HospitalInspections.org

Bringing transparency to federal inspections

23515 HIGHWAY 190

MANDEVILLE, LA 70448

Fire Alarm System - Testing and Maintenance

Tag No.: K0345

NFPA 72: 10.3.2 System components shall be installed, tested, and maintained in accordance with the manufacturer's published instructions and this Code.

NFPA 72:10.4.1.2 State or local licensure regulations shall be followed to determine qualified personnel. Depending on state or local licensure regulations, qualified personnel shall include, but not be limited to, one or more of the following: (1) Personnel who are registered, licensed, or certified by a state or local authority.

LAC 55:V:3033. Fixed Fire Suppression and Fire Detection and Alarm Systems and Equipment... B. All existing required fixed fire suppression systems including kitchen, pre-engineered and engineered systems, and fire detection and alarm systems shall be certified, hydrostatically tested, inspected, integrated, maintained and serviced in an operational condition in accordance with the manufacturer's installation manuals, specifications, and per the inspection, testing and maintenance chapters of the applicable codes and standards adopted in L.A.C.55:V.103 or noted in these rules.

LRS 40:1646 (A)(B)(C) The fire marshal is authorized to cause the inspection and testing of all life safety systems and equipment in the state, whether in public or private buildings, during installation or immediately after installation to determine compliance with applicable standards. The owner of any building containing a life safety system and equipment shall cause at a minimum an annual inspection to be made of the life safety system and equipment in that building to assure compliance with applicable safety standards and to determine whether structural changes in the building or in the contents of the building mandate alteration of a system. Life safety systems and equipment includes but is not limited to fire sprinkler, fire alarm, fire suppression, special locking systems and equipment, and portable fire extinguishers.

Based on visual observation the facility failed to assure that the fire alarm system was inspected and tested in accordance with the approved maintenance and testing program in NFPA 72. The fire alarm system gives a sense of security to offer an advance warning in fire and/or smoke emergency. This deficient practice could potentially affect eighty seven of eighty seven patients.

Findings:

During the facility tour on March 30, 2023 between the hours of 9:00 a.m. to 2:30 p.m. the fire alarm system was lacking a annual inspection in the following buildings: Pharmacy, Staff Education, Admissions, Ward O (Esplanade 1), Ward L (Esplanade 2), Ward M (Esplanade 3), Ward N (Decatur), Children's Cafeteria and Ness Healthcare.


The interview with the Maintenance Director revealed the facility was not aware that the required inspections had not been conducted on the fire alarm system.

Sprinkler System - Maintenance and Testing

Tag No.: K0353

NFPA 25:4.3.2 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.

NFPA 25:4.3.3* Records shall be maintained by the property owner.

LAC 55:V:3033. Fixed Fire Suppression and Fire Detection and Alarm Systems and Equipment... B. All existing required fixed fire suppression systems including kitchen, pre-engineered and engineered systems, and fire detection and alarm systems shall be certified, hydrostatically tested, inspected, integrated, maintained and serviced in an operational condition in accordance with the manufacturer's installation manuals, specifications, and per the inspection, testing and maintenance chapters of the applicable codes and standards adopted in L.A.C.55:V.103 or noted in these rules.

LRS 40:1646 (A)(B)(C) The fire marshal is authorized to cause the inspection and testing of all life safety systems and equipment in the state, whether in public or private buildings, during installation or immediately after installation to determine compliance with applicable standards. The owner of any building containing a life safety system and equipment shall cause at a minimum an annual inspection to be made of the life safety system and equipment in that building to assure compliance with applicable safety standards and to determine whether structural changes in the building or in the contents of the building mandate alteration of a system. Life safety systems and equipment includes but is not limited to fire sprinkler, fire alarm, fire suppression, special locking systems and equipment, and portable fire extinguishers.

Based on visual observation the facility failed to assure that the sprinkler system was inspected and tested in accordance with the approved maintenance and testing program in NFPA 25. The fire alarm system gives a sense of security to offer an advance warning in fire and/or smoke emergency. This deficient practice could potentially affect eighty seven of eighty seven patients.

Findings:

During the facility tour on March 30, 2023 between the hours of 9:00 a.m. to 2:30 p.m. the partially sprinklered Pharmacy building was yellow tagged due to the water flow switch not being operable. The fully sprinklered Ness Healthcare building was also yellow tagged by a licensed sprinkler company due to missing spare sprinkler heads in the cabinet, there was no sign of the FDC and hydro completed.

The interview with the Maintenance Supervisor revealed the facility was unaware the licensed sprinkler company had yellow tagged the sprinkler system due to the impairments listed in the findings.

