HospitalInspections.org

Based on observation, the facility failed to maintain the structure of the building in a condition that would resist the passage of smoke and fire. This was evidenced by penetrations in the walls and ceiling. This affected staff and patients in four of nine smoke compartments and could potentially result in the spread of smoke and fire from one smoke compartment to another.

Findings:

During a tour of the facility with the Physical Plant Manager on 3/5/13, penetrations were observed in the gypsum wallboard and ceiling.

1. At 1:00 p.m., there were three one-quarter inch penetrations, in the east wall of Room 207, in the Med-Surge Department.

2. At 1:25 p.m., in Server Room 200, there was an approximately one-quarter inch penetration, around a two and one-quarter inch pipe sleeve, in the ceiling. Approximately two inches from this pipe was another smaller sleeve in the ceiling that was not sealed on the end.

3. At 2:19 p.m., there were two four inch square penetrations in the east wall of the janitor's closet in the Emergency Department. They were located approximately six feet and eight inches above the floor. This room was also the back side of the flash sterilizer. On the right side of the sterilizer, there was an approximately 18 inch by 18 inch cut out in the wall sheeting that had been removed, exposing the wood framing.

4. At 3:12 p.m., Room 800 to 802 had an approximately one inch penetration in the south wall. There were two approximately two inch penetrations in the center east wall, and two approximately one inch penetrations in the west wall. These penetrations were approximately five feet above the floor.

5. At 3:14 p.m., the Medical Supplies Room 816, had five penetrations in the north wall, six penetrations in the west wall, and three penetrations in the south wall. These penetrations were all approximately one-quarter inch in size.

Based on observation, the facility failed to maintain the corridor construction with a one-half hour fire rating, as evidenced by penetrations in the corridor walls. This deficient practice affected staff and patients in five of nine smoke compartments and could potentially result in the spread of smoke and fire.

Findings:

During a tour of the facility with the Physical Plant Manager, on 3/6/13, corridor walls were observed:

1. At 8:55 a.m., there was an unsealed one-half inch pipe penetrating the ceiling on both sides of the cross corridor doors, between the north corridor 500 and 700 wing.

2. At 9:02 a.m., there was an unsealed one-half inch pipe penetrating the ceiling on both sides of the cross corridor doors by Room 400.

3. At 9:03 a.m., there was an unsealed one-half inch pipe penetrating the ceiling on both sides of the cross corridor doors by Room 301.

4. At 9:04 a.m., there was an unsealed one-half inch pipe penetrating the ceiling on both sides of the cross-corridor doors by the Exam and Treatment Room.

The attic above the ceiling could be seen through the pipe sleeves.

Based on observation, the facility failed to maintain corridor doors free from obstructions. This was evidenced by corridor doors that failed to close and latch. It is critical that corridor doors can be closed and latched quickly to prevent the spread of smoke and fire into other areas of the facility. This deficient practice affected staff and patients in four of nine smoke compartments.


Findings:

During a tour of the facility with the Physical Plant Manager, on 3/5/13, doors were observed.

1. At 11:55 a.m., the corridor door to the Ophthalmology Exam Room was held open by a cloth strap that was tied around the door knob.

2. At 1:02 p.m., the corridor door to Storage Room 243 did not positive latch when closed.

3. At 1:03 p.m., the door to the Sleep Room was held open by a magnetic hold-open device, designed to release upon activation of the fire alarm system. The bed in the room was located within the swing area of the door, obstructing it from closing.

4. At 1:15 p.m., the self-closing door to Storage Room 225, did not positive latch when closed by releasing the door from a fully open position.

5. At 1:16 p.m., there was a door wedge holding the door open to the Med-Surge Kitchen. The door was obstructed from closing

6. At 1:22 p.m., the self-closing mechanism was disconnected on the nurses' breakroom door. The door was held open by a magnetic hold-open device designed to release upon activation of the fire alarm system.

7. At 2:27 p.m., the door to Cardiopulmonary Room 402 did not positive latch when closed by releasing the door from a fully open position.

Glenn Family Medical Group
2. At 10:57 a.m., standing in the common exit path from the exam rooms and office, the direction of egress was not apparent. The door opposite the Nurses' Office, leading into the waiting room, should have a sign identifying the door as an exit. At the other end of the corridor, near the Equipment Room, a directional exit sign should identify the exit at the end of the hall.

Surveyor: Compton, Robert
Based on observation and interview, the facility failed to mark all exits with readily visible signs where the exit was not apparent. This was evidenced by locations that did not have the direction of exits marked. This affected staff and patients in two of two offsite locations and could potentially result in injury or delayed egress during an evacuation.

39.2.1.1 All means of egress shall be in accordance with Chapter 7 and this chapter.

SECTION 7.10 MARKING OF MEANS OF EGRESS
7.10.1 General.
7.10.1.1 Where Required. Means of egress shall be marked in accordance with Section 7.10 where required in Chapters 11 through 42.

