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NFPA 101, 2000 Edition
7.10.1.2 Exits:
Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.

7.10.1.4 Exit Access: Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants.

7.10.2 Directional Signs: A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent.


Based on observation and staff interview, the facility failed to ensure exit signs were arranged readily visible to provide clear direction of travel to the nearest exit.
This failed practice could result in delay and unclear direction during emergency evacuation, which presents a risk of potential harm to employees and visitors within the Department of Pediatrics located on 3rd floor of Building #2. The findings are:

A. On 04/17/12 at 1:00 pm, during a tour of the Department of Pediatrics with the Life Safety Director, Life Safety Code Surveyor #1 observed office corridor #810 (south corridor) was not provided with directional signs indicating the direction of travel to reach the nearest exit.
B. On 04/17/12 at 1:05 pm, during interview, the Life Safety Director stated he was unaware directional signs were not provided in the corridor.
C. On 04/26/12 at 10:00 am, the Executive Director, Life Safety Director and several other hospital staff acknowledged the above findings at the exit conference.



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Based on observation, the facility's practice failed to ensure exit signs installed are arranged readily visible with directional indicators to provide clear direction of travel to the nearest exit. This failed practice could result in delay and unclear direction during emergency evacuation, which presents a risk of potential harm to patients and staff within the 5th floor Operating Suite in Building #3. The findings are:

A. On 04/19/12 at 6:15 am, during a tour of the 5th floor Operating Suite in Building #3 with the Life Safety Director and Executive Director, the Life Safety Code Surveyor #2 observed the exit sign, within the 5th floor Operating Suite in Building #3, leading to the service corridor did not have a chevron or directional indicator providing clear direction of travel to the nearest exit.
B. On 04/26/12 at 10:00 am, the Executive Director, Life Safety Director and several other hospital staff acknowledged the above findings at the exit conference.

Based on observation and staff interview, the facility failed to ensure the fire alarm system and its components were maintained in accordance with NFPA 72 (National Fire Alarm Code), which resulted in a constant trouble signal at the fire alarm panel located in Building #3. This failed practice presents a risk of potential harm to all two hundred nineteen (219) patients located in Building #3 as identified by the census list provided by the Life Safety Director on 04/16/12 at 1:00 pm. The findings are:

A. Life Safety Code Surveyor #1 observed the fire alarm system panel located in Building #3 was in the "trouble" mode the duration of the life safety code survey (04/16/12 - 04/26/12).
B. On 04/18/12 at 11:00 am, during interview, the Life Safety Director stated the trouble signal was resulting from a variable frequency drive (VFD) and from a dirty duct detector. He stated the fire alarm system was in the trouble mode for a couple of weeks now because they had to order a new VFD and it hasn't yet arrived. When asked if the integrity of the system was compromised the response was, "No, the system works as it should and is not compromised because we functionally test the system routinely."
C. On 04/26/12 at 10:00 am, the Executive Director, Life Safety Director and several other hospital staff acknowledged the above findings at the exit conference.


NFPA 72 1999 Edition
2-3.5.1*
In spaces served by air-handling systems, detectors shall not be located where airflow prevents operation of the detectors.

A-2-3.5.1 (Used for Guidance only)
Detectors should not be located in a direct airflow no closer than 3 ft (1 m) from an air supply diffuser or return air opening. Supply or return sources larger than those commonly found in residential and small commercial establishments can require greater clearance to smoke detectors. Similarly, smoke detectors should be located farther away from high velocity air supplies.


Based on observation and staff interview, the facility failed to ensure smoke detectors are located no closer than 3 ft from direct airflow components such as air supply diffusers or return air openings as required by NFPA 72 (National Fire Alarm Code). This failed practice could result in airflow preventing smoke detectors from detecting smoke. This failed practice presents a risk of potential harm to eighteen (18) patients located on the 4th floor East within Building #1 as identified by the census list provided by the Life Safety Director on 04/16/12 at 1:00 pm. This failed practice also presents a risk of potential harm to all patients, employees and visitors within the outpatient clinics located on the 5th floor of Building #2. The findings are:

A. On 04/17/12 at 11:15 am, during a tour of the Trauma/Surgical/Subacute located on the 4th floor east within Building #1, Life Safety Code Surveyor #1 observed
the corridor smoke detector near patient room 15 measured ten (10) inches from the air supply diffuser.
B. On 04/17/12 at 11:30 am, during a tour of the 5th floor of Building #2, Life Safety Code Surveyor #1 observed the smoke detectors located on both sides of privacy doors within the north corridor, measured ten (18) inches from the air supply diffuser.
C. On 04/17/12 at 11:35 am, during interview, the Life Safety Director stated he never noticed the smoke detectors were installed too close to the supply diffusers.





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Reference NFPA 72:

Section 7-1.1.1
Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturer's recommendations, and shall verify correct operation of the fire alarm system.

