HospitalInspections.org

Based on random observation it was determined the hospital failed to maintain all corridor doors to be smoke resistant and to close and latch without impediment.

Findings include:

1. During tour of the hospital on 06/28/11 at approximately 1:00 p.m., the following corridor doors were observed not to close and latch without impediment:

a. Kitchen dish washing room.
b. Janitor room (near dish washing room).
c. Infusion room (positive latch missing).

Based on observation it was determined the hospital failed to maintain all means of egress readily accessible.

Findings include:

1. On 06/29/11 at approximately 9:30 a.m., three (3) computers on rolling stands were observed unattended and on charge in the corridor egress path on the patient care unit.

NFPA (National Fire Protection Association) 13, Standard for the Installation of Sprinkler Systems
1-6 Level of Protection.
1-6.1
A building, where protected by an automatic sprinkler system installation, shall be provided with sprinklers in all areas.

This Standard is not met as evidenced by:

Based on observation it was determined the hospital failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 13.

Findings include:

1. During a tour of the facility on 06/29/11 at approximately 10:00 a.m., the following areas of the hospital were observed not to have sprinkler coverage. These areas do not have sprinkler coverage due to changes of the original construction of the hospital.

a. Emergency room registration area.
b. X-ray department main office/file storage room.
c. X-ray storage room.
d. Infusion room.

NFPA 96 - Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations
Chapter 7 - Fire-Extinguishing Equipment
7-2.2.1
Automatic fire-extinguishing systems shall be installed in accordance with the terms of their listing, the manufacturer"s instructions, and the following standards where applicable.
(a) NFPA 12, Standard on Carbon Dioxide Extinguishing Systems
(b) NFPA 13, Standard for the Installation of Sprinkler Systems
(c) NFPA 17, Standard for Dry Chemical Extinguishing Systems
(d) NFPA 17A, Standard for Wet Chemical Extinguishing Systems

NFPA (National Fire Protection Association) 17 - Standard for Dry Chemical Extinguishing Systems
9-3 Maintenance.
9-3.1*
At least semiannually, maintenance shall be conducted in accordance with the manufacturer's listed installation and maintenance manual. As a minimum, such maintenance shall include the following:
(a) A check to see that the hazard has not changed
(b) An examination of all detectors, expellant gas container(s), agent container(s), releasing devices, piping, hose assemblies, nozzles, signals, and all auxiliary equipment
(c) * Verification that the agent distribution piping is not obstructed
(d) Examination of the dry chemical (If there is evidence of caking, the dry chemical shall be discarded and the system shall be recharged in accordance with the manufacturer's instructions.)
Exception: Dry chemical in stored pressure systems shall not require semiannual examination but shall be examined at least every 6 years.
(e) Where semiannual maintenance of any dry chemical containers or system components reveals conditions such as, but not limited to, corrosion or pitting in excess of the manufacturer's limits, structural damage or fire damage, or repairs by soldering, welding, or brazing, the affected part(s) shall be replaced or hydrostatically tested in accordance with the recommendations of the manufacturer or the listing agency. The hydrostatic testing of dry chemical containers shall follow the applicable procedures outlined in Section 9-5.
(f) All dry chemical systems shall be tested, which shall include the operation of the detection system, signals, and releasing devices, including manual stations and other associated equipment. A discharge of the dry chemical normally is not part of this test.
g) Where the maintenance of the system(s) reveals defective parts that could cause an impairment or failure of proper operation of the system(s), the affected parts shall be replaced or repaired in accordance with the manufacturer's recommendations.
(h) The maintenance report, including any recommendations, shall be filed with the owner or with the designated party responsible for the system.
(i) * Each dry chemical system shall have a tag or label indicating the month and year the maintenance is performed and identifying the person performing the service. Only the current tag or label shall remain in place.

7-2.2*
Automatic fire-extinguishing systems shall comply with standard UL 300, Fire Testing of Fire Extinguishing Systems for Protection of Restaurant Cooking Areas, or other equivalent standards and shall be installed in accordance with their listing.

