HospitalInspections.org

Based on observation and interview it was determined the facility failed to ensure smoke barriers would resist the passage of smoke in accordance with the National Fire Protection Association (NFPA) standards. The deficiency had the potential to affect four (4) of eight (8) smoke compartments, patients, staff and visitors.

The findings include:

Observation during a Life Safety Tour with the Director of Maintenance (DOM) and Regional Director of Maintenance (RDOM) on 9/5/19 revealed the following:
1. 11:20 AM - The cross-corridor doors located in the smoke barrier wall near the 2nd Floor Staff Lounge and Elevator would not resist the passage of smoke due to a damaged sweep. The damaged sweep created a gap in excess of 1/8th of an inch. Gaps of this size allow for the passage of smoke in case of a fire.
2. 1:20 PM - The smoke barrier wall near the Lobby into the Diagnostic Area was found to have two penetrations in Cable Runs in the wall. Fire Block Foam was observed to have fallen out or been removed from the run exposing the penetrations. The block foam was observed on top of the drop ceiling near the penetrations. The penetrations were observed to be approximately one (1) inch in diameter.

Interview on 9/6/19 at the time of the discoveries with the DOM revealed he was not aware the cross-corridor doors were not functioning properly due to a damaged sweep. He was also unaware that the Fire Block Foam had fallen out or been removed by person(s) unknown in the cable runs near the lobby smoke wall. Further interview with the DOM revealed he was aware of the requirements for smoke barriers to resist the passage of smoke and the facility has a policy to routinely inspect the doors in the smoke barriers along with the barriers themselves.

The findings were acknowledged by the Director of Operations and verified by the DOM at the exit interview.

Based on observation and interview, it was determined the facility failed to ensure portable heaters were used according to National Fire Protection Association (NFPA). The deficiency had the potential to affect two (2) of eight (8) smoke compartments, patients, staff and visitors.

The findings include:
Observation during a Life Safety Tour with the Director of Maintenance (DOM) and Regional Director of Maintenance (RDOM) on 9/5/19 revealed the following:
1. 11:15 AM - A portable space heater was observed in the Clinical Document Specialist office. The heater was a Soleil Ceramic Heater Model MH-01P.
2. 11:25 PM - A portable space heater was observed in the ICU Staff Lounge. The heater was a Lasko Model 754200
Portable heaters used in non-patient care areas should be inspected for compliance and be accounted for in the organization's equipment inventory.

Interview, with the DOM at the time of observation, revealed he was unaware of the portable heater's presence or the heating element rating of the space heater that was discovered. He further advised that the facility had a policy prohibiting such as the devices found during the tour.

The findings were acknowledged by the Director of Operations and verified by the DOM at the exit interview.

Based on observation and interview, it was determined the facility failed to ensure electrical wiring was maintained in accordance with National Fire Protection Association (NFPA) standards. The deficiency had the potential to affect one patients, staff, and visitors.

The findings include:

Observation during the life safety tour on 9/5/19 at 1:20 PM with the Director of Maintenance (DOM) and the Regional Director of Maintenance (RDOM) revealed an electrical junction box with an open cover above the drop ceiling attached to the smoke wall from the lobby area to the Diagnostic Center. The junction box was found to have a malfunctioning latch.

The open junction box cover exampled a failure to ensure physical barriers were in place to prevent accidental / inadvertent contact with energized electrical equipment.

Interview, on 9/5/19 at the time of the observations, with the DOM revealed he aware of the regulation regarding electrical systems however he was unaware that he junction box cover was open and malfunctioning.

The findings were acknowledged by the Director of Operations and verified by the DOM at the exit interview.

Actual NFPA Standard:

Reference: NFPA 101 (2012 Edition)

9.1.2 Electric.
Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

Reference: NFPA 70 (2011 Edition).

408.3 Support and Arrangement of Busbars and Conductors.
(A) Conductors and Busbars on a Switchboard or Panelboard.
Conductors and busbars on a switchboard or panelboard shall comply with 408.3(A)(1), (A)(2), and (A)(3) as applicable.
(2) Service Switchboards. Barriers shall be placed in all service switchboards such that no uninsulated, ungrounded
service busbar or service terminal is exposed to inadvertent contact by persons or maintenance equipment while servicing load terminations