7.10.1.2* Exits. Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.

7.10.1.7* Visibility. Every sign required in Section 7.10 shall be located and of such size, distinctive color, and design that it is readily visible and shall provide contrast with decorations,interior finish, or other signs. No decorations, furnishings, or equipment that impairs visibility of a sign shall be permitted. No brightly illuminated sign (for other than exit purposes), display, or object in or near the line of vision of the required exit sign that could detract attention from the exit sign shall be permitted.

Findings:

During a tour of the facility with the Physical Plant Manager, on 3/6/13, the path of egress was observed.

Rural Health Clinic
1. At 10:45 a.m., standing in the common exit path from the patient rooms and office area, the direction of egress was not apparent. This area needed two directional exit signs pointing towards the Waiting Room exit.

Based on observation, the facility failed to maintain its cross corridor doors to continuously serve as a smoke barrier. This was evidenced by one set of cross-corridor fire doors that were equipped with latching hardware that failed to latch during testing. This affected all staff and patients in one of nine smoke compartments within the facility and could potentially result in the spread of smoke and fire.

2000 NFPA 101
8.2.3.2 Fire Protection-Rated Opening Protectives.
8.2.3.2.1 Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following.
(a) *Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies.
Exception: The requirement of 8.2.3.2.1(a) shall not apply where otherwise specified by 8.2.3.2.3.1.
(b) Fire doors shall be self-closing or automatic-closing in accordance with 7.2.1.8 and, where used within the means of egress, shall comply with the provisions of 7.2.1.

NFPA 80
Standard for Fire Doors and Fire Windows
2-4.1.2* A closing device shall be installed on every fire door. Exception: With approval by the authority having jurisdiction, where pairs of doors are provided for mechanical equipment rooms to allow the movement of equipment, the device shall be permitted to be omitted on the inactive leaf.
2-4.1.4* All closing mechanisms shall be adjusted to overcome the resistance of the latch mechanism so that positive latching is achieved on each door operation.

Findings:

During a tour of the facility with the Physical Plant Manager, on 3/5/13, fire doors were observed.

At 2:10 p.m., the three hour fire-rated doors to the Emergency Room did not close and latch when manually released from their magnetic hold open devices.

Based on observation, the facility failed to protect its hazardous area enclosures. This was evidenced by rooms which contained combustible storage that were not equipped with self-closing mechanisms.
This deficient practice affected all staff and patients in three of nine smoke compartments and could potentially result in the spread of smoke and fire.

Findings:

During a tour of the facility with the Physical Plant Manager, on 3/5/13, hazardous area enclosures were observed. Hazardous areas include laboratories, soiled linen and trash rooms, and storage areas greater than 50 square feet in size.

1. At 1:30 p.m., the self-closing mechanism was removed from the corridor door to the Blood Draw Room. The room is part of the laboratory compartment.

2. At 3:05 p.m., the Medical Records Storage, Room 702, did not have a self-closing mechanism on the door.

3. At 3:08 p.m., the door to Storage Room 801 did not have a self-closing mechanism on the door.

Based on observation, the facility failed to provide emergency illumination in accordance with NFPA 99. This was evidenced by the failure to provide a battery-powered emergency lighting unit in an anesthetizing location. This deficient practice affected one of one operating room and could potentially result in a loss of lighting in the operating room during a power outage.

19.3.2.3 Anesthetizing Locations. Anesthetizing locations shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA 99 3-3.2.1.2, 5 (e)
5. Wiring in Anesthetizing Locations
e. Battery-powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12(e)

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.


Findings:.

During a tour of the facility with the Physical Plant Manager, on 3/5/13, at 1:50 p.m., there was no battery powered back-up lighting unit in Operating Room 1.

During an interview the Physical Plant Manager reported that no other surgeries were scheduled that day. The facility made arrangements to install battery powered lighting immediately. Emergency LED lights were provided until permanent lights could be installed.

Based on document review and interview, the facility failed to inspect, test, and certify the complete fire alarm system. This was evidenced by the failure to provide documentation for a current Annual Alarm Certification from a certified vendor. This affected all staff and patients in nine of nine smoke compartments and could potentially result in a delay in notification in the event of a fire.

1999 NFPA 72 National Fire Alarm Code
7-1.1.1 Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturer ' s recommendations, and shall verify correct operation of the fire alarm system.

7-1.2.2 Service personnel shall be qualified and experienced in the inspection, testing, and maintenance of fire alarm systems.
Examples of qualified personnel shall be permitted to include, but shall not be limited to, individuals with the following qualifications:
(1) Factory trained and certified
(2) National Institute for Certification in Engineering Technologies fire alarm certified
(3) International Municipal Signal Association fire alarm certified
(4) Certified by a state or local authority
(5) Trained and qualified personnel employed by an organization listed by a national testing laboratory for the servicing of fire alarm systems

Findings:

During record review with the Physical Plant Manager, on 3/5/13, at 8:45 a.m., the facility was unable to provide documentation for the Annual Alarm Certification by a certified vendor. Documentation provided was for in-house testing of the fire alarm devices.

