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Based on observation and staff interview, the facility failed to ensure smoke barriers were constructed and properly protected from penetrations in accordance with NFPA 101, section 8.3. Incomplete construction, unprotected penetrations, openings and gaps in smoke barriers walls would permit the movement of smoke form one smoke compartment to another. This deficient practice had the potential to harm patients within two (2) of two (2) smoke compartments located on the first floor. The findings are:

A. On 07/20/11 between 7:30 am and 9:00 am, during smoke barrier inspections with the Director of Facilities, the surveyor observed the following:

1st Floor:

1. At 7:45 am, inspection of the smoke barrier wall located near the emergency department entrance revealed an unsealed 1 1/4 inch diameter sleeve.
2. At 9:00 am, inspection of the smoke barrier wall located above the door leading to the Front End of the Business Office revealed an unsealed 1 1/2 inch diameter sleeve.
3. During interview at this time, the Director of Facilities stated he was unaware the penetrations were unsealed.
4. On 07/20/11 at 10:00 am, the Chief Financial Officer and the Director of Facilities acknowledged the above findings at the exit conference.

Based on observation and staff interview, the facility failed to ensure hazardous areas in sprinklered building are separated from all other areas by smoke partitions and doors that would resist the passage of smoke. Openings in these smoke partitions would result in the passage of smoke from these hazardous areas into adjacent spaces including the exit access. This deficient practice had the potential to harm kitchen staff. At the time of survey, six (6) staff were working the kitchen. The findings are:

A. On 07/19/11 at 2:30 pm, during a tour of the kitchen with the Director of Facilities, the surveyor observed the door to the dry storage room was propped in the open position using a plastic bag. This bag was tied to the doorknob and also tied to shelving which did not allow the door to self close as required.
1. During interview at this time, the Director of Facilities stated he was unaware staff was propping the door open.
2. On 07/20/11 at 10:00 am, the Chief Financial Officer and the Director of Facilities acknowledged the above findings at the exit conference.

NFPA 101, 2000 Edition
7.2.1.5.1 Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for the operation from the egress side.

7.2.1.5.4 A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions...

7.2.1.5.5 Where pairs of doors are required in a means of egress, each leaf of the pair shall be provided with its own releasing device. Devices that depend on the release of one door before the other shall not be used.

Exception: Where exit doors are used in pairs and approved automatic flush bolts are used, the door leaf equipped with the automatic flush bolts shall have no doorknob or surface mounted hardware. The unlatching of any leaf shall not require more than one operation.

Based on observation and staff interview, the facility failed to ensure where pairs of doors are provided in a required means of egress, the releasing devices do not depend on the release of one door before the other unless approved automatic flush bolts are used. This deficient practice had the potential to harm all patients, staff and occupants located on the first floor. The findings are:

A. On 07/19/11 at 3:00 pm, during a tour of the facility with the Director of Facilities the surveyor observed the exterior double doors located near the dining room
were provided with manual flush bolts instead of automatic flush bolts or other approved method of locking and latching. Also, the unlatching of these doors requires one door to be unlatched and opened before the other door can be unlatched and opened.
1. During interview at this time, the Director of Facilities stated he was unaware the hardware was not allowed on the exit doors.
2. On 07/20/11 at 10:00 am, the Chief Financial Officer and the Director of Facilities acknowledged the above findings at the exit conference.

Reference NFPA 101, 2000 Edition
Section. 19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift.

Based on record review and staff interview, the facility failed to ensure fire drills are conducted at least quarterly on every shift to assure preparedness for emergency response (Federal regulations require that fire drills shall not exceed 90-day spacing between drills on each shift). This deficient practice has the potential to harm all thirty- six (36) inpatients of the hospital as identified by the Room Bed Census report provided by the Chief Quality Officer on 07/19/11 at 10:30 am. The findings are:

A. The facility has two (2) shifts:
Day Shift (6:00 am - 6:00 pm)
Night Shift (6:00 pm - 6:00 am)


1. On 07/19/11 at 11:05 am, review of the fire drill log with the Director of Facilities revealed a fire drill was conducted 09/01/10 on the night shift. The next fire drill on this shift wasn't conducted until 02/17/11. This exceeds the 90-day spacing between drills on this shift.
2. During interview at this time, the Director of Facilities stated he didn't realize he was exceeding the 90-day interval between fire drills.
3. No further records were available for review.
4. On 07/20/11 at 10:00 am, the Chief Financial Officer and the Director of Facilities acknowledged the above findings at the exit conference.

Reference NFPA 101, 2000 Edition
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.

Reference NFPA 72, 1998 Edition
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.

Reference NFPA 72, 1998 Edition
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.

Reference NFPA 72, 1998 Edition
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 interview, the facility failed to ensure delayed egress door magnetic locking devices installed on doors located in the path of emergency egress de-energized (unlock) when the fire alarm system was in active alarm and placed in the silence mode. This deficient practice had the potential to harm six (6) patients in labor and delivery and four (4) patients in the nursery as identified by the Room Bed Census report provided by the Chief Quality Officer on 07/19/11 at 10:30 am. The findings are:
The findings are:

A. On 07/19/11 at 3:50 pm, a fire alarm system test was conducted at the facility to ensure fire alarm system integrity. The alarm was activated on the second floor at the pull station located near the pharmacy.
1. During this time, the surveyor observed the magnetic locking devices installed on the labor and delivery/nursery exit doors. Three doors were affected specifically: one door which leads into stairwell #521, and the double set of doors which lead into the main central corridor leading to medical surgical. All of these doors released during active alarm. However, when the fire alarm system was placed in the silence mode but still in active alarm, the surveyor observed these door magnetic locking devices failed to remain unlocked.
2. During interview at this time, the Director of Facilities stated he was unaware the doors were not unlocking when the system was placed in the the silence mode.
3. On 07/20/11 at 10:00 am, the Chief Financial Officer and the Director of Facilities acknowledged the above findings at the exit conference.

Reference NFPA 72, Section 7-3.2.1*
Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector 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. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector 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/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

7-5.2.2
A permanent 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 7-5.2.2.
(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, for example, tests performed in accordance with Section 7-2 and 7-3
(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) Other tests as required by equipment manufacturers
(13) Other tests as required by the authority having jurisdiction
(14) Signatures of tester and approved authority representative
(15) Disposition of problems identified during test (for example, owner notified, problem corrected/successfully retested, device abandoned in place)


Based on record review and staff interview, the facility failed to ensure smoke detectors were tested for sensitivity as required by NFPA 72 (National Fire Alarm Code). Without this testing, the facility has no assurance the smoke detectors would function reliably. This deficient practice has the potential to harm all thirty-six (36) inpatients of the hospital as identified by the Room Bed Census report provided by the Chief Quality Officer on 07/19/11 at 10:30 am. The findings are:

A. On 07/19/11 at 11:30 am, review of the fire alarm maintenance records with the Director of Facilities revealed no evidence that sensitivity testing was performed on the facility's smoke detectors.
1. During interview at this time, the Director of Facilities stated the professional company performs testing of each smoke detector annually. However, he stated sensitivity testing wasn't being conducted.
2. No further records were available for review.
3. On 07/20/11 at 10:00 am, the Chief Financial Officer and the Director of Facilities acknowledged the above findings at the exit conference.

Reference NFPA 1999, Standard for the Installation of Automatic Sprinkler Systems

5-14.1.1.3*
Valves on connections to water supplies, sectional control and isolation valves, and other valves in supply pipes to sprinklers and other fixed water-based fire suppression systems shall be supervised by one of the following methods:
(1) Central station, proprietary, or remote station signaling service
(2) Local signaling service that will cause the sounding of an audible signal at a constantly attended point
(3) Valves locked in the correct position
(4) Valves located within fenced enclosures under the control of the owner, sealed in the open position, and inspected weekly as part of an approved procedure


Based on observation and staff interview, the facility failed to ensure the Pressure Indicator Valve (PIV) was supervised by one of the above mentioned methods. This deficient practice had the potential to harm all thirty-six (36) inpatients of the hospital as identified by the Room Bed Census report provided by the Chief Quality Officer on 07/19/11 at 10:30 am. The findings are:

A. On 07/19/11 at 12:00 pm, during a tour of the facility with the Director of Facilities, the surveyor observed the PIV which is located outside near the facility's oxygen storage room, was neither locked or supervised by an approved method.
1. During interview at this time, the Director of Facilities stated the valve was not electronically supervised but should have been locked in the open position.
2. On 07/20/11 at 10:00 am, the Chief Financial Officer and the Director of Facilities acknowledged the above findings at the exit conference.

Reference NFPA 99:
3-4.4.2 Record keeping:
A written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction.

Based on observation, record review and staff interview, the facility's practice failed to ensure specific gravity was being tested for all generator starting batteries in accordance with NFPA 110 (Standard for Emergency and Standby Power Systems). Specific gravity shall be tested and recorded at least once a month for all generator batteries to determine their serviceability. This deficient practice could result in the emergency generator failing to start due to weak generator batteries. This deficient practice has the potential to harm all thirty-six (36) inpatients of the hospital as identified by the Room Bed Census report provided by the Chief Quality Officer on 07/19/11 at 10:30 am. The findings are:

A. On 07/19/11 at 11:45 am, review of the generator's maintenance records with the Director of Facilities the surveyor revealed specific gravity of the batteries was not being tested.
1. During interview at this time, the Director of Facilities stated specific gravity was not being tested.
2. No further records were available for review.
3. At 4:45 pm, inspection of the emergency generator revealed two maintenance free batteries. Generator set batteries of the "maintenance-free" variety are prohibited. All generator set batteries shall be the serviceable variety.
4. During interview at this time, the Director of Facilities stated he was unaware maintenance free batteries were prohibited.
5. On 07/20/11 at 10:00 am, the Chief Financial Officer and the Director of Facilities acknowledged the above findings at the exit conference.


NFPA 110:
Section 6-4.2*
Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating.
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer.
The date and time of day for required testing shall be decided by the owner, based on facility operations.

6-4.3
Load tests of generator sets shall include complete cold starts.

* Light loading creates a condition termed wet stacking, indicating the presence of unburned fuel or carbon, or both, in the exhaust system. Its presence is readily indicated by the presence of continual black smoke during engine-run operation. The testing requirements of 6-4.2 are intended to reduce the possibility of wet stacking.

Based on observation, record review and staff interview, the facility failed to ensure the emergency generator used to protect patients during times of primary power failure was being tested underload at least once a month for a minimum of thirty minutes as required by NFPA 110 (Standard for Emergency and Standby Power Systems). This deficient practice had the potential to harm all thirty-six (36) inpatients of the hospital as identified by the Room Bed Census report provided by the Chief Quality Officer on 07/19/11 at 10:30 am. The findings are:

A. On 07/19/11 at 11:50 am, review of the generator's testing log book with the Director of Facilities revealed the emergency generator was being tested without load every week. However, there was no record of underload testing.
1. During interview at this time, the Director of Facilities stated he thought having an annual load bank test every year precluded him from this requirement.
2. No further records were available for review.
3. On 07/20/11 at 10:00 am, the Chief Financial Officer and the Director of Facilities acknowledged the above findings at the exit conference.

Based on observation and staff interview, the facility failed to ensure smoke barriers were constructed and properly protected from penetrations in accordance with NFPA 101, section 8.3. Incomplete construction, unprotected penetrations, openings and gaps in smoke barriers walls would permit the movement of smoke form one smoke compartment to another. This deficient practice had the potential to harm patients within two (2) of two (2) smoke compartments located on the first floor. The findings are:

A. On 07/20/11 between 7:30 am and 9:00 am, during smoke barrier inspections with the Director of Facilities, the surveyor observed the following:

1st Floor:

1. At 7:45 am, inspection of the smoke barrier wall located near the emergency department entrance revealed an unsealed 1 1/4 inch diameter sleeve.
2. At 9:00 am, inspection of the smoke barrier wall located above the door leading to the Front End of the Business Office revealed an unsealed 1 1/2 inch diameter sleeve.
3. During interview at this time, the Director of Facilities stated he was unaware the penetrations were unsealed.
4. On 07/20/11 at 10:00 am, the Chief Financial Officer and the Director of Facilities acknowledged the above findings at the exit conference.

Based on observation and staff interview, the facility failed to ensure hazardous areas in sprinklered building are separated from all other areas by smoke partitions and doors that would resist the passage of smoke. Openings in these smoke partitions would result in the passage of smoke from these hazardous areas into adjacent spaces including the exit access. This deficient practice had the potential to harm kitchen staff. At the time of survey, six (6) staff were working the kitchen. The findings are:

A. On 07/19/11 at 2:30 pm, during a tour of the kitchen with the Director of Facilities, the surveyor observed the door to the dry storage room was propped in the open position using a plastic bag. This bag was tied to the doorknob and also tied to shelving which did not allow the door to self close as required.
1. During interview at this time, the Director of Facilities stated he was unaware staff was propping the door open.
2. On 07/20/11 at 10:00 am, the Chief Financial Officer and the Director of Facilities acknowledged the above findings at the exit conference.

NFPA 101, 2000 Edition
7.2.1.5.1 Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for the operation from the egress side.

7.2.1.5.4 A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions...

7.2.1.5.5 Where pairs of doors are required in a means of egress, each leaf of the pair shall be provided with its own releasing device. Devices that depend on the release of one door before the other shall not be used.

Exception: Where exit doors are used in pairs and approved automatic flush bolts are used, the door leaf equipped with the automatic flush bolts shall have no doorknob or surface mounted hardware. The unlatching of any leaf shall not require more than one operation.

Based on observation and staff interview, the facility failed to ensure where pairs of doors are provided in a required means of egress, the releasing devices do not depend on the release of one door before the other unless approved automatic flush bolts are used. This deficient practice had the potential to harm all patients, staff and occupants located on the first floor. The findings are:

A. On 07/19/11 at 3:00 pm, during a tour of the facility with the Director of Facilities the surveyor observed the exterior double doors located near the dining room
were provided with manual flush bolts instead of automatic flush bolts or other approved method of locking and latching. Also, the unlatching of these doors requires one door to be unlatched and opened before the other door can be unlatched and opened.
1. During interview at this time, the Director of Facilities stated he was unaware the hardware was not allowed on the exit doors.
2. On 07/20/11 at 10:00 am, the Chief Financial Officer and the Director of Facilities acknowledged the above findings at the exit conference.

Reference NFPA 101, 2000 Edition
Section. 19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift.

Based on record review and staff interview, the facility failed to ensure fire drills are conducted at least quarterly on every shift to assure preparedness for emergency response (Federal regulations require that fire drills shall not exceed 90-day spacing between drills on each shift). This deficient practice has the potential to harm all thirty- six (36) inpatients of the hospital as identified by the Room Bed Census report provided by the Chief Quality Officer on 07/19/11 at 10:30 am. The findings are:

A. The facility has two (2) shifts:
Day Shift (6:00 am - 6:00 pm)
Night Shift (6:00 pm - 6:00 am)


1. On 07/19/11 at 11:05 am, review of the fire drill log with the Director of Facilities revealed a fire drill was conducted 09/01/10 on the night shift. The next fire drill on this shift wasn't conducted until 02/17/11. This exceeds the 90-day spacing between drills on this shift.
2. During interview at this time, the Director of Facilities stated he didn't realize he was exceeding the 90-day interval between fire drills.
3. No further records were available for review.
4. On 07/20/11 at 10:00 am, the Chief Financial Officer and the Director of Facilities acknowledged the above findings at the exit conference.

Reference NFPA 101, 2000 Edition
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.

Reference NFPA 72, 1998 Edition
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.

Reference NFPA 72, 1998 Edition
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.

Reference NFPA 72, 1998 Edition
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 interview, the facility failed to ensure delayed egress door magnetic locking devices installed on doors located in the path of emergency egress de-energized (unlock) when the fire alarm system was in active alarm and placed in the silence mode. This deficient practice had the potential to harm six (6) patients in labor and delivery and four (4) patients in the nursery as identified by the Room Bed Census report provided by the Chief Quality Officer on 07/19/11 at 10:30 am. The findings are:
The findings are:

A. On 07/19/11 at 3:50 pm, a fire alarm system test was conducted at the facility to ensure fire alarm system integrity. The alarm was activated on the second floor at the pull station located near the pharmacy.
1. During this time, the surveyor observed the magnetic locking devices installed on the labor and delivery/nursery exit doors. Three doors were affected specifically: one door which leads into stairwell #521, and the double set of doors which lead into the main central corridor leading to medical surgical. All of these doors released during active alarm. However, when the fire alarm system was placed in the silence mode but still in active alarm, the surveyor observed these door magnetic locking devices failed to remain unlocked.
2. During interview at this time, the Director of Facilities stated he was unaware the doors were not unlocking when the system was placed in the the silence mode.
3. On 07/20/11 at 10:00 am, the Chief Financial Officer and the Director of Facilities acknowledged the above findings at the exit conference.

Reference NFPA 72, Section 7-3.2.1*
Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector 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. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector 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/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

7-5.2.2
A permanent 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 7-5.2.2.
(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, for example, tests performed in accordance with Section 7-2 and 7-3
(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) Other tests as required by equipment manufacturers
(13) Other tests as required by the authority having jurisdiction
(14) Signatures of tester and approved authority representative
(15) Disposition of problems identified during test (for example, owner notified, problem corrected/successfully retested, device abandoned in place)


Based on record review and staff interview, the facility failed to ensure smoke detectors were tested for sensitivity as required by NFPA 72 (National Fire Alarm Code). Without this testing, the facility has no assurance the smoke detectors would function reliably. This deficient practice has the potential to harm all thirty-six (36) inpatients of the hospital as identified by the Room Bed Census report provided by the Chief Quality Officer on 07/19/11 at 10:30 am. The findings are:

A. On 07/19/11 at 11:30 am, review of the fire alarm maintenance records with the Director of Facilities revealed no evidence that sensitivity testing was performed on the facility's smoke detectors.
1. During interview at this time, the Director of Facilities stated the professional company performs testing of each smoke detector annually. However, he stated sensitivity testing wasn't being conducted.
2. No further records were available for review.
3. On 07/20/11 at 10:00 am, the Chief Financial Officer and the Director of Facilities acknowledged the above findings at the exit conference.

Reference NFPA 1999, Standard for the Installation of Automatic Sprinkler Systems

5-14.1.1.3*
Valves on connections to water supplies, sectional control and isolation valves, and other valves in supply pipes to sprinklers and other fixed water-based fire suppression systems shall be supervised by one of the following methods:
(1) Central station, proprietary, or remote station signaling service
(2) Local signaling service that will cause the sounding of an audible signal at a constantly attended point
(3) Valves locked in the correct position
(4) Valves located within fenced enclosures under the control of the owner, sealed in the open position, and inspected weekly as part of an approved procedure


Based on observation and staff interview, the facility failed to ensure the Pressure Indicator Valve (PIV) was supervised by one of the above mentioned methods. This deficient practice had the potential to harm all thirty-six (36) inpatients of the hospital as identified by the Room Bed Census report provided by the Chief Quality Officer on 07/19/11 at 10:30 am. The findings are:

A. On 07/19/11 at 12:00 pm, during a tour of the facility with the Director of Facilities, the surveyor observed the PIV which is located outside near the facility's oxygen storage room, was neither locked or supervised by an approved method.
1. During interview at this time, the Director of Facilities stated the valve was not electronically supervised but should have been locked in the open position.
2. On 07/20/11 at 10:00 am, the Chief Financial Officer and the Director of Facilities acknowledged the above findings at the exit conference.

Reference NFPA 99:
3-4.4.2 Record keeping:
A written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction.

Based on observation, record review and staff interview, the facility's practice failed to ensure specific gravity was being tested for all generator starting batteries in accordance with NFPA 110 (Standard for Emergency and Standby Power Systems). Specific gravity shall be tested and recorded at least once a month for all generator batteries to determine their serviceability. This deficient practice could result in the emergency generator failing to start due to weak generator batteries. This deficient practice has the potential to harm all thirty-six (36) inpatients of the hospital as identified by the Room Bed Census report provided by the Chief Quality Officer on 07/19/11 at 10:30 am. The findings are:

A. On 07/19/11 at 11:45 am, review of the generator's maintenance records with the Director of Facilities the surveyor revealed specific gravity of the batteries was not being tested.
1. During interview at this time, the Director of Facilities stated specific gravity was not being tested.
2. No further records were available for review.
3. At 4:45 pm, inspection of the emergency generator revealed two maintenance free batteries. Generator set batteries of the "maintenance-free" variety are prohibited. All generator set batteries shall be the serviceable variety.
4. During interview at this time, the Director of Facilities stated he was unaware maintenance free batteries were prohibited.
5. On 07/20/11 at 10:00 am, the Chief Financial Officer and the Director of Facilities acknowledged the above findings at the exit conference.


NFPA 110:
Section 6-4.2*
Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating.
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer.
The date and time of day for required testing shall be decided by the owner, based on facility operations.

6-4.3
Load tests of generator sets shall include complete cold starts.

* Light loading creates a condition termed wet stacking, indicating the presence of unburned fuel or carbon, or both, in the exhaust system. Its presence is readily indicated by the presence of continual black smoke during engine-run operation. The testing requirements of 6-4.2 are intended to reduce the possibility of wet stacking.

Based on observation, record review and staff interview, the facility failed to ensure the emergency generator used to protect patients during times of primary power failure was being tested underload at least once a month for a minimum of thirty minutes as required by NFPA 110 (Standard for Emergency and Standby Power Systems). This deficient practice had the potential to harm all thirty-six (36) inpatients of the hospital as identified by the Room Bed Census report provided by the Chief Quality Officer on 07/19/11 at 10:30 am. The findings are:

A. On 07/19/11 at 11:50 am, review of the generator's testing log book with the Director of Facilities revealed the emergency generator was being tested without load every week. However, there was no record of underload testing.
1. During interview at this time, the Director of Facilities stated he thought having an annual load bank test every year precluded him from this requirement.
2. No further records were available for review.
3. On 07/20/11 at 10:00 am, the Chief Financial Officer and the Director of Facilities acknowledged the above findings at the exit conference.