Section 7-1.1.2
System defects and malfunctions shall be corrected. If a defect or malfunction is not corrected at the conclusion of system inspection, testing, or maintenance, the system owner or the owner's designated representative shall be informed of the impairment in writing within 24 hours.


Based on observation and staff interview, the facility failed to ensure the fire alarm system is maintained and smoke detectors are installed in accordance with NFPA 70 (National Electric Code) and NFPA 72 (National Fire Alarm Code). This presents a potential risk of patients and staff failing to be notified of fire or smoke. This failed practice presents a risk of potential harm to all two hundred twenty-three (223) patients, employees and visitors within Building #1, as identified by the census list provided by the Life Safety Director on 04/16/12 at 1:00 pm. This failed practice also presents a risk of potential harm to all patients, employees and visitors within the outpatient clinics located in Building #2. The findings are:


A. On 04/17/12 at 11:20 am, during a tour of the facility with the Director of Clinical Engineering, the Life Safety Code Surveyor #2 observed a smoke detector was removed from the 4-1 IT Phone Closet in Building #1.
B. On 04/17/12 at 11:29 am, during interview, the Director of Clinical Engineering stated, "It does appear the smoke detector was removed. We will replace it immediately."
C. On 04/26/12 at 10:00 am, the Executive Director, Life Safety Director and several other hospital staff acknowledged the above findings at the exit conference.



Actual NFPA Standard: NFPA 101, Ch 7.2.1.6.2 (e). Activation of the building automatic sprinkler or fire detection system, if provided, shall automatically unlock the doors in the direction of egress and the doors shall remain unlocked until the fire-protective signaling system has been manually reset.

Actual NFPA Standard: NFPA 72, 3-9.7.1. Any device or system intended to actuate the locking or unlocking of exits shall be connected to the fire alarm system serving the protected premises.

Actual NFPA Standard: NFPA 72, 3-9.7.2. All exits connected in accordance with 3-9.7.1 shall unlock upon receipt of any fire alarm signal by means of the fire alarm system serving the protected premises.

Actual NFPA Standard: NFPA 72, 3-9.7.3. All exits connected in accordance with 3-9.7.1 shall unlock upon loss of the primary power to the fire alarm system serving the protected premises. The secondary power supply shall not be utilized to maintain these doors in the locked condition.


Based on observation and staff interview, the facility failed to ensure magnetic locking devices installed on doors located in the path of emergency egress de-energize (unlock) when the fire alarm system is activated. This would not allow for emergency egress by patients and staff during a fire or other emergency. This failed practice presents a risk of potential harm to twenty-six (26) patients, employees and visitors within 5th floor west of Building #1 as identified by the census list provided by the Life Safety Director on 04/16/12 at 1:00 pm. The findings are:


A. On 04/23/12 at 10:03 am, during the activation of the fire alarm system and a tour of the facility with the Director of Clinical Engineering, the Life Safety Code Surveyor #2 observed the exit doors leading out from 5th floor West were equipped with magnetic locking hardware designed to allow security card access only. This magnetic locking hardware failed to automatically unlock during activation of the fire alarm system.
B. On 04/26/12 at 10:00 am, the Executive Director, Life Safety Director and several other hospital staff acknowledged the above findings at the exit conference.

Reference NFPA 72:

Section 1-5.2.6
The secondary supply shall consist of one of the following:
(a) A storage battery arranged in accordance with 1-5.2.9.
(b) An automatic starting, engine-driven generator arranged in accordance with 1-5.2.10 and storage batteries with 4 hours of capacity under maximum normal load followed by 5 minutes of alarm/emergency capacity arranged in accordance with 1-5.2.9.

Section 1-5.2.5.2
Connections to the light and power service shall be on a dedicated branch circuit(s). The circuit(s) and connections shall be mechanically protected. Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit.

Section 7-1.1.1
Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturer's recommendations, and shall verify correct operation of the fire alarm system.

Section 7-1.1.2
System defects and malfunctions shall be corrected. If a defect or malfunction is not corrected at the conclusion of system inspection, testing, or maintenance, the system owner or the owner's designated representative shall be informed of the impairment in writing within 24 hours.


A fire alarm system with approved components, devices or equipment is installed according to NFPA 72, National Fire Alarm Code, to provide effective warning of fire in any part of the building. Activation of the complete fire alarm system is by manual fire alarm initiation, automatic detection or extinguishing system operation. Pull stations in patient sleeping areas may be omitted provided that manual pull stations are within 200 feet of nurse's stations. Pull stations are located in the path of egress. Electronic or written records of tests are available. A reliable second source of power is provided. Fire alarm systems are maintained in accordance with NFPA 72 and records of maintenance are kept readily available. There is remote annunciation of the fire alarm system to an approved central station. 19.3.4, 9.6



