HospitalInspections.org

Based on observations, the facility failed to maintain proper doors which protect the corridor. Doors within a corridor that do not meet the minimum qualifications may allow the passage of heat, smoke, fire, or toxic gases into the corridor. The corridor must be maintained as a safe pathway for egress in an emergency situation. A hazard which starts or travels into the exit access can seriously affect everyone in the facility and their ability to exit in an emergency situation.

The findings include:
During the facility tour with the Director of Maintenance on 10/21/2014 at 2:15 PM, it was found that the Mechanical closet (Information Technology /Data room) which open directly to the corridor were equipped with a door with vent grills. This would not meet the minimum requirements for a corridor door (must resist the passage of smoke in sprinklered buildings). NFPA 101 19.3.6

Based on observations, the facility failed to maintain safe and reliable exit egress. All exit doors must be maintained in proper operational condition. Reliable egress is essential to the safety of all persons within the facility in an emergency situation.

The findings include:
During the facility tour with the Director of Maintenance at 2:30 am on 10/21/2014, it was found that the entrance/exit horizontal sliding doors were not being maintained. The doors that were not operational were at: 1) Main entrance, 2) Eemergency Room lobby entrance, 3) Ambulance entrance. These doors required an excessive amount of force to operate the break-away feature. Horizontal sliding doors must break away with 15lbf per NFPA 101 7.2

Based on document review, the facility failed to maintain proper testing and proper documentation for the emergency lighting. Testing of the emergency light helps to ensure emergency lighting in emergency conditions. Failure of emergency lighting may endanger all of the occupants within the facility.

The findings include:
During the document review with the Maintenance Director on 10/21/2014 at 11:30 am, it was found that testing of the emergency lights were not being performed or documented. Emergency lights must be tested for 30 sec. monthly and 90 min. annually. Documentation of the tests must be maintained. NFPA 101- 7.9 and 19.2.9.1

Based on document review, the facility failed to conduct and document the required annual Internal/External disaster drills. These drills increase the knowledge of staff of the action to take in an emergency situation.

The findings include:
During the document review with the director of maintenance on 10`/21/2014, it was found that the annual Internal drill had not been done. "Each organizational entity shall implement two or more ((1)Internal & (1)External 4-7 months apart) specific responses of the emergency operations plan during each year". NFPA 99 Chapter 12 & 17.3.12

During document review with the Director of Maintenance at 11:45am on 10/21/2014, it was found that the inspection and testing of the fire alarm system had not been performed as per NFPA 70 and NFPA 72. The inspection and testing are required on an annual basis.

During document review with the Director of Maintenance at 11:45am on 10/21/2014, it was found that the documentation for inspection and testing for smoke detector sensitivity was missing. This is not in accordance with NFPA 101 9.6.1.5 and NFPA 72, 7.3.2.1.

NFPA 72, 7-3.2.1* Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer ' s calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the
detector causes a signal at the control unit where its sensitivity
is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the
authority having jurisdiction

Based on document review, the facility failed to maintain proper inspection and testing of the Sprinkler system. Timely maintenance and inspection of the sprinkler system helps to ensure proper function of the system in time of emergency. Sprinkler malfunction could affect all persons within the facility.

The findings include:
During document review with the Director of Maintenance at 11:15 am on 10/21/2014, it was found that facility did not have documentation (inspection report or inspection tag by contractor on the standpipe) of the 4th quarter (2013). NFPA 101, 18.3.5 and 19.3.5, NFPA 25

During document review with the Director of Maintenance at 11:25 am on 10/21/2014, it was found that facility did not have documentation of the 5-year internal obstruction inspection of the sprinkler system. According to NFPA 25 13.2.3.2, internal inspections shall be accomplished by examining the interior of the following points: 1- System valve. 2- Riser. 3- Cross Main. 4- Branch line.


During document review with the Director of Maintenance at 11:28 am on 10/21/2014, it was found that facility did not have documentation of the testing of the private fire hydrants on the property and their flow test.

Based on record review and interview of the Director of Maintenance, the facility failed to maintain the Fire/Smoke dampers within the HVAC system and the supporting documentation. Fire/Smoke dampers help to prevent the spread of fire and smoke from room to room by sealing the HVAC ducts in emergency situations. The dampers must be serviced to maintain proper operation.

The Findings:
During document review with maintenance staff at 10:10 am on 10/21/2014, it was found that documentation of maintenance and testing of the fire/smoke dampers were not present. It was confirmed by maintenance staff that damper inspection and maintenance had not been done in accordance with NFPA 101, 8.3.6. Fusible linked dampers must be lubricated, exercised, and links checked every 6 years.

Based on observations during facility tour, the facility failed to properly store flammables. Flammables not stored correctly can increase the chance of a hazardous situation and severely increase fire spread and heat release of the fire.

The findings include:
During facility tour with the Director of maintenance on 10/21/2014 at 3:30 PM, it was found that the flammables (Alchohol hand sanitizers) in housekeeping (over 5 gallons)were not contained in a flammable cabinet. Flammable and Combustible Liquids Code, NFPA 99. 4.3, 10.7.2.1. NFPA 30, NFPA 101, 19.3.2

Based on observations, the facility failed to provide safe utilization of Alchohol Based Hand Rub Sanitizers (AHBR). AHBR's are highly flammable (65% - 90% alchohol) and must be kept from electrical hazards (ignition source) and in a safe conditions. AHBRs not adhearing to safety regulations, increase the chance of fire or an other emergency situation which could affect all persons within the facility.

