HospitalInspections.org

Based on observation and staff interview, the facility failed to provide smoke barriers that would resist the passage of smoke. This condition had the potential to allow smoke to migrate between smoke compartments.

Findings are:
Observation above ceiling during the facility tour on 8/18/15, from 1:54 pm to 2:04 pm revealed:
1. Multiple penetrations and holes around pipes and wires failed to be sealed above the Laundry Corridor N 1070 Smoke Doors.
2. Multiple penetrations and holes around pipes and wires failed to be sealed above the Housekeeping 1040 Smoke Doors.
In an interview conducted at the time of observation, (8/18/15, from 1:54 pm to 2:04 pm), Maintenance A acknowledged the findings.

Based on observation and staff interview, the facility failed to provide one-hour fire separation from a non-sprinkled hazardous area. This condition would allow smoke or fire to spread from the hazardous areas.

Findings are:
Observation during the facility tour on 8/18/15, at 12:03 pm revealed storage in plastic containers was observed in the Old Dark Room which was open to the Air Handler Room. The storage failed to be removed, or a 45-minute fire rated self-closing fire door failed to separate the Air Handler Room from the exit corridor.
In an interview conducted at the time of observation and record review, (8/18/15, at 12:03 pm), Maintenance A acknowledged the findings.

Based on observation and staff interview, the facility failed to maintain a battery backup emergency light. This condition would not provide battery backup illumination of the Electric Switch Room in the area with lighting connected to the emergency generator.

Findings are:
Observation during the facility tour on 8/18/15, at 11:36 am revealed the battery backup emergency light in the Electric Switch Room failed to function when tested.
In an interview conducted at the time of observation, (8/18/15, at 11:36 am) Maintenance A acknowledged the findings.

NFPA 101, 2000 Ed, NFPA 101, 4.6.12.2*
Existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed.

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 ½ 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 conduct fire drills for 1 of 2 shifts in accordance with the National Fire Protection Association 101. This condition would not provide simulated training for staff to respond to a fire emergency.

Findings are:
Record review of fire drills during the survey on 8/18/15, at 10:53 am revealed:
1. Fire drills failed to have at least one hour difference between each quarter for the past year on the 2nd Shift:
2nd Shift: 5/20/15 at 6:10 am, 11/21/14 at 6:00 am.
2. Fire drills failed to be documented for the 2nd Shift in the 1st Quarter of 2015 and for the 2nd Shift in the 3rd Quarter of 2014.
In an interview conducted at the time of record review (8/18/15, at 10:53 am), Maintenance A acknowledged the findings.

NFPA 101, 2000, 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.

Based on observation and staff interview, the facility failed to maintain the sprinkler system in accordance with the National Fire Protection Association 13. This condition had the potential of damaging the sprinkler system.

Findings are:
Observation during the facility tour on 8/18/15, at 11:49 am revealed a data cable was attached to the sprinkler pipe in the Clean Laundry, and failed to be removed.
In an interview conducted at the time of observation, (8/18/15, at 11:49 am), Maintenance A acknowledged the findings.

NFPA 13, 1999, 6-1.1.5*
Sprinkler piping or hangers shall not be used to support nonsystem components.

Based on record review and staff interview, the facility failed to maintain humidity levels in the operating room in accordance with the National Fire Protection Association 99 throughout the last year. This condition created the potential for a burn or fire to occur during a procedure.

Findings are:
Record review during the facility tour on 8/18/15, at 11:47 am revealed humidity levels failed to be maintained at a minimum of 35% consistently throughout the last 12 months during procedures in the OR.
In an interview conducted at the time of record review, (8/18/15, at 11:47 am), Maintenance A acknowledged the findings.

Based on record review and staff interview, the facility failed to maintain the emergency generator in accordance with the National Fire Protection Association (NFPA), 110. This condition increased the potential that the generator would fail to run during loss of power.

Findings are:
Record review on 8/18/15, at 11:09 am of emergency generator inspection and testing revealed:
1. Documentation that the generator picked up the emergency system load within 10 seconds after loss of normal power failed to be recorded during monthly load testing.
2. The percentage of KW that the generator ran at during monthly load testing failed to be documented.
3. The electrical system, air/exhaust system, cooling system and generator enclosure failed to be inspected and documented weekly.
In an interview conducted at the time of record review, (8/18/15, at 11:09 am), Maintenance A acknowledged the findings.

Actual NFPA Standard:
NFPA 110, 1999, 6-4.1*
Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
Exception: If the generator set is used for standby power or for peak load shaving, such use shall be recorded and shall be permitted to be substituted for scheduled operations and testing of the generator set, provided the appropriate data are recorded.
6-4.2*
Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
The date and time of day for required testing shall be decided by the owner, based on facility operations.
NFPA 99, 1999, 3-4.1.1.8 + Load Pickup.
The generator set(s) shall have sufficient capacity to pick up the load and meet the minimum frequency and voltage stability requirements of the emergency system within 10 seconds after loss of normal power. [110: 3-4.1]

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

Findings are:
Observation during the facility tour on 8/18/15 at 2:07 pm revealed a power strip was daisy chained into a battery backup power strip in the IT Room. The power strips failed to be plugged directly into a wall outlet.
In an interview conducted at the time of observation (8/18/15 at 2:07 pm), Maintenance A acknowledged the findings.

