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Based on review of facility documentation it was determined the hospital failed to inspect, test and maintain all components of the hospital fire alarm system annually and in accordance with National Fire Protection Association (NFPA) 72. Findings include:

1. On 10/18/10 at approximately 3:00 p.m., the hospital annual fire alarm inspection reports for the previous twelve (12) month period were reviewed. The reports were prepared by Simplex Grinnell Company and dated 09/20/10, 06/22/10, 03/31/10, and 12/29/09. These reports identified the following devices failed or were not tested:

a. Seventeen (17) audio/visual signal devices in the Behavior Science Unit (BSU) were not tested.
b. Two (2) photo smoke detectors on the 4th floor were not tested and one (1) smoke detector failed.
c. Three (3) analog smoke detectors, one (1) pull station and one (1) audio/visual signal devices were not tested on the 1st floor. Two (2) audible devices failed on the 1st floor.
d. M4-63 is indicating a no answer trouble on the fire alarm control panel. The customer has removed the device. Control panel Multiplex failed. Key switch failed 3rd floor (LED inoperative).

2. At the time of this survey, there was no documented evidence available to indicate that the devices that failed during these inspections were repaired or replaced.

3. This practice does not meet the requirement of annually (twelve (12) month interval) inspecting, testing and maintaining all components of the hospital fire alarm system.

Based on documentation review it was determined the hospital failed to inspect, test and maintain the automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 25. Findings include:

1. On 10/20/10 at approximately 11:00 p.m., the quarterly sprinkler reports for the previous twelve (12) month period were reviewed. These reports were prepared by Simplex Grinnell and dated 09/07/10, 06/28/10, 03/18/10 and 12/28/09. According to these reports, the sub basement (zone #1) was not inspected and tested for the 1st and 3rd quarter. Also, the inspection report dated 09/07/10 indicated the tamper switch for the 3rd floor (zone #3) did not signal fire alarm control panel and the tamper switch on the valve in the hall for the basement (zone #1) did not send signal to the panel.

2. At the time of this survey, there was no documented evidence available to indicate that the tamper switches that failed had been repaired or replaced.

National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 1999 Edition
Chapter 8 Gas Equipment
8-3.1.11 Storage Requirements.
8-3.1.11.3 Signs.
A precautionary sign, readable from a distance of 5 ft (1.5 m), shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum:
CAUTION
OXIDIZING GAS(ES) STORED WITHIN
NO SMOKING

8-3.1.11.2
Storage for nonflammable gases less than 3000 ft3 (85 m3).
1. Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry.
2. Oxidizing gases, such as oxygen and nitrous oxide, shall not be stored with any flammable gas, liquid, or vapor.
3. Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by either:
a. A minimum distance of 20 ft (6.1 m), or
b. A minimum distance of 5 ft (1.5 m) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, or
c. An enclosed cabinet of noncombustible construction having a minimum fire protection rating of one-half hour for cylinder storage. An approved flammable liquid storage cabinet shall be permitted to be used for cylinder storage.

This Standard is not met as evidenced by:

Based on observation it was determined the hospital failed to store all oxygen cylinders in accordance with NFPA 99. Findings include:

1. During a tour of the hospital x-ray department on 10/19/10 at approximately 3:30 p.m., eleven (11) small oxygen cylinders were observed stored in a room identified as bone densitometry. This room was not identified with a proper sign as having oxygen storage.

2. On 10/20/10 at approximately 10:00 a.m., fourteen (14) small oxygen cylinders were observed stored in the clean utility room in the emergency department. These oxygen cylinders were stored approximately one (1) foot from combustible materials (carts of clean bed linens). Also, there was not a proper sign identifying this room as having oxygen storage.

Based on review of facility documentation it was determined the hospital failed to maintain the medical gas system in accordance with National Fire Protection Association (NFPA) 99, Chapter 4. Findings include:

1. On 10/18/10 at approximately 3:00 p.m., a medical gas system inspection report prepared by Environmental Monitoring Technology and dated 11/09/09 was reviewed. This report indicated the following deficiencies were found during the medical gas inspection:

a. The oxygen system does not have a local alarm signal at the pad.
b. There is not a "Reserve Low Pressure" master alarm for the oxygen system.
c. Gas specific demand check valve is not installed on main gauge and oxygen sensor.
d. The MEDAES vacuum system does not have a properly installed (brazed) source valve.
e. The MEDAES vacuum system main gauge is not installed in the proper location.
f. The low pressure alarm switch and main vacuum gauge are not installed in the proper location (should be upstream of source valve).
g. All alarm panels must be labeled for area under surveillance.
h. The warning panels in the boiler room and PBX each have two (2) vacuum line pressure low alarms. These need to be labeled for the vacuum pump controlled (MEDAES or INGERSOL RAND).
i. PBX warning panel audible alarm is not working.
j. Local signal plus two (2) master alarm panels, one (1) monitored 7/24? (answer NO)
k. Does the "Reserve Low-Pressure" alarm operate properly? (answer NO).
l. Gas specific demand check valve installed on main gauge/oxygen sensor? (answer NO).
m. Is the main gauge installed in the proper location? (answer NO).
n. Properly installed (brazed) source valve (main if required)? (answered NO).
o. Is the alarm sensor installed immediately downstream of source valve? (answered NO).

2. At the time of this survey, there was no documented evidence to indicate the aforementioned deficiencies have been corrected.

National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities
Chapter 3 Electrical Systems
3-3.3.4.2 Line Isolation Monitor Tests.
The proper functioning of each line isolation monitor (LIM) circuit shall be ensured by the following:
(a) The LIM circuit shall be tested after installation, and prior to being placed in service, by successively grounding each line of the energized distribution system through a resistor of 200 V ohms, where V = measured line voltage. The visual and audible alarms [see 3-3.2.2.3(b)] shall be activated.
(b) The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch [see 3-3.2.2.3(f)]. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators.
Based on staff interview it was determined the hospital failed to maintain all electrical wiring and equipment in accordance with NFPA 99.
(c) After any repair or renovation to an electrical distribution system and at intervals of not more than 6 months, the LIM circuit shall be tested in accordance with paragraph (a) above and only when the circuit is not otherwise in use. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months.

This Standard is not met as evidenced by:

Based on observation and documentation review it was determined the hospital failed to maintain all electrical wiring/equipment in accordance with NFPA 99. Findings include:

1. On 10/18/10 at approximately 12:10 p.m., a tour of the facility dietary department was conducted. At this time, three (3) extension cords were observed in use for equipment.

2. On 10/19/10 at approximately 3:00 p.m., a tour of the hospital operating rooms was conducted. At this time, four (4) of four (4) LIM (line isolation monitors) were observed to have safety check stickers dated 2006. Also, at the time of this survey there was no documented evidence available to verify certification of the line isolation monitors located in the operating rooms.

Based on review of facility documentation it was determined the hospital failed to inspect, test and maintain all components of the hospital fire alarm system annually and in accordance with National Fire Protection Association (NFPA) 72. Findings include:

1. On 10/18/10 at approximately 3:00 p.m., the hospital annual fire alarm inspection reports for the previous twelve (12) month period were reviewed. The reports were prepared by Simplex Grinnell Company and dated 09/20/10, 06/22/10, 03/31/10, and 12/29/09. These reports identified the following devices failed or were not tested:

a. Seventeen (17) audio/visual signal devices in the Behavior Science Unit (BSU) were not tested.
b. Two (2) photo smoke detectors on the 4th floor were not tested and one (1) smoke detector failed.
c. Three (3) analog smoke detectors, one (1) pull station and one (1) audio/visual signal devices were not tested on the 1st floor. Two (2) audible devices failed on the 1st floor.
d. M4-63 is indicating a no answer trouble on the fire alarm control panel. The customer has removed the device. Control panel Multiplex failed. Key switch failed 3rd floor (LED inoperative).

2. At the time of this survey, there was no documented evidence available to indicate that the devices that failed during these inspections were repaired or replaced.

3. This practice does not meet the requirement of annually (twelve (12) month interval) inspecting, testing and maintaining all components of the hospital fire alarm system.

Based on documentation review it was determined the hospital failed to inspect, test and maintain the automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 25. Findings include:

1. On 10/20/10 at approximately 11:00 p.m., the quarterly sprinkler reports for the previous twelve (12) month period were reviewed. These reports were prepared by Simplex Grinnell and dated 09/07/10, 06/28/10, 03/18/10 and 12/28/09. According to these reports, the sub basement (zone #1) was not inspected and tested for the 1st and 3rd quarter. Also, the inspection report dated 09/07/10 indicated the tamper switch for the 3rd floor (zone #3) did not signal fire alarm control panel and the tamper switch on the valve in the hall for the basement (zone #1) did not send signal to the panel.

2. At the time of this survey, there was no documented evidence available to indicate that the tamper switches that failed had been repaired or replaced.

