HospitalInspections.org

Based on observation and interview, the facility failed to ensure that the doors in the corridor were capable of resisting the passage of smoke and failed to ensure the doors had no impediment when closing the door. These deficient practices would allow smoke and fire to migrate into the corridor. This facility census was 7.

Findings are:
Observations on 9-9-11 between 11:28 am and 11:35 am revealed:
1. The student housing Apartment #3 bathroom door which is connected to the corridor had louvers.
2. The set of smoke doors next to room #301 had an astragal that prevented the closing of the doors

During an interview on 9-9-11 between 11:28 am and 11:35 am, Maintenance A confirmed the findings.

NFPA Standard:
Doors in corridor walls of sprinklered buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors in non-sprinklered buildings shall have doors constructed to resist the passage of smoke for at least twenty minutes and shall be provided with suitable means of keeping the doors closed. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 19.3.6.3.1 and 19.3.6.3

Based on observation and interview the facility failed to provide doors in hazard areas which would close securely into door frames, failed to provide self-closing devices and allowed doors to hazard areas to be obstructed and held open. These deficient practices would allow smoke and fire to migrate from hazard areas into other portions of the building. The facility census was 7.

Findings are:
Observations on 9-9-11 from 2:00 pm to 2:02 pm revealed:

1. The chiller room failed to have a closure.
2. The salt room failed to have a closure.

During an interview on Observations on 9-9-11 from 2:00 pm to 2:02 pm, Maintenance A confirmed the confirmed all the findings.

NFPA Standard:
Hazardous areas without sprinkler protection require one-hour fire resistance rating construction and doors shall be 3/4 hour fire rated with self-closers and positive latches. 2000 NFPA 101, 19.3.2.1

Based on observation and interview, the facility failed to provide maintenance records and failed to assure that the fire alarm system is installed and maintained in accordance with NFPA 72. The facility census was 7.

Findings Include:

Observations on 9-9-11 at 11:27 am revealed the student housing area had no smoke detection and visible notification appliance in 5 out of 5 sleeping rooms.

During an interview 9-9-11 at 11:27 am, Maintenance A confirmed and acknowledges all of the findings.

Records review on 9-9-11 at 3:00 pm revealed that the fire alarm is due to be tested. The last inspection date of inspection is 1-9-9

During an interview 9-9-11 at 3:00 pm, Maintenance A confirmed and acknowledges all of the findings.

NFPA Standard:
Combination smoke detectors and visible notification appliances shall be installed in sleeping areas. 1999, NFPA 72, 4-4.4.3.1

Based on observation and interview, the facility failed to maintain portable fire extinguishers in accordance with NFPA 10. This deficient practice would prevent the effeteness of a portable fire extinguisher in extinguishing a fire. The facility census was 7.

Findings are:

Observation on 9-9-11 at 11:24 am revealed the 3 out of 3 fire extinguisher in the ER area was being inspected every other month.

During an interview on 9-9-11 at 11:24, Maintenance A confirmed and acknowledges all the findings. Also, Maintenance A stated the all of the fire extinguisher in the facility is being inspected every other month.

NFPA Standard:
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. 2002, NFPA10, 4-3.1
Periodic inspection of fire extinguishers shall include a check of at least the following items: 2002, NFPA 10, 4-3.2
(a) Location in designated place
(b) No obstruction to access or visibility
(c) Operating instructions on nameplate legible and facing outward
(d) Safety seals and tamper indicators not broken or missing
(e) Fullness determined by weighing or "hefting "
(f) Examination for obvious physical damage, corrosion, leakage, or clogged nozzle
(g) Pressure gauge reading or indicator in the operable range or position
(h) Condition of tires, wheels, carriage, hose, and nozzle checked (for wheeled units)
(i) HMIS label in place

Based on record review and interview, the facility failed to provide current annual boiler inspection certification for the boiler. This failure would increase the probability of boiler failure and affected all residents in the facility. Facility census was 7.

Findings are:
Record review of the boilers ' certificate revealed an expiration date of 8-31-11.

During an interview on 2-24-11 at 1:18 pm Maintenance A confirmed the expired certificate and failed to identify when an inspection was scheduled.

