resist the passage of smoke. Findings include: During the survey, the following are examples of what was observed:

1. The door to ISU Office had holes at the top left side of the door.

2. The Office across from the Nurses Station on the Six Floor had holes above the door handle.

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NFPA 101, 19.3.6.3.1 Exception No.2. In the smoke compartments protected throughout by an approved, supervised automatic sprinkler system, doors in corridor walls shall be constructed to resist the passage of smoke and be provided with suitable means of keeping the doors closed.

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The facility failed to maintain the corridor openings per code. Findings include:

During the survey, the following are examples of what was observed:
Second Floor
1. The corridor door to PACU had four holes in it at the door knob
Fourth Floor
2. The Case Manager's Office across from room 424 had four holes in it at the door knob

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2000 NFPA 101, 19.3.6.3.1 Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.
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The facility failed to provide smoke barriers that would provide at least a half hour fire resistance rating. Findings include: During the survey, the following are examples of what was observed:

1. Unsealed penetrations around a sprinkler line, and flex conduit, in the Smoke Barrier at PT Entrance.

2. Unsealed penetrations around conduit at the deck, in the Smoke Barrier, by Patient room 618.

3. Unsealed penetrations around a sprinkler line, in the Smoke Barrier, by Patient Room 621.

4. Unsealed penetrations around conduit at the deck, in the Smoke Barrier, by Control Room Sleep Disorders Center.


27382


Second Floor
5. The smoke barrier at room 210 a group of conduits were not sealed around at the deck, on both sides of the barrier
Third Floor
6. The smoke barrier at the Pixis/Dictation Area - conduit with a blue and a white wire, the end of the conduit was not sealed

___________________

2000 NFPA 101, 8.2.4.4.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through smoke partitions shall be protected as follows: (1) The space between the penetrating item and the smoke partition shall meet one of the following conditions: a. It shall be filled with a material that is capable of limiting the transfer of smoke. b. It shall be protected by an approved device that is designed for the specific purpose. (2) Where the penetrating item uses a sleeve to penetrate the smoke partition, the sleeve shall be solidly set in the smoke partition, and the space between the item and the sleeve shall meet one of the following conditions: a. It shall be filled with a material that is capable of limiting the transfer of smoke. b. It shall be protected by an approved device that is designed for the specific purpose. (3) Where designs take transmission of vibrations into consideration, any vibration isolation shall meet one of the following conditions: a It shall be made on either side of the smoke partitions. b. It shall be made by an approved device that is designed for the specific purpose.
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The facility failed to maintain the smoke barrier to restrict the passage of smoke. Findings include: During the survey, the following is an example of what was observed:

The doors in the smoke barrier by the elevators on the First floor, failed to close tight.
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NFPA 101, 19.3.7.6., 8.3.4 Doors in smoke barriers to be self-closing. Doors in smoke barriers shall close the opening in the wall leaving only a minimum clearance to allow door(s) to function properly.


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The facility failed to maintain separation of hazardous areas. Findings include: During the survey, the following is an example of what was observed:

The combustible storage room located outside, under the Educational Bldg, had two area were the ceiling was missing.
______________________

NFPA 101, 19.3.2.1 Hazardous areas shall be safeguarded by a fire barrier of a one-hour fire resistance rating or provided with an automatic sprinkler system.

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The facility failed to maintain stairways with at least 2 hour fire resistance rating. During the survey, the following is an example of what was observed:

Unsealed penetrations around a sprinkler line, in the Stairwell by the Gift Shop First Floor.

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LSC 2000 Edition, 19.3.1.1 Any vertical openings shall be enclosed or protected in accordance with 8.2.5. Where enclosure is provided, the construction shall have not less than 2-hour fire resistance rating.


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The facility failed to provide protection of openings in fire barriers to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. During the survey, the following are examples of what was observed:

1. Unsealed penetrations at the end of a sleeve, in the two hour barrier, by Plant Operations.

2. Unsealed penetrations at the end of a sleeve, and around wiring, in the two hour barrier, at the Educational Department.

3. Unsealed penetrations at the deck, in the two hour barrier, above the doors at the Educational Department.


27382


Second Floor
4. The two hour fire barrier that separates the two story from the six story had the following unsealed penetrations:
a. HVAC pipe not sealed around it
b. Several conduit ends not sealed
c. A conduit was not sealed around it
d. Foam used to seal a penetration
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NFPA 101, 19.2.2.5 and 7.2.4.3 Openings in fire barriers shall be constructed to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other.

2000 NFPA 101, 8.2.3.2.4.2 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows: (1) The space between the penetrating item and the fire barrier shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier. b. It shall be protected by an approved device that is designed for the specific purpose. (2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier. b. It shall be protected by an approved device that is designed for the specific purpose. (3) * Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met: a. The material shall be capable of maintaining the fire resistance of the fire barrier. b. The material shall be protected by an approved device that is designed for the specific purpose. (4) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions: a. It shall be made on either side of the fire barrier. b. It shall be made by an approved device that is designed for the specific purpose.
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The facility failed to provide protection of openings in fire barriers to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. During the survey, the following is an example of what was observed:

1. Unsealed penetrations around conduit, and at the end of a sleeve, in the two hour barrier by the Elevators on the First Floor.


27382


First Floor
2. Cardiopulmonary Care "Alabama Office" - the fire barrier had an unsealed conduit end
3. Imaging Director's Office - the fire barrier had an unsealed conduit end

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NFPA 101, 19.2.2.5 and 7.2.4.3 Openings in fire barriers shall be constructed to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other.

