HospitalInspections.org

Based on observation and staff interview, the facility failed to ensure doors within the means of egress would not be locked to prevent egress. This condition would prevent the evacuation of occupants during an emergency.

Findings are:
Observation on 7/11/18, at 1:54 pm revealed a thumb latch was installed in both sets of powered horizontal sliding doors at the Main Entrance/Exit that the facility used to lock the doors overnight. The doors would not break away when locked.

In an interview on 7/11/18, at 1:54 pm, Administration A confirmed the locking arrangement.

NFPA 101, 2012, 7.2.1.5.1 Door leaves shall be arranged to be opened readily
from the egress side whenever the building is occupied.

Based on observation and staff interview, the facility failed to separate a hazardous area with smoke resistive partitions. This condition would allow smoke to migrate into the exit corridors.

Findings are:
Observation on 7/11/18, 1:07 pm revealed conduits and a sprinkler pipe were unsealed in the wall above the door in the Boiler Room.

In an interview on 7/11/18, 1:07 pm, Maintenance A acknowledged the unsealed penetrations.

Based on record review and staff interview, the facility failed to have a preventative maintenance plan in place to inspect and test fire doors annually throughout the facility.

Findings are:

Record review on 7/11/18, at 11:49 am revealed a preventative maintenance plan to inspect and test fire doors annually was not provided for review. Some fire doors were checked for gaps monthly, but not all requirements were documented as being completed.

In an interview on 7/11/18, at 11:49 am, Maintenance A confirmed fire door testing had not been implemented.

NFPA 80, 2010, 5.2* Inspections.
5.2.1* Fire door assemblies shall be inspected and tested not
less than annually, and a written record of the inspection shall
be signed and kept for inspection by the AHJ.

5.2.4 Swinging Doors with Builders Hardware or Fire Door
Hardware.
5.2.4.1 Fire door assemblies shall be visually inspected from
both sides to assess the overall condition of door assembly.
5.2.4.2 As a minimum, the following items shall be verified:
(1) No open holes or breaks exist in surfaces of either the
door or frame.
(2) Glazing, vision light frames, and glazing beads are intact
and securely fastened in place, if so equipped.
(3) The door, frame, hinges, hardware, and noncombustible
threshold are secured, aligned, and in working order
with no visible signs of damage.
(4) No parts are missing or broken.
(5) Door clearances do not exceed clearances listed in 4.8.4
and 6.3.1.7.
(6) The self-closing device is operational; that is, the active
door completely closes when operated from the full
open position.
(7) If a coordinator is installed, the inactive leaf closes before
the active leaf.
(8) Latching hardware operates and secures the door when
it is in the closed position.
(9) Auxiliary hardware items that interfere or prohibit operation
are not installed on the door or frame.
(10) No field modifications to the door assembly have been
performed that void the label.
(11) Gasketing and edge seals, where required, are inspected
to verify their presence and integrity.

Based on record review and staff interview, the facility failed to test patient bed receptacles annually throughout the facility. This practice increased the risk of fire from a failed outlet.

Findings are:
Record review on 7/11/18, at 11:45 am revealed documentation of annual patient bed location receptacle testing was not provided for review.

In an interview on 7/11/18, at 11:45 am, Maintenance A confirmed the testing was not conducted, and was not aware of the requirement.

NFPA 99, 2012, 6.3.4.1.2 Additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data.
6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months.

Based on record review and staff interview, the facility failed to have the diesel fuel tested annually for quality. This practice increased the potential that emergency power would not be supplied to the facility.

Findings are:
Record review on 7/11/18, at 11:29 am revealed documentation was not provided to verify the diesel fuel for the generator was tested annually for quality.

In an interview on 7/11/18, at 11:29 am, Maintenance A confirmed the testing was not conducted, and was not aware of the requirements.

NFPA 99, 2012, 8.3.8 A fuel quality test shall be performed at least annually
using tests approved by ASTM standards.

Based on observation and staff interview, the facility failed to use electrical wiring and equipment in a way that would not create a fire hazard. This condition had the potential to cause a fire.

Findings are:
Observation on 7/11/18, at 12:15 pm revealed power strips were daisy chained, and not plugged directly into hardwired outlets at the west desk in the Business Office.

In an interview on 7/11/18, at 12:15 pm, Maintenance A acknowledged the findings.

UL Standard: Relocatable power taps are not intended to be piggybacked or daisy chained. UL 1363 User Guide for Relocatable Power Taps