During an interview, Staff stated that they were testing all of the devices in-house.

Smoke sensitivity testing was performed by an outside vendor on 1/19/12. The detectors were tested for sensitivity and functionality. In this report one of three fire alarm control panels was tested. There was no current record to indicate that the complete fire alarm system was tested and certified.

Based on observation and interview, the facility failed to maintain and inspect its supervised automatic sprinkler system. This was evidenced by two automatic sprinkler system water supply control valves that failed to activate a local alarm when closed. This affected all staff and patients in nine of nine smoke compartments, and could potentially result in the loss of water to the automatic sprinkler system, and a loss of sprinkler fire protection, without staff knowledge.

9.7.2.1* Supervisory Signals. Where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for
integrity in accordance with NFPA 72, National Fire Alarm Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.

Findings:

During fire alarm testing with the Physical Plant Manager, on 3/6/13, supervised sprinkler control valves were tested.

1. At 10:20 a.m., the tamper alarm on the south OS & Y valve, did not produce an audible local alarm when the valve was closed. Closing the OS& Y valve shuts off the water supply to the sprinkler system.

2. At 10:25 a.m., the tamper alarm on the sprinkler riser main valve, did not produce an audible local alarm when closed.

Based on record review and staff interview, the facility failed to periodically inspect and test its automatic sprinkler system. This was evidenced by a lack of documentation for the quarterly sprinkler inspections, by no record for a current annual sprinkler inspection, and by no testing by a certified vendor. This affected nine of nine smoke compartments within the facility and could potentially result in the spread of smoke and fire.

NFPA 101
4.6.12 Maintenance and Testing.
4.6.12.3 Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction.

1998 NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems
2-2 Inspection
2-2.6 Alarm Devices. Alarm devices shall be inspected quarterly to verify that they are free of physical damage.
2-2.3 Alarm Devices. Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.

NFPA 72 National Fire Alarm Code 199 edition
Table 7-3.2 Testing Frequencies
15. Initiating Devices
l. Valve Tamper Switches Semiannually

Findings:

During record review with the Physical Plant Manager, on 3/5/13 at 8:45 a.m., documentation for automatic sprinkler system testing and inspection was reviewed.

1. The facility failed to provide documentation for the Annual Sprinkler System Inspection and Testing. Documentation was provided for the "Automatic Fire Sprinkler Inspection Report" dated 11/24/08, by a certified vendor. The report was for the Five Year Sprinkler Certification.
During an interview, the Physical Plant Manager reported he conducts the sprinkler testing in house.

2. Documentation provided for in-house quarterly sprinkler sprinkler flow tests did not include the required visual inspection or semi annual testing for the supervisory alarms.

Based on observation, the facility failed to maintain its portable fire extinguishers. This was evidenced by fire extinguishers that were not immediately visible and available for use, by fire extinguishers that were mounted too high above the floor, and by fire extinguishers that were unsecured on the floor. This affected staff and patients in three of nine smoke compartments and could potentially cause a delay in access to the fire extinguishers.

NFPA 10, 1998 Edition.
1-6.6* Fire extinguishers shall not be obstructed or obscured from view.
Exception: In large rooms and in certain locations where visual obstruction cannot be completely avoided, means shall be provided to indicate the location.
1-6.12 Fire extinguishers mounted in cabinets or wall recesses shall be placed so that the fire extinguisher operating instructions face outward. The location of such fire extinguishers shall be marked conspicuously. (See 1-6.6.)

1-6.10 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. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 3 1/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).

Findings:

During a tour of the facility with the Physical Plant Manager, on 3/5/13, fire extinguishers were observed.

1. At 11:15 a.m., two fire extinguishers, located in the generator enclosure, were sitting on the floor on either side of the generator.

2. At 1:25 p.m., one fire extinguisher was mounted 73 inches above the floor, in the Lab Storage/Breaker.

3. At 1:30 p.m., there was a fire extinguisher sitting on the floor in the X-Ray Control Room.

4. At 1:31 p.m., the fire extinguisher was under an open counter top work surface in the Laboratory. The fire extinguisher was partially concealed from sight.

Based on record review and interview, the facility failed to maintain its heating, ventilation, and air conditioning system, in accordance with NFPA 90A. This was evidenced by incomplete documentation for damper inspections. This affected one of nine smoke compartments within the facility and could potentially result in the spread of smoke and fire.

9.2.1 Air conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, as applicable, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 90A 3-4.7 Maintenance. At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.

The maintenance interval can be extended to six years for hospitals

Findings:

During record review with the Physical Plant Manager, on 3/5/13, at 10:45 a.m., the facility failed to provide documentation indicating that all dampers had been inspected within the last six years. Documentation provided, titled "Quarterly Fire Component Check," indicated that the actuator driven dampers in the 100 and 300 wings were inspected annually. Documentation did not include the fusible link type dampers.