This Standard is not met as evidenced by:

Based on review of facility documentation and staff interview it was determined the hospital failed to maintain the range hood extinguishing system in accordance with NFPA 96.

Findings include:

1. On 06/28/11 at approximately 9:30 a.m., the range hood extinguishing system inspection report dated 02/25/10 and prepared by Mountain States Airgas Company was reviewed. This report indicated the agent cylinders need hydrotested and that the dry chemical system needs updated to a wet chemical system. Also, on this same date and time a Fire Safety Inspection Report dated 03/14/11 and prepared by a West Virginia State Fire Marshal was reviewed. This report indicated that the hood suppression system was not UL 300 compliant.

2. On 06/28/11 at approximately 1:00 p.m., an interview with the maintenance director revealed that the rangehood extinguishing system had not been upgraded as of this date 06/28/11.

NOTE:
Facilities may continue to use pre-UL 300 range hood extinguishing system so long as contractors who service the system have spare parts. However, when the time comes for the six (6) year system test, twelve (12) year hydrostatic or the system has been discharged, facilities must replace their systems and must upgrade to meet UL 300 standard.

Based on review of facility documentation and staff interview it was determined the hospital failed to maintain the medical gas system in accordance with National Fire Protection Association (NFPA) 99, Chapter 4.

Findings include:

1. On 06/28/11 at approximately 2:00 p.m., an inspection report for the hospital liquid oxygen supply system was reviewed. This report was prepared by Praxair and dated 10/20/10. This report revealed that the following alarms/switches were not wired to the hospital panel.

a. Main Low Level.
b. Reserve- in-Use/Main Low Pressure

2. On 06/28/11 at approximately 2:15 p.m., an interview with the maintenance director revealed that the alarms/switches have not been wired to the hospital panel as of this date 06/28/11.

3. On 06/28/11 at approximately 2:30 p.m., an interview with the maintenance director was conducted in reference to preventative maintenance on the hospital piped-in oxygen system and vacuum system. At this time, the interview revealed that the hospital did not have a policy and procedure in place for routine inspection and testing of the components for the piped-in oxygen and vacuum system.

Based on random observation it was determined the hospital failed to maintain all corridor doors to be smoke resistant and to close and latch without impediment.

Findings include:

1. During tour of the hospital on 06/28/11 at approximately 1:00 p.m., the following corridor doors were observed not to close and latch without impediment:

a. Kitchen dish washing room.
b. Janitor room (near dish washing room).
c. Infusion room (positive latch missing).

Based on observation it was determined the hospital failed to maintain all means of egress readily accessible.

Findings include:

1. On 06/29/11 at approximately 9:30 a.m., three (3) computers on rolling stands were observed unattended and on charge in the corridor egress path on the patient care unit.

NFPA (National Fire Protection Association) 13, Standard for the Installation of Sprinkler Systems
1-6 Level of Protection.
1-6.1
A building, where protected by an automatic sprinkler system installation, shall be provided with sprinklers in all areas.

This Standard is not met as evidenced by:

Based on observation it was determined the hospital failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 13.

Findings include:

1. During a tour of the facility on 06/29/11 at approximately 10:00 a.m., the following areas of the hospital were observed not to have sprinkler coverage. These areas do not have sprinkler coverage due to changes of the original construction of the hospital.

a. Emergency room registration area.
b. X-ray department main office/file storage room.
c. X-ray storage room.
d. Infusion room.

NFPA 96 - Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations
Chapter 7 - Fire-Extinguishing Equipment
7-2.2.1
Automatic fire-extinguishing systems shall be installed in accordance with the terms of their listing, the manufacturer"s instructions, and the following standards where applicable.
(a) NFPA 12, Standard on Carbon Dioxide Extinguishing Systems
(b) NFPA 13, Standard for the Installation of Sprinkler Systems
(c) NFPA 17, Standard for Dry Chemical Extinguishing Systems
(d) NFPA 17A, Standard for Wet Chemical Extinguishing Systems