Based on observation and staff interview, the facility failed to ensure the fire alarm system breaker location was displayed at the panel, the breaker was equipped with a locking device and that the back-up batteries were replaced every two (2) years to protect the power supply for the fire alarm system in accordance with NFPA 70 (National Electric Code) and NFPA 72 (National Fire Alarm Code). This failed practice presents a risk that the fire alarm system would not be operational in the event of fire or other emergency. This failed practice presents a risk of potential harm to all two hundred twenty-three (223) patients in Building #1, as identified by the census list provided by the Life Safety Director on 04/16/12 at 1:00 pm. This failed practice also presents a risk of potential harm to all patients, employees and visitors within the outpatient clinics located in Building #2 since this panel serves this building too. The findings are:

A. On 04/17/12 at 2:35 pm, Life Safety Code Surveyor #3 observed there are (2) batteries which supply back up power to the main fire alarm control panel. Both batteries were labeled with the last date of replacement being 09/09, which results in being past due. These batteries are required to be replaced every two (2) years.

B. On 04/17/12 at 2:37 pm, the Manager of Utility Systems stated the fire panel serves Buildings #1 and #2. He stated he thought the batteries were not required since the generator supply's power to the entire facility, including the fire panel, in the event of a power failure.

C. On 04/17/17 at 2:40 pm, Life Safety Code Surveyor #3 observed the main fire alarm panel did not identify the location of the breaker for the power supply displayed as required.

D. On 04/17/12 at 5:00 pm, Life Safety Code Surveyor #3 observed the fire alarm system breaker was not equipped with a lock-out device as required.

E. On 04/17/12 at 5:10 pm, the Manager of Utility Systems stated he was unaware the breaker locatation was not identified at the panel and that the breaker was not equipped with a lock-out device.

F. On 04/26/12 at 10:00 am, the Executive Director, Life Safety Director and several other hospital staff acknowledged the above findings at the exit conference.

Reference NFPA 13, 1999 Edition

11-3 Tag Impairment System.
11-3.1*
A tag shall be used to indicate that a system, or part thereof, has been removed from service.

11-3.2*
The tag shall be posted at each fire department connection and system control valve indicating which system, or part thereof, has been removed from service. The authority having jurisdiction shall specify where the tag is to be placed.

11-4 Impaired Equipment.
The impaired equipment shall be considered to be the water-based fire protection system, or part thereof, that is removed from service. This shall include, but shall not be limited to, the following:
(a) Sprinkler systems
(b) Standpipe systems
(c) Fire hose systems
(d) Underground fire service mains
(e) Fire pumps
(f) Water storage tanks
(g) Water spray fixed systems
(h) Foam-water systems
(i) Fire service control valves


Based on observation and staff interview, the facility failed to ensure sprinkler components, which are no longer in service, are identified as being removed from service (tagged out). This failed practice could result in emergency response personnel connecting supplemental fire fighting equipment (ie: water pump trucks) to abandoned Fire Department Connections (FDC's) and other sprinkler components instead of plumbed in components. This failed practice presents a risk of potential harm to all two hundred twenty-three (223) patients, employees and visitors within Building #1 and two hundred nineteen (219) patients, employees and visitors within Building #3 as identified by the census list provided by the Life Safety Director on 04/16/12 at 1:00 pm. This failed practice also presents a risk of potential harm to all patients, employees and visitors within the outpatient clinics located in Building #2. The findings are:

A. On 04/18/12 at 8:30 am, during interview, Life Safety Tech #1 revealed the hospital buildings #1 and #2 are moving toward becoming fully sprinklered which entailed extensive sprinkler design modifications. On 04/18/12 at 8:45 am, Life Safety Code Surveyor #1 observed older variety fire department connections (FDCs), and fire sprinkler shut-off valves that were replaced by newly installed FDCs and a post indicator valve (PIV). The older variety FDCs and shut-off valves were not tagged out or otherwise identified as no longer in service.
B. On 04/18/12 at 8:45 am, during interview, Life Safety Tech #1 stated the old FDCs and shut-off valves were in the process of being removed but they hadn't yet done so. He stated the professional company who installed the new sprinkler system components should have identified those abandoned sprinkler components and properly secured them from being used until they could be permanently removed.
C. On 04/26/12 at 10:00 am, the Executive Director, Life Safety Director and several other hospital staff acknowledged the above findings at the exit conference.

Based on observation and staff interview, the facility failed to ensure the smoking policy is enforced and areas indicating smoke free are not being used by smokers. This deficient practice has the potential to affect all patients within Building #6 clinic. The findings are:


A. On 04/25/12 at 9:30 am, during a tour of Building #6 with the Life Safety Director and Executive Director, the Life Safety Code Surveyor #2 observed that the patio on the second floor had numerous cigarette butts around the floor and in potted plants and planters. The patio had signage throughout stating, "No Fumar" and "UNM Hospital Property is Smoke Free."

B. On 04/25/12 at 9:40 am, during interview with the Life Safety Director, it was stated the patio on the second floor of Building #6 is a smoke free area and it appears patients are using the patio to smoke.

