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Based on Staff Interview and Record Review the facility failed to provide and maintain documentation of annual inspection and testing of the fire alarm system as required by NFPA 72. The absence of complete, verifiable documented maintenance and repair history on the fire alarm system fails to ensure reliability of the alarm system in the event of an emergency, affecting all residents in 4 of 4 smoke zones. The facility has a capacity of 25 and a census of 4 at the time of the survey.

Findings include:


During the record review on November 23, 2020 between 12:00 pm and 2:00 pm the following is observed.
1) During record review it is revealed documentation of sensitivity testing of smoke detectors is not available. There is no indication during annual inspections from February 19, 2020 of the facilities Fire Alarm System that sensitivity testing of detectors with a listed manufactures range and a tested range for each detector is performed.


Staff B was present and acknowledged the findings.

In Review of the following NFPA standard; 2012 NFPA 101

19.3.4.1 Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.


9.6.1.3 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use.

9.6.1.4 All systems and components shall be approved for the
purpose for which they are installed.

9.6.1.5 To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code.

In Review of the following NFPA standard; 2011 NFPA 72

14.1.1 The inspection, testing, and maintenance of systems, their initiating devices, and notification appliances shall comply with the requirements of this chapter.

14.1.2 The inspection, testing, and maintenance of single and multiple station smoke and heat alarms and household fire alarm systems shall comply with the requirements of this chapter.

14.6.2.4 A record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 14.6.2.4:
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance tests, or combination thereof, and affiliation, business
address, and telephone number
(6) Name, address, and representative of approving agency(ies)
(7) Designation of the detector(s) tested
(8) Functional test of detectors
(9) *Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed temperature, line type heat detectors
(12) Functional test of mass notification system control units
(13) Functional test of signal transmission to mass notification systems
(14) Functional test of ability of mass notification system to silence fire alarm notification appliances
(15) Tests of intelligibility of mass notification system speakers
(16) Other tests as required by the equipment manufacturer's published instructions
(17) Other tests as required by the authority having jurisdiction
(18) Signatures of tester and approved authority representative
(19) Disposition of problems identified during test (e.g., system owner notified, problem corrected/successfully retested, device abandoned in place)


14.4.5.3.1 Sensitivity shall be checked within 1 year after installation.

14.4.5.3.2 Sensitivity shall be checked every alternate year thereafter unless otherwise permitted by compliance with14.4.5.3.3.

14.4.5.3.3 After the second required calibration test, if sensitivity tests indicate that the device has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years.


14.4.5.3.3.1 If the frequency is extended, records of nuisance alarms and subsequent trends of these alarms shall be maintained.

14.4.5.3.3.2 In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.

14.4.5.3.4 To ensure that each smoke detector or smoke alarm is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method.
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/fire alarm control unit arrangement whereby the detector causes a signal at the fire alarm control unit where its sensitivity is outside its listed sensitivity range.
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction

14.4.5.3.5 Unless otherwise permitted by 14.4.5.3.6 smoke detectors or smoke alarms found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.

Based on Staff Interview and Record Review the facility failed to ensure that the automatic sprinkler system is installed in accordance with NFPA 13 and maintained in accordance with NFPA 25. This deficient practice fails to ensure the sprinkler system will operate properly without delay during a fire event affecting all occupants in 4 of 4 smoke zones. The facility has a capacity of 25 and a census of 4 at the time of the survey.
Findings Include:
During the record review on November 23, 2020 between 12:00 pm and 2:00 pm the following is observed.

1. The facility did not provide documentation of quarterly inspections of the dry pipe and wet pipe sprinkler systems from December of 2019 to November of 2020.

2. The facility did not provide documentation that an annual inspection of the dry pipe and wet pipe sprinkler systems have been completed within the last 12 months.


Staff B was present and acknowledged the findings.

In review of the following Standard; 2012 NFPA 101

19.3.5.3 Where required by 19.1.6, buildings containing hospitals or limited care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by

9.7.1.1* Each automatic sprinkler system required by another section of this Code shall be in accordance with one of the following:
(1) NFPA 13, Standard for the Installation of Sprinkler Systems
(2) NFPA 13D, Standard for the Installation of Sprinkler Systems in
One- and Two-Family Dwellings and Manufactured Homes
(3) NFPA 13R, Standard for the Installation of Sprinkler Systems in
Residential Occupancies up to and Including Four Stories in
Height
9.7.5 All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems

9.7.8 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. 2011 NFPA 25, 13.7.1

Record Keeping and maintenance records required by NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, shall be maintained at an approved, secured location.

In review of the following Standard; 2011 NFPA 25

5.2.5 Waterflow alarm and supervisory alarm devices shall be inspected quarterly to verify that they are free of physical damage.

5.2.6 The hydraulic design information sign for hydraulically designed systems shall be inspected quarterly to verify that it is attached securely to the sprinkler riser and is legible.

5.3.3.1 Mechanical waterflow alarm devices including, but not limited to, water motor gongs, shall be tested quarterly.

5.3.3.5 Testing waterflow alarm devices on dry pipe, pre-action, or deluge systems shall be accomplished by using the bypass connection.