Findings include:

During the facility tour with the Director of Maintenance at 1:45 PM on 10/21/2014, it was found that the AHBRs throughout the 100 hall patient rooms were placed directly over electrical outlets (in room and bathrooms). AHBRs must be 1 inch from electrical sources (sides and top) with no limit on distance for electrical sources underneath. NFPA 19.3.2.6

Based on observations, the facility failed to maintain proper doors which protect the corridor. Doors within a corridor that do not meet the minimum qualifications may allow the passage of heat, smoke, fire, or toxic gases into the corridor. The corridor must be maintained as a safe pathway for egress in an emergency situation. A hazard which starts or travels into the exit access can seriously affect everyone in the facility and their ability to exit in an emergency situation.

The findings include:
During the facility tour with the Director of Maintenance on 10/21/2014 at 2:15 PM, it was found that the Mechanical closet (Information Technology /Data room) which open directly to the corridor were equipped with a door with vent grills. This would not meet the minimum requirements for a corridor door (must resist the passage of smoke in sprinklered buildings). NFPA 101 19.3.6

Based on observations, the facility failed to maintain safe and reliable exit egress. All exit doors must be maintained in proper operational condition. Reliable egress is essential to the safety of all persons within the facility in an emergency situation.

The findings include:
During the facility tour with the Director of Maintenance at 2:30 am on 10/21/2014, it was found that the entrance/exit horizontal sliding doors were not being maintained. The doors that were not operational were at: 1) Main entrance, 2) Eemergency Room lobby entrance, 3) Ambulance entrance. These doors required an excessive amount of force to operate the break-away feature. Horizontal sliding doors must break away with 15lbf per NFPA 101 7.2

Based on document review, the facility failed to maintain proper testing and proper documentation for the emergency lighting. Testing of the emergency light helps to ensure emergency lighting in emergency conditions. Failure of emergency lighting may endanger all of the occupants within the facility.

The findings include:
During the document review with the Maintenance Director on 10/21/2014 at 11:30 am, it was found that testing of the emergency lights were not being performed or documented. Emergency lights must be tested for 30 sec. monthly and 90 min. annually. Documentation of the tests must be maintained. NFPA 101- 7.9 and 19.2.9.1

Based on document review, the facility failed to conduct and document the required annual Internal/External disaster drills. These drills increase the knowledge of staff of the action to take in an emergency situation.

The findings include:
During the document review with the director of maintenance on 10`/21/2014, it was found that the annual Internal drill had not been done. "Each organizational entity shall implement two or more ((1)Internal & (1)External 4-7 months apart) specific responses of the emergency operations plan during each year". NFPA 99 Chapter 12 & 17.3.12

During document review with the Director of Maintenance at 11:45am on 10/21/2014, it was found that the inspection and testing of the fire alarm system had not been performed as per NFPA 70 and NFPA 72. The inspection and testing are required on an annual basis.

During document review with the Director of Maintenance at 11:45am on 10/21/2014, it was found that the documentation for inspection and testing for smoke detector sensitivity was missing. This is not in accordance with NFPA 101 9.6.1.5 and NFPA 72, 7.3.2.1.

NFPA 72, 7-3.2.1* Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer ' s calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the
detector causes a signal at the control unit where its sensitivity
is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the
authority having jurisdiction

Based on document review, the facility failed to maintain proper inspection and testing of the Sprinkler system. Timely maintenance and inspection of the sprinkler system helps to ensure proper function of the system in time of emergency. Sprinkler malfunction could affect all persons within the facility.

The findings include:
During document review with the Director of Maintenance at 11:15 am on 10/21/2014, it was found that facility did not have documentation (inspection report or inspection tag by contractor on the standpipe) of the 4th quarter (2013). NFPA 101, 18.3.5 and 19.3.5, NFPA 25

During document review with the Director of Maintenance at 11:25 am on 10/21/2014, it was found that facility did not have documentation of the 5-year internal obstruction inspection of the sprinkler system. According to NFPA 25 13.2.3.2, internal inspections shall be accomplished by examining the interior of the following points: 1- System valve. 2- Riser. 3- Cross Main. 4- Branch line.


During document review with the Director of Maintenance at 11:28 am on 10/21/2014, it was found that facility did not have documentation of the testing of the private fire hydrants on the property and their flow test.

Based on record review and interview of the Director of Maintenance, the facility failed to maintain the Fire/Smoke dampers within the HVAC system and the supporting documentation. Fire/Smoke dampers help to prevent the spread of fire and smoke from room to room by sealing the HVAC ducts in emergency situations. The dampers must be serviced to maintain proper operation.

The Findings:
During document review with maintenance staff at 10:10 am on 10/21/2014, it was found that documentation of maintenance and testing of the fire/smoke dampers were not present. It was confirmed by maintenance staff that damper inspection and maintenance had not been done in accordance with NFPA 101, 8.3.6. Fusible linked dampers must be lubricated, exercised, and links checked every 6 years.

Based on observations during facility tour, the facility failed to properly store flammables. Flammables not stored correctly can increase the chance of a hazardous situation and severely increase fire spread and heat release of the fire.

The findings include:
During facility tour with the Director of maintenance on 10/21/2014 at 3:30 PM, it was found that the flammables (Alchohol hand sanitizers) in housekeeping (over 5 gallons)were not contained in a flammable cabinet. Flammable and Combustible Liquids Code, NFPA 99. 4.3, 10.7.2.1. NFPA 30, NFPA 101, 19.3.2