C. On 04/26/12 at 10:00 am, the Executive Director, Life Safety Director and several other hospital staff acknowledged the above findings at the exit conference..

Reference NFPA 96
Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations
1998 Edition
1-3.1
Cooking equipment used in processes producing smoke or grease-laden vapors shall be equipped with an exhaust system that complies with all the equipment and performance requirements of this standard, and all such equipment and performance shall be maintained per this standard during all periods of operation of the cooking equipment. Specifically, the following equipment shall be kept in good working condition:
(a) Cooking equipment
(b) Hoods
(c) Ducts (if applicable)
(d) Fans
(e) Fire suppression systems
(f) Special effluent or energy control equipment

7-1.2
Cooking equipment that produces grease-laden vapors (such as, but not limited to, deep fat fryers, ranges, griddles, broilers, woks, tilting skillets, and braising pans) shall be protected by fire-extinguishing equipment.




Based on observation, staff interview and record review, the facility failed to ensure range hood extinguishing nozzles are properly positioned above all cooking appliances, to include grills and all deep fat fryers, as required by NFPA 96, (Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations). This condition resulted in a grill and deep fat fryer being only partially protected by the range hood extinguishing system. This deficient practice has the potential to harm all kitchen staff within Building #1. The findings are:


A. During a review of the Fire Marshall inspection report for Building #1 dated 01/05/2012, the Life Safety Code Surveyor #2 observed the following notation: "Rear Hood - One grill extends 2 to 3 inches outside the hood, code requires all appliances to be 6" inside the hood."
B. During a review of the Fire Marshall inspection report for Building #1 dated 01/05/2012, the Life Safety Code Surveyor #2 observed the following concerns:
1. "Are all appliances properly covered by the range hood? (NO)."
2. "Do system nozzles properly cover all appliances? (NO)."
C. On 04/17/12 at 4:00 pm, during a tour of Building #1 serving kitchen with the Life Safety Director, the Life Safety Code Surveyor #2 observed the range hood extinguishing nozzles were positioned in a manner that did not provide protection for one of two deep fat fryers.
D. On 04/18/12 at 8:12 am, during a review of work orders and an interview with the Life Safety Tech #1, it was stated that the concerns with Building #1 kitchen range hood were not completed.
E. On 04/26/12 at 10:00 am, the Executive Director, Life Safety Director and several other hospital staff acknowledged the above findings at the exit conference.




Reference NFPA 96, 1998 Edition
Section 8-3.1
Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Table 8-3.1.

Table 8-3.1 Exhaust System Inspection Schedule

Type or Volume of Cooking Frequency Frequency
Systems serving solid fuel cooking operations Monthly
Systems serving high-volume cooking operations such as 24-hour cooking, charbroiling or wok cooking Quarterly
Systems serving moderate-volume cooking operations Semiannually
Systems serving low-volume cooking operations, such as churches, day camps, seasonal businesses, or senior centers Annually



Based on observation and staff interview, the facility failed to ensure the kitchen hood duct system and its appurtenances are cleaned to bare metal at frequent intervals in accordance with NFPA 96, (Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations). This deficient practice has the potential to affect all staff working within the kitchen at Building #5. The findings are:

A. On 04/25/12 at 8:45 am, the Life Safety Code Surveyor #2 observed within Building #5 there are two kitchen range hood ducts. The kitchen range hood ducts had stickers indicating they were last professionally cleaned on March 2010. The stickers had a suggested return date of March 2011.
B. On 04/25/12 at 8:55 am, during interview with the Life Safety Director, it was stated there was no evidence indicating that Building #5 kitchen hood duct systems were cleaned professionally at least semi-annually or otherwise recommended within the past two years.
C. On 04/26/12 at 10:00 am, the Executive Director, Life Safety Director and several other hospital staff acknowledged the above findings at the exit conference..

Based on observation and staff interview, the facility failed to ensure means of egress corridors were maintained free of obstructions and impediments to full instant use which resulted in equipment left unattended in the surgical suite corridors of Building #1. This failed practice presents a risk that in the event of an emergency, facility staff may not evacuate the surgical suite safely and without delay. This failed practice had the potential to harm all forty-one (41) patients scheduled for surgery in the surgical suite on 04/18/12 at 11:45 am as identified during interview with the Quality Assurance Director. The findings are:

A. On 04/18/12 at 6:35 am, during a tour of the surgical suite, Life Safety Code Surveyor #3 observed one (1) side of the surgical suite corridors was being used to store surgery equipment carts, medical supply carts, a rolling clothing rack with lead protective vest and other miscellaneous equipment left unattended impeding the path of egress. This stored equipment reduced the eight (8) foot wide corridor to four (4) feet wide.
B. On 04/18/12 at 6:38 am, during interview, the Life Safety Director stated the surgical suite was classified as a "suite" and did not require an eight (8) foot clear path of egress.
C. On 04/26/12 at 10:00 am, the Executive Director, Life Safety Director and several other hospital staff acknowledged the above findings at the exit conference.