During a tour of the facility with the Physical Plant Manager, at 2:45 p.m., there was a fusible link type fire damper in the ceiling supply register in Room 611.

The Physical Plant Manager confirmed that it was a damper. He stated that there was no documentation that the dampers had been inspected in that part of the building within the past six years.

Based on observation, the facility failed to ensure that all means of egress are continuously maintained free of obstructions, as evidenced by items stored in one exit corridor. This affected all staff and residents in one of nine smoke compartments, and could potentially result in injury or a delayed evacuation in the event of an emergency.


Findings:

During a tour of the facility with the Physical Plant Manager, on 3/5/13, exit corridors were observed.

At 3:12 p.m., the exit corridor between Room 806 and 818 had three boxes of paper, two gurneys, six empty boxes, a wooden box on wheels full of boxes, two rolling shelves/carts full of supplies, and a six foot tall rolling shelf.

During a tour of the facility with the Physical Plant Manager on 3/6/13, at 10:08 a.m., the same exit corridor was observed with the same items store in the same locations.

The Physical Plant Manager confirmed the above items were stored in the corridor.

Based on observation, the facility failed to ensure medical compressed gas cylinders were stored in accordance with NFPA 99. This was evidenced by cylinders which were unsecured on the floor. This affected one of nine smoke compartments and could potentially result in injury or damage to the cylinders if they were to fall.

4-3.1.1.1 Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.

Findings:

During a tour of the facility with the Physical Plant Manager, on 3/5/13, oxygen cylinders were observed.

1. At 12:03 p.m., there was one E size oxygen tank lying flat in the floor in Room 117.

2. At 1:55 p.m., there were one nitrogen and two E size carbon dioxide cylinders unsecured, on the floor, in the Sterile Core of Surgery.

Based on document review and staff interview, the facility failed to provide complete documentation of weekly generator inspections and failed to maintain the battery-powered back-up light at the generator set location. This was evidenced by a lack of documentation for weekly inspections for eight of 52 weeks in a twelve month period, and by a missing light bulb in the light fixture in the generator area. This affected all staff and patients in nine of nine smoke compartments, and could potentially result in generator failure or no light in the generator room during a power outage, if the generator failed to start.


NFPA 110, 5-3 Lighting.
5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.

Findings:

During record review with the Physical Plant Manager, on 3/5/13, generator logs were reviewed.

1. At 8:45 a.m., weekly generator inspections were missing for six of 52 weeks. During an interview, Maintenance Staff stated that the inspections were done, but not documented, for January and February of 2013

During a tour of the facility with with the Physical Plant Manager, on 3/5/13, the facility generator location was observed.

2. At 1:15 p.m., the bulb was missing in the generator light fixture that provides battery-powered task illumination.

Based on observation, the facility failed to comply with the regulations regarding electrical wiring and utilities. This was evidenced by high wattage devices that were plugged into power strips, by the use of extension cords, and by power strips that were linked together. This affected all staff and patients in three of nine smoke compartments and could potentially result in the ignition of an electrical fire.

1999 NFPA 70 - National Electrical Code
400.8 Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors.

110-12 requires that electrical equipment be installed in a neat and workman like manner.

370-25 Covers and Canopies. In completed installations, each box shall have a cover, faceplate, or fixture canopy.

NFPA 99 Health Care Facilities 1999 edition
3-3.2.1.2, All patient care areas.
(d)(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.


Findings:

During a tour of the facility with the Physical Plant Manager on 3/5/13, electrical wiring and equipment were observed.

1. At 11:20 a.m., the were two extension cords running from the Boiler Room to a light in the generator enclosure and to an ambulance unit near the generator.

2. At 11:50 a.m., there was an approximately 14-16 gauge ungrounded lamp cord in Room 100.

3. At 12:00 p.m., the Doctors' Sleep Room had three power strips that were linked together with one power strip running to the opposite side of the room to the wall outlet. There was a George Foreman Grill, a microwave oven, and a refrigerator that were all plugged into the end power strip.

4. At 12:55 p.m., there was an approximately 14-16 gauge ungrounded extension cord in the Radiology Registration Office.

5. At 1:02 p.m., the ceiling light fixture canopy cover was missing in the housekeeping closet by Room 241.

6. At 1:22 p.m., there was a four inch junction box missing a cover in Server Room 200.

7. At 2:12 p.m., there was a four foot florescent light fixture that was missing a canopy cover in the Trauma Room.

Based on observation, the facility failed to ensure alcohol-based hand rub (ABHR) dispensers were not adjacent to or above sources of potential ignition. This was evidenced by ABHR dispensers located above light switches in five areas. This affected one of nine smoke compartments and could potentially result in the ignition of fire.

Findings:

During a tour of the facility with the Physical Plant Manager on 3/5/13, ABHR dispensers were observed.

