HospitalInspections.org

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The facility failed to provide corridor doors that would latch securely in the door frame without an impediments to the closing of the corridor doors. Findings include:

During the survey, the following is an example of what was observed.

1. Janitor room corridor door across from room 118 was held open by a wooden wedge.
2. Closet corridor door (originally Biomedical) located next to supply room was not positive latching.
3. Corridor door into Storage room next to kitchen did not positive latch.
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2000 NFPA 101, 19.2.2.2.6* Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.
2000 NFPA 101, 19.3.6.3.2* Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.

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The facility failed to maintain smoke barriers that would provide at least a half hour fire resistance rating. Findings include:

During the survey, the following are examples of what was observed.

1. Unsealed penetration at the smoke barrier in the corridor outside the Dining Room around a sprinkler line.
2. Unsealed penetration at the smoke barrier in the corridor outside Mammography around a sprinkler line and a large group of small cables.
3. Unsealed penetration at the smoke barrier at Room 106 around 2 electrical conduits, around a sprinkler line and a open hole in the barrier.
4. Unsealed penetration at the smoke barrier in the Lobby around existing piping.
5. Unsealed penetration at the smoke barrier in the corridor outside Room 118 around a 2 inch water line and around the bottom of a square metal duct.

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Review of NFPA 101, 19.3.7.3

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The facility failed to maintain smoke tight separation of hazardous areas. Findings include:

During the survey, the following are examples of what was observed:

1. In the Storage room next to the Kitchen there were missing ceiling tiles.
2. In the Generator/Boiler room there were missing ceiling tiles.
3. In Storage room across from Pharmacy room 105 has missing ceiling tile.

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2000 NFPA 101 19.3.2.1 Hazardous Areas.

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The facility failed to maintain the exit access per code. Findings include:

During the survey, the following are examples of what was observed:

The following doors in the path of egress were observed with more than one releasing operation:
1. Kitchen to Dining dutch door.
2. Kitchen corridor door next to Dishwashing
3. Dry Storage at Kitchen
4. Central Supply next to Cardiac Care
5. Cardiac Care fire door.
6. The door into the Storage room across from Pharmacy room 105
7. The door into room 107 .
8. Conference Vestibule door
9. Doctor Lounge door
10. X-ray door (#1) had a barrel bolt locking device installed on the door.
11. Radiologist room door

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2000 NFPA 101, 7.2.1.5.4 A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.

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The facility failed to maintain the horizontal exit per code. Findings include:

During the survey, the following are examples of what was observed.

1. Unsealed penetration at the fire barrier between the hospital and clinic around a group of conduits.
2. Unsealed penetration at the fire barrier in the stairwell, there is a large square hole in the wall.
3. Unsealed penetration at the fire barrier at the Elevator Room, there are several penetrations at 3 of the 4 walls.
4. The fire wall doors at the Cardiac Care Unit were being propped open with 2 plants.
5. At the 3-hour fire wall the door separating Grove Hill Hospital from Grove Hill Healthcare Clinic was held open by a rubber wedge preventing the fire door from closing in the event of a fire.

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2000 NFPA 101, 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. 2000 NFPA 101, 19.1.1.4.3 Doors in barriers required by 19.1.1.4.1 shall normally be kept closed.

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The facility failed to provide continuously illuminated exit signs. Findings include:

During the survey, the following is an example of what was observed.

1. Exit sign was not illuminated over the exit from the general storage room by Lab.
2. The Exit sign located above exit door at end of Central Delivery Hall was not illuminated.

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2000 NFPA 101, 7.10.5.2 Every sign required to be illuminated by 7.10.6.3 and 7.10.7 shall be continuously illuminated as required under the provisions of Section 7.8.

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The facility failed to provide a complete written fire safety plan per code. Findings include:

During the survey, the following is an example of what was observed:

The Fire Evacuation Plan does not include the evacuation from "smoke compartment to smoke compartment".

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2000 NFPA 101, 19.7.2.2 A written health care occupancy fire safety plan shall provide for the following: (1) Use of alarms (2) Transmission of alarm to fire department (3) Response to alarms (4) Isolation of fire (5) Evacuation of immediate area (6) Evacuation of smoke compartment (7) Preparation of floors and building for evacuation (8) Extinguishment of fire

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The facility failed to identify the location of the dedicated branch circuit(s) for the fire alarm system. Findings include:

During the survey the following is an example of what was observed:

Testing loss of Primary Power could not be conducted because the facility could not locate electrical panel/breaker that fed the Fire Alarm system.

This deficiency impacts 8 of 8 smoke compartments. Failure to maintain smoke compartments increases the risk of death or injury due to fire.
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1999 NFPA 72, 1-5.2.5.2 Connections to the light and power service shall be on a dedicated branch circuit(s). The circuit(s) and connections shall be mechanically protected. Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit.

