HospitalInspections.org

Based on observation, the facility failed to maintain their smoke barrier doors as evidenced by smoke barrier doors that failed to release from their magnetic hold open device and close. This affected the North Wing of hospital old building. This finding could result in the delay in evacuation from one smoke compartment to another and increase the risk of injury to resident and staff in the event of a fire.

Findings:

During the testing of the fire alarm system in the Old Hospital Building with the Maintenance Director on 9/17/13, the smoke barrier doors were observed.


At 11:51 a.m., the smoke barrier doors by the Administration was held open with magnetic-hold open device. When the fire alarm was tested, the smoke barrier doors failed to release from the magnetic hold open device and close.

Based on observation and interview, the facility failed to instruct their staff on their emergency procedures to ensure that procedures were followed during an actual emergency. This was evidenced by staff who failed to investigate and follow-up the trouble alarm on their fire alarm system when the electric power was restored to the hospital. This affected the old hospital building, north wing, south wing and pediatrics. This could result in failure to notify the facility of a fire due to a non-functioning fire alarm system.

NFPA 101, Life Safety Code, 2000 Edition
19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.
Findings:

During the investigation of an entity reported incident (ERI) with Maintenance Director on 9/17/13, fire alarm panel was observed, and the PBX(private box exchange)and the PBX log was reviewed.

At 11:47 a.m., the fire alarm panel in the PBX was observed to be in trouble. The PBX log showed that the trouble was documented on 9/15/13, the day of the power outage. During an interview with the Maintenance Supervisor on 9/17/2013 at 11:48 p.m., he stated that he was not told that there was trouble alarm on the fire alarm panel. The PBX staff stated the trouble alarm was noted but nobody addressed the problem.

Based on observation, interview and record review, the facility failed to ensure that their fire alarm system was maintained in reliable operating condition. This was evidenced by strobes and audio devices that failed to activate during fire alarm testing and no expiration date on the battery in the sub-fire alarm panel. This affected North Wing, South Wing and Pediatrics of the old hospital building. The South Wing and Pediatrics were not occupied with patients, but radiology , and women's clinic and staff office was occupied. This could result in delay in notification of fire to staff and visitors and patients, in the event of fire.

Findings:
On 9/17/2013, during the investigation with the Maintenance Supervisor of the entity reported incident, which happened on 9/16/13, the fire alarm system was tested in the North Wing. The strobes and audio alarm boxes were observed.
1. At 11:40 a.m., the Maintenance Supervisor stated that the fire alarm system is working and was not affected by the reported power outage.
2. At 11:47 a.m., during inspection of the fire alarm main control panel in the PBX (Private Box Exchange)located in the new building, it showed trouble alarm at Node 2( a sub- fire alarm panel of the old building). PBX log showed that the trouble alarm for Node 2 was noted on 9/15/13.
3. At 11:50 a.m., the sub-fire alarm panel by Administration of the old hospital building showed an audio, visible trouble/door holder disabled alarm.
4. At 11:51 a.m., a pull station at the exit door by Administration of the old building was pulled to initiate an alarm. There was no audio alarms and strobes that activated in the old building.
5. At 2:19 p.m., the battery for the fire alarm sub-panel located by the nurse station in the old building did not have an expiration date. The facility was not aware if the battery was expired or not.
6. At 2:56 p.m., during an interview with the fire alarm vendor, he stated the battery in the sub-fire alarm panel did not have enough power to activate the fire alarm during power outage.

Based on observation, the facility failed to maintain their smoke barrier doors as evidenced by smoke barrier doors that failed to release from their magnetic hold open device and close. This affected the North Wing of hospital old building. This finding could result in the delay in evacuation from one smoke compartment to another and increase the risk of injury to resident and staff in the event of a fire.

Findings:

During the testing of the fire alarm system in the Old Hospital Building with the Maintenance Director on 9/17/13, the smoke barrier doors were observed.


At 11:51 a.m., the smoke barrier doors by the Administration was held open with magnetic-hold open device. When the fire alarm was tested, the smoke barrier doors failed to release from the magnetic hold open device and close.

Based on observation and interview, the facility failed to instruct their staff on their emergency procedures to ensure that procedures were followed during an actual emergency. This was evidenced by staff who failed to investigate and follow-up the trouble alarm on their fire alarm system when the electric power was restored to the hospital. This affected the old hospital building, north wing, south wing and pediatrics. This could result in failure to notify the facility of a fire due to a non-functioning fire alarm system.

NFPA 101, Life Safety Code, 2000 Edition
19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.
Findings:

During the investigation of an entity reported incident (ERI) with Maintenance Director on 9/17/13, fire alarm panel was observed, and the PBX(private box exchange)and the PBX log was reviewed.

At 11:47 a.m., the fire alarm panel in the PBX was observed to be in trouble. The PBX log showed that the trouble was documented on 9/15/13, the day of the power outage. During an interview with the Maintenance Supervisor on 9/17/2013 at 11:48 p.m., he stated that he was not told that there was trouble alarm on the fire alarm panel. The PBX staff stated the trouble alarm was noted but nobody addressed the problem.

Based on observation, interview and record review, the facility failed to ensure that their fire alarm system was maintained in reliable operating condition. This was evidenced by strobes and audio devices that failed to activate during fire alarm testing and no expiration date on the battery in the sub-fire alarm panel. This affected North Wing, South Wing and Pediatrics of the old hospital building. The South Wing and Pediatrics were not occupied with patients, but radiology , and women's clinic and staff office was occupied. This could result in delay in notification of fire to staff and visitors and patients, in the event of fire.

Findings:
On 9/17/2013, during the investigation with the Maintenance Supervisor of the entity reported incident, which happened on 9/16/13, the fire alarm system was tested in the North Wing. The strobes and audio alarm boxes were observed.
1. At 11:40 a.m., the Maintenance Supervisor stated that the fire alarm system is working and was not affected by the reported power outage.
2. At 11:47 a.m., during inspection of the fire alarm main control panel in the PBX (Private Box Exchange)located in the new building, it showed trouble alarm at Node 2( a sub- fire alarm panel of the old building). PBX log showed that the trouble alarm for Node 2 was noted on 9/15/13.
3. At 11:50 a.m., the sub-fire alarm panel by Administration of the old hospital building showed an audio, visible trouble/door holder disabled alarm.
4. At 11:51 a.m., a pull station at the exit door by Administration of the old building was pulled to initiate an alarm. There was no audio alarms and strobes that activated in the old building.
5. At 2:19 p.m., the battery for the fire alarm sub-panel located by the nurse station in the old building did not have an expiration date. The facility was not aware if the battery was expired or not.
6. At 2:56 p.m., during an interview with the fire alarm vendor, he stated the battery in the sub-fire alarm panel did not have enough power to activate the fire alarm during power outage.