HospitalInspections.org

Reference NFPA 101, 2012 Edition

19.2.3.4* Any required aisle, corridor, or ramp shall be not less than 48 in. (1220 mm) in clear width where serving as means of egress from patient sleeping rooms, unless otherwise permitted by one of the following:
(1) Aisles, corridors, and ramps in adjunct areas not intended for the housing, treatment, or use of inpatients shall be not less than 44 in. (1120 mm) in clear and unobstructed width.
(2)*Where corridor width is at least 6 ft (1830 mm), noncontinuous projections not more than 6 in. (150 mm) from the corridor wall, above the handrail height, shall be permitted.
(3) Exit access within a room or suite of rooms complying with the requirements of 19.2.5 shall be permitted.
(4) Projections into the required width shall be permitted for wheeled equipment, provided that all of the following conditions are met:
(a) The wheeled equipment does not reduce the clear unobstructed corridor width to less than 60 in.(1525 mm).
(b) The health care occupancy fire safety plan and training program address the relocation of the wheeled equipment during a fire or similar emergency.
(c)*The wheeled equipment is limited to the following:
i. Equipment in use and carts in use
ii. Medical emergency equipment not in use
iii. Patient lift and transport equipment

Based on observation and interview, the facility failed to ensure projections into the required width of the egress (the action or right of going or coming out) corridors were in accordance with Life Safety Code 101. Transport equipment, such as wheel chairs, shall not reduce the clear unobstructed corridor width of egress corridors to less than 60 inches. Not maintaining required corridor width is likely to result in staff or other emergency personnel being unable to safely and timely evacuate residents in case of fire or other emergency, which presents the risk of potential harm to all patients, staff and visitors of emergency department. The findings are:

A. On 04/10/18 at 10:00 am, during observation within the emergency department, two (2) clean linen carts were placed on one side of the egress corridor and two (2) monitors on wheels were placed on the opposite side of the corridor. The width of egress was reduce to two (2) feet in this egress corridor.

B. On 04/10/18 at 10:03 am, during interview, the Plant Operations Director stated staff doesn't typically place equipment on both sides of the corridors.
























39903

National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition.

19.2 Means of Egress Requirements.

19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7, unless otherwise modified by 19.2.2 through 19.2.11.

7.1.10 Means of Egress Reliability.

7.1.10.1* General. 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.

7.1.10.2 Furnishings and Decorations in Means of Egress.

7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits or their access there to, egress there from, or visibility thereof.

Based on observation and interview, the facility failed to ensure means of egress (the action or right of going or exiting), exit access were maintained free of obstructions and impediments. Placing equipment and/or furnishings in corridors, and exit enclosures may result in staff, patients or visitors being unable to safely and timely evacuate in the event of fire or other emergency. This failed practice presents the risk of potential harm to patients, visitors and staff in the following areas. The findings are:

A. On 04/10/18 at 9:11 am, during observation of the northwest exit of the Intensive Care unit, a large chair, and equipment was placed near the exit in the corridor, which reduced the corridor width from eight (8) feet to four (4) feet.

B. On 04/10/18 at 10:23 am, during observation, two recliners, and a scale were observed to be blocking the exit in the infusion lab to the service corridor.

C. On 04/10/18 at 10:25 am, during interview, the Mechanical and Energy Infrastructure Manager stated, "We were not aware that these objects are obstructing the corridors and exits."

National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition.

19.3.2.1.1 An automatic extinguishing system, where used in hazardous areas, shall be permitted to be in accordance with 19.3.5.9.

9.7.3 Other Automatic Extinguishing Equipment.

9.7.3.1 In any occupancy where the character of the fuel for fire is such that extinguishment or control of fire is accomplished by a type of automatic extinguishing system in lieu of an automatic sprinkler system, such system shall be installed in accordance with the appropriate standard, as determined in accordance with Table 9.7.3.1.

National Fire Protection Association (NFPA) 2001, Standard for Clean Agent Fire Extinguishing Systems, 2012 Edition

4.3 Detection, Actuation, Alarm, and Control Systems.

4.3.1.1 Detection, actuation, alarm, and control systems shall be installed, tested, and maintained in accordance with appropriate NFPA protective signaling systems standards. (See NFPA 70 and 72)

National Fire Protection Association (NFPA) 72 National Fire Alarm and Signaling Code, 2010 Edition

18.5.2.5 Lights used to signal occupants to seek information or instructions shall be clear, nominal white, or other color as required by the emergency plan and the authority having jurisdiction for the area or building.