Based on Observation, the facility failed to maintain smoke barrier doors in compliance with NFPA 101, Life Safety Code 2012 edition. The deficient practice of not maintaining proper doors in a smoke barrier would prevent the doors from providing compliance with the requirements and may not prevent the passage of smoke and fire product beyond the smoke barrier affecting all residents in 2 of 4 smoke zones. The facility has a capacity of 25 with a census of 4 at the time of survey.

Findings include:


During the survey on November 23, 2020 between 2:30 pm and 4:30 pm the following is observed:

1. The North door of the rated self-closing double door assembly in the 300 hall outside the locker room did not latch into the strike when a drop test is performed.

Staff B was present and acknowledged the findings.

In Review of the following standard; 2012 NFPA 101
19.3.7.8* Doors in smoke barriers shall comply with 8.5.4 and all of the following:

(1) The doors shall be self-closing or automatic-closing in accordance with 19.2.2.2.7.
(2) Latching hardware shall not be required
(3) The doors shall not be required to swing in the direction of egress travel.

8.5.4.1. Review of the following NFPA Standard revealed: Doors in smoke barriers shall close the opening, leaving only the minimum clearance necessary for proper operation, and shall be without louvers or grilles. The clearance under the bottom of a new door shall be a maximum of ¾ in. (19 mm)

In Review of the following standard; 2010 NFPA 80
6.3.1.7.1 and 6.3.1.7.2 Review of the following NFPA Standard revealed: The clearances between the top and vertical edges of the door and the frame, and the meeting edges of doors swinging in pairs, shall be 1?8 in. ± 1?16 in. (3.18 mm ± 1.59 mm) for steel doors and shall not exceed 1?8 in. (3.18 mm) for wood doors. Clearances shall be measured from the pull face of the door(s).

Based on Observation, Staff Interview and Record Review the facility failed to ensure that the facility's medical gas warning alarm system equipment is maintained and inspected in accordance with NFPA 99. The annual medical gas systems report was completed on November 18, 2020 the report was given to the maintenance director who had it on file and was waiting on a cost estimate from the vendor to correct the deficiencies that were identified on the report. On the vendor's report it is noted: The CO sensor in the following location is bad and has not been fixed:
Located in room 807 on the decadent air dryer that is connected to the compressor. This has the potential to result in failure to notify master alarm panel #1 near the maintenance office and master alarm panel #2 at the main nurses' station which resulted in an Immediate Jeopardy level (IJ - a situation in which the providers noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairments or death to a patient) and could adversely affect all patients in all 4 of 4 smoke zones using or receiving piped in medical gases from the bulk medical system throughout, which includes the OR, ED and all patient treatment areas. This deficient practice of not maintaining the medical gas warning alarm system has a direct impact on the day to day operations of the medical gas system and allows undetected variances in the medical gases to occur without immediate alarm notification. The Director of Nursing was interviewed at 1:30 pm; she indicated the only procedures performed in the OR are endoscopy or cataract, any procedure outside of an endoscopy or cataract procedure are diverted to Via Christi Hospital in Manhattan. During this interview it was indicated there were endoscopy and cataract procedures performed in the OR the week prior to the survey with five endoscopy or cataract surgeries scheduled for December 3, as well as two endoscopy or cataract procedures scheduled on December 7 and two on December 9. The facility has a capacity of 25 with a census of 4 at the time of the survey.
Findings Include:

During the record review on November 23, 2020 between 12:00 pm and 2:00 pm the following is observed.
The annual medical gas systems report was completed on November 18, 2020. On the vendor's report the following remarks are noted:
1. The CO sensor in Room 807 on the decadent air dryer that is connected to the compressor is bad and not alarming during the November 11, 2020 inspection. This has the potential to result in failure to notify master alarm panel #1 near the maintenance office and master alarm panel #2 at the main nurses' station. The facility currently has 3 patients on continuous oxygen per nasal cannula and has the potential to see patients in the emergency department that need oxygen and/or to admit additional patients requiring oxygen. At 1:15 pm the DON (Director of Nursing) and the Maintenance Supervisor were advised of the concern with the med gas vendor's findings that CO sensor was bad, needed to be replaced and they were informed, further investigation will take place. The DON (Director of Nursing) and the Maintenance Director took preemptive action to alleviate the concern. The DON instructed staff to use portable oxygen cylinders for patient care, exclusively. The Maintenance Director contacted the med gas vendor to schedule repairs. The master alarm panel #1 near the maintenance office was observed at 2:00 pm and master alarm panel #2 at the nurses' station was observed at 2:10 pm; They were both working with no alarms or trouble signals.

At 5:44 PM on November 23, 2020 the facility Maintenance Director was notified that this deficiency constitutes an Immediate Jeopardy (IJ, a situation in which the providers noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairments or death to a patient). At 5:44 PM on November 23, 2020 the Maintenance Director acknowledged that the facility had received the IJ template and at 5:44 pm on the same day the Maintenance Director sent the plan to abate the IJ by taking the following actions; At 3:09 PM the DON (Director of Nursing) had preemptively emailed staff, directing them not to use the oxygen ports from the piped in med gas system and to use portable praxair oxygen cylinders exclusively. At 3:09 PM the DON emailed the oxygen supplier to request additional cylinders until the bulk system is available to use again. At 5:44 PM the Maintenance director confirmed the med gas vendor will be onsite Wednesday November 25, 2020 to make repairs and to recertify the med gas system.

