HospitalInspections.org

Based on observation and staff interview it was determined the interior wall finish for rooms does not meet the minimum fire smoke rating as require. This condition could have a negative outcome for patient's staff and other occupants of the building in case of a fire.

The finding include:

In the Library located near the dining room area it was observed a hard wood material on the wall. This material covered the entire right side of the room. This condition was noted at 9:20 a.m., on 01/09/12.

The Chief Operating Officer and the Director of Maintenance were unable to produce any documents to indicate the fire/smoke rating for these materials noted above.

NFPA 101 Life Safety Code (2000) 18.3.3 & 19.3.3

(In fully sprinkled buildings, flame spread rating of Class A, Class B, or Class C may be continued in use within rooms separated in accordance with 19.3.6 from the access corridors).

Based on a review of the facility records, and interview with the staff on 01/10/12, it was determined that the facility failed to train all staff in disaster preparedness. A lack of these training exercises could in the event of an internal or external disaster cause confusion and/or panic from a lack of knowledge of staff and raise potential for negative outcomes to the patients and staff, and other building occupants.

The findings include:

During the interview on 1/9/12 with staff members it was revealed 3 of the 4 staff members interviewed were unable to open the double doors leading out of the 100 wing. The 100 wing is equipped with a magnetic lock device that can be released by entering a code on the key pad provided. When asked, 3 of the 4 staff members were unable to enter the proper code to release the magnetic lock. All three staff indicated the code had been changed and they were not informed of the new number. During staff interviews it was stated that these doors are shut during the evening hours.

NFPA 101 Life Safety Code (2000) 18.1.1.1.8, 19.1.1.1.8, & 18.7.1 & 19.7.1.

Based on observation with the director of maintenance, The Willough at Naples failed to provide a properly tested and maintained fire alarm system. The deficient practice would affect all smoke compartments, all patients and staff.

The findings include:

It was observed on 01/10/12 at 10:55 a.m., during the inspection and testing of the fire alarm system that consisted of multiple components, the automatic dialer component, when placed in trouble from phone line failure, did send a trouble signal to the main fire alarm control panel (FACP), which was located in the first floor. The main fire alarm control panel (FACP), remote zone indicator, located at the front door gave an audible trouble signal, when the (FACP) panel of the system was in trouble. Neither location is occupied around the clock (24 hours a day). The trouble signal could not be heard at the nurses' stations in the 100 or 200 wings.


NFPA 101, 2000 Edition
NFPA 72 section 1-5.4.6.
The trouble signal(s) shall be located in an area where it is likely to be heard.

Based on an observation, staff interview, and record review conducted during the survey on 01/09/12 it was determined the fire sprinkler system, including tamper switches, failed to be completely maintained. The record review indicated the last fire sprinkler system inspection and test was conducted on 09/30/11. This failure and lack of tamper switches could place the lives of the occupants in danger should a fire occur and the fire sprinkler system failed to respond.

The findings include:

During the tour of the facility with the director of maintenance at 10:35 a.m. on 1/9/12, it was noted the three outside stem and yoke (OSY) valves were not equipped with tamper switches. These valves are located near the front entrance driveway.


NFPA 101 (2000 edition) 9.7.2.1

The facility has requested a three month extension to correct this deficiency and the facility was e-mailed the wavier forms as requested.

Based on an observation, staff interview, and record review conducted during the survey on 01/09/12, it was determined the fire sprinkler system failed to be completely maintained. The record review indicated the last fire sprinkler system inspection and test was conducted on 09/30/11. This condition could place the lives of the occupants in danger should a fire occur and the fire sprinkler system failed to respond properly do to obstructions.

The findings include:

During the tour of the facility at 1:35 p.m., with the director of maintenance, it was observed in the storage room on the 200 wing that cardboard boxes were stored on the top shelve obstructing the spray pattern of the sprinkler head. This was confirmed by the director of maintenance at the exit conference.

NFPA 101 (2000 edition) 19.7.6, 4.6.12
NFPA 13
NFPA 25, 9.7.5

Based on a review of the facility records,observation and interview with the staff, it was determined that the facility failed to ensure that the Heating, Ventilating and Air Conditioning System (HVAC) was maintained in reliable operating condition.

The findings include:

Inspection of the main kitchen on 01/09/12 at 2:25 p.m. revealed that there was a notable negative pressure relationship between the kitchen and the dining room. opening only on door to the kitchen yielded enough pressure to defeat the hydraulic door closure and keep the door open with significant cubic feet of dining room air entering the kitchen. It was noted that the kitchen supply air was not operable and the exhaust and make up hood air was on. The kitchen air supply was shut down because it caused condensation on the A/C grilles. This condition was noted by the director of maintenance and kitchen manager.

NFPA 101, (2000) 9.2; 18.5.2, 19.5.2
NFPA 90A

The facility has requested a three month extension to correct this deficiency and the facility was e-mailed the wavier forms as requested.

