HospitalInspections.org

Based on document review and interview, the facility failed to produce a complete fire watch policy for the fire alarm system to include notifications to all authorities having jurisdiction (AHJs).

Findings include:

On 09/09/20, the facility's Interim Life Safety Measures (ILSM) for Construction and Maintenance Projects policy, dated 05/30/19, failed to include the requirement to notify the Bureau of Health Care Quality and Compliance (HCQC) as an AHJ.

On 09/09/20, the CEO/Administrator confirmed the facility's ILSM for Construction and Maintenance Projects policy failed to document the requirement to notify to all AHJs in the fire watch policy.

Ref: NFPA 13
National Fire Protection Association (NFPA) 13, Standard for the Installation of Sprinkler Systems, 2010 Edition

6.2.7 Escutcheons and Cover Plates.
6.2.7.1 Plates, escutcheons, or other devices used to cover the annular space around a sprinkler shall be metallic or shall be listed for use around a sprinkler.
6.2.7.2* Escutcheons used with recessed, flush-type, or concealed sprinklers shall be part of a listed sprinkler assembly.
6.2.7.3 Cover plates used with concealed sprinklers shall be part of the listed sprinkler assembly.
6.2.8 Guards. Sprinklers subject to mechanical injury shall be protected with listed guards.

6.2.9.7 A list of the sprinklers installed in the property shall be posted in the sprinkler cabinet.
6.2.9.7.1* The list shall include the following:
(1) Sprinkler Identification Number (SIN) if equipped; or the manufacturer, model, orifice, deflector type, thermal sensitivity, and pressure rating
(2) General description
(3) Quantity of each type to be contained in the cabinet
(4) Issue or revision date of the list

8.6.4.1.1.1 Under unobstructed construction, the distance between the sprinkler deflector and the ceiling shall be a minimum of 1 in. (25.4 mm) and a maximum of 12 in. (305 mm) throughout the area of coverage of the sprinkler.

24.4 Instructions
The installing contractor shall provide the property owner or the property owner's authorized representative with the following:
(1) All literature and instructions provided by the manufacturer describing proper operation and maintenance of any equipment and devices installed
(2) NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition

5.2.1.1.1* Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall).
5.2.1.1.2 Any sprinkler that shows signs of any of the following shall be replaced:
(1) Leakage
(2) Corrosion
(3) Physical damage
(4) Loss of fluid in the glass bulb heat responsive element
(5)* Loading
5.2.1.1.3* Any sprinkler that has been installed in the incorrect orientation shall be replaced.
5.2.1.1.4 Any sprinkler shall be replaced that has signs of leakage; is painted, other than by the sprinkler manufacturer, corroded, damaged, or loaded; or is in the improper orientation.
5.2.1.1.5 Glass bulb sprinklers shall be replaced if the bulbs have emptied.

Based on observation, interview and document review, the facility failed to maintain the automatic fire sprinkler system as required.

Findings include:

1) On 09/09/20 and 09/10/20, the following sprinkler heads were identified to be loaded with foreign material, paint and/or had physical damage:

- Paint overspray on the arms of a sprinkler in Rehab
- Paint overspray on entire sprinkler in Rehab
- A sprinkler in the Surgery admitting nursing station was loaded with dust.
- A sprinkler with fuzz on the arms and frangible bulb in the Med-Surg and ICU Manager's office.
- A sprinkler with fuzz on the arms and frangible bulb Over Bed 1 and Bed 2 in Room 203.
- A sprinkler with a missing deflector tooth outside Clean Storage in the Med Surg hallway.
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2) On 09/09/20 and 09/10/20, the following sprinkler escutcheon issues were identified:

- A sprinkler with a gap between the ceiling and escutcheon in the Surgery hallway.
- A sprinkler with a missing escutcheon in the hallway outside EKG/Stress.
- A sprinkler with a gap between the ceiling and escutcheon in the Surgery break room.
- A sprinkler with a gap between the ceiling and escutcheon in the supply room.
- A sprinkler with a gap between the ceiling and escutcheon in the Med Staff Manager's office.
- A sprinkler with a missing escutcheon in the hallway outside EKG/Stress.
- A sprinkler with a gap between the ceiling and escutcheon in the Clean Utility Room.

