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NFPA 101 Life Safety Code 2012 Edition

9.6.1.3 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70 National Electrical Code, and NFPA 72 National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use.

NFPA 72 National Fire Alarm and Signaling Code 2010 Edition

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
15. Initiating Devices
(c) Fire extinguishing system(s) or suppression system(s) switches - Annually
(f) Manual fire alarm boxes - Annually
(h) System smoke detectors - Annually
(j) Singles - and multi-station smoke alarms - Annually
(m) Waterflow devices - Semianually

14.6.2.1 Records shall be retained until the next test and for 1 year thereafter.

14.6.3.2 Upon request, a hard copy record shall be provided
to the authority having jurisdiction.

The Code and Standard was not met as evidenced by:

Based on document review and interview, the facility failed to provide documented evidence of corrections made to strobes, speaker strobes and and a smoke detector that failed, and documented evidence of current testing and inspection of the fire alarm system. In the event of a fire, the effective operation of the fire alarm system is essential. The deficiency practice has the potential for the fire alarm system to not work as designed.

Findings:

Hospital A

1. During a Life Safety Code survey document review of the hospital on 03/23/2022, at 9:40 a.m., the Annual Duct, Heat, Smokes, Pulls Inspection Report dated 03/31/2021, indicated that there were fails that as follows:

a) Speaker Strobe at the Pavilion basement back mechanical room corridor to north-east mechanical room failed to flash.
b) Speaker Strobe at the Pavilion 1st floor laboratory main entrance failed to flash.
c) Speaker Strobe at the Pavilion penthouse inside chiller room by service elevator failed to flash.
d) Strobe at the Pavilion basement inside Radiology by the double doors failed to flash.
e) Strobe at the Pavilion restroom closest to the clinical laboratory failed to flash.
f) Smoke detector #3030281 at the Pavilion 6th floor public women's bath failed to activate.
g) Smoke detector #3030311 at the Pavilion 6th floor, outside of patient room 604, reports as room 609 at the panel.

During a concurrent interview the Plant Operations Director and Lead Man were asked to provide documented evidence that the deficiencies noted in the Annual Duct, Heat, Smokes, Pulls Inspection Report were corrected. By the end of the survey there was no documented evidence provided that the deficiencies were corrected.

Hospital C

2. During a Life Safety Code survey document review of the hospital on 03/24/2022 at 10:40 a.m., a review of the Annual Fire Alarm Test revealed the test was conducted on 01/27/2021. The test was two months overdue. There was no documented evidence of a current Annual Fire Alarm Test.

During a concurrent interview the Plant Operations Manager stated that the vendor did not want to enter the hospital because the hospital had COVID-19 patients, and that the test is scheduled for April 2022.

NFPA 101 Life Safety Code 2012 Edition

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.

4.3.5 Subsequent records shall be retained for a period of 1 year after the next inspection, test, or maintenance of that type required by the standard.

The Code and Standard was not met as evidenced by:

Based on observation, interview, and document review, the facility failed to ensure a sprinkler escutcheon was maintained and to failed to provide current testing and inspection documentation of the sprinkler system. In the event of a fire, the activation of the fire alarm and effective operation of the sprinkler system is essential. The deficiency practice had the potential for the sprinkler system to not work as designed.

Findings:

Hospital A

1. During a Life Safety Code survey tour of the hospital on 03/22/2022, at 2:48 p.m., at the basement Cardiac Cath Lab office, there was a loose sprinkler head escutcheon hanging off the ceiling.

During a concurrent interview, the Chief Operating Officer was informed of the deficiency.

Hospital C

2. During a Life Safety Code survey document review of the hospital on 03/24/2022, at 10:40 a.m., review of the Annual Automatic Fire Sprinkler System Inspection and Test revealed the test was conducted on 01/27/2021. The test was two months overdue. There was no documented evidence of a current Annual Sprinkler System Inspection and Test.

During a concurrent interview, the Plant Operations Manager stated that the vendor did not want to enter the hospital because the hospital had COVID-19 patients, and that the test is scheduled for April 2022.

NFPA 101 Life Safety Code 2012 Edition

9.7.4.1 Where required by provisions of another section of this Code, portable fire extinguishers shall be selected, installed, inspected, and maintained with NFPA 10 Standard for Portable Fire Extinguishers.

NFPA 10 Standard for Portable Fire Extinguishers 2010 Edition

6.1.3.3.1 Fire extinguishers shall not be obstructed or obscured from view.

6.1.3.4 Portable fire extinguishers other than wheeled extinguishers shall be installed using any of the following means:

(1) Securely on a hanger intended for the extinguisher
(2) In the bracket supplied by the extinguisher manufacturer
(3) in a listed bracket approved for such purpose
(4) In cabinets or wall recesses.

