HospitalInspections.org

Based on observation and facility staff interview, the facility failed to ensure the building construction Type II (111) was maintained. Failure to maintain the construction type puts the residents at risk in a fire by increasing the flammability of the structural frame of the building from fire. This facility had a capacity of 57. The facility census was two with one of those in Swing Bed status (Swing Bed, a Medicare program in which a patient can receive acute care then, if needed Skilled Nursing Home care).

Observations made 5/16/2019 at approximately 11:46 A.M., of the employee entrance, showed a covered 14 feet by eight feet entrance enclosure. Observation showed the enclosure had a 2x6 wood frame construction Type V(000), no sprinkler coverage and unrated exterior green carpet glued to the sidewalk. Observation showed the entrance enclosure connected to the 1976 Type II (111) hospital section.

Record review of NFPA 101, Life Safety Code, 2012 edition, showed Type V (000) construction standard required full sprinkler coverage.

During an interview on 5/16/2019 at approximately 3:17 P.M., the Maintenance Director said entrance enclosure was built prior to his/her employment in 2011.

Based on observation, staff interview, and record review, the facility staff failed to provide continuously maintained exit ways free of all obstructions or impediments continuous to a public way such as a parking lot. This deficient practice has the potential to affect all patients, staff and visitors in the facility. Failure to ensure exterior exit ways comply with LSC requirements could delay evacuation out of the building in the event of a fire or other emergency. This facility had a capacity of 57. The facility census was two with one of those in Swing Bed status (Swing Bed, a Medicare program in which a patient can receive acute care then, if needed Skilled Nursing Home care).


1. Observation on 5/16/2019, during the facility tour, showed the accounting hallway exit discharge area led to a grass covered yard that required residents, staff, and visitors to traverse approximately 25 feet of grass to reach the parking lot:


Record review of the facility layout showed the exit discharge area designated for patient, staff and visitors use.

During an interview on 5/16/2019 at 3:18 P.M., the Maintenance Director said the building was constructed in 1976 and never had a sidewalk.


The National Fire Protection Association 101, Life Safety Code 2012 Edition, section 7.7 states:


7.7 Discharge from Exits.

7.7.1* Exit Termination. Exits shall terminate directly, at a
public way or at an exterior exit discharge, unless otherwise
provided in 7.7.1.2 through 7.7.1.4.

Based on observation and facility staff interview, the facility staff failed to ensure all designated exit corridors are illuminated with emergency egress lights not controlled by a light switch. One designated exit corridor contained switches controlling the emergency egress lighting fixtures. Failure to provide emergency egress lighting fixtures not controlled by a light switch has the potential to affect all facility residents. This deficient practice could delay the safe evacuation of patients, staff and visitors in the event of an emergency. This facility had a capacity of 57. The facility census was two with one of those in Swing Bed status (Swing Bed, a Medicare program in which a patient can receive acute care then, if needed Skilled Nursing Home care).


1. Observation on 5/16/19, during the building tour, showed the operating room sterile designated exit hallway contained switches controlling the egress lighting fixtures.

During an interview on 5/16/19 at 3:13 P.M., the Maintenance Director said he/she did not know the egress lights were not installed per code requirements.


19.2.8 Illumination of Means of Egress. Means of egress shall
be illuminated in accordance with Section 7.8.


7.8.1.2 Illumination of means of egress shall be continuous
during the time that the conditions of occupancy require that
the means of egress be available for use, unless otherwise provided
in 7.8.1.2.2.

Based on observation and facility staff interview, facility staff failed to provide emergency lighting not controlled by light switches. This deficient practice has the potential to affect all patients, staff and visitors within the facility. Failure to provide emergency lighting could prevent proper illumination of required areas in the event of power loss. This facility had a capacity of 57. The facility census was two with one of those in Swing Bed status (Swing Bed, a Medicare program in which a patient can receive acute care then, if needed Skilled Nursing Home care).

1. Observations on 5/16/19, during the Life Safety Code (LCS) tour, showed the following light fixtures in the facility controlled by light switches:

-Pharmacy room,

-Nurse Command medication room,

-Operating room medication room.

During an interview on 5/16/2019 at 3:14 P.M., the Maintenance Director said he/she did not know the emergency lights were not installed per code requirements.