NFPA 101, 2000 Edition
7.10.1.2 Exits:
Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.

7.10.1.4 Exit Access: Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants.

7.10.2 Directional Signs: A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent.


Based on observation and staff interview, the facility failed to ensure exit signs were arranged readily visible to provide clear direction of travel to the nearest exit.
This failed practice could result in delay and unclear direction during emergency evacuation, which presents a risk of potential harm to employees and visitors within the Department of Pediatrics located on 3rd floor of Building #2. The findings are:

A. On 04/17/12 at 1:00 pm, during a tour of the Department of Pediatrics with the Life Safety Director, Life Safety Code Surveyor #1 observed office corridor #810 (south corridor) was not provided with directional signs indicating the direction of travel to reach the nearest exit.
B. On 04/17/12 at 1:05 pm, during interview, the Life Safety Director stated he was unaware directional signs were not provided in the corridor.
C. On 04/26/12 at 10:00 am, the Executive Director, Life Safety Director and several other hospital staff acknowledged the above findings at the exit conference.



21700

Based on observation, the facility's practice failed to ensure exit signs installed are arranged readily visible with directional indicators to provide clear direction of travel to the nearest exit. This failed practice could result in delay and unclear direction during emergency evacuation, which presents a risk of potential harm to patients and staff within the 5th floor Operating Suite in Building #3. The findings are:

A. On 04/19/12 at 6:15 am, during a tour of the 5th floor Operating Suite in Building #3 with the Life Safety Director and Executive Director, the Life Safety Code Surveyor #2 observed the exit sign, within the 5th floor Operating Suite in Building #3, leading to the service corridor did not have a chevron or directional indicator providing clear direction of travel to the nearest exit.
B. On 04/26/12 at 10:00 am, the Executive Director, Life Safety Director and several other hospital staff acknowledged the above findings at the exit conference.

Based on observation and staff interview, the facility failed to ensure the fire alarm system and its components were maintained in accordance with NFPA 72 (National Fire Alarm Code), which resulted in a constant trouble signal at the fire alarm panel located in Building #3. This failed practice presents a risk of potential harm to all two hundred nineteen (219) patients located in Building #3 as identified by the census list provided by the Life Safety Director on 04/16/12 at 1:00 pm. The findings are:

A. Life Safety Code Surveyor #1 observed the fire alarm system panel located in Building #3 was in the "trouble" mode the duration of the life safety code survey (04/16/12 - 04/26/12).
B. On 04/18/12 at 11:00 am, during interview, the Life Safety Director stated the trouble signal was resulting from a variable frequency drive (VFD) and from a dirty duct detector. He stated the fire alarm system was in the trouble mode for a couple of weeks now because they had to order a new VFD and it hasn't yet arrived. When asked if the integrity of the system was compromised the response was, "No, the system works as it should and is not compromised because we functionally test the system routinely."
C. On 04/26/12 at 10:00 am, the Executive Director, Life Safety Director and several other hospital staff acknowledged the above findings at the exit conference.


NFPA 72 1999 Edition
2-3.5.1*
In spaces served by air-handling systems, detectors shall not be located where airflow prevents operation of the detectors.

A-2-3.5.1 (Used for Guidance only)
Detectors should not be located in a direct airflow no closer than 3 ft (1 m) from an air supply diffuser or return air opening. Supply or return sources larger than those commonly found in residential and small commercial establishments can require greater clearance to smoke detectors. Similarly, smoke detectors should be located farther away from high velocity air supplies.


Based on observation and staff interview, the facility failed to ensure smoke detectors are located no closer than 3 ft from direct airflow components such as air supply diffusers or return air openings as required by NFPA 72 (National Fire Alarm Code). This failed practice could result in airflow preventing smoke detectors from detecting smoke. This failed practice presents a risk of potential harm to eighteen (18) patients located on the 4th floor East within Building #1 as identified by the census list provided by the Life Safety Director on 04/16/12 at 1:00 pm. This failed practice also presents a risk of potential harm to all patients, employees and visitors within the outpatient clinics located on the 5th floor of Building #2. The findings are:

A. On 04/17/12 at 11:15 am, during a tour of the Trauma/Surgical/Subacute located on the 4th floor east within Building #1, Life Safety Code Surveyor #1 observed
the corridor smoke detector near patient room 15 measured ten (10) inches from the air supply diffuser.
B. On 04/17/12 at 11:30 am, during a tour of the 5th floor of Building #2, Life Safety Code Surveyor #1 observed the smoke detectors located on both sides of privacy doors within the north corridor, measured ten (18) inches from the air supply diffuser.
C. On 04/17/12 at 11:35 am, during interview, the Life Safety Director stated he never noticed the smoke detectors were installed too close to the supply diffusers.





21700


Reference NFPA 72:

Section 7-1.1.1
Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturer's recommendations, and shall verify correct operation of the fire alarm system.