The Code and Standard was not met as evidenced by:

Based on observation and interview, the facility failed to ensure a fire extinguisher was readily accessible, and another fire extinguisher was properly secured. The deficiency had the potential to delay or prevent the use of a fire extinguisher by preventing immediate access to a fire extinguisher.

Findings:

Hospital A

1. During a Life Safety Code survey tour of the hospital on 03/22/2022, at 2:00 p.m., at the 1st floor Pharmacy, the evaluator observed a fire extinguisher obstructed from view by jackets hanging on a rack above the fire extinguisher.

During a concurrent interview, the Plant Operations Director was informed of the deficiency.

Hospital B

2. During a Life Safety Code survey tour of the hospital on 03/24/2022, at 9:00 a.m., in the basement, the evaluator observed a fire extinguisher standing unsecured on the ground being used to hold the telephone equipment room corridor door open.

During a concurrent interview, the Plant Maintenance Mechanic was informed of the deficiency.

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.

The Code was not met as evidenced by:

Based on observation and interview, the hospital failed to ensure a patient sleeping room (room 227) corridor door was suitable for keeping the door closed. The deficiency had the potential to create a condition conducive to the spread of fire, smoke, and heat.

Finding:

Hospital A

During a Life Safety Code survey tour of the hospital on 03/22/2022, at 12:12 p.m., at the 2nd floor Telemetry Unit, the evaluator observed the corridor door to room 227 failed to hold closed. Closer observation revealed an 18-inch split at the spine of the door and that one of three hinges was missing its screw fasteners.

During a concurrent interview, the Plant Operations Director stated that the door failed to hold closed because the spine of the door was damaged, and the Lead Man stated that the door was in that condition for two weeks.

NFPA 101 Life Safety Code 2012 Edition

8.5.3 Fire Barrier Used as Smoke Barrier. A fire barrier shall be permitted to be used as a smoke barrier, provided that it meets the requirements of Section 8.5.

8.5.6.2 Penetrations for cables, cable trays, conduits, pipes, tubes, vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a smoke barrier, or through the ceiling membrane of the roof/ceiling of a smoke barrier assembly, shall be protected by a system or material capable of restricting the transfer of smoke.

8.5.6.3 Where a smoke barrier is also constructed as a fire barrier, the penetrations shall be protected in accordance with the requirements of 8.3.5 to limit the spread of fire for a time period equal to the fire resistance rating of the assembly and 8.5.6 to restrict the transfer of smoke, unless the requirements of 8.5.6.4 are met.

This Code was not met as evidenced by:

Based on observation and interview, the hospital failed to ensure smoke barrier walls were maintained to restrict the transfer of smoke. Smoke barriers assist to limit the spread/movement of smoke, limit the number of occupants exposed to a single fire and create a safe relocation area. The deficiencies had the potential for permitting the spread of fire, smoke and toxic gases driven by the heat and pressure of a fire moving through the penetrations and traveling to other parts of the building.

Findings:

Hospital A

1. During a Life Safety Code survey tour of the hospital on 03/22/2022 at 11:20 a.m. at the 3rd floor Critical Care Unit (CCU) the evaluator observed a four-by-four-inch penetration through the smoke barrier wall separating room 333L from the corridor. The penetration was visible from above the drop-down ceiling.

During a concurrent interview the Plant Operations Director stated that he was not sure what the rating of the wall was and would have to look at the LSC drawings to find out.

By the end of the Life Safety Code survey, the rating of the wall was not provided.

2. During a Life Safety Code survey tour of the hospital on 03/22/2022, at 2:07 p.m., at the 1st floor corridor, the evaluator observed a penetration through the corridor wall separating the 1st floor corridor from the service elevator shaft.

During a concurrent interview, the Plant Operations Director stated that that the penetration went through the elevator shaft wall because it was part of the current elevator project.

NFPA 101 Life Safety Code 2012 Edition

9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to continue in service.

NFPA 70 National Electrical Code 2011 Edition

110.26 Spaces About Electrical Equipment. Access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment.

(B) Clear Spaces. Working space required by this section shall not be used for storage. When normally enclosed live parts are exposed for inspection or servicing, the working space, if in a passageway or general open space, shall be suitably guarded.

The Code were not met as evidenced by:

Based on observation and interview, the facility failed to ensure electrical equipment was in accordance with NFPA 70 by having storage in front of an electrical panel. The deficiency had the potential to delay or prevent access to the electrical panel and for items in front of the panel to act as a conductor.

