HospitalInspections.org

The inspector observed, while accompanied by the Maintenance Director during the hours of the inspection from 1:30 pm to 4:30 pm on 3/26/2019 that documentation for the following inspections was not available for review: Fire-rated door assemblies and certain other doors in the means of egress shall be tested annually or per an accepted performance-based evaluation schedule approved by the AHJ per NFPA 80, 2010, Ch. 5.2. A written record of the inspections and testing shall be signed and kept for inspection by the AHJ. NFPA101, 7.2.1.15

The inspector observed, while accompanied by the Maintenance Director during the hours of the inspection from 1:30 pm to 4:30 pm on 3/26/2019 that there were the following issues. They were:
There were items stored in the kitchen pantry that violated the following. "The clearance between the deflector and the top of storage shall be 18 inches or greater." - NFPA 13, 2010: 8.5.6.1.
In the maintenance work room there was a sprinkler head located directly above a fluorescent light fixture.

In the corridor there were electrical panel boxes that were unlocked. These should remain locked to prevent unauthorized tampering of the circuit breakers.

The inspector observed, while accompanied by the Maintenance Director during the hours of the inspection from 1:30 pm to 4:30 pm on 3/26/2019 that documentation for interior wall, floor and ceiling finishes was not available for review.

The inspector observed, while accompanied by the Maintenance Director during the hours of the inspection from 1:30 pm to 4:30 pm on 3/26/2019 that there was a Type ABC fire extinguisher within 25 feet of combustible cooking media in the kitchen. This is not allowed.
A type K fire extinguisher must be located in this area.

"Class K Cooking Media Fires. Fire extinguishers provided for the protection of cooking appliances that use combustible cooking media (vegetable or animal oils and fats) shall be listed and labeled for Class K fires." - NFPA 10, 2012: 5.5.5

The inspector observed, while accompanied by the Maintenance Director during the hours of the inspection from 1:30 pm to 4:30 pm on 3/26/2019 that that there were the following issues. They were:

Documentation was not available for review for draperies, curtains and loosely hanging fabrics stating that they meet the smoke development and flame spread requirements per NFPA-701.

Patient restroom shower curtains did not have labels indicating that they meet the requirements of NFPA-701.

The inspector observed, while accompanied by the Maintenance Director during the hours of the inspection from 1:30 pm to 4:30 pm on 3/26/2019 that documentation for the following inspections was not available for review: Building systems are designed to meet Category 1 through 4 requirements as detailed in NFPA 99. Categories are determined by a formal and documented risk assessment procedure performed by qualified personnel. Chapter 4 (NFPA 99)

The inspector observed, while accompanied by the Maintenance Director during the hours of the inspection from 1:30 pm to 4:30 pm on 3/26/2019 that the emergency generator was missing a battery backed up light.

Gen Set Light and Receptacle:
"The life safety branch shall supply power for lighting, receptacles, and equipment as follows:
"(4) Generator set locations as follows:
(a) Task illumination,
(b) Battery charger for emergency battery-powered lighting unit(s),
(c) Select receptacles at the generator set location and essential electrical system transfer switch locations." NFPA 99, 2012, 6.4.2.2.3.2

The inspector observed, while accompanied by the Maintenance Director during the hours of the inspection from 1:30 pm to 4:30 pm on 3/26/2019 that oxygen tanks were being stored in the ambulance garage. This is a fire hazard.

Storage: 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. (Min. 1 hour enclosure)
> 300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
? 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of ? 300 cubic feet are not required to be stored in an enclosure.
Cylinders must be handled with precautions as specified in 11.6.2 A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING". Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)