HospitalInspections.org

Unsealed openings/penetrations were observed in the fire walls as follows: During the survey, the following are examples of what was observed:


1. Unsealed penetrations around conduit in the 2 hour wall, by the Elevator at the Conference Room.

2. Unsealed penetrations around conduit in the 2 hour wall, by Patient Room 205.

------------------------------------------------
8.2.2.2* Fire compartments shall be formed with fire barriers that are continuous from outside wall to outside wall, from one fire barrier to another, or a combination thereof, including continuity through all concealed spaces, such as those found above a ceiling, including interstitial spaces. Walls used as fire barriers shall comply with Chapter 3 of NFPA 221, Standard for Fire Walls and Fire Barrier Walls. The NFPA 221 limitation on percentage width of openings shall not apply.

8.2.3.2.4.2* Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows:
(1) The space between the penetrating item and the fire barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire 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 fire barrier, the sleeve shall be solidly set in the fire 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 fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) * Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met:
a. The material shall be capable of maintaining the fire resistance of the fire barrier.
b. The material shall be protected by an approved device that is designed for the specific purpose.
(4) 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 fire barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

.

The facility failed to provide a maintain the building construction type per code. Building has been classificied as a type I(000) with partial sprinkler system. Findings include:

During the survey, the following are examples of what was observed:
1. OR Substerile Room had an unsealed penetration in the gypsum ceiling.
2. The OR Room had three unsealed penetrations in the gypsum ceiling.
3. The Outside Mechanical Room was missing ceiling tiles.
4. Surveyors could not verify if ceiling grid was one hour rated throughout facility.
5. The recessed light fixtures were not tented.
6. No fire dampers were observed in the HVAC ceiling supply and return diffusers.

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

2000 NFPA 101, 19.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)

Table 19.1.6.2 Construction Type Limitations
Construction Stories
Type
1 2 3 4 or
More
I(443) X X X X
I(332) X X X X
II(222) X X X X
II(111) X X* X* NP
II(000) X* X* NP NP
III(211) X* X* NP NP
III(200) X* NP NP NP
IV(2HH) X* X* NP NP
V(111) X* X* NP NP
V(000) X* NP NP NP
X: Permitted type of construction.
NP: Not permitted.
*Building requires automatic sprinkler protection. (See 19.3.5.1.)
.

The facility failed to provide corridor walls that would provide at least a 30 minute fire resistance rating. Findings include: During the survey, the following are examples of what was observed:

1. Unsealed penetrations around water lines, conduit, and at the deck, in the corridor wall by Patient Room 118.

2. Unsealed penetrations around conduit, and at the deck, in the corridor wall, at Nurse Station/Breakroom, near Patient Room 116.

3. Unsealed penetrations around water lines, and at the deck, in the corridor wall. by Patient room 119.

4. Unsealed penetrations at the end of a sleeve, in the corridor wall, by Patient Room 122.

5. Unsealed penetrations at the deck, in the corridor wall, by the Nursery.

6. Unsealed penetrations at the end of a sleeve, in the corridor wall, by Patient room 124.

7. Unsealed penetrations at the end of a sleeve, in the corridor wall, by Surgery Delivery.

8. Unsealed penetrations in the corridor wall, and around a section of duct, and at the deck, by Emergency Waiting Area.

9. Unsealed penetrations around a section of conduit, and at the deck, in the corridor wall, by the Kitchen Entrance.

10. Unsealed penetrations around a group of wiring, in the corridor wall, by Patient Room 102.

11. Unsealed penetrations around a black cable, in the corridor wall, by Patient room 106.

12. Unsealed penetrations around two beams, in the corridor wall, by Patient Room 107.


------------------------------------------------
NFPA 101, 19.3.6.1 Corridors in unsprinklered smoke compartments shall be separated from all other areas by partitions having a fire resistance rating of at least 30 minutes.

.

The facility failed to maintain the corridor openings per code. Findings include:

A) During the survey, the following are examples of what was observed:
1. Dining Room door failed to positive latch.
2. X-Ray door failed to positive latch.
3. The Dutch door between the kitchen/dining room failed to close tight so as to resist the passage of smoke.
4. The Exit from the OR was blocked at the discharge by a Decontamination Trailer. Also a vehicle was parked in means of egress, which both of these prevent/obstruct your means of egress to the public way from the facility.

--------------------------------
Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7 except as modified in 19.2.2-19.2.11.

NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments for full instant use in case of fire or other emergencies.




27382


B) During the survey, the following are examples of what was observed:
1. The OR Suite corridor door did not have positive latching hardware.
2. The following corridor doors had unsealed penetrations in them, near the door knobs:
a. Sitz Bath next to room 125
b. Room 125

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

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.

