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Based on observation and staff interview the facility is not ensuring that doors to resident rooms are free of impediments that prevent the doors from being closed. This deficient practice of not ensuring that room doors are free of impediments from closing the door prevents the ability of the facility to properly confine fire and smoke products and to properly defend occupants in place, affecting 18 residents one of nine smoke zones in the hospital building. The facility has a capacity of 76 with a census of 22 at the time of survey.

Findings Include:

During the tour beginning on February 18, 2013 at 10:00 AM and ending on February 19, 2013 at 3:15 PM it is observed that the door to room 204 in the hospital building was been held open by a small waste container.

Maintenance Staff A was present at the time of the findings and removed the impediment at that time.

Review of the following NFPA Standard revealed: Doors in corridor walls of sprinklered buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors in non sprinklered buildings shall have doors constructed to resist the passage of smoke for at least twenty minutes and shall be provided with suitable means of keeping the doors closed. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop down or plunger type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 19.3.6.3.1 and 19.3.6.3

Based on observation and staff interview, the facility fails to provide a fire alarm system installed according to NFPA 101 and NFPA 72. The deficient practice of failing to have the fire alarm control unit trouble signals received in a constantly attended location, fails to ensure that trouble on the system will not go unnoticed, affecting two of two smoke zones in the ambulatory surgery center. The facility has a capacity of 17 with a census of 1 at the time of survey.

Findings include:

During the tour beginning on February 18, 2013 at 10:00 AM and ending on February 19, 2013 at 3:15 PM it is observed that the fire alarm control unit is located on the 2nd floor in the west entrance foyer of the ambulatory surgery center building and this area is unattended. No provision has been made for annunciation of trouble signals where there is a responsible person on duty at all times.

Maintenance Staff A and Maintenance Staff B were present and acknowledged the ambulatory surgery center is located on the first floor of this building and a trouble signal on the fire alarm control unit would not be heard in the ambulatory surgery center or in the other occupancies.

Review of the following NFPA Standard revealed: Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction. 2000 NFPA 101, 4.6.12.1

Review of the following NFPA Standard revealed: A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, and NFPA 72. 2000 NFPA 101, 9.6.1.4

Review of the following NPFA Standard revealed: Protected premises fire alarm systems shall be arranged to annunciate alarm, supervisory, and trouble signals in accordance with 1-5.7. 1999 NFPA 3-8.4.2.1

Review of the following NFPA Standard revealed: Trouble signals and their restoration to normal shall be indicated within 200 seconds at the locations identified in 1-5.4.6.1 or 1-5.4.6.2. Trouble signals required to indicate at the protected premises shall be indicated by distinctive audible signals. These audible trouble signals shall be distinctive from alarm signals. If an intermittent signal is used, it shall sound at least once every 10 seconds, with a minimum duration of ? second. An audible trouble signal shall be permitted to be common

Based on staff interview and record review, the facility fails to maintain fire dampers in heating, ventilation and air conditioning assemblies as required. This deficient practice of not identifying, testing and maintaining fire dampers as required, increases the risk of fire to nine of nine smoke zones affecting approximately all occupants in the hospital building. The facility has a capacity of 76 with a census of 22 at the time of survey.

Findings Include:

During the record review beginning on February 18, 2013 at 10:00 AM and ending on February 19, 2013 at 3:15 PM it is observed that the last fire damper testing for the hospital building was conducted during January of 2007.