Section 7-1.1.2
System defects and malfunctions shall be corrected. If a defect or malfunction is not corrected at the conclusion of system inspection, testing, or maintenance, the system owner or the owner's designated representative shall be informed of the impairment in writing within 24 hours.


Based on observation and staff interview, the facility failed to ensure the fire alarm system is maintained and smoke detectors are installed in accordance with NFPA 70 (National Electric Code) and NFPA 72 (National Fire Alarm Code). This presents a potential risk of patients and staff failing to be notified of fire or smoke. This failed practice presents a risk of potential harm to all two hundred twenty-three (223) patients, employees and visitors within Building #1, as identified by the census list provided by the Life Safety Director on 04/16/12 at 1:00 pm. This failed practice also presents a risk of potential harm to all patients, employees and visitors within the outpatient clinics located in Building #2. The findings are:


A. On 04/17/12 at 11:20 am, during a tour of the facility with the Director of Clinical Engineering, the Life Safety Code Surveyor #2 observed a smoke detector was removed from the 4-1 IT Phone Closet in Building #1.
B. On 04/17/12 at 11:29 am, during interview, the Director of Clinical Engineering stated, "It does appear the smoke detector was removed. We will replace it immediately."
C. On 04/26/12 at 10:00 am, the Executive Director, Life Safety Director and several other hospital staff acknowledged the above findings at the exit conference.



Actual NFPA Standard: NFPA 101, Ch 7.2.1.6.2 (e). Activation of the building automatic sprinkler or fire detection system, if provided, shall automatically unlock the doors in the direction of egress and the doors shall remain unlocked until the fire-protective signaling system has been manually reset.

Actual NFPA Standard: NFPA 72, 3-9.7.1. Any device or system intended to actuate the locking or unlocking of exits shall be connected to the fire alarm system serving the protected premises.

Actual NFPA Standard: NFPA 72, 3-9.7.2. All exits connected in accordance with 3-9.7.1 shall unlock upon receipt of any fire alarm signal by means of the fire alarm system serving the protected premises.

Actual NFPA Standard: NFPA 72, 3-9.7.3. All exits connected in accordance with 3-9.7.1 shall unlock upon loss of the primary power to the fire alarm system serving the protected premises. The secondary power supply shall not be utilized to maintain these doors in the locked condition.


Based on observation and staff interview, the facility failed to ensure magnetic locking devices installed on doors located in the path of emergency egress de-energize (unlock) when the fire alarm system is activated. This would not allow for emergency egress by patients and staff during a fire or other emergency. This failed practice presents a risk of potential harm to twenty-six (26) patients, employees and visitors within 5th floor west of Building #1 as identified by the census list provided by the Life Safety Director on 04/16/12 at 1:00 pm. The findings are:


A. On 04/23/12 at 10:03 am, during the activation of the fire alarm system and a tour of the facility with the Director of Clinical Engineering, the Life Safety Code Surveyor #2 observed the exit doors leading out from 5th floor West were equipped with magnetic locking hardware designed to allow security card access only. This magnetic locking hardware failed to automatically unlock during activation of the fire alarm system.
B. On 04/26/12 at 10:00 am, the Executive Director, Life Safety Director and several other hospital staff acknowledged the above findings at the exit conference.

Reference NFPA 72:

Section 1-5.2.6
The secondary supply shall consist of one of the following:
(a) A storage battery arranged in accordance with 1-5.2.9.
(b) An automatic starting, engine-driven generator arranged in accordance with 1-5.2.10 and storage batteries with 4 hours of capacity under maximum normal load followed by 5 minutes of alarm/emergency capacity arranged in accordance with 1-5.2.9.

Section 1-5.2.5.2
Connections to the light and power service shall be on a dedicated branch circuit(s). The circuit(s) and connections shall be mechanically protected. Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit.

Section 7-1.1.1
Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturer's recommendations, and shall verify correct operation of the fire alarm system.

Section 7-1.1.2
System defects and malfunctions shall be corrected. If a defect or malfunction is not corrected at the conclusion of system inspection, testing, or maintenance, the system owner or the owner's designated representative shall be informed of the impairment in writing within 24 hours.


A fire alarm system with approved components, devices or equipment is installed according to NFPA 72, National Fire Alarm Code, to provide effective warning of fire in any part of the building. Activation of the complete fire alarm system is by manual fire alarm initiation, automatic detection or extinguishing system operation. Pull stations in patient sleeping areas may be omitted provided that manual pull stations are within 200 feet of nurse's stations. Pull stations are located in the path of egress. Electronic or written records of tests are available. A reliable second source of power is provided. Fire alarm systems are maintained in accordance with NFPA 72 and records of maintenance are kept readily available. There is remote annunciation of the fire alarm system to an approved central station. 19.3.4, 9.6