NFPA 99, 2012 edition, section 6.4.2.2.4.2 states:

"6.4.2.2.4.2 The critical branch shall supply power for task illumination,
fixed equipment, select receptacles, and select power
circuits serving the following areas and functions related to patient
care:
(1) Critical care areas that utilize anesthetizing gases, task illumination,
select receptacles, and fixed equipment
(2) Isolated power systems in special environments
(3) Task illumination and select receptacles in the following:
(a) Patient care rooms, including infant nurseries, selected
acute nursing areas, psychiatric bed areas (omit receptacles),
and ward treatment rooms
(b) Medication preparation areas
(c) Pharmacy dispensing areas
(d) Nurses ' stations (unless adequately lighted by corridor
luminaires)
(4) Additional specialized patient care task illumination and
receptacles, where needed
(5) Nurse call systems
(6) Blood, bone, and tissue banks
(7)*Telephone equipment rooms and closets
(8) Task illumination, select receptacles, and select power circuits
for the following areas:
(a) General care beds with at least one duplex receptacle
per patient bedroom, and task illumination as required
by the governing body of the health care facility
(b) Angiographic labs
(c) Cardiac catheterization labs
(d) Coronary care units
(e) Hemodialysis rooms or areas
(f) Emergency room treatment areas (select)
(g) Human physiology labs
(h) Intensive care units
(i) Postoperative recovery rooms (select)
(9) Additional task illumination, receptacles, and select power
circuits needed for effective facility operation, including
single-phase fractional horsepower motors, which are permitted
to be connected to the critical branch"

Based on observation, the facility staff failed to provide a 1-hour rated separation between a hazardous area (areas that pose a degree of hazard greater than normal to the general occupancy of the building such as areas used for storage or use of combustibles or flammables, toxic, noxious, or corrosive materials, or heat producing appliances) and designated exit corridors in the facility per NFPA (National Fire Protection Association) requirements. Failure to separate the designated exits and provide rated one hour walls and fire rated doors equipped with a self-closing device puts all patients, staff and visitors at risk of injury or death from a fire by not containing the fire and smoke within the hazardous area and eliminating the two required means of egress. This facility had a capacity of 57. The facility census was two with one of those in Swing Bed status (Swing Bed, a Medicare program in which a patient can receive acute care then, if needed Skilled Nursing Home care).


1. Observation on 5/15/2019, during the facility tour, showed two metal roll down fire doors installed in the outpatient soiled utility room. Observation showed the 1 1/2 hour rated roll down doors equipped with fusible links and not equipped with a self closing devices. Observation showed a fusible link hanging from a disconnected chain releasing device.

Record review of both the attached door drop tests showed the only testing occurred during the installation drop test dated May 2009.

Record review did not show the drop down doors connected to the fire alarm.

During an interview on 5/15/2019 at 3:16 P.M., the Maintenance Director said he/she did not know the hazardous areas separation requirements.


19.3.2.1.5 Hazardous areas shall include, but shall not be restricted
to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Rooms with soiled linen in volume exceeding 64 gal (242 L)
(6) Rooms with collected trash in volume exceeding 64 gal
(242 L)
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including
repair shops, used for storage of combustible supplies and
equipment in quantities deemed hazardous by the authority
having jurisdiction

Based on record review and facility staff interview, facility staff did not ensure all devices connected to the fire alarm system were inspected and tested per NFPA 72, National Fire Alarm and Signaling Code, 2010 edition. This facility had a capacity of 57. The facility census was two with one of those in Swing Bed status (Swing Bed, a Medicare program in which a patient can receive acute care then, if needed Skilled Nursing Home care).

Record review of the annual fire alarm inspections for 2019 did not show connection function tests for the following powered exit corridor access doors:

-Radiology double corridor doors,
-Emergency Department double corridor doors,
-Emergency Department double corridor doors to ED waiting/exit corridor,
-Two roll down fire doors in the outpatient soiled utility room,
-Outpatient back hall to Healing Garden Hall double corridor doors equipped with powered door opener and magnetic hold open device.

Observation showed the elevator shaft missing smoke detector coverage.

Observation showed the Healing Garden courtyard did not contain a fire alarm signaling/sounding device.

Record review of the annual fire alarm inspections for 2015, 2016, 2017, 2018 or 2019 did not show smoke detector sensitivity testing for the facility smoke detectors.


During an interview on 5/16/2019 at 3:16 P.M., the Maintenance Director said he/she believed the fire alarm company installed and inspected the fire alarm system per code requirements.

Refer to NFPA 72, National Fire Alarm and Signaling Code, 2010 edition, Table 14.3.1, Table 14.4.2.2, Table 14.4.5, sections 14.4.5, 14.4.5.3.1 through section 14.4.5.4 for additional testing information.