Maintenance Staff A acknowledged the findings. Maintenance Staff A indicated that no testing of the fire dampers has been performed since that date but preparations for retesting have been made and contracts are awaiting signature to begin the testing. Maintenance Staff A indicated that she was aware that fire and smoke dampers must be tested on a 4-year cycle according to the 1999 edition of NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems; but CMS had determined that an increase in the testing to a 6-year cycle does not lower the fire protection or function, " so long as the hospital ' s testing system conforms to the requirements under the 2007 edition of NFPA 80 and the 2007 edition of NFPA 105: Standard for the Installation of Smoke Door Assemblies. "

Review of the following NFPA Standard revealed: Air conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, as applicable, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction. 2000 NFPA 101, 9.2.1

Review of the following NFPA Standard revealed: At least every 4 years, fusible links shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary. 1999 NFPA 90A, 3-4.7

Based on observation and staff interview, the facility failed to provide an emergency generator power supply as required. The deficient practice may prevent the emergency power supply from being available at the time of a power loss, affecting two of two smoke zones in the ambulatory surgery center. The facility has a capacity of 17 with a census of 1 at the time of survey.

Findings include:

During the tour beginning on February 18, 2013 at 10:00 AM and ending on February 19, 2013 at 3:15 PM it is observed that the annunciator for the generator is not in a regularly attended area and no provision has been made to provide an audible or visual derangement signal in a constantly attended area in the ambulatory surgery center building.

Maintenance Staff A and Maintenance Staff B acknowledged that the annunciator for the generator is located in a room that is not constantly attended.

Review of the following NFPA Standard revealed: Alarm Annunciation where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuous monitored location. 1999 NFPA 99, 3-4.1.1.15

Review of the following NFPA Standard revealed: A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station. The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows: Individual visual signals shall indicate: when the emergency power source is operating to supply power to load and when the battery charger is malfunctioning. Individual visual signals plus an audible signal shall warn of the following engine-generator alarm conditions: low oil pressure, low water temperature, excessive water temperature, low fuel (main fuel storage tank contains less than a 3-hour supply), over crank (failed to start), and over speed. Where a regular workstation will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions occur, but need not display these conditions individually. [110: 3-5.5.2].
1999 NFPA 99, 3-4.1.1.15, 3-5.1, 3-6.1

Based on observation and staff interview, the facility failed to provide a type 1 essential electrical distribution system comprised of two separate systems. The facility fails to provide an emergency system limited to the critical branch and life safety branch and an equipment system. This deficient practice may prevent the power during an emergency to the areas critical to patient care and life safety systems, affecting all patients requiring life support in the hospital building ' s surgery suite, intensive care suite, and emergency suite. The facility has a capacity of 76 with a census of 22 at the time of survey.

Findings Include:

During a review of records beginning on February 18, 2013 at 10:00 AM and ending on February 19, 2013 at 3:15 PM it is observed that the existing type 1 essential electrical system in the orginal hospital has equipment power distrubution in the orginal mechanical room and the emergency power distrubution in the hospital is for the emergency power load.

Maintenance Staff A and Maintenance Staff B were present and acknowledged the findings. Maintenance Staff A also confirmed that the essential electrical system is not comprised of an emergency system and equipment system. Maintenance Staff A also stated that there is no critical branch or life safety branch.

Maintenance Staff A states that when the electrical load is transferred to the generator all circuits are supplied power at the same time without and division into systems or branches.

Additional information provided by the facility from an electrical engineering firm dated 4/23/13, revealed the power distribution of an emergency system and an equipment system were not honored as the facility developed and expanded.

Review of the following NFPA Standard revealed: Type I essential electrical systems are comprised of two separate systems capable of supplying a limited amount of lighting and power service, which is considered essential for life safety and effective facility operation during the time the normal electrical service is interrupted for any reason. These two systems are the emergency and the equipment system. The emergency system shall be limited to circuits essential to life safety and critical patient care. These are designated the life safety branch and the critical branch. The equipment system shall supply major electrical equipment necessary for patient care and basic Type I operation. Both systems shall be arranged for connection, within time following a loss of the normal source. The number of transfer switches to be used shall be based upon reliability, design, and load considerations. Each branch of the emergency system and each equipment system shall have one or more transfer switches. One transfer switch shall be permitted to serve one or more branches or systems in a facility with a maximum demand on the essential electrical system of 150 kVA (120 kW). 1999 NFPA 99, 3-4.2.2.1

Based on observation and staff interview the facility is not ensuring that doors to resident rooms are free of impediments that prevent the doors from being closed. This deficient practice of not ensuring that room doors are free of impediments from closing the door prevents the ability of the facility to properly confine fire and smoke products and to properly defend occupants in place, affecting 18 residents one of nine smoke zones in the hospital building. The facility has a capacity of 76 with a census of 22 at the time of survey.