2000 NFPA 101, 19.3.6.3.1 Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.
.

An unsealed penetration at the end of a sleeve, in the elevator shaft was observed during the survey.

--------------------------------
NFPA 101, 19.3.1.1 and 8.2.5.4. minimum one-hour fire resistance rating is required.

.

The facility failed to provide exit signs. Findings include: During the survey, the following are examples of what was observed:


An exit sign was not provided for the exit between Rehab, and Shipping Receiving.

-----------------------------------------------
7.10.1.4 Exit access shall be marked by signs.

.

The facility failed to provide 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 penetrations around sections of conduit, in the Smoke Barrier, by the Main Lobby Exit.
2. Unsealed penetrations around conduit, and around a sprinkler line, in the Smoke Barrier, at the Main Entrance.
3. Unsealed penetrations at the end of a sleeve, in the Smoke Barrier, Admitting Lobby.
4. Unsealed penetrations at the end of a sleeve, in the Smoke Barrier, above the Public Telephone Sign, waiting area.
5. Unsealed penetrations in the corner of the Smoke Barrier, and at the deck, in the Dining Room.
6. Unsealed penetrations around conduit, in two separate locations, of the Smoke Barrier, in Patient Room 106.
7. Unsealed penetrations around a group of wiring, and around conduit, in the Smoke Barrier, by Patient Room 106.

-----------------------------------------------
NFPA 101, 19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.

NFPA 101, 8.3.2 Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.


.

The facility failed to maintain exits.

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

In the GPU wing three Exits from this area are equipped with magnetic locking devices, an emergency release switch was not provided.

------------------------------------------------
Alabama Department of Public Health Memo "Exit Door Locking Arrangements in Health Care Facilities" revised 12/19/03, as authority having jurisdiction: an "emergency release switch" or "kill switch" shall be provided at the nearest nurse's station.



27382


B) The facility failed to provide a path of travel per code. Findings include:

During the survey, the following are examples of what was observed:
The facility failed to provide an all weather sound path of travel to a public way from the following exits:
1. Both of the Geri-Psych. Unit
2. Stairway for the Cardiac Rehab. Unit

------------------------------------
2000 NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.
.

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

During the survey, the following are examples of what was observed:
1. The exit sign at the Engineers Office, the directional arrow was pointing in the wrong direction.
2. The exit sign at the ER exit was not illuminated.

---------------------------------------------------------
2000 NFPA 101, 7.10.2 A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent.
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.
.

The facility failed to provide a fire evacuation plan per code. Findings include:

During the survey, the following is an example of what was observed:
The fire evacuation plan provided by the facility did not include the evacuation of smoke compartments.

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

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
.

The facility failed to conduct fire drills quarterly. Findings include: During the survey, the following are examples of what was observed:


Documentation provided by the facility indicated that drills were not being conducted on all shifts quarterly. Documentation for staff participation was not provided, form to indicate proper procedures were being followed.


NFPA 101, 19.7.1.2 Fire drills shall be conducted at least quarterly on each shift and at unexpected times under varied conditions on all shifts to simulate the unusual conditions occurring in case of fire.


NFPA 101, 19.7.1.2 and 19.7.1.3 Drills shall include proper procedures, making sure all staff members participate.

.

Facility failed to maintain the Digital Alarm Communicator Transmitter in the fire alarm system. Findings include: During the survey, the following are examples of what was observed:


1. When the Auto Dialer was tested for phone line 1, failure was not indicated at the protected premise within the allotted four (4) minute time frame.

2. When the Auto Dialer was tested for phone line 2, failure was not indicated at the protected premise within the allotted four (4) minute time frame.

3. When the Auto Dialer was tested for Communication Failure, failure was not indicated at the protected premise within the allotted fifteen (15) minute time frame (5 minimum to 10 maximum attempts for signal transmission).

------------------------------------------------
1999 NFPA 72, Section 1-5.4.6, 5-5.3.2.1.5, and 5-5.3.2.1.6.2. Phone line and communication failure shall be indicated at the facility.


.

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

While conducting the Fire Alarm test, the surveyors were unable to hear the alarm in the corridor, at the Conference Room. There was not a horn/strobe located in this area.

2000 NFPA 101, 9.6.3.1 Occupant notification shall provide signal notification to alert occupants of fire or other emergency as required by other sections of this Code.

2000 NFPA 101,9.6.3.2 Notification shall be provided by audble and visible signals in accordance with 9.6.3.3 through 9.6.3.12.









27382


The facility failed to maintain the fire alarm system per code. Findings include:

During the survey, the following is an example of what was observed:
The audible fire alarm device by the Laboratory did not work, while testing the fire alarm system.