Based on record review, facility staff failed to inspect the one wet sprinkler system per NFPA 25, Standard for the Inspection, Testing, and maintenance of Water-Based Fire Protection Systems, 2011 edition. This facility had a capacity of 57. The facility census was two with one of those in Swing Bed status (Swing Bed, a Medicare program in which a patient can receive acute care then, if needed Skilled Nursing Home care).


1) Record review on 5/15/2019 did not show the following inspections:

- monthly system gauge & valve inspections for the one wet sprinkler system

-Quarterly/semi annual inspection & testing for the one wet sprinkler system

-five (5) year internal pipe inspections/testing for the one wet sprinkler system (Chapter 14)

-five year check valve/backflow interior inspections

During an interview on 5/16/2019 at 2:55 P.M., the Maintenance Director said he/she believed the sprinkler inspection company inspected the sprinkler system per code requirements.

Refer to NFPA 25, Standard for the Inspection, Testing, and maintenance of Water-Based Fire Protection Systems, 2011 edition, Chapters 5, 13 and 14 for additional information.

5.2.4 Gauges.
5.2.4.1* Gauges on wet pipe sprinkler systems shall be inspected
monthly to ensure that they are in good condition and
that normal water supply pressure is being maintained.

13.3.2.2* The valve inspection shall verify that the valves are in
the following condition:
(1) In the normal open or closed position
(2)*Sealed, locked, or supervised
(3) Accessible
(4) Provided with correct wrenches
(5) Free from external leaks
(6) Provided with applicable identification

13.3.3.5* Supervisory Switches.
13.3.3.5.1 Valve supervisory switches shall be tested semiannually

13.4.2 Check Valves.
13.4.2.1 Inspection. Valves shall be inspected internally every
5 years to verify that all components operate correctly, move
freely, and are in good condition.


13.4 System Valves.
13.4.1 Inspection of Alarm Valves. Alarm valves shall be inspected
as described in 13.4.1.1 and 13.4.1.2.

13.4.1.1* Alarm valves and system riser check valves shall be
externally inspected monthly and shall verify the following:
(1) The gauges indicate normal supply water pressure is being
maintained.
(2) The valve is free of physical damage.
(3) All valves are in the appropriate open or closed position.
(4) The retarding chamber or alarm drains are not leaking.

13.4.1.2* Alarm valves and their associated strainers, filters,
and restriction orifices shall be inspected internally every
5 years unless tests indicate a greater frequency is necessary.

13.7 Fire Department Connections.
13.7.1 Fire department connections shall be inspected quarterly
to verify the following:
(1) The fire department connections are visible and accessible.
(2) Couplings or swivels are not damaged and rotate
smoothly.
(3) Plugs or caps are in place and undamaged.
(4) Gaskets are in place and in good condition.
(5) Identification signs are in place.
(6) The check valve is not leaking.
(7) The automatic drain valve is in place and operating properly.
(8) The fire department connection clapper(s) is in place
and operating properly.

13.2.6 Alarm Devices.
13.2.6.1 Mechanical waterflow devices, including but not limited
to water motor gongs, shall be tested quarterly.
13.2.6.2 Vane-type and pressure switch-type waterflow devices
shall be tested semiannually.

Based on observation and facility staff interview, facility staff failed to ensure corridor doors had positive latching mechanisms and remained closed during activation of the fire alarm system. This deficient practice has the potential to affect all patients, staff and visitors. Failure to ensure corridor doors had positive latching and powered double doors closed during activation of the fire alarm system has the potential to prevent or delay evacuation out of the building in the event of a fire or other emergency by allowing smoke, fumes and the products of fire from entering the exit corridors in the event of a fire. This facility had a capacity of 57. The facility census was two with one of those in Swing Bed status (Swing Bed, a Medicare program in which a patient can receive acute care then, if needed Skilled Nursing Home care).

1. Observation on 5/16/2019, during the building tour, showed the following powered exit corridor access doors had a hold open feature and were not connected to the fire alarm system to ensure they closed and resisted the passage of smoke:

-Radiology double corridor doors,
-Emergency Department double corridor doors,
-Emergency Department double corridor doors to ED waiting/exit corridor,
-Outpatient back hall to Healing Garden Hall double corridor doors

2. Observation of the corridor doors on 5/16/2019, during the building tour, showed the following rooms on the Administration hall did not have positive latching devices: #5, #6, #7, #8, #9, #10, #11, #12, #15


During an interview on 5/16/2019 at 3:19 P.M., the Maintenance Director said the Administration hall doors and latches are original to the 1968 building construction date.