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The facility failed to maintain sprinkler system per code. Findings include:

During the survey, the following is an example of what was observed:

The last documented sprinkler inspection was performed on 01-28-13

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2000 NFPA 101, 9.7.5 All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

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The facility failed to maintain the fire extinguishers per code. Findings include:
During the survey, the following is an example of what was observed:

1. The fire extinguisher in the MRI portable unit was not up to date on monthly inspections. Last inspection was 5/21/2014.
2. The fire extinguisher in the Generator/Boiler room opposite entrance door not current on monthly or annual inspections. No inspection tag attached.

This deficiency impacts 1 of 8 smoke compartments. Failure to maintain smoke compartments increases the risk of death or injury due to fire.
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1998 NFPA 10, 4-4.1 Frequency. Fire extinguishers shall be subjected to maintenance at intervals of not more than 1 year, at the time of hydrostatic test, or when specifically indicated by an inspection.

1998 NFPA 10, 4-4.4* Maintenance Recordkeeping. Each fire extinguisher shall have a tag or label securely attached that indicates the month and year the maintenance was performed and that identifies the person performing the service.

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The facility failed to provide noncombustible ashtrays for disposing of cigarette butts and ashes. Findings include: During the survey, the following is an example of what was observed.

At the exit to the 200 Hall there were excessive cigarette butts disposed of in the grass all around the exit. The amount of cigarette butts numbered between 50 to 75 butts. Per documentation the facility is smoke, so no ash can or ashtray was provided at exit to the 200 Hall.

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The facility failed to maintain the dietary hood. Findings include:

During the survey, the following is an example of what was observed:

1) The protective cap at 1 of the spray heads was observed to be missing.
2) Facility failed to provide hood inspection documentation for the last 12 months.

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1998 NFPA 17A, 2-3.1.4 All discharge nozzles shall be provided with caps or other suitable devices to prevent the entrance of grease vapors, moisture, or other foreign materials into the piping. The protection device shall blow off, open, or blow out upon agent discharge.
1998 NFPA 96, 8-2* Inspection. An inspection and servicing of the fire-extinguishing system and listed exhaust hoods containing a constant or fire-actuated water system shall be made at least every 6 months by properly trained and qualified persons.

1998 NFPA 96, 8-2.1 All actuation components, including remote manual pull stations, mechanical or electrical devices, detectors, actuators, and fire-actuated dampers, shall be checked for proper operation during the inspection in accordance with the manufacturer ' s listed procedures. In addition to these requirements, the specific inspection requirements of the applicable NFPA standard shall also be followed.

1998 NFPA 96, 8-2.2 Fusible links (including fusible links on fire-actuated damper assemblies) and automatic sprinkler heads shall be replaced at least annually, or more frequently if necessary, to ensure proper operation of the system. Other detection devices shall be serviced or replaced in accordance with the manufacturer ' s recommendations.

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Based on observation and review of documentation on 08/05/2014 the facility failed to provide a medical gas alarm panel that indicated audibly if a monitored condition occurred and to provide documentation of periodic maintenance and testing for nonflammable medical gas and related alarm systems. Findings include:

1. During the testing of the medical gas alarm panel at the Nurses' Station, the surveyor observed that the medical gas alarm panel failed to indicated audibly if a monitored condition occurred
2. Per documentation and interview the facility failed to conduct periodic maintenance and testing for nonflammable medical gas and related alarm systems.

The deficiency impacted 6 of 8 smoke compartments and has the potential to impact 18 of 18 of the patients. Building is licensed for 50 patients.

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Review of the 1999 NFPA 99, 4-3.1.2.2 Gas Warning Systems.

Review of the 1999 NFPA 99, 4-3.5.2.3 Patient Gas Systems - Level 1.

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The facility failed to maintain the electrical wiring and equipment per code. Findings include:

During the survey, the following are examples of what was observed:

1. The Elevator Equipment Room had a open electrical junction box with exposed wires above the ceiling.
2. Central Supply next to Cardiac Care was observed with a microwave plugged into a surge protector (extension cord).

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1999 NFPA 70, 370-25 and 410-12. Each box in completed installations to have a cover, face plate, or fixture canopy. 1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99. The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip.

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The facility failed to provide a sprinkler fire watch policy per code. Findings include:

During the survey, the following is an example of what was observed:

The facility failed to provide a complete sprinkler fire watch policy.

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2000 NFPA 101, 9.7.6.1 Where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service.

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The facility failed to provide a fire alarm fire watch policy per code. Findings include:

During the survey, the following is an example of what was observed:

The facility failed to provide a complete fire alarm fire watch policy.

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2000 NFPA 101, 9.6.1.8 Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.

