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Based on observation and interview, the facility failed to maintain the means of egress. This was evidenced by an egress door that failed to open when pressure was applied. This affected one of one smoke compartment and could result in a delay during an evacuation.

NFPA 101 Life Safety Code, 2012 Edition
19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7, unless otherwise modified by 19.2.2 through 19.2.11.

19.2.2.2.1 Doors complying with 7.2.1 shall be permitted.
19.7.3.1 Proper maintenance shall be provided to ensure the dependability of the method of evacuation selected.

7.1.10.1 General. Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

7.2.1.5.1 Door leaves shall be arranged to be opened readily from the egress side whenever the building is occupied.

7.2.1.5.3 Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.

7.2.1.7.3 Required panic hardware and fire exit hardware, in other than detention and correctional occupancies as otherwise provided in Chapters 22 and 23, shall not be equipped with any locking device, set screw, or other arrangement that prevents the release of the latch when pressure is applied to the releasing device.


Findings:

During a tour of the facility and interview with staff on 12/28/22, the facility's means of egress were observed.

At 11:15 a.m., the single leaf egress door in the 1175 Vestibule was observed. The egress door failed to open when the panic bar was activated and pressure was applied. The egress door was equipped with an exit sign. Upon interview, Staff 2 confirmed the finding and stated that the door was not used often so it would get stuck. Staff 2 was able to open the door by first pulling the door before pushing it.

Based on record review and interview, the facility failed to maintain the fire alarm system. This was evidenced by missing one of two records of a semi-annual inspection and by incomplete testing of the fire alarm control panel batteries. This affected one of one smoke compartment and could result in a malfunctioning fire alarm system.

NFPA 101, Life Safety Code, 2012 Edition
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with section 9.6

9.6.1* General.
9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code.

NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition.
14.3 Inspection.
14.3.1* Unless otherwise permitted by 14.3.2 visual inspections shall be performed in accordance with the schedules in Table 14.3.1 or more often if required by the authority having jurisdiction.
14.3.4 The visual inspection shall be made to ensure that there are no changes that affect equipment performance.

Table 14.3.1 Visual Inspection Frequencies-semiannually
3. Batteries
5. Fire alarm control unit trouble signals
7. In- building fire emergency voice/alarm communications equipment
8. Remote annunciators
9. Initiating devices
11. Combination systems (a) Fire extinguisher electronic monitoring device/systems
(b) Carbon monoxide detectors/systems
12. Interface equipment
13. Alarm notification appliances
15. Supervising station alarm systems-transmitters
17. Supervising station alarm systems-receivers

14.4.5* Testing Frequency. Unless otherwise permitted by other sections of this Code, testing shall be performed in accordance with the schedules in Table 14.4.5, or more often if required by the authority having jurisdiction.

Table 14.4.5 Testing Frequencies
6. Batteries-fire alarm systems
(d) Sealed lead-acid type:
(1) Charger test (Replace battery within 5 years after manufacture or more frequently as needed)-annually
(2) Discharge test (30 minutes)-annually
(3) Load voltage test-semi-annually

Table 14.4.2.2 Test Methods
5. Batteries-general tests: Prior to conducting any battery testing, the person conducting the test shall ensure that all system software stored in volatile memory is protected from loss.
(e) Load voltage test: With the battery charger disconnected, the terminal voltage shall be measured while supplying the maximum load required by its application. The voltage level shall not fall below the levels specified for the specific type of battery. If the voltage falls below the level specified, corrective action shall be taken and the batteries shall be retested.

Findings:

During record review and interview with staff on 12/28/22, the fire alarm system testing and inspection records were reviewed.

1. At 3:10 p.m., the facility failed to provide documentation indicating that one of two semi-annual fire alarm system inspections were completed within the last 12 months. The facility provided a document that indicated the fire alarm system received an annual test and inspection on 1/21/22. The facility failed to provide documentation of a second inspection within the last 12 months. Upon interview, Staff 3 confirmed the finding and stated that the fire alarm system was inspected by the vendor on a quarterly basis but was unable to obtain records from them.

2. At 3:10 p.m., the facility failed to provide documentation indicating that one of two semi-annual load voltage tests were completed on the sealed lead acid fire alarm control panel batteries. The facility provided a document that indicated the batteries received a load voltage test on 1/21/22. The facility failed to provide documentation of a second test within the last 12 months. Upon interview, Staff 3 confirmed the finding and stated the battery testing was only conducted annually by the vendor.