In Review of the following standard; 2012 NFPA 99
5.1.3.6.3.14 Medical Air Systems shall have air quality monitoring for their piped medical air systems.
Review of the following NFPA Standard revealed: Medical air quality shall be monitored downstream of the medical air regulators and upstream of the piping system as follows:
(1) Dew point shall be monitored and shall activate a local alarm and all master alarms when the dew point at system delivery pressure exceeds +2°C (+35°F).
(2) Carbon monoxide shall be monitored and shall activate a local alarm when the CO level exceeds 10 ppm. [See 5.1.9.5.4(2).]
(3) Dew point and carbon monoxide monitors shall activate their individual monitor's signal at the alarm panels where their signals are required when their power is lost

During the record review on November 23, 2020 between 12:00 pm and 2:00 pm the following is observed.
The annual medical gas systems report was completed on November 18, 2020. On the vendor's report the following remarks are noted:

2. Gas specific demand check valves are not on the main line, source pressure source pressure switch and gauge.

3. Source valve is not installed and in the proper location.

4. Vacuum exhaust is not located 10 feet from any door, window, air intake, other building opening or places of public assembly.


Staff B was present and acknowledged the findings.

In Review of the following standard; 2012 NFPA 99

5.1.8.2.3 All pressure-sensing devices and main line pressure gauges downstream of the source valves shall be provided with a gas-specific demand check fitting to facilitate service testing or replacement.

5.1.4.4 Source Valve. A shutoff valve shall be placed at the immediate connection of each source system to the piped distribution system to allow the entire source, including all accessory devices (e.g., air dryers, final line regulators), to be isolated from the facility.

5.1.4.4.1 The source valve shall be located in the immediate vicinity of the source equipment.

5.1.4.4.2 The source valve shall be labeled in accordance with

5.1.3.7.7.2 The exhaust shall be located as follows:
(1) Outdoors
(2) At least 3.05 m (10 ft) from any door, window, air intake, or other openings in buildings or places of public assembly
(3) At a level different from air intakes
(4) Where prevailing winds, adjacent buildings, topography, or other influences will not divert the exhaust into occupied
areas or prevent dispersion of the exhaust.

Based on record review and staff interview the facility fails to provide a documented maintenance and testing program for electrical receptacles. This deficient practice prevents the facility from ensuring that electrical receptacles are maintained and testing as required by NFPA 99 Health Care Facilities and could adversely affect all residents in 4 of 4 smoke zones. The facility has a capacity of 25 with a census of 4 residents at the time of the survey.

Findings include:

During the record review on November 23, 2020 between 12:00 pm and 2:00 pm the following is observed.
1. The facility failed to present documentation indicating annual testing of outlet receptacles in resident rooms has been performed in the last 12 months. Documentation should include an itemized list of outlet receptacles per resident room.


Staff B was present at the time of the observation and acknowledged the findings.


In Review of the following standard; 2012 NFPA 99


6.3.3.2.1 to 6.3.3.2.4 The physical integrity of each receptacle shall be confirmed by visual inspection. The continuity of the grounding circuit in each electrical receptacle shall be verified. Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed. The retention force of the grounding blade of each electrical receptacle (except locking type receptacles) shall be not less than 115 g (4 oz).

6.3.4.2.1.1 and 6.3.4.2.1.2 Review of the following NFPA Standard revealed: A record shall be maintained of the tests required by this chapter and associated repairs or modification. At a minimum, the record shall contain the date, the rooms or areas tested, and an indication of which items have met, or have failed to meet, the performance requirements of this chapter.

Based on Staff Interview and Record Review the facility failed to assure the generator is inspected and tested in accordance with NFPA 110. This deficient practice fails to ensure that the generator will not fail when needed in the event of an emergency, affecting all residents in 4 of 4 smoke zones. The facility has a capacity of 25 and census of 4 at the time of the survey.

Findings include:

During the record review on November 23, 2020 between 12:00 pm and 2:00 pm the following is observed.
1. The facility failed to present documentation of a Main and circuit breaker testing and inspection report based on manufacture requirements.

Staff B was present during the survey and acknowledged the findings.

In review of the following NFPA Standard; 2010 NFPA 110
8.3.5* Transfer switches shall be subjected to a maintenance and testing program that includes all of the following operations:

(1) Checking of connections
(2) Inspection or testing for evidence of overheating and excessive
contact erosion
(3) Removal of dust and dirt
(4) Replacement of contacts when required
8.4.7* EPSS circuit breakers for Level 1 system usage, including main and feed breakers between the EPS and the transfer switch load terminals, shall be exercised annually with the EPS in the "off" position.

8.4.7.1 Circuit breakers rated in excess of 600 volts for Level 1 system usage shall be exercised every 6 months and shall be tested under simulated overload conditions every 2 years.