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Based on observation and interviews with staff, it was determined that the facility failed to provide a safe means of egress out of the emergency exit doors. Failure to provide a clear and unimpeded means of egress could cause harm to the patients and staff in a fire emergency.

NFPA 101, Life Safety Code, 2012, Chapter 19, Section 19.2.1 "Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7. Section 7.1.10.1 " Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergencies." Section 7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits or their access thereto egress therefrom, or visibility thereof."

During a facility tour conducted on February 1-2, 2022, the facility had construction ongoing in the portions of the hospital that blocked exits and exit pathways without notification of the authority having jurisdiction or taking any compensatory measures. The areas of concern involved asbestos removable areas.

Employees #2 and #7 acknowledged during the exit conference that the emergency exit doors and pathways were blocked by construction materials.

Based on observation the facility failed to maintain the one-hour fire-rated door. Failing to maintain fire barriers could allow a fire to spread more rapidly through the two-hour fire barrier and give residents less time to evacuate the building.

NFPA101: Life Safety Code, 2012 Edition - Chapter 8 Features of Fire Protection 8.3 Fire Barriers.
8.3.1 General. 8.3.1.1
Fire barriers used to provide enclosure, subdivision, or protection under this Code shall be classified in accordance with one of the following fire-resistance ratings: 3-hour fire-resistance rating, 2-hour fire-resistance rating, 1-hour fire-resistance rating, or 1/ 2-hour fire-resistance rating. 8.3.1.2 * Fire barriers shall comply with one of the following:
(1) The fire barriers are continuous from outside wall to an outside wall or from one fire barrier to another, or a combination thereof, including continuity through all concealed spaces, such as those found above a ceiling, including interstitial spaces.
(2) The fire barriers are continuous from outside wall to an outside wall or from one fire barrier to another, and from the floor to the bottom of the interstitial space, provided that the construction assembly forming the bottom of the interstitial space has a fire-resistance rating not less than that of the fire barrier. 8.3.1.3 Walls used as fire barriers shall comply with Chapter 7 of NFPA 221, Standard for High Challenge Fire Walls, Fire Walls, and Fire Barrier Walls. The NFPA 221 limitation on the percentage width of openings shall not apply.
8.3.3.3 Unless otherwise specified, fire doors shall be self-closing or automatic-closing in accordance with 7.2.1.8.


Findings include:

Observations while on tour February 1-2, 2022 revealed the fire door in the firewall located in the middle of the pharmacy does not include a self-closed door. The door was in the open position when discovered during the survey.


Employees #2 and #7 confirmed the fire door in the pharmacy was missing the self-closure device as required in the firewall it was installed in.

Based on observation, interview, and record review it was determined the facility failed to inspect and maintain the facility's fire /smoke dampers or fusible links. Failing to inspect and maintain the facility's smoke dampers may cause harm to the patients and staff.

NFPA 101 Life Safety Code, 2012 Edition Chapter 19, Section 19.5.2, "Heating Ventilating and Air Conditioning." Section 19.5.2.1 "Heating, ventilating and air conditioning shall comply with the provisions of section 9.2 and shall be installed in accordance with the manufacture's specifications" Section 9.2.1 " Air Conditioning, Heating, Ventilating, Ductwork, and Related Equipment." Air conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90 A." "Standard for Installation of Air Conditioning and Ventilating Systems, NFPA 105 Standard for Smoke Door Assemblies and Other Opening Protective's.

NFPA 90 A 2012 Edition Section 5.4.8 Maintenance Section 5.4.8.1 Fire dampers and ceiling dampers shall be maintained in accordance with NFPA 80 Standard for Fire Doors and Other Opening Protectives. Section 5.4.8.2 Smoke dampers shall be maintained in accordance with NFPA 105 Standard for Smoke Door Assemblies and Other Opening Protective's.

NFPA 80 Standard for Fire Doors and Other Opening Protective's Chapter 19 Installation, Testing, and Maintenance of Fire Dampers, Section 19.4* Periodic Inspection and Testing. The test and inspection frequency shall be every 4 years, except in hospitals, where the frequency shall be every six years.

