HospitalInspections.org

Based on observation and interview, the facility failed to maintain a 2-hour fire separation between the Hospital (Health Care) and Clinic (Business Occupancy). This deficient practice would allow smoke and fire to migrate from the Clinic into the Cardiac Rehab. area. The facility census was 5.

Findings are:

Observation on 7-11-18 at 1:21 pm revealed the 90-minute fire door between the Medical Clinic and the Hospital next to Exam room 4, failed to latch within the door frame when closed. The door could be pushed open without pushing the door release.

During an interview on 7-11-18 at 1:21 pm, Maintenance A confirmed the 90-minute fire door failed to latch.

Based on observation and interview the facility failed to provide a kitchen exhaust hood system that was seamless and liquid tight and failed to repair unsealed openings in the hood. This deficient practice would not allow the kitchen hood to capture grease laden cooking vapors, would allow the accumulation of grease in the seams and joints of the hood and could prevent the fire suppression system from operating as designed in the occurrence of a kitchen cooking fire. The facility census was 5.

Findings are:

Observations on 7-11-18 at 1:40 pm revealed the kitchen cooking exhaust hood was painted, and contained several unsealed penetrations. The ductwork above the baffle filters was not seamless or liquid tight and appeared to be HVAC duct. The transition from the hood to the ductwork was neither welded nor made with an approved, flanged, bolt-on connection.

During an interview on 7-11-18 at 1:40 pm, Maintenance A confirmed the findings.

Based on interview and record review, the facility failed to provide a complete policy regarding the procedures to be taken in the event that the fire alarm system was out of service for more than four hours in any twenty-four hour period. The lack of a complete written policy and procedure could result in staff failing to implement interim safety measures in the event of an emergency affecting all residents. Facility census was 5.

Findings are:

Record review on 7-11-18 at 11:40 am revealed, the facility failed to provide a copy of the facility's Fire Watch Policy.

During interview on 7-11-18 at 11:40 am, Maintenance A confirmed the findings.

Based on observation and interview, the facility failed to provide fire sprinkler protection for a storage closet. This deficient practice would allow a fire to spread without fire sprinkler protection during a fire emergency which would affect all in the facility. The facility census was 5.

Findings are:

Observations on 7-11-18 at 1:23 pm, revealed the storage closet across from the nurses station had no fire sprinkler protection provided.

During an interview on 7-11-18 at 1:23 pm, Maintenance A confirmed the lack of fire sprinkler protection for the storage closet.

Based on documentation review and interview, the facility failed to conduct a 5-year internal pipe and valve inspection. These deficient practices did not ensure all fire sprinklers were in operable condition and increased the potential that the system would not operate as designed. The facility census was 5.

Findings are:

Fire Sprinkler documentation review on 7-11-18 at 12:16 pm revealed the 5-year internal pipe and valve inspection was last done in 2007.

During an interview on 7-11-18 at 12:16 pm, Maintenance A confirmed the last 5-year internal inspection was last completed in 2007.

Based on record review and interview, the facility did not assure that a complete policy was in place regarding the procedures to be taken in the event that the sprinkler system is out of service for more than ten hours in any twenty-four hour period. The lack of a complete written policy and procedure would result in staff failing to implement interim safety measures in the event of an emergency. This deficient practice affected all residents. This facility census was 5.

Findings are:

Record review on 7-11-18 at 11:42 am, of the fire watch procedures revealed the facility did not have a policy regarding the procedures to be taken in the event that the sprinkler system was out of service for more than ten hours in a twenty-four hour period.

During an interview on 7-11-18 at 11:42 am, Maintenance A confirmed the lack of a policy.

NFPA Standard:
NFPA 25, 2011
15.5* Preplanned Impairment Programs.
15.5.1 All preplanned impairments shall be authorized by the impairment coordinator.
15.5.2 Before authorization is given, the impairment coordinator shall be responsible for verifying that the following procedures have been implemented:
(1) The extent and expected duration of the impairment have been determined.
(2) The areas or buildings involved have been inspected and the increased risks determined.
(3) Recommendations have been submitted to management or the property owner or designated representative.
(4) Where a required fire protection system is out of service for more than 10 hours in a 24-hour period, the impairment coordinator shall arrange for one of the following:
(a) Evacuation of the building or portion of the building affected by the system out of service
(b)*An approved fire watch
(c)*Establishment of a temporary water supply
(d)*Establishment and implementation of an approved program to eliminate potential ignition sources and limit the amount of fuel available to the fire
(5) The fire department has been notified.
(6) The insurance carrier, the alarm company, property owner or designated representative, and other authorities having jurisdiction have been notified.
(7) The supervisors in the areas to be affected have been notified.
(8) A tag impairment system has been implemented. (See Section 15.3.)
(9) All necessary tools and materials have been assembled on the impairment site.

15.6 Emergency Impairments.
15.6.1 Emergency impairments shall include, but are not limited to, system leakage, interruption of water supply, frozen or ruptured piping, and equipment failure.
15.6.2 When emergency impairments occur, emergency action shall be taken to minimize potential injury and damage.
15.6.3 The coordinator shall implement the steps outlined in Section 15.5.