1. At 11:55 a.m., Room 117 had an ABHR dispenser located above a light switch.

2. At 1:01 p.m., the Dirty Utility Room 215 had an ABHR dispenser located approximately eleven inches above a light switch.

3. At 1:02 p.m., the Med-Surge Nurses' Station had an ABHR dispenser located above a light switch.

4. At 1:05 p.m., the was an ABHR dispenser located between Rooms 247 and 249.

5. At 2:15 p.m., there was an ABHR dispenser above a light switch in Room 714

Based on observation, the facility failed to maintain the structure of the building in a condition that would resist the passage of smoke and fire. This was evidenced by penetrations in the walls and ceiling. This affected staff and patients in four of nine smoke compartments and could potentially result in the spread of smoke and fire from one smoke compartment to another.

Findings:

During a tour of the facility with the Physical Plant Manager on 3/5/13, penetrations were observed in the gypsum wallboard and ceiling.

1. At 1:00 p.m., there were three one-quarter inch penetrations, in the east wall of Room 207, in the Med-Surge Department.

2. At 1:25 p.m., in Server Room 200, there was an approximately one-quarter inch penetration, around a two and one-quarter inch pipe sleeve, in the ceiling. Approximately two inches from this pipe was another smaller sleeve in the ceiling that was not sealed on the end.

3. At 2:19 p.m., there were two four inch square penetrations in the east wall of the janitor's closet in the Emergency Department. They were located approximately six feet and eight inches above the floor. This room was also the back side of the flash sterilizer. On the right side of the sterilizer, there was an approximately 18 inch by 18 inch cut out in the wall sheeting that had been removed, exposing the wood framing.

4. At 3:12 p.m., Room 800 to 802 had an approximately one inch penetration in the south wall. There were two approximately two inch penetrations in the center east wall, and two approximately one inch penetrations in the west wall. These penetrations were approximately five feet above the floor.

5. At 3:14 p.m., the Medical Supplies Room 816, had five penetrations in the north wall, six penetrations in the west wall, and three penetrations in the south wall. These penetrations were all approximately one-quarter inch in size.

Based on observation, the facility failed to maintain the corridor construction with a one-half hour fire rating, as evidenced by penetrations in the corridor walls. This deficient practice affected staff and patients in five of nine smoke compartments and could potentially result in the spread of smoke and fire.

Findings:

During a tour of the facility with the Physical Plant Manager, on 3/6/13, corridor walls were observed:

1. At 8:55 a.m., there was an unsealed one-half inch pipe penetrating the ceiling on both sides of the cross corridor doors, between the north corridor 500 and 700 wing.

2. At 9:02 a.m., there was an unsealed one-half inch pipe penetrating the ceiling on both sides of the cross corridor doors by Room 400.

3. At 9:03 a.m., there was an unsealed one-half inch pipe penetrating the ceiling on both sides of the cross corridor doors by Room 301.

4. At 9:04 a.m., there was an unsealed one-half inch pipe penetrating the ceiling on both sides of the cross-corridor doors by the Exam and Treatment Room.

The attic above the ceiling could be seen through the pipe sleeves.

Based on observation, the facility failed to maintain corridor doors free from obstructions. This was evidenced by corridor doors that failed to close and latch. It is critical that corridor doors can be closed and latched quickly to prevent the spread of smoke and fire into other areas of the facility. This deficient practice affected staff and patients in four of nine smoke compartments.


Findings:

During a tour of the facility with the Physical Plant Manager, on 3/5/13, doors were observed.

1. At 11:55 a.m., the corridor door to the Ophthalmology Exam Room was held open by a cloth strap that was tied around the door knob.

2. At 1:02 p.m., the corridor door to Storage Room 243 did not positive latch when closed.

3. At 1:03 p.m., the door to the Sleep Room was held open by a magnetic hold-open device, designed to release upon activation of the fire alarm system. The bed in the room was located within the swing area of the door, obstructing it from closing.

4. At 1:15 p.m., the self-closing door to Storage Room 225, did not positive latch when closed by releasing the door from a fully open position.

5. At 1:16 p.m., there was a door wedge holding the door open to the Med-Surge Kitchen. The door was obstructed from closing

6. At 1:22 p.m., the self-closing mechanism was disconnected on the nurses' breakroom door. The door was held open by a magnetic hold-open device designed to release upon activation of the fire alarm system.

7. At 2:27 p.m., the door to Cardiopulmonary Room 402 did not positive latch when closed by releasing the door from a fully open position.

Glenn Family Medical Group
2. At 10:57 a.m., standing in the common exit path from the exam rooms and office, the direction of egress was not apparent. The door opposite the Nurses' Office, leading into the waiting room, should have a sign identifying the door as an exit. At the other end of the corridor, near the Equipment Room, a directional exit sign should identify the exit at the end of the hall.

Surveyor: Compton, Robert
Based on observation and interview, the facility failed to mark all exits with readily visible signs where the exit was not apparent. This was evidenced by locations that did not have the direction of exits marked. This affected staff and patients in two of two offsite locations and could potentially result in injury or delayed egress during an evacuation.