Finding:

Hospital A

During a Life Safety Code survey tour of the hospital on 03/22/2022, at 2:15 p.m., at the 1st floor Pharmacy storage room, the evaluator observed two electrical panels that did not have a 3-foot clearance in front of the panel doors. There were items placed directly in front of the panel including a copier, chair, and two plastic bins.

During a concurrent interview the Plant Operations Director was informed of the deficiency.

NFPA 101 Life Safety Code 2012 Edition

8.5.5.4.2 Smoke dampers and combination fire and smoke dampers required by this Code shall be inspected, tested, and maintained in accordance with NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives.

NFPA 105 Standard for Smoke Door Assemblies and other Opening Protectives 2010 Edition.

6.5.12 All documentation shall be maintained by the property owner and available for review by the authority having jurisdiction.

6.6.3 If the damper is not operable, repairs shall begin as soon as possible.

6.6.4 Following any repairs, the damper shall be tested for proper operation in accordance with Section 6.5.

6.6.6 All maintenance shall be documented and records shall be retained in accordance with 6.5.11 and 6.5.12.

The Code and Standard was not met as evidenced by:

Based on document review and interview, the hospital facility failed to provide documented evidence that the Heating, Ventilation, and Air Conditioning (HVAC) dampers and a duct detector, that failed to shut down, were corrected. HVAC dampers and duct detectors assist to limit the spread the movement of smoke, limit the number of occupants exposed to a single fire and create a safe relocation area. The deficiencies had the potential for permitting the spread of fire, smoke and toxic gases driven by the heat and pressure of a fire moving through the HVAC duct system and traveling to other parts of the building.

Findings:

Hospital A

1. During a Life Safety Code survey document review of the hospital on 03/23/2022, at 9:40 a.m., a review of the Fire Damper Inspection Report, dated 08/25/2021 to 09/02/2021, indicated that 37 of 514 fire dampers inspected failed to shut down.

The continued review of the report revealed that 8 of the 37 dampers that failed had not been corrected as follows:

#10666513 Pavilion 2 2nd floor corridor above patient room 219.
#10666512 Pavilion 2 2nd floor corridor above patient room 220.
#10666515 Pavilion 2 2nd floor corridor above patient room 218.
#10666516 Pavilion 2 2nd floor corridor above patient room 217.
#10666649 Tower 6 6th floor employee restroom.
#10743773 Pavilion 6 6th floor inside office besides stairs by room 615.
#10743784 Pavilion 6 6th floor inside office by room 633.
#10743882 Pavilion 3 3rd floor above double doors to SDU North.

During a concurrent interview, the Plant Operations Director and Lead Man were informed of the deficiency.

The Lead Man provided a proposal dated 03/22/2022 to the evaluator. The Proposal included to furnish and install a new fire damper access on fire damper unit area #T6, P6 inside office room, P6 office by 633 above 2x door to SDU-N; replace 4 fire with 6x6 dampers on unit 220, 219, 217, 218; and check all dampers linkage and operations.

Closer review of the Proposal revealed the Proposal was not signed or dated as accepted.

2. During a Life Safety Code survey document review of the hospital on 03/23/2022, at 9:40 a.m., a review of the Annual Air Handling Shut Down Inspection Report, dated 03/25/2021, indicated that a duct detector (#2030079) at the Pavilion basement machine room, by dock Cath Lab, failed to shut down.

During a concurrent interview, the Plant Operations Director and Lead Man were asked to provide documented evidence that the deficiencies noted in the Annual Air Handling Shut Down Inspection Report were corrected. By the end of the survey, there was no documented evidence provided that the deficiencies were corrected.

NFPA 101 Life Safety Code 2012 Edition

19.3.2.4 Medical Gas. Medical gas storage and administration shall be in accordance with Section 8.7 and the provisions of NFPA 99 Health Care Facilities Code, applicable to administration, maintenance, and testing.

NFPA 99 Health Care Facilities Code 2012 Edition

5.1.14.2.1 General. Health care facilities with installed medical gas, vacuum, WAGD, or medical support gas systems, or combination there of, shall develop and document periodic maintenance programs for these systems and their subcomponents as appropriate to the equipment installed.

A.5.1.14.2.1 The facility should retain a written or an electronic copy of all findings and any corrections performed.

The Code was not met as evidenced by:

Based on document review and interview, the hospital facility failed to provide documented evidence that medical gas and vacuum discrepancies were corrected. The deficiencies had the potential for the medical gas and vacuum system to not work as designed.