Section 19.4.4 if the damper is equipped with a fusible link, the link shall be removed for testing to ensure full closure and lock-in place if so equipped. Section 19.4.5 The operational test of the fire damper shall verify that there is no damper interference due to rusted, bent, misaligned, or damaged frame or blades, or defective hinges or other moving parts. Section 19.4.6 The damper frame shall not b penetrated by any foreign objects that would affect fire damper operations. Section 19.4.7 The fusible link shall be reinstalled after testing is complete. Section 19.4.8.1 if the link is damaged or painted, it shall be replaced with a link of the same size, temperature, and rating. Section 19.4.9 All inspections and testing shall be documented, indicating the location of the fire damper or combination fire/smoke damper, date of inspection, name of the inspector, and deficiencies discovered. Section 19.4.9.1 The documentation shall have a space to indicate when and how the deficiencies were corrected. Section 19.4.11 Periodic inspections and testing of a combination fire/smoke damper shall also meet the inspection and testing requirements contained in Chapter 6 of NFPA 105 Standard for Smoke Door Assemblies and Other Opening Protective's.

NFPA 105 Standard for Smoke Door Assemblies and Other Opening Protective's Chapter 6 Installation, Testing, and Maintenance smoke dampers. Section 6.5.2 Each damper shall be tested and inspected one year after installation. The test and inspection frequency shall then be every 4 years, except for hospitals, where the frequency shall be every 6 years.

Section 6.5 Periodic Inspection and Testing. Section 6.5.11 All inspections and testing shall be documented, indicating the location of the fire damper or combination fire/smoke damper, date of inspection, name of the inspector, and deficiencies discovered. Section 19.4.9.1 The documentation shall have a space to indicate when and how the deficiencies were corrected. Section 6.5.11

Section 6.6 Maintenance.

Section 6.6.1 Any reports of abrupt changes in airflow or noise from the duct system shall be investigated to verify that it is not related to damper operation. Section 6.6.2* All exposed moving parts of the damper shall be dry lubricated as required by the manufacturer. Section 6.6.3 if the damper is not operable, repairs shall begin as soon a s possible. Section 6.6.4 Following any repairs, the damper shall be tested for proper operation in accordance with Section 6.6.5 Smoke damper actuation shall be initiated at a time interval recommended by the actuator manufacturer. Section 6.6.6 All maintenance shall be maintained and records shall be retained in accordance with 6.5.11 and 6.5.12.

Findings Include:

The review of the facility documentation conducted on February 1-2, 2022 revealed the facility had fire or smoke dampers, they were not aware that the building fire or smoke dampers were not completed. No documentation was found indicating that the smoke dampers were maintained in the past six years.

Employees #2 and #7 confirmed during the exit conference that the facility failed to test the HVAC dampers every six years.

Based on observation the facility failed to prohibit combustible curtains from being used in the facilities. Failing to limit combustible decorations in a smoke compartment could cause harm to residents and/or staff by allowing a fire to spread.

NFPA 101, Life Safety Code, 2012. Chapter 19, Section 19.7.5.6, states 2, "Combustible decorations shall be prohibited in any health care occupancy unless one of the following criteria is met: (1) They are flame-retardant or are treated with approved fire-retardant coating that is listed and labeled for application to the material to which it is applied.
(4) The decorations, such as photographs, paintings, and other art work, are attached directly to the walls, ceiling, and non-fire rated doors in accordance with the following: (c) Decorations do not exceed 30 percent of the wall, ceiling and door areas inside any room or space of a smoke compartment that is protected throughout by an approved supervised automatic sprinkler system in accordance with Section 9.7."

Findings include:

Observations made while on tour on February 1-2, 2022, revealed the facility was utilizing had non-fire rated (NFPA 701) curtains in the facility. Items were hanging in the following areas
1. The curtains in the blood draw area of the laboratory.
2. The storage area of the X-ray area near the Breakroom
3. All the restroom showers

Employees #2 and #7 confirmed during the exit conference on February 2, 2022, the shower curtains and blood draw area curtains were not NFPA 701 compliant.