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The facility failed to provide corridor doors that would latch securely in the door frame without an impediments to the closing of the corridor doors. Findings include:

During the survey, the following is an example of what was observed.

1. Janitor room corridor door across from room 118 was held open by a wooden wedge.
2. Closet corridor door (originally Biomedical) located next to supply room was not positive latching.
3. Corridor door into Storage room next to kitchen did not positive latch.
____________
2000 NFPA 101, 19.2.2.2.6* Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.
2000 NFPA 101, 19.3.6.3.2* Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.

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The facility failed to maintain smoke barriers that would provide at least a half hour fire resistance rating. Findings include:

During the survey, the following are examples of what was observed.

1. Unsealed penetration at the smoke barrier in the corridor outside the Dining Room around a sprinkler line.
2. Unsealed penetration at the smoke barrier in the corridor outside Mammography around a sprinkler line and a large group of small cables.
3. Unsealed penetration at the smoke barrier at Room 106 around 2 electrical conduits, around a sprinkler line and a open hole in the barrier.
4. Unsealed penetration at the smoke barrier in the Lobby around existing piping.
5. Unsealed penetration at the smoke barrier in the corridor outside Room 118 around a 2 inch water line and around the bottom of a square metal duct.

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Review of NFPA 101, 19.3.7.3

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The facility failed to maintain smoke tight separation of hazardous areas. Findings include:

During the survey, the following are examples of what was observed:

1. In the Storage room next to the Kitchen there were missing ceiling tiles.
2. In the Generator/Boiler room there were missing ceiling tiles.
3. In Storage room across from Pharmacy room 105 has missing ceiling tile.

_____________

2000 NFPA 101 19.3.2.1 Hazardous Areas.

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The facility failed to maintain the exit access per code. Findings include:

During the survey, the following are examples of what was observed:

The following doors in the path of egress were observed with more than one releasing operation:
1. Kitchen to Dining dutch door.
2. Kitchen corridor door next to Dishwashing
3. Dry Storage at Kitchen
4. Central Supply next to Cardiac Care
5. Cardiac Care fire door.
6. The door into the Storage room across from Pharmacy room 105
7. The door into room 107 .
8. Conference Vestibule door
9. Doctor Lounge door
10. X-ray door (#1) had a barrel bolt locking device installed on the door.
11. Radiologist room door

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2000 NFPA 101, 7.2.1.5.4 A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.

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The facility failed to maintain the horizontal exit per code. Findings include:

During the survey, the following are examples of what was observed.

1. Unsealed penetration at the fire barrier between the hospital and clinic around a group of conduits.
2. Unsealed penetration at the fire barrier in the stairwell, there is a large square hole in the wall.
3. Unsealed penetration at the fire barrier at the Elevator Room, there are several penetrations at 3 of the 4 walls.
4. The fire wall doors at the Cardiac Care Unit were being propped open with 2 plants.
5. At the 3-hour fire wall the door separating Grove Hill Hospital from Grove Hill Healthcare Clinic was held open by a rubber wedge preventing the fire door from closing in the event of a fire.

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2000 NFPA 101, 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. 2000 NFPA 101, 19.1.1.4.3 Doors in barriers required by 19.1.1.4.1 shall normally be kept closed.

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The facility failed to provide continuously illuminated exit signs. Findings include:

During the survey, the following is an example of what was observed.

1. Exit sign was not illuminated over the exit from the general storage room by Lab.
2. The Exit sign located above exit door at end of Central Delivery Hall was not illuminated.

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2000 NFPA 101, 7.10.5.2 Every sign required to be illuminated by 7.10.6.3 and 7.10.7 shall be continuously illuminated as required under the provisions of Section 7.8.

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The facility failed to provide a complete written fire safety plan per code. Findings include:

During the survey, the following is an example of what was observed:

The Fire Evacuation Plan does not include the evacuation from "smoke compartment to smoke compartment".

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2000 NFPA 101, 19.7.2.2 A written health care occupancy fire safety plan shall provide for the following: (1) Use of alarms (2) Transmission of alarm to fire department (3) Response to alarms (4) Isolation of fire (5) Evacuation of immediate area (6) Evacuation of smoke compartment (7) Preparation of floors and building for evacuation (8) Extinguishment of fire

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The facility failed to identify the location of the dedicated branch circuit(s) for the fire alarm system. Findings include:

During the survey the following is an example of what was observed:

Testing loss of Primary Power could not be conducted because the facility could not locate electrical panel/breaker that fed the Fire Alarm system.

This deficiency impacts 8 of 8 smoke compartments. Failure to maintain smoke compartments increases the risk of death or injury due to fire.
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1999 NFPA 72, 1-5.2.5.2 Connections to the light and power service shall be on a dedicated branch circuit(s). The circuit(s) and connections shall be mechanically protected. Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit.