Finding:

Hospital B

During a Life Safety Code survey document review of the hospital on 03/23/2022, at 1:20 p.m., a review of the Annual Medical Gas and Vacuum System Maintenance Inspection Report for testing conducted on 12/01/2021 indicated that there were 29 discrepancies.

A review of the Discrepancy List-Corrective Maintenance Repairs, dated 12/01/21, indicated five discrepancies were corrected, and that 24 discrepancies had not been corrected as follows:

Basement recovery bed 2 vacuum no flow/reduced flow.
1st floor urgent care bed 2 oxygen leaking with adapter.
2nd floor room 205 oxygen leaking with adapter.
2nd floor room 206 oxygen leaking with adapter.
3rd floor room 301 oxygen leaking with adapter.
3rd floor room 305 oxygen leaking with adapter.
3rd floor room 314-1 vacuum latch defective requires new faceplate/keyed disc.
3rd floor room 306 oxygen leaking with adapter.
3rd floor room 307 oxygen leaking with adapter.
3rd floor room 309 oxygen leaking with adapter.
3rd floor room 319-1 oxygen leaking with adapter.
3rd floor room 319-1 vacuum latch defective requires new faceplate/keyed disc.
3rd floor room 319-2 oxygen leaking with adapter.
3rd floor room 319-3 oxygen leaking with adapter.
4th floor room 406 oxygen leaking with adapter.
4th floor room 411 oxygen missing ID tab.
5th floor room 502 oxygen leaking with adapter.
5th floor room 503 oxygen leaking with adapter.
5th floor room 505 oxygen leaking with adapter.
5th floor room 506 oxygen leaking with adapter.
5th floor room 508 oxygen leaking with adapter.
5th floor room 509 oxygen leaking with adapter.
5th floor room 510 oxygen leaking with adapter.
5th floor room 511 oxygen leaking with adapter.
5th floor room 512 oxygen leaking with adapter.

The Director of Plant Operations provided two Estimates to the evaluator. One dated 12/04/2021 and the other dated 01/08/2022 for work to be done on the medical gases at the hospital.

During a concurrent interview, the Director of Plant Operations stated that the vendor was waiting for a purchase order so he can visit the hospital to make the corrections.

NFPA 99, 2012.

6.5 Essential Electrical System Requirements - Type 2.

6.5.1 Sources (Type 2 EES). The requirements for sources for
Type 2 essential electrical systems shall conform to those listed
in 6.4.1.

6.5.2.2.2 Life Safety Branch.

6.5.2.2.2.1 The life safety and critical branches shall supply
power for lighting, receptacles, and equipment as follows:
(1) Illumination of means of egress in accordance with
NFPA 101, Life Safety Code
(2) Exit signs and exit directional signs in accordance with
NFPA 101, Life Safety Code
(3) Alarm and alerting systems, including the following:
(a) Fire alarms
(b) Alarms required for systems used for the piping of nonflammable
medical gases as specified in Chapter 5
(4)*Communications systems, where used for issuing instructions
during emergency conditions
(5) Sufficient lighting in dining and recreation areas to provide
illumination to exit ways of a minimum of 5 ft-candles
(6) Task illumination and select receptacles at the generator
set location
(7) Elevator cab lighting, control, communications, and signal
Systems


6.5.2.2.2.2 No functions, other than those listed in
6.5.2.2.2.1(1) through (7), shall be connected to the life
safety.

This requirement was not met as evidenced by the following:

Based on observation and interview, the facility failed to ensure that there was task illumination battery operated lighting at the generator set location when normal power was interrupted. Task illumination at the generator set may allow technicians to trouble shoot problems or provide necessary maintenance in the event of a power outage and generator failure, and other illuminated areas used by occupants and residents may reduce panic and allow the occupants to safely evacuate from the building in the event of an emergency.

Findings:

Hospital B

On March 23, 2022, from 1:00 p.m. to 3:30 p.m., during a tour of the facility, the evaluator, in the presence of Maintenance Engineer, observed the Generator set was located at the basement level in an enclosed structure of the facility. The evaluator and Maintenance Engineer also observed there was no task illumination battery operated lighting at the Generator set location.

On March 23, 2022, at 3:00 p.m., during an interview with the Maintenance Engineer at the time of the observation, he stated that he was not sure if the existing lighting equipment at the Generator set was battery operated during a power outage. The Maintenance Engineer stated that he needed to verify with the Director of Plant Operations to ensure the requirement for the necessary battery-operated emergency lighting, as indicated, was met.