HospitalInspections.org

Based on observation the facility failed to provide adequate documentation on an interior finish in the corridor.

The inspector observed, while accompanied by the Environmental Services Director during the hours of the inspection from 8:00 am to 11:15 am on 3/14/2013 that there was no flame spread/smoke development documentation on the plastic laminate waincoat in the main corridor.

Based on observation the facility failed to provide an adequate smoke barrier.

The inspector observed, while accompanied by the Environmental Services Director during the hours of the inspection from 8:00 am to 11:15 am on 3/14/2013 that there was a penetration in the smoke barrier on the west side, above the cross corridor doors. This was adjacent to the upper, right hand corner of a EMT.

Based on observation the facility failed to provide adequate hazardous area separation.

The inspector observed, while accompanied by the Environmental Services Director during the hours of the inspection from 8:00 am to 11:15 am on 3/14/2013 that there were the following issues. The following spaces had doors that did not close and latch on their own: 1) Respiratory Storage, 2) Storage Room adjacent to the Staff Lounge, 3) P.T. Storage, 4) both Medical Records Rooms , and 5) the Pharmacy.

Based on observation the facility failed to provide an adequate fire door.

The inspector observed, while accompanied by the Environmental Services Director during the hours of the inspection from 8:00 am to 11:15 am on 3/14/2013 that there was the following issue. The fire door at the west stair tower door did not have a complete latching mechanism.

Fire doors shall be self-closing or automatic-closing - NFPA 101, 2003: 8.3.3.3 & 7.2.1.8.

Based on observation the facility failed to provide adequate cross referencing of the fire alarm control panel, FACP.

The inspector observed, while accompanied by the Environmental Services Director during the hours of the inspection from 8:00 am to 11:15 am on 3/14/2013 that there were the following issues. The FACP must be cross referenced to the panel and breaker supplying power to the FACP.

Also, the smoke barrier doors did not close when the fire alarm system was activated.

" A dedicated electrical circuit to the life safety branch of the EES shall be provided. The circuit shall be identified with a red marking and identified as "FIRE ALARM CIRCUIT CONTROL". - NFPA 72, 1999: 1-5.2.5.2. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit. - NFPA 72, 1999: 1-5.2.5.2.

Based on observation the facility failed to provide a complete fire sprinkler system.

The inspector observed, while accompanied by the Environmental Services Director during the hours of the inspection from 8:00 am to 11:15 am on 3/14/2013 that there was the following issue: the patient room 501 there was a sprinkler head recessed into the acoustic ceiling. The acoustic ceiling was interfering with spray pattern of the head.

Based on observation the facility failed to provide an adequate smoking policy.

The inspector observed, while accompanied by the Environmental Services Director during the hours of the inspection from 8:00 am to 11:15 am on 3/14/2013 that there was not a written smoking policy.

Based on observation the facility failed to provide adequate documentation on the blinds covering the exterior windows.

The inspector observed, while accompanied by the Environmental Services Director during the hours of the inspection from 8:00 am to 11:15 am on 3/14/2013 that there was no flame spread data showing that the blinds pass the NFPA 701 test.

Based on observation the facility failed to provide adequate medical gas storage.

The inspector observed, while accompanied by the Environmental Services Director during the hours of the inspection from 8:00 am to 11:15 am on 3/14/2013 that there were medical gas bottles in storage that were not individually secured.

" Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over. " - NFPA 99, 1999: 4-3.1.1.1.

Based on observation the facility failed to provide adequate illumination at the emergency generator.

The inspector observed, while accompanied by the Environmental Services Director during the hours of the inspection from 8:00 am to 11:15 am on 3/14/2013 that there was not a light at the emergency generator on a 90 minute battery backup.

" The emergency generator location shall have task illumination, battery charger for emergency battery powered lighting unit(s), and selected receptacles at the generator set location " - NFPA 99, 1999: 3-4.2.2.2.(b)5.

Fire Plan

For health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel. The basic response required of staff shall include the removal of all occupants directly involved with the fire emergency, transmission of an appropriate fire alarm signal to warm other building occupants and summon staff, confinement of the effects of the fire by closing doors to isolate the fire area, and the relocation of patients as detained in the facility ' s fire safety plan. A written fire safety plan shall provide for the following: (1) Use of alarms, (2) Transmission of alarm to fire department, (3) Response to alarms, (4) Isolation of fire., (5) Evacuation of immediate area, (6) Evacuation of smoke compartment, (7) Preparation of floors and building for evacuation, and (8) Extinguishment of fire. - NFPA 101, 2000, 19.7.2. This is often summarized by the use of the acronym RACE. This stands for Rescue/Respond, Alarm, Contain, and Evacuate. The fire safety plan shall be part of the employee manual, and must be updated on lessons learned.

Based on observation the facility failed to provide an adequate fire plan.

The inspector observed, while accompanied by the Environmental Services Director during the hours of the inspection from 8:00 am to 11:15 am on 3/14/2013 that there was not a complete fire plan that integrated all the required components as well as lessons learned from previous fire drills. The fire plan and disaster plans must be living documents that are updated on a regular basis.


Receptacle Testing in Patient Care Areas - NFFA 99, 1999, 3-3.3.3

(a) The physical integrity of each receptacle shall be confirmed by visual inspection.
(b) The continuity of the grounding circuit in each electrical receptacle shall be verified.
(c) Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
(d) The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).

NFPA 99, 1999, 3-3.4.2.3(a) states that testing shall be performed after initial installation, replacement or servicing of a device, and that additional testing shall be performed at intervals defined by documented performance data. Since data is not typically available from the manufacturer, the facility may document the failure rates of the receptacles and provide a testing schedule that will safeguard their patients. This shall be done by the Safety Committee, approved by the Governing Board, and written into the safety policies and procedures. H.L.R. 2007, §133.142. Until this assessment has been done, receptacle testing shall be performed in all general care areas every 12 months and in critical care areas every 6 months. (NFPA 99, 1984).

Based on observation the facility failed to provide a history of records for receptacle testing per NFPA 99: 3-3.3.3. in patient care areas.

The inspector observed, while accompanied by the Environmental Services Director during the hours of the inspection from 8:00 am to 11:15 am on 3/14/2013 that there was not a record of testing receptacles in patient care areas.


Continuity of Essential Building Systems.

When designated by the emergency preparedness management plan to provide continuous service in a disaster or emergency, health care facilities shall establish contingency plans for the continuity of essential building systems, as applicable: (a) Electricity, (b) Water, (c) Ventilation, (d) Fire protection systems, (e) Fuel sources, (f) Medical gas and vacuum systems (if applicable), (g) Communications systems. " - NFPA 99, 1999, 11-5.3.2

Based on observation the facility failed to provide letters from vendors.

The inspector observed, while accompanied by the Environmental Services Director during the hours of the inspection from 8:00 am to 11:15 am on 3/14/2013 that there were no letters from vendors for emergency fuel and water indicating that they have a preferred customer status in the event of an emergency.