------------------------------------
1999 NFPA 72, 4-3.3.2 To ensure that audible private mode signals are clearly heard, they shall have a sound level at least 10 dBA above the average ambient sound level or 5 dBA above the maximum sound level having a duration of at least 60 seconds, whichever is greater, measured 5 ft (1.5 m) above the floor in the occupiable area.

.

A) Sprinkler coverage was observed during the survey not adequately provided. Findings include: During the survey, the following are examples of what was observed:

Two sprinklers were missing the escutcheon plate in the Rehab.

------------------------------------------------
2000 NFPA 13, 3-2.7.2 Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.


27382


B) The facility failed to maintain the automatic sprinkler system per code. Findings include:

During the survey, the following are examples of what was observed:
1. The Basement Mechanical Room was missing ceiling tiles.
2. The facility could not provide flame retardent documentation on the Cardiac Rehab. Unit's canvas awning (over 4'-0") and it was not sprinklered.

-----------------------------------------------
1999 NFPA 13, 5-8.4.2 Deflectors of sprinklers shall be aligned parallel to ceilings or roofs.
1999 NFPA 13, 5-8.4.1.1 Under unobstructed construction, the distance between the sprinkler deflector and the ceiling shall be a minimum of 1 in. (25.4 mm) and a maximum of 12 in. (305 mm).

1999 NFPA 13, 5-13.8.1 Sprinklers shall be installed under exterior roofs or canopies exceeding 4 ft (1.2 m) in width. Exception: Sprinklers are permitted to be omitted where the canopy or roof is of noncombustible or limited combustible construction.
.

A) The facility failed to provide required height for fire extinguishers. Findings
include: During the survey, the following are examples of what was observed:

The K-extinguisher, and dry chemical were mounted approximately 3 ft. from the top of the extinguisher, to the floor, both are located in the kitchen.

----------------------------------------
1998 NFPA 10, 1-6.10 Fire extinguishers weighting not more than 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 31/2 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).


27382


B) The facility failed to maintain the fire extinguishers per code. Findings include:

During the survey, the following is an example of what was observed:
The facility could not provide documentation of the October 2011 monthly inspection for the fire extinguisher in the Laboratory.

-------------------------------------------
1998 NFPA 10, 4-3.1 Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire extinguishers shall be inspected at more frequent intervals when circumstances require.

.

The facility failed to maintain the smoking policy per code. Findings include:

During the survey, the following is an example of what wass observed:
Per documentation provided by the facility and interviews with the staff, the facility does not allow smoking on the premises. Multiple cigarette butts were observed on the ground outside the exit for at the CT Room.

-----------------------------------------------------------------
2000 NFPA 101, 19.7.4 Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
Exception: In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
(2) Smoking by patients classified as not responsible shall be prohibited.
Exception: The requirement of 19.7.4(2) shall not apply where the patient is under direct supervision.
(3) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(4) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.
.

The facility failed to adequately perform testing and inspection of the dietary hood
extinguishment system. Findings include: During the survey, the following are examples of what was observed:


(A). Card attached to manual pull for dietary hood extinguishment system was blank for Sept/October, 2011.

(B). Placard identifying the use of k-extinguisher was not provided.

------------------------------------------------
NFPA 17, 9-2.1- On a monthly basis, inspection shall be conducted in accordance with the manufacturer 's listed installation and maintenance manual or owner 's manual. As a minimum, this "quick check " or inspection shall include verification of the following:
(a) The extinguishing system is in its proper location.
(b) The manual actuators are unobstructed.
(c) The tamper indicators and seals are intact.
(d) The maintenance tag or certificate is in place.
(e) The system shows no physical damage or condition that might prevent operation.
(f) The pressure gauge(s), if provided, is in operable range.
(g) The nozzle blow-off caps, where provided, are intact and undamaged.
(h) Neither the protected equipment nor the hazard has been replaced, modified, or relocated.


NFPA 96 7-2.1.1 A placard identifying the use of the extinguisher as a secondary backup means to the automatic fire suppression system shall be conspicuously placed near each portable fire extinguisher in the cooking area.

.

The facility failed to prohibit portable space heating devices. Findings include:

During the survey, the following are examples of what was observed:
The following rooms were observed with portable space heaters:
1. Nursery
2. Ante Room

------------------------------
2000 NFPA 101, 19.7.8 Portable space-heating devices shall be prohibited in all health care occupancies.
.

The facility failed to maintain the means of egress per code. Findings include:

During the survey, the following are examples of what was observed:
1. A "mail box" was mounted on the corridor wall at the corner by the Ladies Nurses Locker Room and across from the Engineers Office. The "mail box" was mounted where the bottom of it was 3'-0" above the finished floor. The "mail box" itself measured 3'-0" high and 18" deep.
2. The following items were observed in the corridor blocking the path of egress at the Main Nurses Station: an office desk, a filing cart, (2) computers with stands, another machine on a stand, and (2) scales.
3. Nine chairs were observed in the X-ray corridor blocking the path of egress.
4. A portable x-ray machine was observed in the x-ray/laboratory corridor blocking the path of egress.
5. A baby crib was observed in the corridor by room 125 blocking the path of egres.
6. Three lifts and (1) I.V. pole was observed in the corridor by the CT Room blocking the path of egress.