39.2.1.1 All means of egress shall be in accordance with Chapter 7 and this chapter.

SECTION 7.10 MARKING OF MEANS OF EGRESS
7.10.1 General.
7.10.1.1 Where Required. Means of egress shall be marked in accordance with Section 7.10 where required in Chapters 11 through 42.

7.10.1.2* Exits. Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.

7.10.1.7* Visibility. Every sign required in Section 7.10 shall be located and of such size, distinctive color, and design that it is readily visible and shall provide contrast with decorations,interior finish, or other signs. No decorations, furnishings, or equipment that impairs visibility of a sign shall be permitted. No brightly illuminated sign (for other than exit purposes), display, or object in or near the line of vision of the required exit sign that could detract attention from the exit sign shall be permitted.

Findings:

During a tour of the facility with the Physical Plant Manager, on 3/6/13, the path of egress was observed.

Rural Health Clinic
1. At 10:45 a.m., standing in the common exit path from the patient rooms and office area, the direction of egress was not apparent. This area needed two directional exit signs pointing towards the Waiting Room exit.

Based on observation, the facility failed to maintain its cross corridor doors to continuously serve as a smoke barrier. This was evidenced by one set of cross-corridor fire doors that were equipped with latching hardware that failed to latch during testing. This affected all staff and patients in one of nine smoke compartments within the facility and could potentially result in the spread of smoke and fire.

2000 NFPA 101
8.2.3.2 Fire Protection-Rated Opening Protectives.
8.2.3.2.1 Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following.
(a) *Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies.
Exception: The requirement of 8.2.3.2.1(a) shall not apply where otherwise specified by 8.2.3.2.3.1.
(b) Fire doors shall be self-closing or automatic-closing in accordance with 7.2.1.8 and, where used within the means of egress, shall comply with the provisions of 7.2.1.

NFPA 80
Standard for Fire Doors and Fire Windows
2-4.1.2* A closing device shall be installed on every fire door. Exception: With approval by the authority having jurisdiction, where pairs of doors are provided for mechanical equipment rooms to allow the movement of equipment, the device shall be permitted to be omitted on the inactive leaf.
2-4.1.4* All closing mechanisms shall be adjusted to overcome the resistance of the latch mechanism so that positive latching is achieved on each door operation.

Findings:

During a tour of the facility with the Physical Plant Manager, on 3/5/13, fire doors were observed.

At 2:10 p.m., the three hour fire-rated doors to the Emergency Room did not close and latch when manually released from their magnetic hold open devices.

Based on observation, the facility failed to protect its hazardous area enclosures. This was evidenced by rooms which contained combustible storage that were not equipped with self-closing mechanisms.
This deficient practice affected all staff and patients in three of nine smoke compartments and could potentially result in the spread of smoke and fire.

Findings:

During a tour of the facility with the Physical Plant Manager, on 3/5/13, hazardous area enclosures were observed. Hazardous areas include laboratories, soiled linen and trash rooms, and storage areas greater than 50 square feet in size.

1. At 1:30 p.m., the self-closing mechanism was removed from the corridor door to the Blood Draw Room. The room is part of the laboratory compartment.

2. At 3:05 p.m., the Medical Records Storage, Room 702, did not have a self-closing mechanism on the door.

3. At 3:08 p.m., the door to Storage Room 801 did not have a self-closing mechanism on the door.

Based on observation, the facility failed to provide emergency illumination in accordance with NFPA 99. This was evidenced by the failure to provide a battery-powered emergency lighting unit in an anesthetizing location. This deficient practice affected one of one operating room and could potentially result in a loss of lighting in the operating room during a power outage.

19.3.2.3 Anesthetizing Locations. Anesthetizing locations shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA 99 3-3.2.1.2, 5 (e)
5. Wiring in Anesthetizing Locations
e. Battery-powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12(e)

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.


Findings:.

During a tour of the facility with the Physical Plant Manager, on 3/5/13, at 1:50 p.m., there was no battery powered back-up lighting unit in Operating Room 1.

During an interview the Physical Plant Manager reported that no other surgeries were scheduled that day. The facility made arrangements to install battery powered lighting immediately. Emergency LED lights were provided until permanent lights could be installed.

Based on document review and interview, the facility failed to inspect, test, and certify the complete fire alarm system. This was evidenced by the failure to provide documentation for a current Annual Alarm Certification from a certified vendor. This affected all staff and patients in nine of nine smoke compartments and could potentially result in a delay in notification in the event of a fire.

1999 NFPA 72 National Fire Alarm Code
7-1.1.1 Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturer ' s recommendations, and shall verify correct operation of the fire alarm system.