Findings Include:

During the tour beginning on February 18, 2013 at 10:00 AM and ending on February 19, 2013 at 3:15 PM it is observed that the door to room 204 in the hospital building was been held open by a small waste container.

Maintenance Staff A was present at the time of the findings and removed the impediment at that time.

Review of the following NFPA Standard revealed: Doors in corridor walls of sprinklered buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors in non sprinklered buildings shall have doors constructed to resist the passage of smoke for at least twenty minutes and shall be provided with suitable means of keeping the doors closed. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop down or plunger type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 19.3.6.3.1 and 19.3.6.3

Based on observation and staff interview, the facility fails to provide a fire alarm system installed according to NFPA 101 and NFPA 72. The deficient practice of failing to have the fire alarm control unit trouble signals received in a constantly attended location, fails to ensure that trouble on the system will not go unnoticed, affecting two of two smoke zones in the ambulatory surgery center. The facility has a capacity of 17 with a census of 1 at the time of survey.

Findings include:

During the tour beginning on February 18, 2013 at 10:00 AM and ending on February 19, 2013 at 3:15 PM it is observed that the fire alarm control unit is located on the 2nd floor in the west entrance foyer of the ambulatory surgery center building and this area is unattended. No provision has been made for annunciation of trouble signals where there is a responsible person on duty at all times.

Maintenance Staff A and Maintenance Staff B were present and acknowledged the ambulatory surgery center is located on the first floor of this building and a trouble signal on the fire alarm control unit would not be heard in the ambulatory surgery center or in the other occupancies.

Review of the following NFPA Standard revealed: Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction. 2000 NFPA 101, 4.6.12.1

Review of the following NFPA Standard revealed: A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, and NFPA 72. 2000 NFPA 101, 9.6.1.4

Review of the following NPFA Standard revealed: Protected premises fire alarm systems shall be arranged to annunciate alarm, supervisory, and trouble signals in accordance with 1-5.7. 1999 NFPA 3-8.4.2.1

Review of the following NFPA Standard revealed: Trouble signals and their restoration to normal shall be indicated within 200 seconds at the locations identified in 1-5.4.6.1 or 1-5.4.6.2. Trouble signals required to indicate at the protected premises shall be indicated by distinctive audible signals. These audible trouble signals shall be distinctive from alarm signals. If an intermittent signal is used, it shall sound at least once every 10 seconds, with a minimum duration of ? second. An audible trouble signal shall be permitted to be common

Based on staff interview and record review, the facility fails to maintain fire dampers in heating, ventilation and air conditioning assemblies as required. This deficient practice of not identifying, testing and maintaining fire dampers as required, increases the risk of fire to nine of nine smoke zones affecting approximately all occupants in the hospital building. The facility has a capacity of 76 with a census of 22 at the time of survey.

Findings Include:

During the record review beginning on February 18, 2013 at 10:00 AM and ending on February 19, 2013 at 3:15 PM it is observed that the last fire damper testing for the hospital building was conducted during January of 2007.

