HospitalInspections.org

Based on random observation it was determined the hospital failed to maintain all corridor doors to be smoke resistant and to close and latch without impediment. Findings include:

1. During tour of the hospital on 03/09/11 at approximately 10:00 a.m., the corridor door to an equipment storage room located on the 2nd floor was observed not to have a positive latching mechanism. This corridor door was also observed to have an open vent installed. Also, during this tour the following corridor doors were observed to be held open with a wooden wedge: room 200, 2nd floor kitchenette and cafeteria.

NFPA 96 - Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations
Chapter 7 - Fire-Extinguishing Equipment
7-2.2.1
Automatic fire-extinguishing systems shall be installed in accordance with the terms of their listing, the manufacturer"s instructions, and the following standards where applicable.
(a) NFPA 12, Standard on Carbon Dioxide Extinguishing Systems
(b) NFPA 13, Standard for the Installation of Sprinkler Systems
(c) NFPA 17, Standard for Dry Chemical Extinguishing Systems
(d) NFPA 17A, Standard for Wet Chemical Extinguishing Systems

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 rangehood wet chemical extinguishing system is not maintained and inspected in accordance with National Fire Protection Association (NFPA) 96 and 17A. Findings include:

1. On 03/08/11 at approximately 9:15 a.m., the hospital rangehood extinguishing system was inspected. During this inspection, the service tag attached to the rangehood extinguishing system was observed not to have a date or initials recorded, to verify a monthly inspection was conducted on the system. The service tag was dated November 2010. Therefore, a monthly inspection record was not available for the time period from December 2010 to February 2011. Also, at this time a nozzle blowoff cap was observed missing.

2. On 03/08/11 at approximately 10:00 a.m., a rangehood inspection report dated 04/25/10 and prepared by J.T. Martin Fire and Safety was reviewed. This report indicated that the microswitch needs wired. An interview with the director of plant facilities on this same date and time revealed that the microswitch had not been wired as of this date 03/08/11.

Based on review of facility documentation and staff interview it was determined the hospital failed to maintain the medical gas system in accordance with National Fire Protection Association (NFPA) 99, Chapter 4. Findings include:

1. On 03/08/11 at approximately 10:00 a.m., a medical gas system inspection report prepared by Northeast Medical Consulting Incorporated and dated 01/05/11 was reviewed. This report indicated the following deficiencies were found during the medical gas inspection:

A. Source Equipment
I. Oxygen
1. A gas specific demand check should be installed on the master pressure switch and main gauge.
2. The source and main valves are required to be labeled with "Gas", "Area Served" and "Do not close except in emergency". This label must be colored coded.
3. Duplex line pressure regulators should be installed with isolation valves.

II. Medical Air
1. A second dryer and dewpoint/CO monitor should be installed and wired to the master alarm panels.
2. A local audible and visual signal for the lag compressor in use should be installed and wired to the master alarm panels.
3. The receiver needs a drain, sight glass and by-pass valves installed.
4. A gas specific demand check should be installed on the master pressure switch and main gauge.
5. Duplex line-pressure regulators should be installed with isolation valves.

III. Vacuum
1. A local audible and visual signal for the lag pump in use should be installed on the control panel.
2. The receiver should have a drain and by-pass valves installed.
3. A gas specific demand check should be installed on the master pressure switch.
4. The lag alarm is required to be wired to the master alarm panels.
5. A main gauge with a gas specific demand check should be installed immediately downstream of the main valve.
6. The exhaust point is required to be at a different level from air intakes.

B. Alarms
I. Master Alarms
1. A "lag pump in use" alarm point for the vacuum system should be wired to the master alarm panels.
2. The high dew point and high carbon monoxide points should be wired into the master alarm panels when you install the monitors.
3. 2 South nurse station normal operation light bulb is burnt out and is required to be replaced.
II. Area Alarms
1. Emergency instructions with who to call in case of alarm are required to be posted at the alarm panels.

C. Zone Valves
1. Two (2) valve box covers are broken and are required to be replaced.
2. The oxygen valve for 2 South leaks externally when opened and is required to be repaired.
3. The oxygen valves for 2 ICU and 2 South leak externally when closed and are required to be repaired.

D. Patient Terminals
1. Five (5) vacuum inlets leak due to worn o-rings and require correction.

2. On 03/08/11 at approximately 1:15 p.m., an interview with the director of plant facilities revealed that the aforementioned deficiencies cited on the medical system inspection report dated 01/05/11 have not been corrected as of this date 03/08/11.

Based on observation and staff interview it was determined the hospital failed to maintain all fume hoods in accordance with National Fire Protection Association (NFPA) 99. Findings include:

1. On 03/08/11 at approximately 9:30 a.m., the hospital lab hood ventilation system was observed not to have a current certification inspection and testing sticker for the previous twelve (12) month period.

2. An interview with the hospital director of plant services on 03/08/11 at approximately 10:00 a.m., revealed there was no documentation evidence available to indicate that the lab hood ventilation system had been inspected and tested in the previous twelve (12) month period.

NFPA (National Fire Protection Association) 70 - National Electrical Code
Chapter 5 - Special Occupancies
Article 517 - Health Care Facilities
517-20. Wet Locations
a. All receptacles and fixed equipment within the area of the wet location shall have ground-fault circuit-interrupter protection for personnel if interruption of power under fault conditions can be tolerated, or be served by an isolated power system if such interruption cannot be tolerated.

This Standard is not met as evidenced by:

Based on observation and staff interview it was determined the facility failed to maintain all electrical wall receptacles in accordance with National Fire Protection Association (NFPA) 70. Findings include:

1. On 03/09/11 at approximately 10:00 a.m., one (1) electrical receptacle in exam room #1 in the emergency department near a hand sink was observed not to be a ground fault circuit interrupter (GFCI) receptacle. An interview with the director of plant services on 03/09/11 at approximately 10:30 a.m., confirmed that the one (1) aforementioned receptacle was not ground fault protected.