HospitalInspections.org

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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:
1. The Storage Room corridor door by room 709 had a hole in it at the door knob
2. Room 708 corridor door was warpped and did not fit in the door frame (was not smoke resistive)
3. The corridor door to room 703 was not positive latching

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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.
2000 NFPA 101, 19.3.6.3.2 Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. 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. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.
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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 room 228 had a hole in it at the door knob
Third Floor
2. The corridor door to room 302 had a hole 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 maintain the exit access per code. Findings include:

During the survey, the following is an example of what was observed:
The open area did not have a clear and unobstructed path of egress:
From wall to column was 13"
From column to furniture was 27"

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2000 NFPA 101, 19.2.3.3 Any required aisle, corridor, or ramp shall be not less than 4 ft (1.2 m) in clear width where serving as means of egress from patient sleeping rooms. The aisle, corridor, or ramp shall be arranged to avoid any obstructions to the convenient removal of nonambulatory persons carried on stretchers or on mattresses serving as stretchers.
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The facility failed to conduct fire drills per code. 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, that were on the clock at the time of the drill, to sign the drill reports saying that they had participated in the drills.

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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 comply with the required maintenance of the facility sprinkler system. During the survey, the following are examples of what was observed:

1. Fire department connection missing the caps.

2. Documentation not provided for the five year internal inspection.

3. Documentation not provided for the five year replacement of riser gauges.

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NFPA 101,2000 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, Standards for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25, 1998 Edition, 9-7.1 Fire department connections shall be inspected quarterly. The inspection shall verify the following:
(a) The fire department connections are visible and accessible.
(b) Couplings or swivels are not damaged and rotate smoothly.
(c) Plugs or caps are in place and undamaged.
(d) Gaskets are in place and in good conition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly.
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The facility failed to maintain the designated smoking areas per code. Findings include:

During the survey, the following are examples of what was observed:
1. The designated staff smoking area off the Third Floor did not have:
a. An ashtray
b. Metal container with a self-closing cover
2. The designated staff smoking area off the First Floor did not have a metal container with a self-closing cover
3. The PICU designated patient smoking area did not have:
a. An ashtray
b. Metal container with a self-closing cover

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2000 NFPA 101, 19.7.4 Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
Exception: In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
(2) Smoking by patients classified as not responsible shall be prohibited.
Exception: The requirement of 19.7.4(2) shall not apply where the patient is under direct supervision.
(3) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(4) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.
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The facility failed to maintain oxygen cylinders per code. Findings include:

During the survey, the following is an example of what was observed:
Basement
Oxygen cylinders were observed unsecured in the following locations:
1. The Maintenance Office
2. The Oxygen Storage Closet in the Maintenance Office

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2000 NFPA 101, 19.3.2.4 Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.
1999 NFPA 99, 4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
(a) * Nonflammable Gases (Any Quantity; In-Storage, Connected, or Both)
3. Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.
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The facility failed to maintain the generator per code. Findings include:

During the survey, the following is an example of what was observed:
Per documentation from the facility the surveyor could not verify weekly inspections

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1999 NFPA 110, 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.
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The facility failed to to provide a remote annunciator for the generator per code. Findings include:

During the survey, the following is an example of what was observed:
Per observation and interview the emergency generator did not have a remote annunciator

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1971 NFPA 76A, 641 A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station, (see Section 700-12, NFPA N0. 70-1971.) Where a regular work station may be unattended periodically, an appropriately labeled derangement signal shall be exhibited at the telephone switchboard. The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate:
(1) When the emergency or auxiliary power source is operating to supply power to load.
(2) When the battery charger is malfunctioning.
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate:
(1) Low lubricating oil pressure.
(2) Low water temperature (below those required in 623).
(3) Excessive water temperature.
(4) Low fuel - when the main fuel storage tank contains less than a three-hour operating supply.
(5) Overcrank (failure to start).
(6) Overspeed.
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The facility failed to provide a fire watch policy per code. Findings include:

During the survey, the following is an example of what was observed:
The facility failed to provide a fire watch policy

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2000 NFPA 101, 9.6.1.8 Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.
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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:
1. The Storage Room corridor door by room 709 had a hole in it at the door knob
2. Room 708 corridor door was warpped and did not fit in the door frame (was not smoke resistive)
3. The corridor door to room 703 was not positive latching