National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 1999 Edition
Chapter 8 Gas Equipment
8-3.1.11 Storage Requirements.
8-3.1.11.3 Signs.
A precautionary sign, readable from a distance of 5 ft (1.5 m), shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum:
CAUTION
OXIDIZING GAS(ES) STORED WITHIN
NO SMOKING

8-3.1.11.2
Storage for nonflammable gases less than 3000 ft3 (85 m3).
1. Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry.
2. Oxidizing gases, such as oxygen and nitrous oxide, shall not be stored with any flammable gas, liquid, or vapor.
3. Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by either:
a. A minimum distance of 20 ft (6.1 m), or
b. A minimum distance of 5 ft (1.5 m) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, or
c. An enclosed cabinet of noncombustible construction having a minimum fire protection rating of one-half hour for cylinder storage. An approved flammable liquid storage cabinet shall be permitted to be used for cylinder storage.

This Standard is not met as evidenced by:

Based on observation it was determined the hospital failed to store all oxygen cylinders in accordance with NFPA 99. Findings include:

1. During a tour of the hospital x-ray department on 10/19/10 at approximately 3:30 p.m., eleven (11) small oxygen cylinders were observed stored in a room identified as bone densitometry. This room was not identified with a proper sign as having oxygen storage.

2. On 10/20/10 at approximately 10:00 a.m., fourteen (14) small oxygen cylinders were observed stored in the clean utility room in the emergency department. These oxygen cylinders were stored approximately one (1) foot from combustible materials (carts of clean bed linens). Also, there was not a proper sign identifying this room as having oxygen storage.

Based on review of facility documentation it was determined the hospital failed to maintain the medical gas system in accordance with National Fire Protection Association (NFPA) 99, Chapter 4. Findings include:

1. On 10/18/10 at approximately 3:00 p.m., a medical gas system inspection report prepared by Environmental Monitoring Technology and dated 11/09/09 was reviewed. This report indicated the following deficiencies were found during the medical gas inspection:

a. The oxygen system does not have a local alarm signal at the pad.
b. There is not a "Reserve Low Pressure" master alarm for the oxygen system.
c. Gas specific demand check valve is not installed on main gauge and oxygen sensor.
d. The MEDAES vacuum system does not have a properly installed (brazed) source valve.
e. The MEDAES vacuum system main gauge is not installed in the proper location.
f. The low pressure alarm switch and main vacuum gauge are not installed in the proper location (should be upstream of source valve).
g. All alarm panels must be labeled for area under surveillance.
h. The warning panels in the boiler room and PBX each have two (2) vacuum line pressure low alarms. These need to be labeled for the vacuum pump controlled (MEDAES or INGERSOL RAND).
i. PBX warning panel audible alarm is not working.
j. Local signal plus two (2) master alarm panels, one (1) monitored 7/24? (answer NO)
k. Does the "Reserve Low-Pressure" alarm operate properly? (answer NO).
l. Gas specific demand check valve installed on main gauge/oxygen sensor? (answer NO).
m. Is the main gauge installed in the proper location? (answer NO).
n. Properly installed (brazed) source valve (main if required)? (answered NO).
o. Is the alarm sensor installed immediately downstream of source valve? (answered NO).

2. At the time of this survey, there was no documented evidence to indicate the aforementioned deficiencies have been corrected.

National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities
Chapter 3 Electrical Systems
3-3.3.4.2 Line Isolation Monitor Tests.
The proper functioning of each line isolation monitor (LIM) circuit shall be ensured by the following:
(a) The LIM circuit shall be tested after installation, and prior to being placed in service, by successively grounding each line of the energized distribution system through a resistor of 200 V ohms, where V = measured line voltage. The visual and audible alarms [see 3-3.2.2.3(b)] shall be activated.
(b) The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch [see 3-3.2.2.3(f)]. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators.
Based on staff interview it was determined the hospital failed to maintain all electrical wiring and equipment in accordance with NFPA 99.
(c) After any repair or renovation to an electrical distribution system and at intervals of not more than 6 months, the LIM circuit shall be tested in accordance with paragraph (a) above and only when the circuit is not otherwise in use. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months.

This Standard is not met as evidenced by:

Based on observation and documentation review it was determined the hospital failed to maintain all electrical wiring/equipment in accordance with NFPA 99. Findings include:

1. On 10/18/10 at approximately 12:10 p.m., a tour of the facility dietary department was conducted. At this time, three (3) extension cords were observed in use for equipment.

2. On 10/19/10 at approximately 3:00 p.m., a tour of the hospital operating rooms was conducted. At this time, four (4) of four (4) LIM (line isolation monitors) were observed to have safety check stickers dated 2006. Also, at the time of this survey there was no documented evidence available to verify certification of the line isolation monitors located in the operating rooms.