Correction Date: 02/10/12

Based on observation on 01/09/12, with the director of maintenance and manager of the kitchen, the use of the commercial cooking equipment was not in accordance with NFPA 96. If the fixed suppression system equipment is not maintained as required, there is a potential for an increased fire hazard.

The findings include:

Based on observation during the tour in the kitchen at 2:25 p.m., it was determined the commercial kitchen equipment was not properly positioned under the hood system. It was observed that the deep fat fryer was not being fully protected by the suppression system. The kitchen staff stated there was a double fryer in that place originally and it had been replaced with a single fryer. This condition created a situation in which the fixed suppression could be ineffective, due to improper position of the suppression nozzle,(s) for this piece of equipment.


NFPA 101 (2000) 9.2.3. 19.3.2.6,
NFPA 96

Based on an observation during the tour of the facility with the director of maintenance, laundry equipment (domestic clothes dryer) had not maintain on all the components. This condition could allow the propagation of a dryer lint fire, endangering building occupants.

The findings include:

While on tour 01/09/12 and 01/10/12 the clothes dryers located in the laundry room were observed to not have a vent pipe connected to the outside atmosphere. It was observed that a large amount of lint was on the floor and on the wall behind the dryers. Inside this room the temperature was noticeable higher than in other spaces in the facility.


Reference: NFPA 211 "Standard for Chimneys, Fireplaces, Vents, and Solid Fuel-Burning Appliances" (2000 Edition)

7-7.3.7 "Exhaust ducts for Type 2 clothes dryers shall be constructed of sheet metal or other noncombustible material. Such ducts shall be of adequate strength to meet the conditions of service with a minimum thickness equivalent to No. 24 galvanized steel gauge [0.024 in. (0.61 mm)]."

Based on testing of the generator with the facility staff on 01/10/12, it was determined the Willough at Naples, emergency back-up generator failed to function properly in accordance with NFPA 110, the standard for testing Emergency Back-up Generator Systems (2005 edition). A lack of required testing renders the equipment unreliable in this facility which requires secondary or back-up power.

The findings include:

At 1:45 p.m.on 1/10/12 with the director of maintenance, it was observed when the generator started that ATS-NE (automatic transfer switch) failed to transfer power to the facility. The director of maintenance called the generator vendor and stated that something was wrong with the transfer switch. The generator vendor was scheduled to investigate the problem.


NFPA 101, 2000 Edition
NFPA 110, 1999 Edition

Based on observation and staff interview it was determined the interior wall finish for rooms does not meet the minimum fire smoke rating as require. This condition could have a negative outcome for patient's staff and other occupants of the building in case of a fire.

The finding include:

In the Library located near the dining room area it was observed a hard wood material on the wall. This material covered the entire right side of the room. This condition was noted at 9:20 a.m., on 01/09/12.

The Chief Operating Officer and the Director of Maintenance were unable to produce any documents to indicate the fire/smoke rating for these materials noted above.

NFPA 101 Life Safety Code (2000) 18.3.3 & 19.3.3

(In fully sprinkled buildings, flame spread rating of Class A, Class B, or Class C may be continued in use within rooms separated in accordance with 19.3.6 from the access corridors).

Based on a review of the facility records, and interview with the staff on 01/10/12, it was determined that the facility failed to train all staff in disaster preparedness. A lack of these training exercises could in the event of an internal or external disaster cause confusion and/or panic from a lack of knowledge of staff and raise potential for negative outcomes to the patients and staff, and other building occupants.

The findings include:

During the interview on 1/9/12 with staff members it was revealed 3 of the 4 staff members interviewed were unable to open the double doors leading out of the 100 wing. The 100 wing is equipped with a magnetic lock device that can be released by entering a code on the key pad provided. When asked, 3 of the 4 staff members were unable to enter the proper code to release the magnetic lock. All three staff indicated the code had been changed and they were not informed of the new number. During staff interviews it was stated that these doors are shut during the evening hours.

NFPA 101 Life Safety Code (2000) 18.1.1.1.8, 19.1.1.1.8, & 18.7.1 & 19.7.1.

Based on observation with the director of maintenance, The Willough at Naples failed to provide a properly tested and maintained fire alarm system. The deficient practice would affect all smoke compartments, all patients and staff.

The findings include:

It was observed on 01/10/12 at 10:55 a.m., during the inspection and testing of the fire alarm system that consisted of multiple components, the automatic dialer component, when placed in trouble from phone line failure, did send a trouble signal to the main fire alarm control panel (FACP), which was located in the first floor. The main fire alarm control panel (FACP), remote zone indicator, located at the front door gave an audible trouble signal, when the (FACP) panel of the system was in trouble. Neither location is occupied around the clock (24 hours a day). The trouble signal could not be heard at the nurses' stations in the 100 or 200 wings.