7-1.2.2 Service personnel shall be qualified and experienced in the inspection, testing, and maintenance of fire alarm systems.
Examples of qualified personnel shall be permitted to include, but shall not be limited to, individuals with the following qualifications:
(1) Factory trained and certified
(2) National Institute for Certification in Engineering Technologies fire alarm certified
(3) International Municipal Signal Association fire alarm certified
(4) Certified by a state or local authority
(5) Trained and qualified personnel employed by an organization listed by a national testing laboratory for the servicing of fire alarm systems

Findings:

During record review with the Physical Plant Manager, on 3/5/13, at 8:45 a.m., the facility was unable to provide documentation for the Annual Alarm Certification by a certified vendor. Documentation provided was for in-house testing of the fire alarm devices.

During an interview, Staff stated that they were testing all of the devices in-house.

Smoke sensitivity testing was performed by an outside vendor on 1/19/12. The detectors were tested for sensitivity and functionality. In this report one of three fire alarm control panels was tested. There was no current record to indicate that the complete fire alarm system was tested and certified.

Based on observation and interview, the facility failed to maintain and inspect its supervised automatic sprinkler system. This was evidenced by two automatic sprinkler system water supply control valves that failed to activate a local alarm when closed. This affected all staff and patients in nine of nine smoke compartments, and could potentially result in the loss of water to the automatic sprinkler system, and a loss of sprinkler fire protection, without staff knowledge.

9.7.2.1* Supervisory Signals. Where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for
integrity in accordance with NFPA 72, National Fire Alarm Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.

Findings:

During fire alarm testing with the Physical Plant Manager, on 3/6/13, supervised sprinkler control valves were tested.

1. At 10:20 a.m., the tamper alarm on the south OS & Y valve, did not produce an audible local alarm when the valve was closed. Closing the OS& Y valve shuts off the water supply to the sprinkler system.

2. At 10:25 a.m., the tamper alarm on the sprinkler riser main valve, did not produce an audible local alarm when closed.

Based on record review and staff interview, the facility failed to periodically inspect and test its automatic sprinkler system. This was evidenced by a lack of documentation for the quarterly sprinkler inspections, by no record for a current annual sprinkler inspection, and by no testing by a certified vendor. This affected nine of nine smoke compartments within the facility and could potentially result in the spread of smoke and fire.

NFPA 101
4.6.12 Maintenance and Testing.
4.6.12.3 Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction.

1998 NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems
2-2 Inspection
2-2.6 Alarm Devices. Alarm devices shall be inspected quarterly to verify that they are free of physical damage.
2-2.3 Alarm Devices. Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.

NFPA 72 National Fire Alarm Code 199 edition
Table 7-3.2 Testing Frequencies
15. Initiating Devices
l. Valve Tamper Switches Semiannually

Findings:

During record review with the Physical Plant Manager, on 3/5/13 at 8:45 a.m., documentation for automatic sprinkler system testing and inspection was reviewed.

1. The facility failed to provide documentation for the Annual Sprinkler System Inspection and Testing. Documentation was provided for the "Automatic Fire Sprinkler Inspection Report" dated 11/24/08, by a certified vendor. The report was for the Five Year Sprinkler Certification.
During an interview, the Physical Plant Manager reported he conducts the sprinkler testing in house.

2. Documentation provided for in-house quarterly sprinkler sprinkler flow tests did not include the required visual inspection or semi annual testing for the supervisory alarms.

Based on observation, the facility failed to maintain its portable fire extinguishers. This was evidenced by fire extinguishers that were not immediately visible and available for use, by fire extinguishers that were mounted too high above the floor, and by fire extinguishers that were unsecured on the floor. This affected staff and patients in three of nine smoke compartments and could potentially cause a delay in access to the fire extinguishers.

NFPA 10, 1998 Edition.
1-6.6* Fire extinguishers shall not be obstructed or obscured from view.
Exception: In large rooms and in certain locations where visual obstruction cannot be completely avoided, means shall be provided to indicate the location.
1-6.12 Fire extinguishers mounted in cabinets or wall recesses shall be placed so that the fire extinguisher operating instructions face outward. The location of such fire extinguishers shall be marked conspicuously. (See 1-6.6.)

1-6.10 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. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 3 1/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).

Findings:

During a tour of the facility with the Physical Plant Manager, on 3/5/13, fire extinguishers were observed.

1. At 11:15 a.m., two fire extinguishers, located in the generator enclosure, were sitting on the floor on either side of the generator.

2. At 1:25 p.m., one fire extinguisher was mounted 73 inches above the floor, in the Lab Storage/Breaker.

3. At 1:30 p.m., there was a fire extinguisher sitting on the floor in the X-Ray Control Room.

4. At 1:31 p.m., the fire extinguisher was under an open counter top work surface in the Laboratory. The fire extinguisher was partially concealed from sight.

Based on record review and interview, the facility failed to maintain its heating, ventilation, and air conditioning system, in accordance with NFPA 90A. This was evidenced by incomplete documentation for damper inspections. This affected one of nine smoke compartments within the facility and could potentially result in the spread of smoke and fire.