19.3.6.3* Corridor Doors.
19.3.6.3.1* Doors protecting corridor openings in other than
required enclosures of vertical openings, exits, or hazardous
areas shall be doors constructed to resist the passage of smoke
and shall be constructed of materials such as the following:
(1) 13.4 in. (44 mm) thick, solid-bonded core wood
(2) Material that resists fire for a minimum of 20 minutes

19.3.6.3.2 The requirements of 19.3.6.3.1 shall not apply
where otherwise permitted by either of the following:
(1) Doors to toilet rooms, bathrooms, shower rooms, sink
closets, and similar auxiliary spaces that do not contain
flammable or combustible materials shall not be required
to comply with 19.3.6.3.1.

(2) In smoke compartments protected throughout by an approved,
supervised automatic sprinkler system in accordance
with 19.3.5.7, the door construction materials requirements
of 19.3.6.3.1 shall not be mandatory, but the doors
shall be constructed to resist the passage of smoke.

19.3.6.3.10* Doors shall not be held open by devices other
than those that release when the door is pushed or pulled.

19.3.6.3.5* Doors shall be provided with a means for keeping
the door closed that is acceptable to the authority having jurisdiction,
and the following requirements also shall apply:
(1) The device used shall be capable of keeping the door fully
closed if a force of 5 lbf (22 N) is applied at the latch edge
of the door.
(2) Roller latches shall be prohibited on corridor doors in
buildings not fully protected by an approved automatic
sprinkler system in accordance with 19.3.5.7.

Based on facility staff interview and record review, facility staff failed to inspect, test and maintain the fire egress doors in accordance with the 2010 Editions of NFPA 80 (Standard for Fire Doors and Other Opening Protectives) and NFPA 105 (Standard for Fire Doors and Other Opening Protectives). Facility staff failed to conduct an annual inspection of the non rated doors in the building. This facility had a capacity of 57. The facility census was two with one of those in Swing Bed status (Swing Bed, a Medicare program in which a patient can receive acute care then, if needed Skilled Nursing Home care).

1. Review of the facility's inspection, testing and maintenance records did not show documentation of an annual inspection of the fire egress doors and non rated doors in the building.

During an interview on 5/15/2019 at 3:10 P.M., the Maintenance Director said he/she did not know the facility door inspection requirements.

NFPA 101, 2012 Edition states:

19.2.2.2.1 Doors complying with 7.2.1 shall be permitted.

7.2.1.15 Inspection of Door Openings.

7.2.1.15.1* Where required by Chapters 11 through 43, the
following door assemblies shall be inspected and tested not
less than annually in accordance with 7.2.1.15.2 through
7.2.1.15.8:
(1) Door leaves equipped with panic hardware or fire exit
hardware in accordance with 7.2.1.7
(2) Door assemblies in exit enclosures
(3) Electrically controlled egress doors
(4) Door assemblies with special locking arrangements subject
to 7.2.1.6

7.2.1.15.2 Fire-rated door assemblies shall be inspected and
tested in accordance with NFPA 80, Standard for Fire Doors and
Other Opening Protectives. Smoke door assemblies shall be inspected
and tested in accordance with NFPA 105, Standard for
Smoke Door Assemblies and Other Opening Protectives.

7.2.1.15.3 The inspection and testing interval for fire-rated
and nonrated door assemblies shall be permitted to exceed 12
months under a written performance-based program in accordance
with 5.2.2 of NFPA 80, Standard for Fire Doors and Other
Opening Protectives.

7.2.1.15.4 A written record of the inspections and testing
shall be signed and kept for inspection by the authority having
jurisdiction.

7.2.1.15.5 Functional testing of door assemblies shall be performed
by individuals who can demonstrate knowledge and
understanding of the operating components of the type of
door being subjected to testing.

7.2.1.15.6 Door assemblies shall be visually inspected from
both sides of the opening to assess the overall condition of the
assembly.

7.2.1.15.7 As a minimum, the following items shall be verified:
(1) Floor space on both sides of the openings is clear of obstructions,
and door leaves open fully and close freely.
(2) Forces required to set door leaves in motion and move to
the fully open position do not exceed the requirements
in 7.2.1.4.5.
(3) Latching and locking devices comply with 7.2.1.5.
(4) Releasing hardware devices are installed in accordance
with 7.2.1.5.10.1.
(5) Door leaves of paired openings are installed in accordance
with 7.2.1.5.11.
(6) Door closers are adjusted properly to control the closing
speed of door leaves in accordance with accessibility requirements.
(7) Projection of door leaves into the path of egress does not
exceed the encroachment permitted by 7.2.1.4.3.
(8) Powered door openings operate in accordance with
7.2.1.9.
(9) Signage required by 7.2.1.4.1(3), 7.2.1.5.5, 7.2.1.6, and
7.2.1.9 is intact and legible.
(10) Door openings with special locking arrangements function
in accordance with 7.2.1.6
(11) Security devices that impede egress are not installed on
openings, as required by 7.2.1.5.12.