NFPA 101, 2000 Edition
NFPA 72 section 1-5.4.6.
The trouble signal(s) shall be located in an area where it is likely to be heard.

Based on an observation, staff interview, and record review conducted during the survey on 01/09/12 it was determined the fire sprinkler system, including tamper switches, failed to be completely maintained. The record review indicated the last fire sprinkler system inspection and test was conducted on 09/30/11. This failure and lack of tamper switches could place the lives of the occupants in danger should a fire occur and the fire sprinkler system failed to respond.

The findings include:

During the tour of the facility with the director of maintenance at 10:35 a.m. on 1/9/12, it was noted the three outside stem and yoke (OSY) valves were not equipped with tamper switches. These valves are located near the front entrance driveway.


NFPA 101 (2000 edition) 9.7.2.1

The facility has requested a three month extension to correct this deficiency and the facility was e-mailed the wavier forms as requested.

Based on an observation, staff interview, and record review conducted during the survey on 01/09/12, it was determined the fire sprinkler system failed to be completely maintained. The record review indicated the last fire sprinkler system inspection and test was conducted on 09/30/11. This condition could place the lives of the occupants in danger should a fire occur and the fire sprinkler system failed to respond properly do to obstructions.

The findings include:

During the tour of the facility at 1:35 p.m., with the director of maintenance, it was observed in the storage room on the 200 wing that cardboard boxes were stored on the top shelve obstructing the spray pattern of the sprinkler head. This was confirmed by the director of maintenance at the exit conference.

NFPA 101 (2000 edition) 19.7.6, 4.6.12
NFPA 13
NFPA 25, 9.7.5

Based on a review of the facility records,observation and interview with the staff, it was determined that the facility failed to ensure that the Heating, Ventilating and Air Conditioning System (HVAC) was maintained in reliable operating condition.

The findings include:

Inspection of the main kitchen on 01/09/12 at 2:25 p.m. revealed that there was a notable negative pressure relationship between the kitchen and the dining room. opening only on door to the kitchen yielded enough pressure to defeat the hydraulic door closure and keep the door open with significant cubic feet of dining room air entering the kitchen. It was noted that the kitchen supply air was not operable and the exhaust and make up hood air was on. The kitchen air supply was shut down because it caused condensation on the A/C grilles. This condition was noted by the director of maintenance and kitchen manager.

NFPA 101, (2000) 9.2; 18.5.2, 19.5.2
NFPA 90A

The facility has requested a three month extension to correct this deficiency and the facility was e-mailed the wavier forms as requested.

Correction Date: 02/10/12

Based on observation on 01/09/12, with the director of maintenance and manager of the kitchen, the use of the commercial cooking equipment was not in accordance with NFPA 96. If the fixed suppression system equipment is not maintained as required, there is a potential for an increased fire hazard.

The findings include:

Based on observation during the tour in the kitchen at 2:25 p.m., it was determined the commercial kitchen equipment was not properly positioned under the hood system. It was observed that the deep fat fryer was not being fully protected by the suppression system. The kitchen staff stated there was a double fryer in that place originally and it had been replaced with a single fryer. This condition created a situation in which the fixed suppression could be ineffective, due to improper position of the suppression nozzle,(s) for this piece of equipment.


NFPA 101 (2000) 9.2.3. 19.3.2.6,
NFPA 96

Based on an observation during the tour of the facility with the director of maintenance, laundry equipment (domestic clothes dryer) had not maintain on all the components. This condition could allow the propagation of a dryer lint fire, endangering building occupants.

The findings include:

While on tour 01/09/12 and 01/10/12 the clothes dryers located in the laundry room were observed to not have a vent pipe connected to the outside atmosphere. It was observed that a large amount of lint was on the floor and on the wall behind the dryers. Inside this room the temperature was noticeable higher than in other spaces in the facility.


Reference: NFPA 211 "Standard for Chimneys, Fireplaces, Vents, and Solid Fuel-Burning Appliances" (2000 Edition)

7-7.3.7 "Exhaust ducts for Type 2 clothes dryers shall be constructed of sheet metal or other noncombustible material. Such ducts shall be of adequate strength to meet the conditions of service with a minimum thickness equivalent to No. 24 galvanized steel gauge [0.024 in. (0.61 mm)]."

Based on testing of the generator with the facility staff on 01/10/12, it was determined the Willough at Naples, emergency back-up generator failed to function properly in accordance with NFPA 110, the standard for testing Emergency Back-up Generator Systems (2005 edition). A lack of required testing renders the equipment unreliable in this facility which requires secondary or back-up power.

The findings include:

At 1:45 p.m.on 1/10/12 with the director of maintenance, it was observed when the generator started that ATS-NE (automatic transfer switch) failed to transfer power to the facility. The director of maintenance called the generator vendor and stated that something was wrong with the transfer switch. The generator vendor was scheduled to investigate the problem.


NFPA 101, 2000 Edition
NFPA 110, 1999 Edition