Regulation: NBIA 48-701 - 48-743

48-722. State boiler inspector; inspection; exception; contract with authorized inspection agency; certification.
(1) Except as provided in subsections (3) and (4) of this section, the state boiler inspector shall inspect or cause to be inspected at least once every twelve months all boilers required to be inspected by the Boiler Inspection Act to determine whether the boilers are in a safe and satisfactory condition and properly constructed and maintained for the purpose for which the boiler is used, except that (a) hobby boilers, steam farm traction engines, portable and stationary show engines, and portable and stationary show boilers, which are not otherwise exempted from the act pursuant to section 48-726 , shall be subject to inspection at least once every twenty-four months and (b) the commissioner may, by rule and regulation, establish inspection periods for pressure vessels of more than twelve months, but not to exceed the inspection period recommended in the National Board Inspection Code or the American Petroleum Institute Pressure Vessel Inspection Code API-510 for pressure vessels being used for similar purposes. In order to ensure that inspections are performed in a timely manner, the department may contract with an authorized inspection agency to perform any inspection authorized under the Boiler Inspection Act. If the department contracts with an authorized inspection agency to perform inspections, such contract shall be in writing and shall contain an indemnification clause wherein the authorized inspection agency agrees to indemnify and defend the department for loss occasioned by negligent or tortious acts committed by special inspectors employed by such authorized inspection agency when performing inspections on behalf of the department.
(2) No boilers required to be inspected by the act shall be operated without valid and current certification pursuant to rules and regulations adopted and promulgated by the commissioner in accordance with the requirements of the Administrative Procedure Act. The owner of any boiler installed after September 2, 1973, shall file a manufacturer's data report covering the construction of such boiler with the state boiler inspector. Such reports shall be used to assist the state boiler inspector in the certification of boilers. No boiler required to be inspected by the Boiler Inspection Act shall be operated at any type of public gathering or show without first being inspected and certified as to its safety by the state boiler inspector or a special inspector commissioned pursuant to section 48-731 . Antique engines with boilers may be brought into the state from other states without inspection, but inspection as provided in this section shall be made and the boiler certified as safe before being operated.
(3) The commissioner may, by rule and regulation, waive the inspection of unfired pressure vessels registered with the State of Nebraska if the commissioner finds that the owner or user of the unfired pressure vessel follows a safety inspection and repair program that is based upon nationally recognized standards.
(4) A boiler that is used as a water heater to supply potable hot water and that is not otherwise exempt from inspection under the act pursuant to section 48-726 shall be subject to inspection at least once every twenty-four months in accordance with a schedule of inspection established by the commissioner by rule and regulation.
Source:Laws 1943, c. 112, ? 2(1), p. 392; R.S.1943, ? 48-702 ; Laws 1961, c. 235, ? 5, p. 698; Laws 1971, LB 886, ? 1; Laws 1973, LB 481, ? 1; R.S.1943, (1984), ? 48-702 ; Laws 1987, LB 462, ? 4; Laws 1995, LB 438, ? 2; Laws 1997, LB 641, ? 2; Laws 1998, LB 395, ? 13; Laws 1999, LB 66, ? 2; Laws 2007, LB226, ? 2; Laws 2009, LB627, ? 1.Effective Date: August 30, 2009

Based on observation and interview, the facility failed to ensure that the doors in the corridor were capable of resisting the passage of smoke and failed to ensure the doors had no impediment when closing the door. These deficient practices would allow smoke and fire to migrate into the corridor. This facility census was 7.

Findings are:
Observations on 9-9-11 between 11:28 am and 11:35 am revealed:
1. The student housing Apartment #3 bathroom door which is connected to the corridor had louvers.
2. The set of smoke doors next to room #301 had an astragal that prevented the closing of the doors

During an interview on 9-9-11 between 11:28 am and 11:35 am, Maintenance A confirmed the findings.

NFPA Standard:
Doors in corridor walls of sprinklered buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors in non-sprinklered buildings shall have doors constructed to resist the passage of smoke for at least twenty minutes and shall be provided with suitable means of keeping the doors closed. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 19.3.6.3.1 and 19.3.6.3

Based on observation and interview the facility failed to provide doors in hazard areas which would close securely into door frames, failed to provide self-closing devices and allowed doors to hazard areas to be obstructed and held open. These deficient practices would allow smoke and fire to migrate from hazard areas into other portions of the building. The facility census was 7.

Findings are:
Observations on 9-9-11 from 2:00 pm to 2:02 pm revealed:

1. The chiller room failed to have a closure.
2. The salt room failed to have a closure.

During an interview on Observations on 9-9-11 from 2:00 pm to 2:02 pm, Maintenance A confirmed the confirmed all the findings.

NFPA Standard:
Hazardous areas without sprinkler protection require one-hour fire resistance rating construction and doors shall be 3/4 hour fire rated with self-closers and positive latches. 2000 NFPA 101, 19.3.2.1

Based on observation and interview, the facility failed to provide maintenance records and failed to assure that the fire alarm system is installed and maintained in accordance with NFPA 72. The facility census was 7.

Findings Include:

Observations on 9-9-11 at 11:27 am revealed the student housing area had no smoke detection and visible notification appliance in 5 out of 5 sleeping rooms.

During an interview 9-9-11 at 11:27 am, Maintenance A confirmed and acknowledges all of the findings.

Records review on 9-9-11 at 3:00 pm revealed that the fire alarm is due to be tested. The last inspection date of inspection is 1-9-9

During an interview 9-9-11 at 3:00 pm, Maintenance A confirmed and acknowledges all of the findings.

