HospitalInspections.org

Based on observation and staff interview, it was determined the hospital failed to maintain all corridor doors to close and latch without impediment.

Findings Include:

1. During a tour of the hospital 2nd floor on 01/12/15 at approximately 9:45 a.m., room 200 Intensive Care Unit (ICU) door would not close and latch when tested.

2. During an interview with the hospital facility director on 01/12/15 at approximately 9:50 a.m., it was agreed that room 200 ICU door would not close and latch properly.

National Fire Protection Association (NFPA) 17A - Standard for Wet Chemical Extinguishing Systems
Chapter 5 - Inspection, Maintenance, and Recharging
5-2 Owner's Inspection.
5-2.1
On a monthly basis, inspection shall be conducted in accordance with the manufacturer's listed installation and maintenance manual or owner's manual. As a minimum, this "quick check" or inspection shall include verification of the following:
(a) The extinguishing system is in its proper location.
(b) The manual actuators are unobstructed.
(c) The tamper indicators and seals are intact.
(d) The maintenance tag or certificate is in place.
(e) The system shows no physical damage or condition that might prevent operation.
(f) The pressure gauge(s), if provided, is in operable range.
(g) The nozzle blowoff caps, where provided, are intact and undamaged.
(h) Neither the protected equipment nor the hazard has been replaced, modified, or relocated.
5-2.2
If any deficiencies are found, appropriate corrective action shall be taken immediately.
5-2.3
Personnel making inspections shall keep records for those extinguishing systems that were found to require corrective actions.
5-2.4
At least monthly, the date the inspection is performed and the initials of the person performing the inspection shall be recorded. The records shall be retained until the next semiannual maintenance.

This Standard is not met as evidenced by:

Based on observation and staff interview it was determined the hospital failed to inspect the range hood extinguishing system in accordance with NFPA 17A.

Findings include:

1. On 01/14/15 at approximately 10:25 a.m., the hospital range hood extinguishing system located in the kitchen was inspected. During this inspection, observation of the service tag attached to the range hood extinguishing system indicated dates and initials were not recorded to verify monthly inspections were conducted on the system. Therefore, a monthly inspection record was not available for the past twelve (12) months.

2. An interview with the hospital facility director on 01/14/15 at approximately 10:30 a.m., revealed a monthly inspection was not available for the range hood extinguishing system.

Based on observation and staff interview, it was determined the hospital failed to maintain all corridor doors to close and latch without impediment.

Findings Include:

1. During a tour of the hospital 2nd floor on 01/12/15 at approximately 9:45 a.m., room 200 Intensive Care Unit (ICU) door would not close and latch when tested.

2. During an interview with the hospital facility director on 01/12/15 at approximately 9:50 a.m., it was agreed that room 200 ICU door would not close and latch properly.

National Fire Protection Association (NFPA) 17A - Standard for Wet Chemical Extinguishing Systems
Chapter 5 - Inspection, Maintenance, and Recharging
5-2 Owner's Inspection.
5-2.1
On a monthly basis, inspection shall be conducted in accordance with the manufacturer's listed installation and maintenance manual or owner's manual. As a minimum, this "quick check" or inspection shall include verification of the following:
(a) The extinguishing system is in its proper location.
(b) The manual actuators are unobstructed.
(c) The tamper indicators and seals are intact.
(d) The maintenance tag or certificate is in place.
(e) The system shows no physical damage or condition that might prevent operation.
(f) The pressure gauge(s), if provided, is in operable range.
(g) The nozzle blowoff caps, where provided, are intact and undamaged.
(h) Neither the protected equipment nor the hazard has been replaced, modified, or relocated.
5-2.2
If any deficiencies are found, appropriate corrective action shall be taken immediately.
5-2.3
Personnel making inspections shall keep records for those extinguishing systems that were found to require corrective actions.
5-2.4
At least monthly, the date the inspection is performed and the initials of the person performing the inspection shall be recorded. The records shall be retained until the next semiannual maintenance.

This Standard is not met as evidenced by:

Based on observation and staff interview it was determined the hospital failed to inspect the range hood extinguishing system in accordance with NFPA 17A.

Findings include:

1. On 01/14/15 at approximately 10:25 a.m., the hospital range hood extinguishing system located in the kitchen was inspected. During this inspection, observation of the service tag attached to the range hood extinguishing system indicated dates and initials were not recorded to verify monthly inspections were conducted on the system. Therefore, a monthly inspection record was not available for the past twelve (12) months.

2. An interview with the hospital facility director on 01/14/15 at approximately 10:30 a.m., revealed a monthly inspection was not available for the range hood extinguishing system.