Based on observation and staff interview, the facility failed to ensure the fire alarm system breaker location was displayed at the panel, the breaker was equipped with a locking device and that the back-up batteries were replaced every two (2) years to protect the power supply for the fire alarm system in accordance with NFPA 70 (National Electric Code) and NFPA 72 (National Fire Alarm Code). This failed practice presents a risk that the fire alarm system would not be operational in the event of fire or other emergency. This failed practice presents a risk of potential harm to all two hundred twenty-three (223) patients in Building #1, as identified by the census list provided by the Life Safety Director on 04/16/12 at 1:00 pm. This failed practice also presents a risk of potential harm to all patients, employees and visitors within the outpatient clinics located in Building #2 since this panel serves this building too. The findings are:

A. On 04/17/12 at 2:35 pm, Life Safety Code Surveyor #3 observed there are (2) batteries which supply back up power to the main fire alarm control panel. Both batteries were labeled with the last date of replacement being 09/09, which results in being past due. These batteries are required to be replaced every two (2) years.

B. On 04/17/12 at 2:37 pm, the Manager of Utility Systems stated the fire panel serves Buildings #1 and #2. He stated he thought the batteries were not required since the generator supply's power to the entire facility, including the fire panel, in the event of a power failure.

C. On 04/17/17 at 2:40 pm, Life Safety Code Surveyor #3 observed the main fire alarm panel did not identify the location of the breaker for the power supply displayed as required.

D. On 04/17/12 at 5:00 pm, Life Safety Code Surveyor #3 observed the fire alarm system breaker was not equipped with a lock-out device as required.

E. On 04/17/12 at 5:10 pm, the Manager of Utility Systems stated he was unaware the breaker locatation was not identified at the panel and that the breaker was not equipped with a lock-out device.

F. On 04/26/12 at 10:00 am, the Executive Director, Life Safety Director and several other hospital staff acknowledged the above findings at the exit conference.

Reference NFPA 13, 1999 Edition

11-3 Tag Impairment System.
11-3.1*
A tag shall be used to indicate that a system, or part thereof, has been removed from service.

11-3.2*
The tag shall be posted at each fire department connection and system control valve indicating which system, or part thereof, has been removed from service. The authority having jurisdiction shall specify where the tag is to be placed.

11-4 Impaired Equipment.
The impaired equipment shall be considered to be the water-based fire protection system, or part thereof, that is removed from service. This shall include, but shall not be limited to, the following:
(a) Sprinkler systems
(b) Standpipe systems
(c) Fire hose systems
(d) Underground fire service mains
(e) Fire pumps
(f) Water storage tanks
(g) Water spray fixed systems
(h) Foam-water systems
(i) Fire service control valves


Based on observation and staff interview, the facility failed to ensure sprinkler components, which are no longer in service, are identified as being removed from service (tagged out). This failed practice could result in emergency response personnel connecting supplemental fire fighting equipment (ie: water pump trucks) to abandoned Fire Department Connections (FDC's) and other sprinkler components instead of plumbed in components. This failed practice presents a risk of potential harm to all two hundred twenty-three (223) patients, employees and visitors within Building #1 and two hundred nineteen (219) patients, employees and visitors within Building #3 as identified by the census list provided by the Life Safety Director on 04/16/12 at 1:00 pm. This failed practice also presents a risk of potential harm to all patients, employees and visitors within the outpatient clinics located in Building #2. The findings are:

A. On 04/18/12 at 8:30 am, during interview, Life Safety Tech #1 revealed the hospital buildings #1 and #2 are moving toward becoming fully sprinklered which entailed extensive sprinkler design modifications. On 04/18/12 at 8:45 am, Life Safety Code Surveyor #1 observed older variety fire department connections (FDCs), and fire sprinkler shut-off valves that were replaced by newly installed FDCs and a post indicator valve (PIV). The older variety FDCs and shut-off valves were not tagged out or otherwise identified as no longer in service.
B. On 04/18/12 at 8:45 am, during interview, Life Safety Tech #1 stated the old FDCs and shut-off valves were in the process of being removed but they hadn't yet done so. He stated the professional company who installed the new sprinkler system components should have identified those abandoned sprinkler components and properly secured them from being used until they could be permanently removed.
C. On 04/26/12 at 10:00 am, the Executive Director, Life Safety Director and several other hospital staff acknowledged the above findings at the exit conference.

Based on observation and staff interview, the facility failed to ensure the smoking policy is enforced and areas indicating smoke free are not being used by smokers. This deficient practice has the potential to affect all patients within Building #6 clinic. The findings are:


A. On 04/25/12 at 9:30 am, during a tour of Building #6 with the Life Safety Director and Executive Director, the Life Safety Code Surveyor #2 observed that the patio on the second floor had numerous cigarette butts around the floor and in potted plants and planters. The patio had signage throughout stating, "No Fumar" and "UNM Hospital Property is Smoke Free."

B. On 04/25/12 at 9:40 am, during interview with the Life Safety Director, it was stated the patio on the second floor of Building #6 is a smoke free area and it appears patients are using the patio to smoke.