3) On 09/09/20, the following sprinkler deflector was less than the required one inch:

- A sprinkler's deflector, in the Radiology hallway, measured 1/16 of an inch from the ceiling.

4) The facility's fire sprinkler riser room revealed the fire sprinkler spare boxes did not have a list of sprinklers installed within the building along with a listing of the quantity of each type of sprinkler to be contained in the spare cabinet.

5) The facility did not have a copy of NFPA 25 on site.

On 09/09/20 - 09/10/20, The Safety, Security and Emergency Preparedness Manager confirmed the findings at the time of discovery.

Based on document review and interview, the facility failed to produce a complete fire watch policy for the automatic sprinkler system to include notifications to all authorities having jurisdiction (AHJs).

Findings include:

On 09/09/20, the facility's Interim Life Safety Measures (ILSM) for Construction and Maintenance Projects policy, dated 05/30/19, failed to include the requirement to notify the Bureau of Health Care Quality and Compliance (HCQC) as an AHJ.

On 09/09/20, the CEO/Administrator confirmed the facility's ILSM for Construction and Maintenance Projects policy failed to document the requirement to notify to all AHJs in the fire watch policy.

National Fire Protection Association (NFPA) 10, Standard for Portable Fire Extinguishers, 2010 Edition.

6.1.3 Placement.
6.1.3.1 Fire extinguishers shall be conspicuously located where they are readily accessible and immediately available in the event of fire.
6.1.3.2 Fire extinguishers shall be located along normal paths of travel, including exits from areas.

6.1.3.3 Visual Obstructions.
6.1.3.3.1 Fire extinguishers shall not be obstructed or obscured from view.
6.1.3.3.2* In large rooms and in certain locations where visual obstructions cannot be completely avoided, means shall be provided to indicate the extinguisher location.
6.1.3.4* Portable fire extinguishers other than wheeled extinguishers shall be installed using any of the following means:
(1) Securely on a hanger intended for the extinguisher
(2) In the bracket supplied by the extinguisher manufacturer
(3) In a listed bracket approved for such purpose
(4) In cabinets or wall recesses

6.1.3.8 Installation Height.
6.1.3.8.1 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor.
6.1.3.8.2 Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be installed so that the top of the fire extinguisher is not more than 31.2 ft
(1.07 m) above the floor.
6.1.3.8.3 In no case shall the clearance between the bottom of the portable fire extinguisher and the floor be less than 4 in. (102 mm).

7.2 Inspection.
7.2.1 Frequency.
7.2.1.1* Fire extinguishers shall be manually inspected when initially placed in service.
7.2.1.2* Fire extinguishers shall be inspected either manually or by means of an electronic monitoring device/system at a minimum of 30-day intervals.
7.2.1.2.1 Where electronic monitoring is used and the specific extinguisher cannot be verified electronically, the extinguisher shall be continuously monitored for location.
7.2.2 Procedures. Periodic inspection or electronic monitoring of fire extinguishers shall include a check of at least the following items:
(1) Location in designated place
(2) No obstruction to access or visibility
(3) Pressure gauge reading or indicator in the operable range or position
(4) Fullness determined by weighing or hefting for self-expelling-type extinguishers, cartridge-operated extinguishers, and pump tanks
(5) Condition of tires, wheels, carriage, hose, and nozzle for wheeled extinguishers
(6) Indicator for nonrechargeable extinguishers using push-to-test pressure indicators

Based on observation and interview, the facility failed to install and maintain all portable fire extinguishers (PFE).