--------------------------------------------------------
2000 NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.
2000 NFPA 101, 7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof.
.

The facility failed to maintain the curtains/draperies per code. Findings include:

During the survey, the following are examples of what was observed:
The facility failed to provide documentation of the flame resistance of the curtains/draperies in the following rooms:
1. Conference Room
2. Medical Records
3. Geri-Psych. Unit

-----------------------------------------------------
2000 NFPA 101, 10.3.1 Where required by the applicable provisions of this Code, draperies, curtains, and other similar loosely hanging furnishings and decorations shall be flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.
.

The facility failed to maintain the medical gas storage per code. Findings include:

During the survey, the following are examples of what was observed:
1. Four medical gas cylinders (nitrous oxide) were observed unsecured in a closet with flamable material in OR's Central Sterile Supply Storage Room.
2. The facility was using the Outside Mechanical Room for the storage of the oxygen cylinders, full and empty. This room had flamable material stored in it.

-------------------------------------------------
1999 NFPA 99, 4-3.1.1.2
3. Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.
5. Storage locations for oxygen and nitrous oxide shall be kept free of flammable materials [see also 4-3.1.1.2(a)7].
6. Cylinders containing compressed gases and containers for volatile liquids shall be kept away from radiators, steam piping, and like sources of heat.
9. Containers shall not be stored in a tightly closed space such as a closet [see 8-2.1.2.3(c)].
.

Based upon observation and interview with Maintenance Director of Plant Operations, an alternate Emergency Power Plan was not provided during the survey. Purpose of plan is to have a written policy for a back-up generator in case the generator failed. This policy should be undated annually.

NFPA 110 6-1.2 Consideration shall be given to temporarily providing a portable or alternate source whenever the emergency generator is out of service.

.

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

During the survey, the following are examples of what was observed:
The facility failed to provide documentation on the following:
1. Weekly inspections and monthly load tests for the period between 09/17/2010 to 01/07/2011.
2. The weekly inspection for 10/28/2011.


--------------------------------------------------
1999 NFPA 110, 6-4.2 Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
The date and time of day for required testing shall be decided by the owner, based on facility operations.
1999 NFPA 110, 6-4.1 Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
.

The facility failed to maintain the generator remote annunciator per code. Findings include: During the survey, the following are examples of what was observed:

Not indicating "EPS" Supplying Load or Gen-set when the generator was tested.

--------------------------------
1999 NFPA 99, 3-4.1.1.15 A remote annunciator, storage battery powered, shall be provided to operate outside of the Generating Room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12.) The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows: (a) Individual visual signals shall indicate the following: 1. When the emergency or auxiliary power source is operating to supply power to load 2. When the battery charger is malfunctioning (b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following: 1. Low lubricating oil pressure 2. Low water temperature (below those required in 3-4.1.1.9) 3. Excessive water temperature 4.Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply 5. Overcrank (failed to start) 6. Overspeed Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. [110: 3-5.5.2]

.

A) The facility failed to provide receptacles for appliances. Findings include: During the survey, the following are examples of what was observed:


1. A junction box was missing the cover in the prep room.
2. A junction box was missing the cover above the ceiling at the drink machines Admitting Lobby Area.
3. A junction box was missing the cover above the ceiling in the Chapel.
4. A junction box was missing the cover above the ceiling in Patient room 123.
5. A junction box was missing the cover above the ceiling near Unsterile Storage.
6. Two junction boxes were missing covers above the ceiling by Surgery Delivery.
7. Refrigerator plugged into a overcurrent protection device in Respiratory Therapy.
8. Refrigerator located in the Kitchen, cord had been spiced together.

----------------------------------------------
1999 NFPA 70, 370-25 and 410-12. Each box in completed installations to have a cover, face late, or fixture canopy.

Appliances, such as air conditioners and refrigerators, shall plug directly into a receptacle. 1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99.

NFPA 101, 19.5.1 Utilities shall comply with NFPA 101, 9.1. Electrical utilities shall comply with 1999 NFPA 70, National Electrical Code.




27382


B) The facility failed to maintain the electrical system per code. Findings include:

During the survey, the following is an example of what was observed:
The OR did not have any electrical outlets designated to be supplied by the emergency generator.

----------------------------------------------
1999 NFPA 70, 517-33 (a) Receptacle Identification. The receptacles or the faceplates for receptacles supplied by the critical branch shall have a distinctive color or marking so as to be readily recognizable.

.