C. On 04/26/12 at 10:00 am, the Executive Director, Life Safety Director and several other hospital staff acknowledged the above findings at the exit conference..

Reference NFPA 96
Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations
1998 Edition
1-3.1
Cooking equipment used in processes producing smoke or grease-laden vapors shall be equipped with an exhaust system that complies with all the equipment and performance requirements of this standard, and all such equipment and performance shall be maintained per this standard during all periods of operation of the cooking equipment. Specifically, the following equipment shall be kept in good working condition:
(a) Cooking equipment
(b) Hoods
(c) Ducts (if applicable)
(d) Fans
(e) Fire suppression systems
(f) Special effluent or energy control equipment

7-1.2
Cooking equipment that produces grease-laden vapors (such as, but not limited to, deep fat fryers, ranges, griddles, broilers, woks, tilting skillets, and braising pans) shall be protected by fire-extinguishing equipment.




Based on observation, staff interview and record review, the facility failed to ensure range hood extinguishing nozzles are properly positioned above all cooking appliances, to include grills and all deep fat fryers, as required by NFPA 96, (Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations). This condition resulted in a grill and deep fat fryer being only partially protected by the range hood extinguishing system. This deficient practice has the potential to harm all kitchen staff within Building #1. The findings are:


A. During a review of the Fire Marshall inspection report for Building #1 dated 01/05/2012, the Life Safety Code Surveyor #2 observed the following notation: "Rear Hood - One grill extends 2 to 3 inches outside the hood, code requires all appliances to be 6" inside the hood."
B. During a review of the Fire Marshall inspection report for Building #1 dated 01/05/2012, the Life Safety Code Surveyor #2 observed the following concerns:
1. "Are all appliances properly covered by the range hood? (NO)."
2. "Do system nozzles properly cover all appliances? (NO)."
C. On 04/17/12 at 4:00 pm, during a tour of Building #1 serving kitchen with the Life Safety Director, the Life Safety Code Surveyor #2 observed the range hood extinguishing nozzles were positioned in a manner that did not provide protection for one of two deep fat fryers.
D. On 04/18/12 at 8:12 am, during a review of work orders and an interview with the Life Safety Tech #1, it was stated that the concerns with Building #1 kitchen range hood were not completed.
E. On 04/26/12 at 10:00 am, the Executive Director, Life Safety Director and several other hospital staff acknowledged the above findings at the exit conference.




Reference NFPA 96, 1998 Edition
Section 8-3.1
Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Table 8-3.1.

Table 8-3.1 Exhaust System Inspection Schedule

Type or Volume of Cooking Frequency Frequency
Systems serving solid fuel cooking operations Monthly
Systems serving high-volume cooking operations such as 24-hour cooking, charbroiling or wok cooking Quarterly
Systems serving moderate-volume cooking operations Semiannually
Systems serving low-volume cooking operations, such as churches, day camps, seasonal businesses, or senior centers Annually



Based on observation and staff interview, the facility failed to ensure the kitchen hood duct system and its appurtenances are cleaned to bare metal at frequent intervals in accordance with NFPA 96, (Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations). This deficient practice has the potential to affect all staff working within the kitchen at Building #5. The findings are:

A. On 04/25/12 at 8:45 am, the Life Safety Code Surveyor #2 observed within Building #5 there are two kitchen range hood ducts. The kitchen range hood ducts had stickers indicating they were last professionally cleaned on March 2010. The stickers had a suggested return date of March 2011.
B. On 04/25/12 at 8:55 am, during interview with the Life Safety Director, it was stated there was no evidence indicating that Building #5 kitchen hood duct systems were cleaned professionally at least semi-annually or otherwise recommended within the past two years.
C. On 04/26/12 at 10:00 am, the Executive Director, Life Safety Director and several other hospital staff acknowledged the above findings at the exit conference..

Based on observation and staff interview, the facility failed to ensure means of egress corridors were maintained free of obstructions and impediments to full instant use which resulted in equipment left unattended in the surgical suite corridors of Building #1. This failed practice presents a risk that in the event of an emergency, facility staff may not evacuate the surgical suite safely and without delay. This failed practice had the potential to harm all forty-one (41) patients scheduled for surgery in the surgical suite on 04/18/12 at 11:45 am as identified during interview with the Quality Assurance Director. The findings are:

A. On 04/18/12 at 6:35 am, during a tour of the surgical suite, Life Safety Code Surveyor #3 observed one (1) side of the surgical suite corridors was being used to store surgery equipment carts, medical supply carts, a rolling clothing rack with lead protective vest and other miscellaneous equipment left unattended impeding the path of egress. This stored equipment reduced the eight (8) foot wide corridor to four (4) feet wide.
B. On 04/18/12 at 6:38 am, during interview, the Life Safety Director stated the surgical suite was classified as a "suite" and did not require an eight (8) foot clear path of egress.
C. On 04/26/12 at 10:00 am, the Executive Director, Life Safety Director and several other hospital staff acknowledged the above findings at the exit conference.