Based on record review and interview, the facility failed to maintain the automatic fire sprinkler system. This was evidenced by the failure to complete four of twelve monthly automatic fire sprinkler gauge and control valve inspections. This affected one of one smoke compartment and could result in a delayed notification of a malfunctioning automatic fire sprinkler system component.

NFPA 101 Life Safety Code, 2012 Edition
19.3.5.3 Where required by 19.1.6, buildings containing hospitals or limited care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5.

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, 2011 Edition.
4.3.1 Records shall be made for all inspections, tests, and maintenance of the system and its components and shall be made available to the authority having jurisdiction upon request.

5.2.4.1* Gauges on wet pipe sprinkler systems shall be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained.

13.1.1.2 Table 13.1.1.2 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance.

Table 13.1.1.2 Summary of Valves, Valve Components, and Trim Inspection, Testing, and Maintenance
Inspection
Control Valves
Locked: Monthly 13.3.2.1.1
Tamper switches: Monthly 13.3.2.1.1

13.3.2.1.1 Valves secured with locks or supervised in accordance with applicable NFPA standards shall be permitted to be inspected monthly.

13.3.2.2* The valve inspection shall verify that the valves are in the following condition:
(1) In the normal open or closed position
(2)*Sealed, locked, or supervised
(3) Accessible
(4) Provided with correct wrenches
(5) Free from external leaks
(6) Provided with applicable identification

Findings:

During record review and interview with staff on 12/28/22, the automatic fire sprinkler system inspection records were reviewed.

At 1:36 p.m., the facility failed to provide documentation indicating that four of 12 monthly visual inspections of the automatic fire sprinkler system gauges and control valves were completed during the last 12 months. The facility was unable to provide documentation for the months of August, September, October and December of 2022. Upon interview, Staff 3 confirmed the finding and stated that he had two new employees and he needed to train them on the monthly inspection.

Based on observation and interview, the facility failed to maintain the corridor doors. This was evidenced by corridor doors that failed to latch. This affected one of one smoke compartment and could result in the spread of smoke and fire in the event of a fire emergency.

NFPA 101 Life Safety Code, 2012 Edition
19.3.6.3.5* Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction, and the following requirements also shall apply:

(1) The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door.

Findings:

During a tour of the facility and interview with staff on 12/28/22, the facility's corridor doors were observed and staff was interviewed.

1. At 11:21 a.m., the corridor door to Bathroom 1171 was observed. The door was equipped with a self-closing device and failed to fully close and latch when allowed to self-close. Upon interview, Staff 3 confirmed that the door failed to latch.

2. At 11:31 a.m., the corridor door to Bedroom 1157 was observed. The door was equipped with a self-closing device and failed to fully-close and latch when allowed to self-close. Upon interview, Staff 3 confirmed that the door failed to latch.

3. At 11:33 a.m., the corridor door to Office 1155C was observed. The door was equipped with a self-closing device and failed to fully-close and latch when allowed to self-close. Upon interview, Staff 3 confirmed that the door failed to latch.

4. At 11:38 a.m., the corridor door to Bedroom 1155B was observed. The door was equipped with a self-closing device and failed to fully-close and latch when allowed to self-close. Upon interview, Staff 3 confirmed that the door failed to latch.

Based on record review and interview, the facility failed to conduct fire drills per regulatory requirements. This was evidenced by the failure to conduct fire drills at least once per shift per quarter. This affected one of one smoke compartment and could result in a delayed staff response to a fire emergency.

NFPA 101 Life Safety Code, 2012 Edition
19.7.1.4 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions.

19.7.1.6 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.

19.7.1.8 Employees of health care occupancies shall be instructed in life safety procedures and devices.

Finding:

During record review and interview with staff on 12/28/22, the facility's fire drill records were requested.

At 2:12 p.m., the facility failed to provide documentation indicating that fire drills were conducted at least once per shift per quarter in the general acute care hospital during the last 12 months. Upon interview, Staff 3 confirmed the finding and stated that fire drills were not conducted because during the last 12 months they only had one or two patients stay in the hospital for one to two nights. He also stated he was not aware that fire drills needed to be conducted in the hospital if they did not have patients.

During the Life Safety Code survey on 11/28/18, the facility received a deficiency for the failure to conduct fire drills at least once per shift per quarter.