Based on observation and interview the facility failed to ensure, a separate distinctive visual signaling appliance (Horn/Strobe with a different color Lens) was installed for the FM-200 System in the main hospital located within the IT (Information Technology) Sever room within the materials management warehouse. This failed practice allows for the potential of not being able to readily identify and differentiate activation of the FM-200 System from the Main Fire Alarm system, and poses a potential hazard to staff working this is area, who may accidentally enter the IT room when the extinguishing agent has been released. This poses an asphyxiation hazard to anyone present in the area where the system discharges. The findings are:

A. On 4/10/18 at 11:30 am, during observation of the entrance to the IT Room in the Materials Management Warehouse, it was noted that the horn/strobe designated to identify activation of the FM-200 system showed a clear lens over the strobe device, which is the same as the Fire Alarm System Strobes.

B. On 4/10/18 at 11:34 am, during interview the Mechanical and Energy Infrastructure Manager advised, "We were not aware that different colored lenses are needed for the FM-200 Systems."

National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition

19.3.2.5.1 Cooking facilities shall be protected in accordance with 9.2.3, unless otherwise permitted by 19.3.2.5.2, 19.3.2.5.3, or 19.3.2.5.4.

National Fire Protection Association (NFPA) 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 Edition

11.6.13 When an exhaust cleaning service is used, a certificate showing the name of the servicing company, the name of the person performing the work, and the date of inspection or cleaning shall be maintained on the premises.

11.6.14 After cleaning or inspection is completed, the exhaust cleaning company and the person performing the work at the location shall provide the owner of the system with a written report that also specifies areas that were inaccessible or not cleaned.

Based on record review and interview, the facility failed to ensure the kitchen's range hood in the main cafeteria had been cleaned on a regular basis, as required by National Fire Protection Association (NFPA) 96 (Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations), by not having hood cleaning documentation available for review. Not cleaning the range hood on regular intervals could result in a a more rapidly and aggressive spreading fire conditions under the hood. This practice a risk of potential harm to any patients, visitors, and staff in the kitchen and cafeteria area. The findings are:


A. On 04/10/18 at 10:23 am, during a review of the range hood maintenance records, revealed no documentation indicating cleaning of the main range hood had been performed by a professional cleaning company. Additionally there was no further documentation showing such services performed prior to January 2018.

B. On 04/10/18 at 10:50 am, during interview, the Plant Operations Director stated, "We are having the services performed, but were not aware that the company was supposed to provide us with a written report."






National Fire Protection Association (NFPA) 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 Edition

5.1.4* Internal hood joints, seams, filter support frames, and appurtenances attached inside the hood shall be sealed or otherwise made greasetight.


Based on observation and interview facility failed to ensure the range hood located in the main kitchen was free of any open gaps or seams which would trap and accumulate grease. This failed practice could result in a highly flammable and aggressive fire in the kitchen/ cafeteria area, which presents harm to staff working in the kitchen as well as patients, visitors and staff who may be present in the dining area. The findings are:

A. On 04/10/18 at 11:19 am, during observation of the main kitchen, surveyor observed an open gap of approximately 3/4" inch to 1" inch gap in the center of the the two installed hoods. This gap also showed visible evidence of accumulation of cooking grease.

B. On 04/10/18, at 11:25 am, during interview, the Director of Plant Operations stated, "I wasn't aware of the open gap in the center of the hood."

NFPA 25, 2011 Edition

13.6.2 Testing.
13.6.2.1* All backflow preventers installed in fire protection system piping shall be tested annually by conducting a forward flow test of the system at the designed flow rate, including hose stream demand, where hydrants or inside hose stations are located downstream of the backflow preventer.

13.6.3 Maintenance.
13.6.3.1 Maintenance of all backflow prevention assemblies
shall be conducted by a trained individual following the manufacturer's
instructions in accordance with the procedure and policies of the authority having jurisdiction.


Based on record review and interview, the facility failed to ensure the backflow preventer assemblies installed in the facility's wet fire protection system piping, were tested annually as required by NFPA 25 (Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems). The backflow preventer protects water supplies from contamination or pollution due to backflow from the sprinkler system. This failed practice is likely to result in contamination of the facility's potable water supply, which presents a risk of potential harm to all patients, staff and visitors of the facility. The findings are:

A. Record review of the fire sprinkler system maintenance records with the Director of Plant Operations revealed no evidence the backflow preventer assemblies installed on the wet sprinkler system were being tested at least every twelve (12) months.

B. On 04/09/18 at 3:05 pm, during interview the Plant Operations Director stated the facilty has about eight sprinkler risers that all have backflow preventer devices. He stated he did not know the backflow preventers were not being tested under the former Director of Plant Operations. He stated the testing has since been scheduled.