Findings include:

On 09/09/20, during a tour of the facility, the following deficiencies were observed:

- A PFE was observed standing on the floor of the boiler room and not hung .
- An exercise bicycle was observed blocking access to the PFE in the Rehab room.
- The sign over a PFE and the PFE were not visible from 14 feet away. The sign and PFE were around a corner of a pillar.

On 09/09/20 - 09/10/20, The Safety, Security and Emergency Preparedness Manager confirmed the findings at the time of discovery.

Based on observation and interview, the facility failed to ensure that corridor doors did not have impediments to closure, could latch close, and could resist the passage of smoke.

Findings include:

On 09/09/20 the door to Admitting, equipped with self-closing devices, was held open with a door chock and would not close as required.

On 09/09/20, the Safety, Security and Emergency Preparedness Manager confirmed the finding at the time of discovery.

National Fire Protection Association (NFPA) 70, National Electric Code, 2011 Edition

110.27 Guarding Live Parts.
(A) Live Parts Guarded Against Accidental Contact. Except as elsewhere required or permitted by this Code, live parts of electrical equipment operating at 50 volts or more shall be guarded against accidental contact by approved enclosures or by any of the following means:
(1) By location in a room, vault, or similar enclosure that is accessible only to qualified persons.
(2) By suitable permanent, substantial partitions or screens arranged so that only qualified persons have access to the space within reach of the live parts. Any openings in such partitions or screens shall be sized and located so that persons are not likely to come into accidental contact with the live parts or to bring conducting objects into contact with them.
(3) By location on a suitable balcony, gallery, or platform elevated and arranged so as to exclude unqualified persons.
(4) By elevation of 2.5 m (8 ft) or more above the floor or other working surface.

Article 400 - Flexible Cords and Cables
400.8 Uses Not Permitted. Unless specifically permitted in 400.7, flexible cords and cables shall not be used for the following:
1) As a substitute for the fixed wiring of a structure
2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
3) Where run through doorways, windows, or similar openings
4) Where attached to building surfaces
Exception to 4): Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of 368.56(B)
5) Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings
6) Where installed in raceways, except as otherwise permitted in the Code
7) Where subject to physical damage

Article 408.4 - Field Identification Required
A) Circuit Directory of Circuit Identification. Every circuit and circuit modification shall be legibly identified as to its clear, evident, and specific purpose or use. The identification shall include an approved degree of detail that allows each circuit to be distinguished from all others. Spare positions that contain unused overcurrent devices or switches shall be described accordingly. The identification shall be included in a circuit directory that is located on the face or inside of the panel door in the case of a panelboard and at each switch or circuit breaker in a switchboard or switchgear. No circuit shall be described in a manner that depends on transient conditions of occupancy.

Article 406.6 Receptacle faceplates (Cover plates).
Receptacle faceplates shall be installed so as to completely cover the opening and seat against the mounting surface.

Based on observation, the facility failed to maintain electrical wiring, equipment, and installations as required by NFPA 70.

Findings include:

On 09/09/20, during a tour of the facility the following deficiencies were observed:

- A receptacle was missing a face plate.
- There was a broken receptacle face plate.
- A panelboard, located in the boiler room, contained a schedule directory printed on blue paper on which circuit breaker number 54 was not labeled. This panelboard contained two different schedule directories stored inside.
- An electric razor was plugged into a residential relocatable power tap in the clean utility room.
- There was an open receptacle in the Clinical Education room in the horseshoe hallway.

On 09/09/20 and 09/10/20, the Safety, Security and Emergency Preparedness Manager confirmed the findings at the time of discovery.

Based on document review and interview, the facility failed to conduct weekly inspections of its essential electrical system (EES) as required.

Findings include:

The facility's maintenance logs lacked documented evidence of EES's weekly inspections for the following weeks:

- 09/29/19 - 10/05/19
- 10/13/19 - 10/19/19
- 10/20/19 - 10/26/19
- 05/31/20 - 06/06/20
- 07/05/20 - 07/11/20


On 09/10/20, the CEO/Administrator confirmed the inspections were not performed weekly as required.