Based on record review and interview it was determined that the facility failed to document humidity testing for the hospital operating rooms. Failing to document humidity testing in all operating rooms could result in harm to the patients.

NFPA 99: Health Care Facilities Code, 2012 Edition - Chapter 9 Heating, Ventilation, and Air conditioning (HVAC) 9.3.1 Heating, Cooling, Ventilating, and Process Systems. 9.3.1.1 Heating, cooling, ventilating, and process systems serving spaces or providing health care functions covered by this code or listed within ASHRAE 170, Ventilation of Health Care Facilities, shall be provided in accordance with ASHRAE 170.
ASHRAE 170 Addendum r to ANSI/ASHRAE/ASHE Standard 170-2008
6.6 Humidifiers. When outdoor humidity and internal moisture sources are not sufficient to meet the requirements of Table 7-1, humidification shall be provided by means of the healthcare facility air-handling systems. Locate humidifiers within air-handling units or ductwork to avoid moisture accumulation in downstream components, including filters and insulation. Chemical additives used for steam humidifiers serving health care facilities shall comply with FDA requirements.1 Reservoir-type water humidifiers or evaporative-pan type humidifiers shall not be used in ductwork or air-handling units in health care facilities. A humidity sensor shall be provided, located at a suitable distance downstream from the steam injection source. Controls shall be provided to limit duct humidity to a maximum value of 90% RH when the humidifier is operating. Humidifier steam control valves shall be designed so that they remain OFF whenever the air-handling unit is not in operation. Duct takeoffs shall not be located within the humidifier's absorption distance.
Centers for Disease Control (CDC) Infection Control states
" The sterile storage area should be a limited access area with a controlled temperature (may be as high as 75°F) and relative humidity (30-60% in all works areas except sterile storage, where the relative humidity should not exceed 70%). "
S&C: 15-27-Hospital, CAH & ASC Potential Adverse Impact of Lower Relative Humidity (RH) in Operating Rooms (ORs) Regulations governing hospitals and CAHs require compliance with the 2000 Edition of the National Fire Protection Association (NFPA) 101: LSC, including the mandatory references of the LSC, such as the 1999 Edition of NFPA 99: Health Care Facilities. The NFPA 99 requires that mechanical ventilation systems supplying hospital anesthetizing locations, as defined by NFPA 99, have the capability of controlling RH at a level of 35 % or greater.
Findings Include:

During the review of the facility's documentation conducted on February 1-2, 2022 it was revealed the facility was not reviewing or recording humility displays for the operating rooms. No one was reading/assessing or recording these readings. There were no daily logs to review.

During the exit conference employees #2, and #7, confirmed that the relative humility testing in the operating rooms was not being conducted or recorded.

Based on Observation it was determined the facility allowed the use of power strips and did not use the wall outlet receptacles for appliances. Failure to properly use power cords and outlets could lead to electrical overload or fire which could cause harm to the patients and staff.

NFPA 101, Life Safety Code, 2012. Chapter 2, Section 2.1 The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities, " 2012 Edition. NFPA 99, Chapter 6, Section 6.3.2.2.6.2 , "All Patient Care Areas," Sections 6.3.2.2..6.2 (A) through 6.3.2.2.6.2 (E) Receptacles (2)" Minimum Number of Receptacles." "The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

NFPA 1 The Code. 11.1.5.2 Multiplug adapters shall not be used as a substitute for permanent wiring or receptacles.

Findings include:

Observations while on tour February 1-2, 2022, revealed the following locations with power strips plugged being used to carry heavy load drawing appliances (refrigerators, microwaves, and large printers).
All bedrooms in the facility had refrigerators, microwaves, or coffee pots plugged into power strips.

During the exit conference conducted on February 1-2, 2022, Employees # 2 and #7 confirmed the improper use of power strips.