NFPA (National Fire Protection Association) 17 - Standard for Dry Chemical Extinguishing Systems
9-3 Maintenance.
9-3.1*
At least semiannually, maintenance shall be conducted in accordance with the manufacturer's listed installation and maintenance manual. As a minimum, such maintenance shall include the following:
(a) A check to see that the hazard has not changed
(b) An examination of all detectors, expellant gas container(s), agent container(s), releasing devices, piping, hose assemblies, nozzles, signals, and all auxiliary equipment
(c) * Verification that the agent distribution piping is not obstructed
(d) Examination of the dry chemical (If there is evidence of caking, the dry chemical shall be discarded and the system shall be recharged in accordance with the manufacturer's instructions.)
Exception: Dry chemical in stored pressure systems shall not require semiannual examination but shall be examined at least every 6 years.
(e) Where semiannual maintenance of any dry chemical containers or system components reveals conditions such as, but not limited to, corrosion or pitting in excess of the manufacturer's limits, structural damage or fire damage, or repairs by soldering, welding, or brazing, the affected part(s) shall be replaced or hydrostatically tested in accordance with the recommendations of the manufacturer or the listing agency. The hydrostatic testing of dry chemical containers shall follow the applicable procedures outlined in Section 9-5.
(f) All dry chemical systems shall be tested, which shall include the operation of the detection system, signals, and releasing devices, including manual stations and other associated equipment. A discharge of the dry chemical normally is not part of this test.
g) Where the maintenance of the system(s) reveals defective parts that could cause an impairment or failure of proper operation of the system(s), the affected parts shall be replaced or repaired in accordance with the manufacturer's recommendations.
(h) The maintenance report, including any recommendations, shall be filed with the owner or with the designated party responsible for the system.
(i) * Each dry chemical system shall have a tag or label indicating the month and year the maintenance is performed and identifying the person performing the service. Only the current tag or label shall remain in place.

7-2.2*
Automatic fire-extinguishing systems shall comply with standard UL 300, Fire Testing of Fire Extinguishing Systems for Protection of Restaurant Cooking Areas, or other equivalent standards and shall be installed in accordance with their listing.

This Standard is not met as evidenced by:

Based on review of facility documentation and staff interview it was determined the hospital failed to maintain the range hood extinguishing system in accordance with NFPA 96.

Findings include:

1. On 06/28/11 at approximately 9:30 a.m., the range hood extinguishing system inspection report dated 02/25/10 and prepared by Mountain States Airgas Company was reviewed. This report indicated the agent cylinders need hydrotested and that the dry chemical system needs updated to a wet chemical system. Also, on this same date and time a Fire Safety Inspection Report dated 03/14/11 and prepared by a West Virginia State Fire Marshal was reviewed. This report indicated that the hood suppression system was not UL 300 compliant.

2. On 06/28/11 at approximately 1:00 p.m., an interview with the maintenance director revealed that the rangehood extinguishing system had not been upgraded as of this date 06/28/11.

NOTE:
Facilities may continue to use pre-UL 300 range hood extinguishing system so long as contractors who service the system have spare parts. However, when the time comes for the six (6) year system test, twelve (12) year hydrostatic or the system has been discharged, facilities must replace their systems and must upgrade to meet UL 300 standard.

Based on review of facility documentation and staff interview it was determined the hospital failed to maintain the medical gas system in accordance with National Fire Protection Association (NFPA) 99, Chapter 4.

Findings include:

1. On 06/28/11 at approximately 2:00 p.m., an inspection report for the hospital liquid oxygen supply system was reviewed. This report was prepared by Praxair and dated 10/20/10. This report revealed that the following alarms/switches were not wired to the hospital panel.

a. Main Low Level.
b. Reserve- in-Use/Main Low Pressure

2. On 06/28/11 at approximately 2:15 p.m., an interview with the maintenance director revealed that the alarms/switches have not been wired to the hospital panel as of this date 06/28/11.

3. On 06/28/11 at approximately 2:30 p.m., an interview with the maintenance director was conducted in reference to preventative maintenance on the hospital piped-in oxygen system and vacuum system. At this time, the interview revealed that the hospital did not have a policy and procedure in place for routine inspection and testing of the components for the piped-in oxygen and vacuum system.