Based on observation and staff interview, the facility failed to provide smoke barriers that would resist the passage of smoke. This condition had the potential to allow smoke to migrate between smoke compartments.

Findings are:
Observation above ceiling during the facility tour on 8/18/15, from 1:54 pm to 2:04 pm revealed:
1. Multiple penetrations and holes around pipes and wires failed to be sealed above the Laundry Corridor N 1070 Smoke Doors.
2. Multiple penetrations and holes around pipes and wires failed to be sealed above the Housekeeping 1040 Smoke Doors.
In an interview conducted at the time of observation, (8/18/15, from 1:54 pm to 2:04 pm), Maintenance A acknowledged the findings.

Based on observation and staff interview, the facility failed to provide one-hour fire separation from a non-sprinkled hazardous area. This condition would allow smoke or fire to spread from the hazardous areas.

Findings are:
Observation during the facility tour on 8/18/15, at 12:03 pm revealed storage in plastic containers was observed in the Old Dark Room which was open to the Air Handler Room. The storage failed to be removed, or a 45-minute fire rated self-closing fire door failed to separate the Air Handler Room from the exit corridor.
In an interview conducted at the time of observation and record review, (8/18/15, at 12:03 pm), Maintenance A acknowledged the findings.

Based on observation and staff interview, the facility failed to maintain a battery backup emergency light. This condition would not provide battery backup illumination of the Electric Switch Room in the area with lighting connected to the emergency generator.

Findings are:
Observation during the facility tour on 8/18/15, at 11:36 am revealed the battery backup emergency light in the Electric Switch Room failed to function when tested.
In an interview conducted at the time of observation, (8/18/15, at 11:36 am) Maintenance A acknowledged the findings.

NFPA 101, 2000 Ed, NFPA 101, 4.6.12.2*
Existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed.

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 ½ 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 conduct fire drills for 1 of 2 shifts in accordance with the National Fire Protection Association 101. This condition would not provide simulated training for staff to respond to a fire emergency.

Findings are:
Record review of fire drills during the survey on 8/18/15, at 10:53 am revealed:
1. Fire drills failed to have at least one hour difference between each quarter for the past year on the 2nd Shift:
2nd Shift: 5/20/15 at 6:10 am, 11/21/14 at 6:00 am.
2. Fire drills failed to be documented for the 2nd Shift in the 1st Quarter of 2015 and for the 2nd Shift in the 3rd Quarter of 2014.
In an interview conducted at the time of record review (8/18/15, at 10:53 am), Maintenance A acknowledged the findings.

NFPA 101, 2000, 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.

Based on observation and staff interview, the facility failed to maintain the sprinkler system in accordance with the National Fire Protection Association 13. This condition had the potential of damaging the sprinkler system.

Findings are:
Observation during the facility tour on 8/18/15, at 11:49 am revealed a data cable was attached to the sprinkler pipe in the Clean Laundry, and failed to be removed.
In an interview conducted at the time of observation, (8/18/15, at 11:49 am), Maintenance A acknowledged the findings.

NFPA 13, 1999, 6-1.1.5*
Sprinkler piping or hangers shall not be used to support nonsystem components.

Based on record review and staff interview, the facility failed to maintain humidity levels in the operating room in accordance with the National Fire Protection Association 99 throughout the last year. This condition created the potential for a burn or fire to occur during a procedure.

Findings are:
Record review during the facility tour on 8/18/15, at 11:47 am revealed humidity levels failed to be maintained at a minimum of 35% consistently throughout the last 12 months during procedures in the OR.
In an interview conducted at the time of record review, (8/18/15, at 11:47 am), Maintenance A acknowledged the findings.

Based on record review and staff interview, the facility failed to maintain the emergency generator in accordance with the National Fire Protection Association (NFPA), 110. This condition increased the potential that the generator would fail to run during loss of power.

Findings are:
Record review on 8/18/15, at 11:09 am of emergency generator inspection and testing revealed:
1. Documentation that the generator picked up the emergency system load within 10 seconds after loss of normal power failed to be recorded during monthly load testing.
2. The percentage of KW that the generator ran at during monthly load testing failed to be documented.
3. The electrical system, air/exhaust system, cooling system and generator enclosure failed to be inspected and documented weekly.
In an interview conducted at the time of record review, (8/18/15, at 11:09 am), Maintenance A acknowledged the findings.

Actual NFPA Standard:
NFPA 110, 1999, 6-4.1*
Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
Exception: If the generator set is used for standby power or for peak load shaving, such use shall be recorded and shall be permitted to be substituted for scheduled operations and testing of the generator set, provided the appropriate data are recorded.
6-4.2*
Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
The date and time of day for required testing shall be decided by the owner, based on facility operations.
NFPA 99, 1999, 3-4.1.1.8 + Load Pickup.
The generator set(s) shall have sufficient capacity to pick up the load and meet the minimum frequency and voltage stability requirements of the emergency system within 10 seconds after loss of normal power. [110: 3-4.1]

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

Findings are:
Observation during the facility tour on 8/18/15 at 2:07 pm revealed a power strip was daisy chained into a battery backup power strip in the IT Room. The power strips failed to be plugged directly into a wall outlet.
In an interview conducted at the time of observation (8/18/15 at 2:07 pm), Maintenance A acknowledged the findings.