HospitalInspections.org

Based on visual observation the facility failed to maintain the separation of hazardous areas from other parts of the building, including the egress corridor. Hazardous areas within a supervised sprinklered facility are required to be constructed to resist the passage of smoke and provide a minimum 1 ¾ inch solid wood core door that self closes and self latches properly. The deficient practice had the potential to affect 0 of 4 residents.
2 of 4 smoke compartments have hazardous areas that are not separated.

Findings:

During the facility tour on 8/7 2018 between the hours of 8:30 am to 4:00 pm it was observed the boiler room and janitor rooms solid core 1 ¾ inch thick doors were not self closing properly.

NFPA 101: 19.3.2.1 Hazardous Areas. Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.7.1.
NFPA 101: 19.3.2.1.1 An automatic extinguishing system, where used in hazardous areas, shall be permitted to be in accordance with 19.3.5.9.

NFPA 101:19.3.2.1.2* Where the sprinkler option of 19.3.2.1 is used, the areas shall be separated from other spaces by smoke partitions in accordance with Section 8.4.

NFPA 101: 19.3.2.1.3 The doors shall be self-closing or automatic-closing.

Interview with the Facilities Manager revealed the facility was not aware that the doors to the hazardous areas were required to self-close and latch in the frame.

Based on visual observation the facility failed to assure that the heating, ventilation and air conditioning system was installed in accordance with NFPA 90A & NFPA 80A. The system fire and smoke dampers routine inspections are necessary to ensure proper maintenance is being implemented for the safety of all facility occupants. The deficient practice had the potential to affect 4 of 10 residents.

Findings:

During the facility tour on 8/7/2018 between the hours of 8:30 am to 4:00 pm it was observed the HVAC smoke and fire damper inspection documentation is lacking.

NFPA 80:19.3.3 Inspection. Following completion of the test, a visual inspection shall be made of the assembly to ensure no obstructions have been introduced.

NFPA 80:19.3.4 Documentation. All inspections and testing shall be documented, indicating the location of the fire damper, date(s) of inspection, name of inspector, and deficiencies discovered. The documentation shall have a space to indicate when and how the deficiencies were corrected.

NFPA 80:19.4* Periodic Inspection and Testing.
NFPA 80:19.4.1 Each damper shall be tested and inspected 1 year after installation.

NFPA 80:19.4.1.1 The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be ever 6 years.

Interview with the Facilities Manager revealed the facility was not aware the HVAC system was lacking the required fire / smoke damper inspections.

Based on visual observation the facility failed to provide the minimum required receptacle plugs required by NFPA 99. Healthcare advanced techniques and modern medical technology require significantly more medial appliances in critical care spaces and operating rooms. The deficient practice had the potential to affect 4 of 10 residents.

Findings:

During the facility tour on 8/7 2018 between the hours of 8:30 am to 4:00 pm it was observed all the Post Anesthesia Care Unit rooms had eight receptacle plugs, thus lacking the required minimum fourteen required by NFPA 99.

NFPA 99:6.3.2.2.6.2 Minimum Number of Receptacles. The number of receptacles shall be determined by the intended use of the patient care rooms in accordance with 6.3.2.2.6.2(A) through 6.3.2.2.6.2(E).

(A) Receptacles for Patient Bed Locations in General Care Areas (Category 2). Each patient bed location shall be provided with a minimum of eight receptacles.

(B) Receptacles for Patient Bed Locations in Critical Care Areas (Category 1). Each patient bed location shall be provided with a minimum of 14 receptacles.

(C) Receptacles for Operating Rooms (Category 1). Operating rooms shall be provided with a minimum of 36 receptacles.

(D) Receptacles for Bathrooms or Toilets. Receptacles shall not be required in bathrooms or toilet rooms.

(E) Receptacles for Special Rooms. Receptacles shall not be required in rooms where medical requirements mandate otherwise (e.g., certain psychiatric, pediatric, or hydrotherapy rooms).

(F) Designated General Care Pediatric Locations. Receptacles that are located within the patient rooms, bathrooms, playrooms, and activity rooms of pediatric units, other than nurseries, shall be listed tamper-resistant or shall employ a listed tamper resistant cover.

Interview with the Facility Manager revealed the facility was not of the minimum number of receptacles for the various General Care, Critical Care and Operating room areas.

Based on visual observation the facility failed to assure that the generator or other alternate power source is capable of restoring electrical service within 10 seconds. Generator sets are inspected weekly and a monthly testing program on the emergency generator must be conducted a min. of 12 times a year under load for a min. of 30 minutes. In cases of a power outage the emergency generator powers essential life safety equipment for the facility. The deficient practice had the potential to affect 4 of 10 residents.
12 of 12 months were deficient.

Findings:

During the record review, between the hours of 8:30 am to 4:00 pm it was observed the generator weekly inspection logs were lacking and the monthly generator load tests logs were lacking important information.

NFPA 110:8.3.7* states, "Storage batteries, including electrolyte levels or battery voltage, used in connection with systems shall be inspected weekly and maintained in full compliance with manufacturer's specifications".

NFPA 110:8.4.1* states, "EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly".


Interview with the Facilities Manager revealed the facility was not aware that all documentation was not complete regarding the inspection/testing of the emergency generator.