34719


Reference NFPA (National Fire Prevention Association) 25 (Standard for the Inspection, Testing and Maintenance of Water Based Fire Protection Systems), 2011 Edition

14.2.1 Except as discussed in 14.2.1.1 and 14.2.1.4 an inspection of piping and branch line conditions shall be conducted every 5 years by opening a flushing connection at the end of one main and by removing a sprinkler toward the end of one branch line for the purpose of inspecting for the presence of foreign organic and inorganic material.
14.2.1.1 Alternative nondestructive examination methods shall be permitted.
14.2.1.2 Tubercules or slime, if found, shall be tested for indications of microbiologically influenced corrosion (MIC).
14.2.1.3* If the presence of sufficient foreign organic or inorganic material is found to obstruct pipe or sprinklers, an obstruction investigation shall be conducted as described in Section 14.3.
14.2.1.4 Non-metallic pipe shall not be required to be inspected internally.


Based on record review and interview, the facility failed to ensure an internal piping investigation was conducted at least every 5 years as required by NFPA 25 (Standard for the Inspection, Testing and Maintenance of Water-Based fire Protection Systems). Not internally inspecting sprinkler piping is likely to result in the presence of foreign organic material (i.e. micro-biologically influenced corrosion) and inorganic material (i.e. rust and scale, gravel, sand) in the piping that is likely to cause obstructions to water flow during a fire, which presents a risk of potential harm to all patients, staff and visitors within the facility. The findings are:

A. On 04/09/18 at 1:40 pm, review of the sprinkler maintenance records failed to reveal evidence that an Internal Piping Investigation was conducted within the last five years.

B. On 04/09/18 at 1:50 pm, during interview with the Director of Plant Operations stated "no internal piping investigation had been conducted, and Mechanical and Energy Ifrastructure Manager has since schedule an internal inspection.






NFPA (National Fire Protection Association) 25 Standard for the Inspection, Testing and Maintenance for Water Based Fire Protection Systems (2011 Edition)

13.3.2 Inspection
13.3.2.1 All valve shall be inspected weekly.
13.3.2.1.2 Valves secured with locks or supervising in accordance with applicable NFPA standards shall be permitted to be inspected monthly.
13.3.2.1.2 After any alterations or repairs, an inspection shall be made by the property owner or designated representative to ensure that the system is in service and all valves are in the normal position and properly sealed, locked, or electrically supervised.

13.3.2.2 The valve inspection shall verify that the valves are in the following condition:
(1) In the normal open or closed position
(2) Sealed, locked, or supervised
(3) Accessible
(4) Provided with correct wrenches
(5) Free from external leaks
(6) Provided with applicable identification


Based on record review and interview, facility failed to ensure all sprinkler control valves were visually inspected on a monthly basis. Not visually inspecting control valves monthly could result in a control valve being removed from it's proper working position, which could result in the failure of the sprinkler system supplying water to extinguishing a fire. This failed practice presents a potential risk of injury by fire to all patients, staff and visitors within the facility. The findings are:

A. On 04/09/18 at. 1:15 pm, during record review no documentation was provided to indicate monthly valve inspections were being conducted.

B. On 04/09/18 at 1:25 pm, during interview the Director of Plant Operations, Mechanical and Energy Infrastructure Manager stated "the procedure will be inserted into a preventative maintenance schedule on a monthly basis".

Reference NFPA 90A, 2012 Edition

5.4.8 Maintenance.

5.4.8.1 Fire dampers and ceiling dampers shall be maintained in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protective's.

5.4.8.2 Smoke dampers shall be maintained in accordance with NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protective's.


Based on record review and interview, the facility failed to ensure fire/smoke dampers were maintained as required by NFPA 90A (Standard for Installation of Air Conditioning and Ventilating Systems) and NFPA 80 (Standard for Fire Doors and other Opening Protective's) and NFPA 105 (Standard for Smoke Door Assemblies and other Opening Protectives). Without this preventative maintenance and in the event of fire, the distribution of smoke, hot gases and fire could travel from one area to another through the ventilation air duct system, which presents the risk of potential harm to all patients, staff and visitors of the facility. The findings are:


A. Record review of the facility's maintenance records revealed that the fire and smoke dampers were inspected February, 2013. However, there was no evidence demonstrating corrective action was taken to address the problems noted in the damper inspection.

B. On 04/09/18 at 3:30 pm, during interview, the Mechanical & Energy Infrastructure Manager stated Plant Operations was unaware the problems noted in the damper inspection [February, 2013] were never addressed by the previous Plant Operations Administration. He stated the dampers have since been scheduled to be repaired.












39903

National Fire Protection Association (NFPA) Life Safety Code 101, 2012 Edition.

19.5.2.1 Heating, ventilating, and air-conditioning shall comply with the provisions of Section 9.2 and shall be installed in accordance with the manufacturer's specifications, unless otherwise modified by 19.5.2.2.