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The facility failed to maintain sprinkler system per code. Findings include:

During the survey, the following is an example of what was observed:

The last documented sprinkler inspection was performed on 01-28-13

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2000 NFPA 101, 9.7.5 All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

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The facility failed to maintain the fire extinguishers per code. Findings include:
During the survey, the following is an example of what was observed:

1. The fire extinguisher in the MRI portable unit was not up to date on monthly inspections. Last inspection was 5/21/2014.
2. The fire extinguisher in the Generator/Boiler room opposite entrance door not current on monthly or annual inspections. No inspection tag attached.

This deficiency impacts 1 of 8 smoke compartments. Failure to maintain smoke compartments increases the risk of death or injury due to fire.
_______________

1998 NFPA 10, 4-4.1 Frequency. Fire extinguishers shall be subjected to maintenance at intervals of not more than 1 year, at the time of hydrostatic test, or when specifically indicated by an inspection.

1998 NFPA 10, 4-4.4* Maintenance Recordkeeping. Each fire extinguisher shall have a tag or label securely attached that indicates the month and year the maintenance was performed and that identifies the person performing the service.

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The facility failed to provide noncombustible ashtrays for disposing of cigarette butts and ashes. Findings include: During the survey, the following is an example of what was observed.

At the exit to the 200 Hall there were excessive cigarette butts disposed of in the grass all around the exit. The amount of cigarette butts numbered between 50 to 75 butts. Per documentation the facility is smoke, so no ash can or ashtray was provided at exit to the 200 Hall.

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The facility failed to maintain the dietary hood. Findings include:

During the survey, the following is an example of what was observed:

1) The protective cap at 1 of the spray heads was observed to be missing.
2) Facility failed to provide hood inspection documentation for the last 12 months.

_______________
1998 NFPA 17A, 2-3.1.4 All discharge nozzles shall be provided with caps or other suitable devices to prevent the entrance of grease vapors, moisture, or other foreign materials into the piping. The protection device shall blow off, open, or blow out upon agent discharge.
1998 NFPA 96, 8-2* Inspection. An inspection and servicing of the fire-extinguishing system and listed exhaust hoods containing a constant or fire-actuated water system shall be made at least every 6 months by properly trained and qualified persons.

1998 NFPA 96, 8-2.1 All actuation components, including remote manual pull stations, mechanical or electrical devices, detectors, actuators, and fire-actuated dampers, shall be checked for proper operation during the inspection in accordance with the manufacturer ' s listed procedures. In addition to these requirements, the specific inspection requirements of the applicable NFPA standard shall also be followed.

1998 NFPA 96, 8-2.2 Fusible links (including fusible links on fire-actuated damper assemblies) and automatic sprinkler heads shall be replaced at least annually, or more frequently if necessary, to ensure proper operation of the system. Other detection devices shall be serviced or replaced in accordance with the manufacturer ' s recommendations.

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Based on observation and review of documentation on 08/05/2014 the facility failed to provide a medical gas alarm panel that indicated audibly if a monitored condition occurred and to provide documentation of periodic maintenance and testing for nonflammable medical gas and related alarm systems. Findings include:

1. During the testing of the medical gas alarm panel at the Nurses' Station, the surveyor observed that the medical gas alarm panel failed to indicated audibly if a monitored condition occurred
2. Per documentation and interview the facility failed to conduct periodic maintenance and testing for nonflammable medical gas and related alarm systems.

The deficiency impacted 6 of 8 smoke compartments and has the potential to impact 18 of 18 of the patients. Building is licensed for 50 patients.

______________

Review of the 1999 NFPA 99, 4-3.1.2.2 Gas Warning Systems.

Review of the 1999 NFPA 99, 4-3.5.2.3 Patient Gas Systems - Level 1.

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The facility failed to maintain the electrical wiring and equipment per code. Findings include:

During the survey, the following are examples of what was observed:

1. The Elevator Equipment Room had a open electrical junction box with exposed wires above the ceiling.
2. Central Supply next to Cardiac Care was observed with a microwave plugged into a surge protector (extension cord).

------------------------------

1999 NFPA 70, 370-25 and 410-12. Each box in completed installations to have a cover, face plate, or fixture canopy. 1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99. The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip.

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The facility failed to provide a sprinkler fire watch policy per code. Findings include:

During the survey, the following is an example of what was observed:

The facility failed to provide a complete sprinkler fire watch policy.

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2000 NFPA 101, 9.7.6.1 Where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service.

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The facility failed to provide a fire alarm fire watch policy per code. Findings include:

During the survey, the following is an example of what was observed:

The facility failed to provide a complete fire alarm fire watch policy.

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2000 NFPA 101, 9.6.1.8 Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.