____________________

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.
2000 NFPA 101, 19.3.6.3.2 Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. 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. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.
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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 room 228 had a hole in it at the door knob
Third Floor
2. The corridor door to room 302 had a hole in it at the door knob

____________________

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 maintain the exit access per code. Findings include:

During the survey, the following is an example of what was observed:
The open area did not have a clear and unobstructed path of egress:
From wall to column was 13"
From column to furniture was 27"

_____________________

2000 NFPA 101, 19.2.3.3 Any required aisle, corridor, or ramp shall be not less than 4 ft (1.2 m) in clear width where serving as means of egress from patient sleeping rooms. The aisle, corridor, or ramp shall be arranged to avoid any obstructions to the convenient removal of nonambulatory persons carried on stretchers or on mattresses serving as stretchers.
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The facility failed to conduct fire drills per code. 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, that were on the clock at the time of the drill, to sign the drill reports saying that they had participated in the drills.

____________________

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 comply with the required maintenance of the facility sprinkler system. During the survey, the following are examples of what was observed:

1. Fire department connection missing the caps.

2. Documentation not provided for the five year internal inspection.

3. Documentation not provided for the five year replacement of riser gauges.

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NFPA 101,2000 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, Standards for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25, 1998 Edition, 9-7.1 Fire department connections shall be inspected quarterly. The inspection shall verify the following:
(a) The fire department connections are visible and accessible.
(b) Couplings or swivels are not damaged and rotate smoothly.
(c) Plugs or caps are in place and undamaged.
(d) Gaskets are in place and in good conition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly.
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The facility failed to maintain the designated smoking areas per code. Findings include:

During the survey, the following are examples of what was observed:
1. The designated staff smoking area off the Third Floor did not have:
a. An ashtray
b. Metal container with a self-closing cover
2. The designated staff smoking area off the First Floor did not have a metal container with a self-closing cover
3. The PICU designated patient smoking area did not have:
a. An ashtray
b. Metal container with a self-closing cover

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2000 NFPA 101, 19.7.4 Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
Exception: In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
(2) Smoking by patients classified as not responsible shall be prohibited.
Exception: The requirement of 19.7.4(2) shall not apply where the patient is under direct supervision.
(3) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(4) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.
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The facility failed to maintain oxygen cylinders per code. Findings include:

During the survey, the following is an example of what was observed:
Basement
Oxygen cylinders were observed unsecured in the following locations:
1. The Maintenance Office
2. The Oxygen Storage Closet in the Maintenance Office

___________________

2000 NFPA 101, 19.3.2.4 Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.
1999 NFPA 99, 4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
(a) * Nonflammable Gases (Any Quantity; In-Storage, Connected, or Both)
3. Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.
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The facility failed to maintain the generator per code. Findings include:

During the survey, the following is an example of what was observed:
Per documentation from the facility the surveyor could not verify weekly inspections

________________

1999 NFPA 110, 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.
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The facility failed to to provide a remote annunciator for the generator per code. Findings include:

During the survey, the following is an example of what was observed:
Per observation and interview the emergency generator did not have a remote annunciator

________________

1971 NFPA 76A, 641 A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station, (see Section 700-12, NFPA N0. 70-1971.) Where a regular work station may be unattended periodically, an appropriately labeled derangement signal shall be exhibited at the telephone switchboard. The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate:
(1) When the emergency or auxiliary power source is operating to supply power to load.
(2) When the battery charger is malfunctioning.
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate:
(1) Low lubricating oil pressure.
(2) Low water temperature (below those required in 623).
(3) Excessive water temperature.
(4) Low fuel - when the main fuel storage tank contains less than a three-hour operating supply.
(5) Overcrank (failure to start).
(6) Overspeed.
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The facility failed to provide a fire watch policy per code. Findings include:

During the survey, the following is an example of what was observed:
The facility failed to provide a fire watch policy

______________________

2000 NFPA 101, 9.7.6.1 Where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service.
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The facility failed to provide a fire watch policy per code. Findings include:

During the survey, the following is an example of what was observed:
The facility failed to provide a fire watch policy

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2000 NFPA 101, 9.6.1.8 Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.
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