Based on observation and interview, facility failed to ensure exhaust ventilation was installed/operating continuously in required hazardous areas. Not having exhaust ventilation installed/operating, could result in the accumulation of noxious fumes/ vapors. This presents a risk of physical harm/sickness to all patients, visitors and staff. The findings are:

A. On 04/10/18 at 9:15 am, during observation, the exhaust fan located within the old Teli Hallway Janitors Closet was not actively running/operational, which prevents the removal of any humidity, fumes or noxious vapors from any cleaning chemicals to escape the enclosure.

B. On 04/10/18 at 9:35 am, during observation, the exhaust fan located within the Soiled Utility Room in the White Sands Hall of the Behavioral Medicine Unit was not actively running/ operational, this prevents the removal of any humidity and fumes from within the enclosure.

C. On 04/10/18 at 9:38 am, during interview, the Plant Operations Director stated, "We were not aware that the exhaust is not operating in these rooms".

Based on record review and interview, the facility failed to ensure fire drills were conducted at least quarterly on all three nursing shifts to ensure preparedness for emergency response (Federal regulations require that fire drills shall not exceed 90-day spacing between drills on each shift). This deficient practice could likely result in staff not being adequately prepared to exercise their duties in accordance to the facility's fire preparedness plan in the event of fire, which presents a risk of potential harm to all patients, staff, and visitors within the facility. The findings are:

A. On 04/09/18, at 2:10 pm, record review of the fire drill log indicated the facility had three (3) nursing shifts.

First Shift (7:00 am - 3:00 pm)
Second Shift (3:00 pm - 11:00 pm)
Third Shift (11:00 pm - 7:00 am)

B. Record review also indicated the third shift did not conduct drills between the months of April, 2017 through August, 2017.


C. On 04/09/18 at 2:30 pm, during interview, the Administrative Secretary for Plant Operations stated "she could not locate documentation to indicate drills had been conducted between the months of April, 2017 through August, 2017".

NFPA (National Fire Preventation Association) 101 Life Safety Code 2012 Edition

19.3.2.4 Medical Gas, Medical gas storage and administration areas shall be in accordance with Section 8.7 and the provisions of NFPA 99, (Health Care Facilities Code), applicable to administration, maintenance, and testing.

NFPA 99 (Health Care Facilities Code), 2012 Edition

5.1.14.4 Medical Gas and Vacuum Systems Maintenance and Record Keeping. See B.5.2
5.1.14.4.1 Permanent records of all tests required by 5.1.12.3.1 through 5.1.12.3.14 shall be maintained in the organization's files.
5.1.14.4.2 The supplier of the bulk cryogenic liquid system shall, upon request, provide documentation of vaporizer(s) sizing criteria to the facility.
5.1.14.4.3 An annual review of bulk system capacity shall be conducted to ensure the source system has sufficient capacity.
5.1.14.4.4 Central supply systems for nonflammable medical gases shall conform to the following:

(1) They shall be inspected annually.
(2) They shall be maintained by a qualified representative of the equipment owner.
(3) A record of the annual inspection shall be available for review by the authority having jurisdiction.


Based on record review and interview, facility failed to ensure category 1 medical gas systems were inspected/tested on an annual basis. Not maintaining medical gas systems as required could result in the failure of the system to supply medical gas to the facility or the failure of the system releasing gases, which could result in a fire. This failed practice presents a risk of injury to all patients, staff and visitors within the facility. The findings are;

A. On 04/09/18, at 1:55 pm, "during record review of the medical gas systems, the provide any documentation to indicate the medical gas systems had been inspected/tested within the last twelve (12), months. Last servicing of system was conducted in 2013.

B. On 04/09/18, at 2:05 pm, during interview the Plant Operations Supervisor stated, "the previous Plant Operations Supervisor had not scheduled the inspections required".

NFPA (National Fire Protection Association) 110 Standard for Emergency and Standby Power Systems (2010 Edition)

8.3.7 Storage batteries, including electrolyte levels or battery voltage, used in connection with systems shall be inspected weekly and maintained in full compliance with manufacturer's specifications.

8.3.7.1 Maintenance of lead-acid batteries shall include the monthly testing and recording of electrolyte specific gravity. Battery conductance testing shall be permitted in lieu of the testing specific gravity when applicable or warranted.

Based on observation and interview, facility failed to ensure the Emergency Generator batteries had specific gravity readings taken from all cells. Not taking specific gravity readings on cells and on all batteries could result in the failure of the Emergency Generator starting in the event of a main power outage, which could leave the facility without electrical power. This failed practice presents a risk of potential harm to all patients, staff and visitors within the facility. The findings are:

A. On 04/09/18, at 2:25 pm, during record review of the facilities Emergency Generator's (4 units) documentation provided indicated specific gravity was not being taken from each cell on all the batteries, for all four generators.

B. On 04/09/18, at 2:35 pm, during interview the Director of Plant Operations and Facilities Electrician stated, "they would include all cells, on all batteries for monthly testing of specific gravity".