NFPA Standard:
Combination smoke detectors and visible notification appliances shall be installed in sleeping areas. 1999, NFPA 72, 4-4.4.3.1

Based on observation and interview, the facility failed to maintain portable fire extinguishers in accordance with NFPA 10. This deficient practice would prevent the effeteness of a portable fire extinguisher in extinguishing a fire. The facility census was 7.

Findings are:

Observation on 9-9-11 at 11:24 am revealed the 3 out of 3 fire extinguisher in the ER area was being inspected every other month.

During an interview on 9-9-11 at 11:24, Maintenance A confirmed and acknowledges all the findings. Also, Maintenance A stated the all of the fire extinguisher in the facility is being inspected every other month.

NFPA Standard:
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. 2002, NFPA10, 4-3.1
Periodic inspection of fire extinguishers shall include a check of at least the following items: 2002, NFPA 10, 4-3.2
(a) Location in designated place
(b) No obstruction to access or visibility
(c) Operating instructions on nameplate legible and facing outward
(d) Safety seals and tamper indicators not broken or missing
(e) Fullness determined by weighing or "hefting "
(f) Examination for obvious physical damage, corrosion, leakage, or clogged nozzle
(g) Pressure gauge reading or indicator in the operable range or position
(h) Condition of tires, wheels, carriage, hose, and nozzle checked (for wheeled units)
(i) HMIS label in place

Based on record review and interview, the facility failed to provide current annual boiler inspection certification for the boiler. This failure would increase the probability of boiler failure and affected all residents in the facility. Facility census was 7.

Findings are:
Record review of the boilers ' certificate revealed an expiration date of 8-31-11.

During an interview on 2-24-11 at 1:18 pm Maintenance A confirmed the expired certificate and failed to identify when an inspection was scheduled.

Regulation: NBIA 48-701 - 48-743

48-722. State boiler inspector; inspection; exception; contract with authorized inspection agency; certification.
(1) Except as provided in subsections (3) and (4) of this section, the state boiler inspector shall inspect or cause to be inspected at least once every twelve months all boilers required to be inspected by the Boiler Inspection Act to determine whether the boilers are in a safe and satisfactory condition and properly constructed and maintained for the purpose for which the boiler is used, except that (a) hobby boilers, steam farm traction engines, portable and stationary show engines, and portable and stationary show boilers, which are not otherwise exempted from the act pursuant to section 48-726 , shall be subject to inspection at least once every twenty-four months and (b) the commissioner may, by rule and regulation, establish inspection periods for pressure vessels of more than twelve months, but not to exceed the inspection period recommended in the National Board Inspection Code or the American Petroleum Institute Pressure Vessel Inspection Code API-510 for pressure vessels being used for similar purposes. In order to ensure that inspections are performed in a timely manner, the department may contract with an authorized inspection agency to perform any inspection authorized under the Boiler Inspection Act. If the department contracts with an authorized inspection agency to perform inspections, such contract shall be in writing and shall contain an indemnification clause wherein the authorized inspection agency agrees to indemnify and defend the department for loss occasioned by negligent or tortious acts committed by special inspectors employed by such authorized inspection agency when performing inspections on behalf of the department.
(2) No boilers required to be inspected by the act shall be operated without valid and current certification pursuant to rules and regulations adopted and promulgated by the commissioner in accordance with the requirements of the Administrative Procedure Act. The owner of any boiler installed after September 2, 1973, shall file a manufacturer's data report covering the construction of such boiler with the state boiler inspector. Such reports shall be used to assist the state boiler inspector in the certification of boilers. No boiler required to be inspected by the Boiler Inspection Act shall be operated at any type of public gathering or show without first being inspected and certified as to its safety by the state boiler inspector or a special inspector commissioned pursuant to section 48-731 . Antique engines with boilers may be brought into the state from other states without inspection, but inspection as provided in this section shall be made and the boiler certified as safe before being operated.
(3) The commissioner may, by rule and regulation, waive the inspection of unfired pressure vessels registered with the State of Nebraska if the commissioner finds that the owner or user of the unfired pressure vessel follows a safety inspection and repair program that is based upon nationally recognized standards.
(4) A boiler that is used as a water heater to supply potable hot water and that is not otherwise exempt from inspection under the act pursuant to section 48-726 shall be subject to inspection at least once every twenty-four months in accordance with a schedule of inspection established by the commissioner by rule and regulation.
Source:Laws 1943, c. 112, ? 2(1), p. 392; R.S.1943, ? 48-702 ; Laws 1961, c. 235, ? 5, p. 698; Laws 1971, LB 886, ? 1; Laws 1973, LB 481, ? 1; R.S.1943, (1984), ? 48-702 ; Laws 1987, LB 462, ? 4; Laws 1995, LB 438, ? 2; Laws 1997, LB 641, ? 2; Laws 1998, LB 395, ? 13; Laws 1999, LB 66, ? 2; Laws 2007, LB226, ? 2; Laws 2009, LB627, ? 1.Effective Date: August 30, 2009