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Based on observation and interview, the facility failed to maintain smoke barriers with at least a one half hour fire resistance rating. The deficient practice affected three of six smoke compartments, staff, and patients.

Findings Include:

1. Observation on 09/05/12 at 10:20 a.m. revealed two 2 ' x 2 ' sections of drop ceiling that were removed in the HIM storage room. Interview with the Director of Engineering on 09/05/12 at 10:20 a.m. disclosed that the facility was unaware of the missing sections of ceiling,

2. Observation on 09/05/12 at 10:35 a.m. revealed an approximately 2 " x 5 " open penetration around the two 2 " conduit pipes that went through the wall of the electric room. Interview with the Director of Engineering on 09/05/12 at 10:35 a.m. disclosed that the facility was unaware of the through the wall penetration.

3. Observation on 09/05/12 at 11:10 a.m. revealed two open penetrations around conduit pipe and one penetration around data wires above the cross corridor door ceiling by patient room #1. Interview with the Director of Engineering on 05-23-12 at 11:10 a.m. revealed that the facility was unaware of the through the wall penetration

The finding was acknowledged by the VP of Diagnostic Services and the Director of Engineering at the exit interview on 09/05/12.

Actual NFPA Standard: NFPA 101, 19.3.7.3. Smoke barriers shall provide at least a one half hour fire resistance rating.
Actual NFPA Standard: NFPA 101, 8.3.6.1. 8.3.6.1
Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Based on observation, record review, and interview, the facility failed to provide fire drills for three of four quarters reviewed. The deficient practice would potentially affect six of six smoke compartments, all patients, and occupants of the building.

The findings include:

Observation during record review on 09/05/12 at 9:30 a.m. revealed that for 2nd shift of the 4th quarter in 2011 and the 1st and 2nd shifts of the 1st and 2nd quarter of 2012, no fire drills were documented as being held. Interview on 09/05/12 at 9:30 a.m. with the Director of Engineering disclosed that the facility was aware the drills were not performed.

The finding was acknowledged by the VP of Diagnostic Services and verified by the Director of Engineering at the exit interview on 09/05/12.

Actual NFPA Standard
NFPA 101, 19.7.1.2
Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.

Based on observation and interview, the facility failed to provide a smoke detector above a fire alarm control panel. The deficient practice would affect six of six smoke compartments, all patients, and occupants of the building.

Findings include:

Observation of the fire alarm control panel located in the unoccupied surgery equipment storage room on 09/05/12 at 10:25 a.m., the facility failed to provide automatic smoke detection at the fire alarm control panel. Lack of smoke detection may cause the fire alarm control panel to be incapacitated by fire before a detection device responded. Interview with the facility Director of Engineering on 09/05/12 at 10:25 a.m., indicated the facility was not aware that smoke detection was required at this location.

The finding was acknowledged by the VP of Diagnostic Services and verified by the Director of Engineering at the exit interview on 09/05/12.

Actual NFPA standard:
NFPA 72,
1-5.6 Protection of Fire Alarm Control Unit(s).
In areas that are not continuously occupied, automatic smoke detection shall be provided at the location of each fire alarm control unit(s) to provide notification of fire at that location.

Exception: Where ambient conditions prohibit installation of automatic smoke detection, automatic heat detection shall be permitted.

Based on observation and interview, the facility failed to provide complete coverage by the automatic sprinkler system as required for a Type V (111) protected, ordinary construction. The deficient practice affected one of six smoke compartments, staff, and patients.

Findings include:

Observation on 09/05/12 at 10:08 a.m. revealed that sprinkler coverage was not provided for the closet in patient room #3. The closet was approximately two feet by four feet in dimension. Interview with the Director of Engineering on 09/05/12 at 10:08 a.m., disclosed that the facility constructed the new closet and was not aware that the closet is required to be provided with sprinkler protection.

The finding was acknowledged by the VP of Diagnostic Services and verified by the Director of Engineering at the exit interview on 09/05/12.

Actual NFPA Standard:
NFPA 101, 19.3.5.1.
Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.

Based on observation, record review, and interview, the facility failed to ensure quarterly automatic fire sprinkler system inspections had been completed. The deficient practice would potentially affect six of six smoke compartments, all patients, and occupants of the building.

The findings include:

Observation during record review of fire sprinkler inspection reports on 09/05/12 at 8:30 a.m. disclosed that the facility had no documentation for a completed quarterly automatic fire sprinkler system inspection as required for the 3rd and 4th quarter of 2011 and the 1st quarter of 2012.

The Director of Facilities stated during interview on 09/05/12 at 8:30 a.m. that, to his knowledge, a quarterly inspection of the sprinkler system had not been completed for the 3rd and 4th quarter of 2011 and the 1st quarter of 2012.

The finding was acknowledged by the VP of Diagnostic Services and verified by the Director of Engineering at the exit interview on 09/05/12.

Actual NFPA Standard:
NFPA 25
2-2 Inspection.
2-2.1 Sprinklers.
Table 2-1 Summary of Sprinkler System Inspection, Testing, and Maintenance:
Alarm devices Test Quarterly
Main drain Test Quarterly
Alarm devices Inspection Quarterly
Gauges Test 5 years
Obstruction- Maintenance- 5 years

Based on observation, record review, and interview, the facility failed to provide semiannual inspection and maintenance of the kitchen suppression and exhaust system at a minimum interval of at least every six months The deficient practice affected one of six smoke compartments, staff and no patients.

Findings include:

Observation during record review on 09/05/12 at 8:30 a.m. revealed that the kitchen hood fire suppression system ' s last inspection and maintenance was accomplished on 01/30/12. The facility was unable to provide a documented inspection and maintenance for the seven month interval between the 01/30/12 and the date of the survey on 09/05/12. Interview on 09/05/12 at 8:30 a.m. with the Director of Engineering revealed that the facility was aware of the requirement for the inspection and servicing of the kitchen hood fire suppression system within a minimum of at least every six months but was not aware of the missing documented inspection and maintenance for the suppression system.

The finding was acknowledged by the VP of Diagnostic Services and verified by the Director of Engineering at the exit interview on 09/05/12.

Actual NFPA Standard:
NFPA 17A, 5-3.1.1.
At least semiannually, maintenance shall be conducted in accordance with the manufacturer's listed installation and maintenance manual.
NFPA 17A, 5-3.1.1 (g).
The maintenance report, with recommendations, if any, shall be filed with the owner or with the designated party responsible for the system.
NFPA 17A, 5-3.1.1 (h).
Each wet chemical system shall have a tag or label securely attached, indicating the month and year the maintenance is performed and identifying the person performing the service. Only the current tag or label shall remain in place.
NFPA 17A, 5-5.
The following parts of wet chemical extinguishing systems shall be subjected to a hydrostatic pressure test at intervals not exceeding 12 years:
(a) Wet chemical containers
(b) Auxiliary pressure containers
(c) Hose assemblies

Based on observation and interview, the facility failed to protect freestanding "E" size oxygen cylinder from accidental damage. The deficient practice affected one of six smoke compartments, staff, and no patients.

Findings include:

Observation on 09/05/12 at 9:55 a.m., revealed that one freestanding "E" size oxygen cylinder located in the cardiopulmonary storage closet was not protected by individual chaining, placement in a rack or use of a cylinder stand/cart. Interview with the Director of Engineering on 09/05/12 at 9:55 a.m., disclosed that the facility was not aware the "E" cylinder was stored lying on the floor without being properly supported or secured.

The finding was acknowledged by the VP of Diagnostic Services and verified by the Director of Engineering at the exit interview on 09/05/12.

Actual NFPA Standard:
NFPA 99, 4-3.5.2.1 (b) 27. Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

Based on observation, record review and interview, it was determined the facility failed to provide continuing safety education for laboratories. This resulted in the potential for the facility ' s inability to effectively deal with the care, health and safety of staff and other individuals when a laboratory emergency occurs.

Findings include:

Observation during record review on 09/05/12 at 11:30 a.m. revealed that the facility failed to provide continuing safety education for the hospital laboratory. There was no documented orientation and training of new laboratory personnel, and no documented continuing safety education. Interview with the VP of Diagnostic Services on 09/05/12 at 11:30 a.m., disclosed that the facility was not aware of the documentation requirements.

The finding was acknowledged by the VP of Diagnostic Services and the Director of Engineering at the exit interview on 09/05/12.

Actual NFPA Standard: NFPA 99, 10-2.1.4 Orientation and Training.
10-2.1.4.1 New laboratory personnel shall be taught general safety practices for the laboratory and specific safety practices for the equipment and procedures they will use.
10-2.1.4.2 Continuing safety education and supervision shall be provided, incidents shall be reviewed monthly, and procedures shall be reviewed annually.

Based on observation and interview, it was determined the facility failed to provide an suitable emergency shower for laboratories. This resulted in the potential for the facility ' s inability to effectively deal with the care, health and safety of staff and other individuals when a laboratory emergency occurs.

Findings include:

Observation 09/05/12 at 11:25 a.m., revealed that the facility failed to provide a suitable emergency shower within the laboratory work area for immediate emergency use. The area beneath the fixed shower was obstructed by a document shredder receptacle and wall mounted coat rack. Interview with the Director of Engineering on 09/05/12 at 11:25 a.m., disclosed that the facility was not aware the obstructions would prevent immediate emergency shower use.

The finding was acknowledged by the VP of Diagnostic Services and the Director of Engineering at the exit interview on 09/05/12.

Actual NFPA Standard:
NFPA 99, 10-6 Emergency Shower.
Where the eyes or body of any person can be exposed to injurious corrosive materials, suitable fixed facilities for quick drenching or flushing of the eyes and body shall be provided within the work area for immediate emergency use. Fixed eye baths shall be designed and installed to avoid injurious water pressure.