2000 NFPA 101, 8.2.3.2.4.2 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows: (1) The space between the penetrating item and the fire barrier shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier. b. It shall be protected by an approved device that is designed for the specific purpose. (2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier. b. It shall be protected by an approved device that is designed for the specific purpose. (3) * Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met: a. The material shall be capable of maintaining the fire resistance of the fire barrier. b. The material shall be protected by an approved device that is designed for the specific purpose. (4) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions: a. It shall be made on either side of the fire barrier. b. It shall be made by an approved device that is designed for the specific purpose.
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The facility failed to document staff participation in the fire drills. Findings include:

During the survey, the following is an example of what was observed:
Per documentation and interview the facility was not getting all staff to sign the participation sheets

_________________

2000 NFPA 101, 19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
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The facility failed to maintain the fire alarm system. Findings include: During the survey, the following are examples of what was observed:

1. The Waiting Room for the Ultrasound was not provided with Audible/Visual device.

2. The Visual devices failed to function upon activation of the fire alarm system in the PT Department.


27382

Fifth Floor
3. SCU - the two sets of double corridor doors did not release under the activation of the fire alarm

First Floor
4. Emergency Department double corridor doors for the entrance from the Waiting Room - the left leaf did not release under activation of the fire alarm

5. The Front Lobby Public Bathrooms - the fire alarm strobes did not activate under activation of the fire alarm

_______________
2000 NFPA 101, 9.6.3.6 Notification signals for occupants to evacuate shall be by audible and visible signals in accordance with NFPA 72, National Fire Alarm Code, and CABO/ANSI A117.1, American National Standard for Accessible and Usable Buildings and Facilities, or other means of notification acceptable to the authority having jurisdiction shall be provided.
2000 NFPA 101, 9.6.3.7 The general evacuation alarm signal shall operate throughout the entire building.
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The facility failed to maintain the fire alarm system per code. Findings include:

During the survey, the following are examples of what was observed:
Second Floor
Lab - the audible/visual device did not activate when the fire alarm was activated

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2000 NFPA 101, 9.6.3.6 Notification signals for occupants to evacuate shall be by audible and visible signals in accordance with NFPA 72, National Fire Alarm Code, and CABO/ANSI A117.1, American National Standard for Accessible and Usable Buildings and Facilities, or other means of notification acceptable to the authority having jurisdiction shall be provided.
2000 NFPA 101, 9.6.3.7 The general evacuation alarm signal shall operate throughout the entire building.
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The facility failed to maintain the cooking facilities per code. Findings include:

During the survey, the following are examples of what was observed:

1. Per documentation and interview the facility was not doing monthly inspections on the kitchen hood
suppression system

2. The facility failed to provide a sign for the K-extinguisher

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1998 NFPA 17A, 5-2.1 Inspection shall be conducted on a monthly basis in accordance with the manufacturer ' s listed installation and maintenance manual or the owner ' s manual. As a minimum, this " quick check " or inspection shall include verification of the following: (a) The extinguishing system is in its proper location. (b) The manual actuators are unobstructed. (c) The tamper indicators and seals are intact. (d) The maintenance tag or certificate is in place. (e)No obvious physical damage or condition exists that might prevent operation. (f) The pressure gauge(s), if provided, is in operable range. (g) The nozzle blowoff caps are intact and undamaged. (h) The hood, duct, and protected cooking appliances have not been replaced, modified, or relocated.
1998 NFPA 96, 7-2.1.1 A placard identifying the use of the extinguisher as a secondary backup means to the automatic fire suppression system shall be conspicuously placed near each portable fire extinguisher in the cooking area. Placard States: " CAUTION - In case of appliance fire, actuate fixed suppression system before using this fire extinguisher "
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The facility failed to provide anesthetizing locations per code. Findings include:

During the survey, the following are examples of what was observed:
Second Floor
1. ORs 2 and 4 were observed without windows and without a smoke venting system
Third Floor
2. C-Section Room was observed without battery back-up lighting

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1999 NFPA 99, 5-4.1.2 Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically vent smoke and products of combustion.
1999 NFPA 99, 5-4.1.3 Ventilating systems for anesthetizing locations shall be provided that automatically (a) prevent recirculation of smoke originating within the surgical suite and (b) prevent the circulation of smoke entering the system intake, without in either case interfering with the exhaust function of the system.
1999 NFPA 99, 5-4.1.4 The electric supply to the ventilating system shall be served by the equipment system of the essential electrical system specified in Chapter 3, " Electrical Systems. "
1999 NFPA 99, 3-3.2.1.2 All Patient Care Areas. 5. Wiring in Anesthetizing Locations. e. Battery-Powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12(e).
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The facility failed to provide receptacles for appliances. Findings include: During the survey, the following is an example of what was observed:


1. A microwave was plugged into a overcurrent device in the office of the Nurse Manager on the 5th. Floor.


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First Floor
2. Cardiopulmonary Care Office - microwave plugged into a surge protector
3. ER Doctors' Sleep Room - microwave and refrigerator plugged into a surge protector
Second Floor

4. Nurses' Lounge -
a. T.V. plugged into an extension cord
b. microwave plugged into a surge protector
5. Blood Assurance 201-B - refrigerator plugged into a surge protector
6. OR Lounge - refrigerator plugged into a surge protector

Third Floor
7. Nurse Manager's Office - refrigerator plugged into a surge protector
8. Lactation Room - refrigerator plugged into a surge protector

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Appliances, such as air conditioners and refrigerators,microwaves, shall plug directly into a receptacle. 1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99.

1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip.

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The facility failed to maintain the electrical wiring and equipment per code. Findings include:

During the survey, the following are examples of what was observed:
Second Floor
1. Medical Records/Transcription Room -
a. the cubicles were plugged into surge protectors (piggy back)
b. microwave plugged into a surge protector
2. Pharmacy - refrigerator plugged into an extension cord
3. Night Stock Room -
a. refrigerator plugged into a surge protector
b. surge protector plugged into a surge protector

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1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip.
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