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Based on observation, it was determined that the facility had not ensured that for two of seven hazardous areas sampled, the self-closing doors of the two rooms were not maintained as required. The census was 23 on the day of the survey. The findings include:

Observation on January 5, 2010 at 1:40 p.m. disclosed that doors had been propped open or disassembled. The door of Mechanical Room #1 had been propped open by carpet installers. The room contained six gas-fired boilers and fuel-fired heaters; the door was observed to be propped open by the installers during observations for two subsequent days.

In addition, the self-closure arm installed on the door of the "Purchasing" central supply department that is used to swing the door shut and latch had been disconnected by construction workers. Within the central supply rooms were typical fuel loads for a hazardous area and by calculation, approximately 13.6 gallons of alcohol based handrub bottled solutions.

Lack of closed doors potentially allows hot gases and smoke to penetrate throughout the smoke compartment in the event of a fire emergency. The observations were observed mutually by Maintenance Director #1 and surveyor.

Actual NFPA 101 reference:

18.3.2.1* Hazardous Areas.
Any hazardous area shall be protected in accordance with Section 8.4. The areas described in Table 18.3.2.1 shall be protected as indicated.
3.3.13.2 Area, Hazardous.
An area of a structure or building that poses a degree of hazard greater than that normal to the general occupancy of the building or structure, such as areas used for the storage or use of combustibles or flammables; toxic, noxious, or corrosive materials; or heat-producing appliances.

Based on observation, it was determined that the facility had not ensured a complete and clear path through corridors serving as exit access for three of eight corridors and one of two stairwells sampled. The census was 23 on the day of the survey. The findings include:

Observation during tour of the building from January 5, 2010 at 11:12 a.m. and January 6, 2010 at 9:44 a.m. disclosed the following obstructions in corridors and one stairwell: 1) the back exit corridor leading from the "Paragon" dining room to the back exit was blocked by a table and four chairs; 2) the corridor leading from the O.R. suite to the exit access corridor was blocked at the doorway area by a shredder, refuse container, and 55 gallon Western Recycling Bin and was being used as a gown up area with bookshelves hung in the corridor access (projections under 6 ft 8 inches in corridor); 3) the "breakdown corridor" which is the back exit access for the Central Supply/Clean Sterile area was reduced to a corridor width varying from 31 inches to 38 inches. Corridor width was not maintained at a minimum of 44 inches. In addition, the stairwell landing within the Stairwell B was observed to have a wooden door used during construction that was stored on the landing. The restricted area at the top landing would potentially interfere with use of the "Stair Chair" or any other number of residents or staff using the stairwell in an emergency. The observations were jointly observed by the surveyor and Maintenance Director #1.

Actual NFPA 101 reference:
7.1.5* Headroom.
Means of egress shall be designed and maintained to provide headroom as provided in other sections of this Code and shall be not less than 7 ft 6 in. (2.3 m) with projections from the ceiling not less than 6 ft 8 in. (2 m) nominal height above the finished floor. The minimum ceiling height shall be maintained for not less than two-thirds of the ceiling area of any room or space, provided the ceiling height of remaining ceiling area is not less than 6 ft 8 in. (2 m). Headroom on stairs shall be not less than 6 ft 8 in. (2 m) and shall be measured vertically above a plane parallel to and tangent with the most forward projection of the stair tread.
18.2.3.3*
Aisles, corridors, and ramps required for exit access in a hospital or nursing home shall be not less than 8 ft (2.4 m) in clear and unobstructed width. Where ramps are used as exits, see 18.2.2.6.
Exception No. 1*: Aisles, corridors, and ramps in adjunct areas not intended for the housing, treatment, or use of inpatients shall be not less than 44 in. (112 cm) in clear and unobstructed width.

Based on record review and staff interview, it was determined that the facility had not ensured that monthly testing was occurring in new operating rooms placed in service equipped with emergency lighting. The findings include:

Record review on January 5, 2009 at 10:09 a.m. disclosed that there was no record of monthly testing of battery packs in emergency lighting located in the operating rooms. Staff interview on January 5, 2009 at 10:10 a.m. disclosed that new battery operated emergency lights had been placed in the operating rooms for additional emergency lighting. Staff stated that monthly logs were not available for review to show that monthly testing was being conducted to determine fully operational lighting.

Actual NFPA 101 reference:

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 1-1/2 hours. Equipment shall be fully operational 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, it was determined that the facility had not ensured that all smoke detectors had received necessary maintenance to assure adequate sensitivity. The census was 23 on the day of the survey. The findings include:

Record review on January 5, 2010 at 9:45 a.m. disclosed that the facility records did not show that sensitivity testing of smoke detectors had been conducted throughout the building for new installations.

The facility was unable to provide documentation of any current or complete sensitivity testing of smoke detectors. There was no written record of test cycles by the fire alarm contractor; no documentation or reports of status of the system detectors was available for review when, during staff interview, Maintenance Director #1 was asked about test results on the system and questioned about the status of the reports. Also, a list of "false alarms" and alarm activations was presented during the record review which disclosed many false alarm episodes during the first half of 2009 caused by construction, paint or dust. The increase of false alarms may indicate that the smoke detectors would decrease in sensitivity over time.

The maintenance director stated that the information available to him to check on condition of the fire alarm control panel was real time only and that only current condition was able to be displayed. The conditions displayed did not and could not include a report on sensitivity testing for each smoke detector according to the director.
The finding was acknowledged and verified by the Maintenance Director.
Actual NFPA standard: NFPA 72, section 7-3.2.1
Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.

Based on observation, it was determined that the facility had not ensured the campus wide no-smoking policy would preclude individuals, waiting at the landing pad of the landing zone for helicopters, from knowing what the smoking policy was on campus (or at the helicopter pad itself). The findings include:

Observation on January 5, 2010 at 1:25 p.m. disclosed that "No Smoking" signs were not posted at the perimeter of the landing pad/zone used by the facility for patient emergency evacuation/reception by helicopter. No Smoking signs were not posted at the access and egress points of the helipad.

Actual NFPA 418 reference:

2.5 No Smoking.
No smoking shall be permitted within 50 ft (15.2 m) of the landing pad edge. No smoking signs shall be erected at access/egress points to the heliport.

Based on observation, it was determined that the facility had not ensured alcohol based hand rub dispensers were installed according to NFPA and CMS requirements. The census on the day of the survey was 23. The findings include:

Observation on January 5, 2010 disclosed that two separate dispensers for alcohol based hand sanitizers were installed above two outlets in the Emergency Department. The dispensers were located above an ignition source. An additional dispenser was installed adjacent to an ignition source in the main lobby area adjacent to the Emergency Department and close to where the old time clock had been installed.

NFPA TIA (Tentative Interim Amendment 03-06):

NFPA 101-2003
Life Safety Code?
TIA Log No. 769
Reference: Chapter 18 and 19
Comment Closing Date: December 10, 2003
Submitter: Dale Woodin, American Society for Healthcare Engineering
1. Add a new 18.1.1.5 and 19.1.1.5 and renumber other sections accordingly.
18.1.1.5 (19.1.1.5) Alcohol-Based Hand-Rub Solutions. It shall be recognized that certain clinical hand hygiene needs of health care staff and visitors require alcohol-based hand-rub solutions (Class 1B flammable liquid) to be installed in egress corridors, in rooms, and in suites of rooms. In such instances, the authority having jurisdiction shall make appropriate modi?fications to those sections of the Code to permit the installation and maximum in-use quantities of alcohol-based hand-rub products.

18.1.1.5.3 (19.1.1.5.3) The dispensers shall not be installed over or directly adjacent to an ignition source.