Based on observation and staff interview, the facility failed to ensure smoke barrier door openings would resist the passage of smoke. This condition would allow smoke from a fire to spread to the adjacent smoke barrier. The facility census was 5.

Findings are:

Observation on 7-11-18, between 12:33 pm and 12:52 pm revealed the following:

1. The Double smoke doors going to the emergency room did not close and seal within the door frame.
2. The Double smoke doors in the hallway next to the lab did not close and seal within the door frame.
3. The Double smoke doors in the hallway next to the kitchen did not close and seal within the door frame.

In an interview on 7-11-18, at 1:24 pm, Maintenance A acknowledged the doors did not close and seal to prevent the passage of smoke.

Based on record review and staff interview, the facility failed to conduct fire drills quarterly for 1 of 2 shifts. This practice did not provide simulated training for staff to respond to a fire emergency during various activities and staffing levels, which would affect fire procedure response for all residents. The facility census was 5.

Findings are:

Record review on 7-11-18 at 10:58 am of fire drills revealed a fire drill was not documented for the 3rd quarter of 2nd shift of 2017.

In an interview on 7-11-18 at 10:58 am, Maintenance A confirmed that the shift did not receive a fire drill, due to an error in scheduling.


NFPA 101, 2012, 19.7.1.4* Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions.

19.7.1.5 Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.

19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.

19.7.1.7 When drills are conducted between 9:00 p.m. and 6:00 a.m. (2100 hours and 0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

Based on interview and documentation review, the facility failed to implement a testing and inspection program to document the integrity and operation of all fire rated doors throughout the facility by a qualified person. This deficient practice failed to ensure that the fire doors would operate as designed to prevent the spread of fire and smoke and affected all residents. The facility census was 5.

Findings are:

Documentation review on 7-11-18 at 11:30 am revealed, that the facility failed to provide written documentation of annual inspection and testing of the fire rated doors throughout the facility by a qualified person.

During an interview on 7-11-18 at 11:30 am, Maintenance A confirmed the lack of inspection.


NPFA Standards
NFPA 80

5.2.4.2 As a minimum, the following items shall be verified:
(1) No open holes or breaks exist in surfaces of either the door or frame.
(2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped.
(3) The door, frame, hinges, hardware, and noncombustible threshold are secured, aligned, and in working order with no visible signs of damage.
(4) No parts are missing or broken.
(5) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7.
(6) The self-closing device is operational; that is, the active door completely closes when operated from the full open position.
(7) If a coordinator is installed, the inactive leaf closes before the active leaf.
(8) Latching hardware operates and secures the door when it is in the closed position.
(9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame.
(10) No field modifications to the door assembly have been performed that void the label.
(11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity.

Based on observation and interview, the facility allowed the use of a portable electric space heaters in the Insurance Business office and front reception area and failed to provide documentation that the heating element of the device did not exceed 212 degrees Fahrenheit. This deficient practice increased the potential of a fire. The facility census was 5.

Findings are:

Observations on 7-11-18 between 12:11 pm and 1:35 pm revealed the following:

1. Two portable electric space heating devices in the Insurance Business Office.
2. One portable electric space heating device in the front reception area.

During an interview on 7-11-18 between 12:11 pm and 1:35 pm, Maintenance A confirmed the facility did not have the manufactures specification for the heaters and could not confirm the heating element of the device did not exceed 212 degrees Fahrenheit.

NFPA Standard:

2012 NFPA 101, 19.7.8
Portable space heating devices shall be prohibited in all health care occupancies, unless both of the following criteria are met:
(1) Such devices are used only in nonsleeping staff and employee areas.
(2) The heating elements of such devices do not exceed 212°F (100°C).

Based on record review and staff interview, the facility failed to have the diesel fuel tested annually for quality. This practice increased the potential that emergency power would not be supplied to the facility.

Findings are:

Record review on 7/11/18, at 11:16 am revealed documentation was not provided to verify the diesel fuel for the generator was tested annually for quality.

In an interview on 7/11/18, at 11:16 am, Maintenance A confirmed the testing was not conducted, and was not aware of the requirements.

NFPA 99, 2012, 8.3.8 A fuel quality test shall be performed at least annually using tests approved by ASTM standards.

Based on observation and interview, the facility failed to provide signage on the door of the Oxygen Storage room identifying the room as oxygen storage. This deficient practice did not alert persons entering the room of the oxidizing gas stored with the storage room and to use extra caution with sources of ignition. Facility census was 5.

Findings are:

Observations on 7-11-18 at 1:09 pm revealed no signage on the door to indicate that oxygen was stored within that room.

During an interview on 7-11-18 at 1:09 pm, Maintenance A confirmed the findings.

NFPA Standard:

2012 ed., NFPA 99 11.3.4.1 A precautionary sign, readable from a distance of 1.5 m (5 ft), shall be displayed on each door or gate of the storage room or enclosure.

2012 ed., NFPA 99 11.3.4.2 The sign shall include the following wording as a minimum:
CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING