HospitalInspections.org

Exception No. 6 to 19.3.6.1 for areas open to the corridor (other than patient sleeping rooms, treatment rooms, and hazardous areas), requires the space and the corridors onto which it opens, when located in the same smoke compartment, be protected by an electrically supervised automatic smoke detection system.

The facility failed to ensure areas that were open to the corridor and the corridor onto which they open were electrically supervised with an automatic smoke detection system or in direct supervision of a nurses station.

Observation determined:

1) The Main Lobby was open to the corridor and was not protected by a smoke detection system.

2) The corridors which the Main Waiting Area, Receptionist/Waiting Area, and Main Lobby open onto were not protected by an automatic smoke detection system.

The facility failed to ensure hazardous areas were equipped with doors that self-closed and automatically latched into the frame.

Observation determined:

1) There was no door protecting the opening to the Record Storage Room in the Business Office.

2) The Kitchen Dry-Good Storage Room door was not equipped with self-closing hardware.

The administration of health care facilities is to develop and distribute to all supervisory personnel written copies of a plan for the protection of all persons in the event of fire and for their evacuation from the building when necessary. All employees are to be periodically instructed and kept informed with respect to their duties under the plan. 19.7.2.

The facility failed to provide a written evacuation plan that indicates safe exiting in the event of a fire.

Review of policies/procedures indicated the facility's Evacuation Plan was not changed or altered to accommodate changes to the number of licensed beds and the building's lack of adequate smoke compartments.

The facility failed to conduct quarterly fire drills on each shift.

Record review determined:

1) Night shift fire drills were not conducted during the first, third, and fourth quarters of 2011.

2) Hospital staff participating in fire drills responded to locations within the complex, such as the fourth floor, that were not used for health care services and were separated from the health care occupancy by two-hour fire resistive construction. Hospital staff were being trained to leave the health care occupancy to respond to locations in other occupancies.

1) The facility failed to ensure the automatic sprinkler system was continuously maintained in a reliable operating condition as required by NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems.

Observation determined:

a) The sprinklers in the corridors throughout the 1957 and 1974 additions were obstructed by soffits and surface mounted light fixtures.

b) The sprinklers in Obstetrics and Radiology Dressing Areas were obstructed by cubicle curtains with mesh less than ? " diagonal in size.

c) The 1936 building was not protected by the automatic fire sprinkler system or was not separated from the 1957 building by two-hour fire resistive rated construction.

d) The C.T. Room, X-Ray Power Distribution Closet, and closets in the Chapel, Accounting Office, Human Resource Office, Finance Director Office, and Patient Accounting Office were not protected by the sprinkler system.

e) The sprinklers in X-Ray Room 1 were obstructed by the x-ray support railing.

f) Several sprinklers in the X-Ray Employee Locker Room were closer than the minimum of six feet apart.

g) The sprinklers in the Kitchen and utility rooms throughout the facility were obstructed by surface mounted light fixtures.

h) The exit corridor by Doctors Lounge and the Dish Drop-off by the Dining Room were not adequately protected by the automatic fire sprinkler system.

2) Where sprinklers have been in service for 50 years, they shall be replaced or representative samples from one or more sample areas shall be submitted to a recognized testing laboratory acceptable to the authority having jurisdiction for field service testing. NFPA 25, 2-3.1.1

The facility failed to insure that sprinklers that have been in service for more than 50 years have been tested for proper operation or replaced.

Record review could not verify that the sprinklers in the 1957 building were either tested or replaced since the original installation.

1) Emergency lighting shall be provided in accordance with Section 7.9. 38.2.9

The emergency lighting system shall be either continuously in operation or shall be capable of repeated automatic operation without manual intervention. 7.9.2.5

a) The facility failed to ensure the illumination of means of egress was arranged so that failure of a single lighting fixture (bulb) would not leave the area in darkness.

Observation determined the windowless exit corridor from the south side of Mercy Therapy to the exterior of the building was not equipped with emergency exit illumination.

b) A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2-hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. 7.9.3

The facility failed to provide documentation of the 30-second monthly testing and the annual 90-minute testing of the emergency illumination and the illuminated exit signs.

2) Means of egress components shall be limited to the types described in 38.2.2.2 through 38.2.2.12. 38.2.2.2.1

Doors complying with 7.2.1 shall be permitted. 38.2.2.1

Doors must 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 operation from the egress side. 7.2.1.5.1 The doors shall be operable with not more than one releasing operation. 7.2.1.5.4

The facility failed to ensure exit doors were equipped with latching hardware that would release with one operation.

Observation determined the exterior door from the south exit corridor was equipped with a dead-bolt lock and lever latch.

3) The capacity of means of egress shall be in accordance with Section 7.3. 38.2.3.1

The width of any means of egress shall be not less than 36 inches. 7.3.4.1.

The facility failed to ensure a 36-inch exit width through the entire means of egress.

Observation determined that a 36-inch wide path was not provided through the weight lifting area to reach the south exit door.

4) Means of egress shall be arranged in accordance with Section 7.5. 38.2.5.1

Access to an exit shall not be through a storeroom. 7.5.2.1

The facility failed to ensure exiting was not through spaces that were used as storerooms.
Observation determined the south exit corridor was being used as a storage room for other businesses that have access to the corridor.

5) Utilities shall comply with the provisions Section 9.1. 38.5.1

Equipment using gas and related gas piping shall be in accordance with NFPA 54, National Fuel Gas Code. 9.1.1

NFPA 54, Section 6.4 Clothes Dryers indicates that the installation of a gas clothes dryer must be installed in accordance with the manufacturer's requirements. Section 6.4 indicates that appliance clearance, exhausting to the outdoors, exhaust duct clearances to combustible construction, and adequate combustion air must be provided to the space in which the unit is being used.

The facility failed to provide adequate installation information for the gas dryer that is currently being used for the laundering of towels.

Observation determined the clothes dryer was installed in a small laundry room in the center of the facility and exhausted approximately 30 feet vertically. There was no documentation that indicated the unit had enough combustion air for the confined space or that the exhaust fan for the unit had enough volume and force for the height and length of the exhaust duct.

Transfer switches must be subjected to a maintenance program including connections, inspection or testing for evidence of overheating and excessive contact erosion, removal of dust and dirt, and replacement of contacts when required. NFPA 110, Standard for Emergency and Standby Power Systems.

Based on record review, the facility failed to provide evidence of quarterly checks and maintenance of the emergency generator electrical transfer switch.

The facility failed to inspect the emergency generator on a weekly basis.

Review of generator test records indicated that weekly inspections were not being done.

Exception No. 6 to 19.3.6.1 for areas open to the corridor (other than patient sleeping rooms, treatment rooms, and hazardous areas), requires the space and the corridors onto which it opens, when located in the same smoke compartment, be protected by an electrically supervised automatic smoke detection system.

The facility failed to ensure areas that were open to the corridor and the corridor onto which they open were electrically supervised with an automatic smoke detection system or in direct supervision of a nurses station.

Observation determined:

1) The Main Lobby was open to the corridor and was not protected by a smoke detection system.

2) The corridors which the Main Waiting Area, Receptionist/Waiting Area, and Main Lobby open onto were not protected by an automatic smoke detection system.

The facility failed to ensure hazardous areas were equipped with doors that self-closed and automatically latched into the frame.

Observation determined:

1) There was no door protecting the opening to the Record Storage Room in the Business Office.

2) The Kitchen Dry-Good Storage Room door was not equipped with self-closing hardware.

The administration of health care facilities is to develop and distribute to all supervisory personnel written copies of a plan for the protection of all persons in the event of fire and for their evacuation from the building when necessary. All employees are to be periodically instructed and kept informed with respect to their duties under the plan. 19.7.2.

The facility failed to provide a written evacuation plan that indicates safe exiting in the event of a fire.

Review of policies/procedures indicated the facility's Evacuation Plan was not changed or altered to accommodate changes to the number of licensed beds and the building's lack of adequate smoke compartments.

The facility failed to conduct quarterly fire drills on each shift.

Record review determined:

1) Night shift fire drills were not conducted during the first, third, and fourth quarters of 2011.

2) Hospital staff participating in fire drills responded to locations within the complex, such as the fourth floor, that were not used for health care services and were separated from the health care occupancy by two-hour fire resistive construction. Hospital staff were being trained to leave the health care occupancy to respond to locations in other occupancies.

1) The facility failed to ensure the automatic sprinkler system was continuously maintained in a reliable operating condition as required by NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems.

Observation determined:

a) The sprinklers in the corridors throughout the 1957 and 1974 additions were obstructed by soffits and surface mounted light fixtures.

b) The sprinklers in Obstetrics and Radiology Dressing Areas were obstructed by cubicle curtains with mesh less than ? " diagonal in size.

c) The 1936 building was not protected by the automatic fire sprinkler system or was not separated from the 1957 building by two-hour fire resistive rated construction.

d) The C.T. Room, X-Ray Power Distribution Closet, and closets in the Chapel, Accounting Office, Human Resource Office, Finance Director Office, and Patient Accounting Office were not protected by the sprinkler system.

e) The sprinklers in X-Ray Room 1 were obstructed by the x-ray support railing.

f) Several sprinklers in the X-Ray Employee Locker Room were closer than the minimum of six feet apart.

g) The sprinklers in the Kitchen and utility rooms throughout the facility were obstructed by surface mounted light fixtures.

h) The exit corridor by Doctors Lounge and the Dish Drop-off by the Dining Room were not adequately protected by the automatic fire sprinkler system.

2) Where sprinklers have been in service for 50 years, they shall be replaced or representative samples from one or more sample areas shall be submitted to a recognized testing laboratory acceptable to the authority having jurisdiction for field service testing. NFPA 25, 2-3.1.1

The facility failed to insure that sprinklers that have been in service for more than 50 years have been tested for proper operation or replaced.

Record review could not verify that the sprinklers in the 1957 building were either tested or replaced since the original installation.

1) Emergency lighting shall be provided in accordance with Section 7.9. 38.2.9

The emergency lighting system shall be either continuously in operation or shall be capable of repeated automatic operation without manual intervention. 7.9.2.5

a) The facility failed to ensure the illumination of means of egress was arranged so that failure of a single lighting fixture (bulb) would not leave the area in darkness.

Observation determined the windowless exit corridor from the south side of Mercy Therapy to the exterior of the building was not equipped with emergency exit illumination.

b) A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2-hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. 7.9.3

The facility failed to provide documentation of the 30-second monthly testing and the annual 90-minute testing of the emergency illumination and the illuminated exit signs.

2) Means of egress components shall be limited to the types described in 38.2.2.2 through 38.2.2.12. 38.2.2.2.1

Doors complying with 7.2.1 shall be permitted. 38.2.2.1

Doors must 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 operation from the egress side. 7.2.1.5.1 The doors shall be operable with not more than one releasing operation. 7.2.1.5.4

The facility failed to ensure exit doors were equipped with latching hardware that would release with one operation.

Observation determined the exterior door from the south exit corridor was equipped with a dead-bolt lock and lever latch.

3) The capacity of means of egress shall be in accordance with Section 7.3. 38.2.3.1

The width of any means of egress shall be not less than 36 inches. 7.3.4.1.

The facility failed to ensure a 36-inch exit width through the entire means of egress.

Observation determined that a 36-inch wide path was not provided through the weight lifting area to reach the south exit door.

4) Means of egress shall be arranged in accordance with Section 7.5. 38.2.5.1

Access to an exit shall not be through a storeroom. 7.5.2.1

The facility failed to ensure exiting was not through spaces that were used as storerooms.
Observation determined the south exit corridor was being used as a storage room for other businesses that have access to the corridor.

5) Utilities shall comply with the provisions Section 9.1. 38.5.1

Equipment using gas and related gas piping shall be in accordance with NFPA 54, National Fuel Gas Code. 9.1.1

NFPA 54, Section 6.4 Clothes Dryers indicates that the installation of a gas clothes dryer must be installed in accordance with the manufacturer's requirements. Section 6.4 indicates that appliance clearance, exhausting to the outdoors, exhaust duct clearances to combustible construction, and adequate combustion air must be provided to the space in which the unit is being used.

The facility failed to provide adequate installation information for the gas dryer that is currently being used for the laundering of towels.

Observation determined the clothes dryer was installed in a small laundry room in the center of the facility and exhausted approximately 30 feet vertically. There was no documentation that indicated the unit had enough combustion air for the confined space or that the exhaust fan for the unit had enough volume and force for the height and length of the exhaust duct.

Transfer switches must be subjected to a maintenance program including connections, inspection or testing for evidence of overheating and excessive contact erosion, removal of dust and dirt, and replacement of contacts when required. NFPA 110, Standard for Emergency and Standby Power Systems.

Based on record review, the facility failed to provide evidence of quarterly checks and maintenance of the emergency generator electrical transfer switch.

The facility failed to inspect the emergency generator on a weekly basis.

Review of generator test records indicated that weekly inspections were not being done.