9.2.1 Air conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, as applicable, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 90A 3-4.7 Maintenance. At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.

The maintenance interval can be extended to six years for hospitals

Findings:

During record review with the Physical Plant Manager, on 3/5/13, at 10:45 a.m., the facility failed to provide documentation indicating that all dampers had been inspected within the last six years. Documentation provided, titled "Quarterly Fire Component Check," indicated that the actuator driven dampers in the 100 and 300 wings were inspected annually. Documentation did not include the fusible link type dampers.

During a tour of the facility with the Physical Plant Manager, at 2:45 p.m., there was a fusible link type fire damper in the ceiling supply register in Room 611.

The Physical Plant Manager confirmed that it was a damper. He stated that there was no documentation that the dampers had been inspected in that part of the building within the past six years.

Based on observation, the facility failed to ensure that all means of egress are continuously maintained free of obstructions, as evidenced by items stored in one exit corridor. This affected all staff and residents in one of nine smoke compartments, and could potentially result in injury or a delayed evacuation in the event of an emergency.


Findings:

During a tour of the facility with the Physical Plant Manager, on 3/5/13, exit corridors were observed.

At 3:12 p.m., the exit corridor between Room 806 and 818 had three boxes of paper, two gurneys, six empty boxes, a wooden box on wheels full of boxes, two rolling shelves/carts full of supplies, and a six foot tall rolling shelf.

During a tour of the facility with the Physical Plant Manager on 3/6/13, at 10:08 a.m., the same exit corridor was observed with the same items store in the same locations.

The Physical Plant Manager confirmed the above items were stored in the corridor.

Based on observation, the facility failed to ensure medical compressed gas cylinders were stored in accordance with NFPA 99. This was evidenced by cylinders which were unsecured on the floor. This affected one of nine smoke compartments and could potentially result in injury or damage to the cylinders if they were to fall.

4-3.1.1.1 Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.

Findings:

During a tour of the facility with the Physical Plant Manager, on 3/5/13, oxygen cylinders were observed.

1. At 12:03 p.m., there was one E size oxygen tank lying flat in the floor in Room 117.

2. At 1:55 p.m., there were one nitrogen and two E size carbon dioxide cylinders unsecured, on the floor, in the Sterile Core of Surgery.

Based on document review and staff interview, the facility failed to provide complete documentation of weekly generator inspections and failed to maintain the battery-powered back-up light at the generator set location. This was evidenced by a lack of documentation for weekly inspections for eight of 52 weeks in a twelve month period, and by a missing light bulb in the light fixture in the generator area. This affected all staff and patients in nine of nine smoke compartments, and could potentially result in generator failure or no light in the generator room during a power outage, if the generator failed to start.


NFPA 110, 5-3 Lighting.
5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.

Findings:

During record review with the Physical Plant Manager, on 3/5/13, generator logs were reviewed.

1. At 8:45 a.m., weekly generator inspections were missing for six of 52 weeks. During an interview, Maintenance Staff stated that the inspections were done, but not documented, for January and February of 2013

During a tour of the facility with with the Physical Plant Manager, on 3/5/13, the facility generator location was observed.

2. At 1:15 p.m., the bulb was missing in the generator light fixture that provides battery-powered task illumination.

Based on observation, the facility failed to comply with the regulations regarding electrical wiring and utilities. This was evidenced by high wattage devices that were plugged into power strips, by the use of extension cords, and by power strips that were linked together. This affected all staff and patients in three of nine smoke compartments and could potentially result in the ignition of an electrical fire.

1999 NFPA 70 - National Electrical Code
400.8 Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors.

110-12 requires that electrical equipment be installed in a neat and workman like manner.

370-25 Covers and Canopies. In completed installations, each box shall have a cover, faceplate, or fixture canopy.

NFPA 99 Health Care Facilities 1999 edition
3-3.2.1.2, All patient care areas.
(d)(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.


Findings:

During a tour of the facility with the Physical Plant Manager on 3/5/13, electrical wiring and equipment were observed.

1. At 11:20 a.m., the were two extension cords running from the Boiler Room to a light in the generator enclosure and to an ambulance unit near the generator.

2. At 11:50 a.m., there was an approximately 14-16 gauge ungrounded lamp cord in Room 100.

3. At 12:00 p.m., the Doctors' Sleep Room had three power strips that were linked together with one power strip running to the opposite side of the room to the wall outlet. There was a George Foreman Grill, a microwave oven, and a refrigerator that were all plugged into the end power strip.

4. At 12:55 p.m., there was an approximately 14-16 gauge ungrounded extension cord in the Radiology Registration Office.

5. At 1:02 p.m., the ceiling light fixture canopy cover was missing in the housekeeping closet by Room 241.

6. At 1:22 p.m., there was a four inch junction box missing a cover in Server Room 200.

7. At 2:12 p.m., there was a four foot florescent light fixture that was missing a canopy cover in the Trauma Room.