Based on record review and facility staff interview, the facility staff failed to provide completed fundamental risk assessments and formally documented risk assessment procedures for all building systems categories are determined by a performed by qualified personnel. Failure to have the building systems risk assessments completed puts patients at risk for a potential negative outcome if category one systems (Category 1 system in which a failure of such equipment or system is likely to cause major injury or death of patients or caregivers) fail with no plan on how to respond if the system fails. This facility had a capacity of 57. The facility census was two with one of those in Swing Bed status (Swing Bed, a Medicare program in which a patient can receive acute care then, if needed Skilled Nursing Home care).


1. Review of the facility documents for fire safety, building system tests, and policies did not show how the categorical risk assessment scores for the building systems were determined.

2. During an interview on 5/16/2019, Staff Z said the hospital safety committee has met and discussed, but have not completed the risk assessments.


The National Fire Protection Association 99 Health Care Facilities Code, 2012 edition, Chapter 4 states:

"Chapter 4 Fundamentals

4.1* Building System Categories. Building systems in health
care facilities shall be designed to meet system Category 1
through Category 4 requirements as detailed in this code.

4.1.1* Category 1. Facility systems in which failure of such equipment
or system is likely to cause major injury or death of patients
or caregivers shall be designed to meet system Category 1 requirements
as defined in this code.

4.1.2* Category 2. Facility systems in which failure of such equipment
is likely to cause minor injury to patients or caregivers shall
be designed to meet system Category 2 requirements as defined
in this code.

4.1.3 Category 3. Facility systems in which failure of such equipment
is not likely to cause injury to patients or caregivers, but can
cause patient discomfort, shall be designed to meet system Category
3 requirements as defined in this code.

4.1.4 Category 4. Facility systems in which failure of such equipment
would have no impact on patient care shall be designed to
meet system Category 4 requirements as defined in this code.

4.2* Risk Assessment. Categories shall be determined by following
and documenting a defined risk assessment procedure.

4.3 Application. The Category definitions in Chapter 4 shall
apply to Chapters 5 through 11."

A.4.2 Risk assessment should follow procedures such as those
outlined in ISO/IEC 31010, Risk Management-Risk Assessment
Techniques, NFPA 551, Guide for the Evaluation of Fire Risk Assessments,
Guide for the Evaluation of Fire Risk Assessments, SEMI S10-
0307E, Safety Guideline for Risk Assessment and Risk Evaluation
Process, or other formal process. The results of the assessment
procedure should be documented and records retained.

Based on interview and record review the facility failed to develop a maintenance program for the medical gas, vacuum, WAGD (Waste Anesthetic Gas Disposal), or support gas system within the facility. This facility had a capacity of 57. The facility census was two with one of those in Swing Bed status (Swing Bed, a Medicare program in which a patient can receive acute care then, if needed Skilled Nursing Home care).

1. Review of the facility maintenance program documentation did not show the facility had a program in place which includes an inventory of all source systems, control valves, alarms, manufactured assemblies, and outlets, and an inspection and maintenance schedule for this system.

During an interview on 5/16/2019 at approximately 3:11 P.M., with the Maintenance Director, he/she said he/she did not know about the maintenance program for the medical gas, vacuum, WAGD, or support gas system requirements.

Section 5.1.14.2.2.1 of the National Fire Protection Association (NFPA 99) states: Health care facilities with installed medical gas, vacuum, WAGD, or medical support gas systems, or combinations thereof, shall develop and document periodic maintenance programs for these systems and their subcomponents as appropriate to the equipment installed.

Based on record review and facility staff interview, the facility staff failed to assure they maintained records of inspections and testing of their piped in oxygen systems in accordance with National Fire Protection Association (NFPA) 99, 2012 edition. This facility had a capacity of 57. The facility census was two with one of those in Swing Bed status (Swing Bed, a Medicare program in which a patient can receive acute care then, if needed Skilled Nursing Home care).

1. Review of the facility's Life Safety Code documentation showed no evidence of any inspections or testing of the piped-in oxygen system.

During an interview on 5/16/2019 at approximately 3:12 P.M., with the Maintenance Director, he/she said he/she did not know about the maintenance program for the piped-in oxygen system requirements.