Corridors - Construction of Walls

Tag No.: K0362

Based on visual observation this sprinklered facility failed to assure that the smoke compartmentalization of the membrane between the egress corridor and rooms, adjacent to the egress corridor, were not compromised. Repairs to assure the protection of occupants and the integrity of the means of egress are essential in case of a fire or other smoke emergency. The deficient practice had the potential to affect eighty seven of eighty seven patients.

Findings:

During the facility tour March 30, 2023 between the hours of 9:00 a.m. to 2:30 p.m. it was observed all the patient psychiatric Hospital sleeping rooms have transfer grills / louvers in the concrete corridor walls. Thus, allowing the corridor to freely transfer smoke and comprise the thirty minute required corridor wall fire rating.

NFPA 101: 19.3.6.2.2* Corridor walls shall have a minimum 1/2-hour fire resistance rating.

The interview with Maintenance Director revealed the facility was not aware of the penetrations in the corridor walls that would allow the transfer of smoke from one room to another.

Corridor - Openings

Tag No.: K0364

NFPA 101:19.3.6.4.1 Transfer grilles, regardless of whether they are protected by fusible link-operated dampers, shall not be used in corridor walls or doors.

Based on visual observation this facility failed to assure that the smoke compartmentalization of the membrane between the egress corridor walls and the sleeping room doors were not compromised. Repairs to assure the protection of the occupants and the integrity of the means of egress are essential in case of a fire or other smoke emergency. The deficient practice had the potential to affect eighty seven of eighty seven patients.

Findings:

During the facility tour March 30, 2023 between the hours of 9:00 a.m. to 2:30 p.m. the patient psychiatric Hospital sleeping rooms have transfer grills / louvers in the concrete corridor walls. Thus, allowing the corridor to freely transfer smoke and comprise the ½ hour required corridor wall fire rating.

The interview with the Maintenance Director revealed the facility was not aware a transfer grill in the corridor wall transferring corridor air freely to the psychiatric sleeping rooms is prohibited.

HVAC

Tag No.: K0521

NFPA 90A: 4.3.12.1.1 Egress corridors in health care, detention and correctional, and residential occupancies shall not be used as a portion of a supply, return, or exhaust air system serving adjoining areas unless otherwise permitted by 4.3.12.1.2.1 through 4.3.12.1.2.4.

NFPA 90A: 4.3.12.1.2 An air transfer opening(s) shall not be permitted in walls or in doors separating egress corridors from adjoining areas.

NFPA 90A: 4.3.12.1.2.1 An air transfer opening(s) shall be permitted in walls or doors from toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces opening directly onto the egress corridor.

NFPA 90A: 4.3.12.1.2.2 Where door clearances do not exceed those specified for fire doors in NFPA 80, Standard for Fire Doors and Other Opening Protectives, air transfer caused by pressure differentials shall be permitted.

NFPA 90A: 4.3.12.1.2.3 Use of egress corridors shall be permitted as part of an engineered smoke-control system.

NFPA 90A: 4.3.12.1.2.4 Air transfer opening(s) shall be permitted in walls or in doors separating egress corridors from adjoining areas in detention and correctional occupancies with corridor separations of open construction (e.g., grating doors or grating partitions).

Based on visual observation the facility failed to assure that the heating, ventilation and air conditioning system was installed in accordance with NFPA 90A. The system could re-circulate smoke originating from one part of the building into other parts of the building otherwise unaffected. The deficient practice had the potential to affect eighty seven of eighty seven patients with two of two corridor smoke compartments being deficient by being used as a return air plenum.

Findings:

During the facility tour on March 30, 2023 between the hours of 9:00 a.m. to 2:30 p.m. the corridor was being used as a return air plenum to all patient sleeping rooms located in Ward O (Esplanade 1), Ward L (Esplanade 2), Ward M (Esplanade 3), Ward N (Decatur). The facility had applied for waiver.

The interview with the Maintenance Director revealed the facility was not aware the HVAC system was using the corridors as a return air plenum.

Fire Drills

Tag No.: K0712

NFPA 101:19.7.1.6 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.

Based on visual observation and record review the facility failed to maintain documentation for fire drills conducted during each quarter on each shift. Fire drills provide training in procedures in cases of emergency. The deficient practice had the potential to affect eight seven of eight seven patents. There were three of four quarters in the year 2022 that were deficient.

Findings:

During the facility record of review on March 30, 2023 between the hours of 9:00 a.m. to 2:30 p.m. the fire drill was lacking for the first, second, third and fourth quarters of the year 2022 was lacking a fire drill for each shift of each quarter for the hospital occupancies identified as Ward O (Esplanade 1), Ward L (Esplanade 2), Ward M (Esplanade 3), Ward N (Decatur), Dorm 1 (Willow), Dorm 2 (Cypress) and dormitory occupancies Wards U, Wards V, Wards W.


The interview with the Maintenance Director revealed the facility was not aware fire drills were not being held for each work shift of each quarter.