Maintenance Staff A acknowledged the findings. Maintenance Staff A indicated that no testing of the fire dampers has been performed since that date but preparations for retesting have been made and contracts are awaiting signature to begin the testing. Maintenance Staff A indicated that she was aware that fire and smoke dampers must be tested on a 4-year cycle according to the 1999 edition of NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems; but CMS had determined that an increase in the testing to a 6-year cycle does not lower the fire protection or function, " so long as the hospital ' s testing system conforms to the requirements under the 2007 edition of NFPA 80 and the 2007 edition of NFPA 105: Standard for the Installation of Smoke Door Assemblies. "

Review of the following NFPA Standard revealed: Air conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, as applicable, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction. 2000 NFPA 101, 9.2.1

Review of the following NFPA Standard revealed: At least every 4 years, fusible links shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary. 1999 NFPA 90A, 3-4.7

Based on observation and staff interview, the facility failed to provide an emergency generator power supply as required. The deficient practice may prevent the emergency power supply from being available at the time of a power loss, affecting two of two smoke zones in the ambulatory surgery center. The facility has a capacity of 17 with a census of 1 at the time of survey.

Findings include:

During the tour beginning on February 18, 2013 at 10:00 AM and ending on February 19, 2013 at 3:15 PM it is observed that the annunciator for the generator is not in a regularly attended area and no provision has been made to provide an audible or visual derangement signal in a constantly attended area in the ambulatory surgery center building.

Maintenance Staff A and Maintenance Staff B acknowledged that the annunciator for the generator is located in a room that is not constantly attended.

Review of the following NFPA Standard revealed: Alarm Annunciation where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuous monitored location. 1999 NFPA 99, 3-4.1.1.15

Review of the following NFPA Standard revealed: A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station. The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows: Individual visual signals shall indicate: when the emergency power source is operating to supply power to load and when the battery charger is malfunctioning. Individual visual signals plus an audible signal shall warn of the following engine-generator alarm conditions: low oil pressure, low water temperature, excessive water temperature, low fuel (main fuel storage tank contains less than a 3-hour supply), over crank (failed to start), and over speed. Where a regular workstation will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions occur, but need not display these conditions individually. [110: 3-5.5.2].
1999 NFPA 99, 3-4.1.1.15, 3-5.1, 3-6.1

Based on observation and staff interview, the facility failed to provide a type 1 essential electrical distribution system comprised of two separate systems. The facility fails to provide an emergency system limited to the critical branch and life safety branch and an equipment system. This deficient practice may prevent the power during an emergency to the areas critical to patient care and life safety systems, affecting all patients requiring life support in the hospital building ' s surgery suite, intensive care suite, and emergency suite. The facility has a capacity of 76 with a census of 22 at the time of survey.

Findings Include:

During a review of records beginning on February 18, 2013 at 10:00 AM and ending on February 19, 2013 at 3:15 PM it is observed that the existing type 1 essential electrical system in the orginal hospital has equipment power distrubution in the orginal mechanical room and the emergency power distrubution in the hospital is for the emergency power load.

Maintenance Staff A and Maintenance Staff B were present and acknowledged the findings. Maintenance Staff A also confirmed that the essential electrical system is not comprised of an emergency system and equipment system. Maintenance Staff A also stated that there is no critical branch or life safety branch.

Maintenance Staff A states that when the electrical load is transferred to the generator all circuits are supplied power at the same time without and division into systems or branches.

Additional information provided by the facility from an electrical engineering firm dated 4/23/13, revealed the power distribution of an emergency system and an equipment system were not honored as the facility developed and expanded.

Review of the following NFPA Standard revealed: Type I essential electrical systems are comprised of two separate systems capable of supplying a limited amount of lighting and power service, which is considered essential for life safety and effective facility operation during the time the normal electrical service is interrupted for any reason. These two systems are the emergency and the equipment system. The emergency system shall be limited to circuits essential to life safety and critical patient care. These are designated the life safety branch and the critical branch. The equipment system shall supply major electrical equipment necessary for patient care and basic Type I operation. Both systems shall be arranged for connection, within time following a loss of the normal source. The number of transfer switches to be used shall be based upon reliability, design, and load considerations. Each branch of the emergency system and each equipment system shall have one or more transfer switches. One transfer switch shall be permitted to serve one or more branches or systems in a facility with a maximum demand on the essential electrical system of 150 kVA (120 kW). 1999 NFPA 99, 3-4.2.2.1