HospitalInspections.org

Based on observation, the facility failed to maintain the electrical equipment. This was evidenced by the circuit breaker for the fire alarm system that was not identified with a red marking. This affected one of three smoke compartments and could result in staff inability to identify the circuit breaker in the event of an emergency.

NFPA 101, Life Safety Code, 2012 Edition
19.5.1 Utilities.
19.5.1.1 Utilities shall comply with the provisions of Section 9.1.
9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service.
9.6.1.3 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use.

NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition
10.5.5.2 Circuit Identification and Accessibility.
10.5.5.2.1 The location of the dedicated branch circuit disconnecting means shall be permanently identified at the control unit.
10.5.5.2.2 For fire alarm systems the circuit disconnecting means shall be identified as "FIRE ALARM CIRCUIT."
10.5.5.2.3 For fire alarm systems the circuit disconnecting means shall have a red marking.
10.5.5.2.4 The circuit disconnecting means shall be accessible only to authorized personnel.

Findings:

During a tour of the facility with CFF and BTS on 8/9/17, the electrical equipment was observed.

1. At 9:31 a.m., the electrical panel that housed the fire alarm circuit breaker 17 did not have a red marking on the circuit breaker that identified as fire alarm. The electrical panel was located in Room 103A. This finding was confirmed by CFF and BTS.

Based on observation and interview, the facility failed to maintain the sprinkler system components. This was evidenced by failure to maintain a sprinkler head. This affected one of three smoke compartments and could result in an ineffective operation of the automatic sprinkler system in the event of a fire.

NFPA 101 Life Safety Code, 2012 Edition
19.3.5.1 Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5.

9.7.1.1* Each automatic sprinkler system required by another section of this Code shall be in accordance with one of the following:

9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition

5.2.1 Sprinklers.
5.2.1.1* Sprinklers shall be inspected from the floor level annually.
5.2.1.1.1* Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall).


Findings:

During a tour of the facility and interview with CFF on 8/9/17, the sprinkler heads were observed and staff was interviewed.

1. At 8:50 a.m., the sprinkler head above Bed A in Room 106 was observed with debris. When interviewed, CFF confirmed the finding.

Based on observation and interview, the facility failed to maintain the fire extinguishers. This was evidenced by an expired service tag on a fire extinguisher. This affected three of three smoke compartments, and could result in a malfunction portable fire extinguisher.

NFPA 101, Life Safety Code, 2012 Edition
19.3.5.12 Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1.
9.7.4.1* Where required by the provisions of another section of this Code, portable fire extinguishers shall be selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

NFPA 10, Standard for Portable Fire Extinguisher, 2010 Edition
7.2 Inspection.
7.2.1 Frequency.
7.2.1.1* Fire extinguishers shall be manually inspected when initially placed in service.
7.2.1.2* Fire extinguishers shall be inspected either manually or by means of an electronic monitoring device/system at a minimum of 30-day intervals.

7.3* Maintenance.
7.3.1 Frequency.
7.3.1.1 All Fire Extinguishers.
7.3.1.1.1 Fire extinguishers shall be subjected to maintenance at intervals of not more than 1 year, at the time of hydrostatic test, or when specifically indicated by an inspection or electronic notification.
7.3.1.1.2 Fire extinguishers shall be internally examined at intervals not exceeding those specified in Table 7.3.1.1.2.


Findings:

During a tour of the facility and interview with CFF on 8/9/17, the fire extinguisher was observed and staff was interviewed.

1. At 9:48 a.m., the fire extinguisher in the Generator location has not been inspected for more than 1 year. The last annual maintenance was conducted on 3/11/16. When interviewed, CFF stated that the vendor must have missed the fire extinguisher in the Generator area.

Based on observation and interview, the facility failed to maintain corridor doors to resist the passage of smoke and/or fire. This was evidenced by a door that failed to latch and by two doors that were obstructed from closing. This affected two of three smoke compartments and could result in the passage smoke and flames in the event of a fire.

Findings:

During a tour of the facility and interview with CFF, FF1, ESS, and BTS on 8/9/17, the corridor doors were observed and staff were interviewed.

1. At 9:34 a.m., the door to 103A was equipped with a self-closing device that failed to latch. This finding was confirmed by CFF.

2. At 10:04 a.m., the 20 minutes fire rated doors to Room 113A and Room 106 were observed. The corridor doors to Room 113A and Room 106 were equipped with magnetic hold open device that were interface with the fire alarm system. During testing, both doors released from the magnetic hold open device, but overlapped each other and caused both doors from fully closing. When interviewed, BTS and CFF confirmed the findings.

Based on observation and interview, the facility failed to maintain the electrical equipment. This was evidenced by electrical panels that were obstructed from access. This affected one of three smoke compartments and could result in delay of access in the event of an emergency.

NFPA 101, Life Safety Code, 2012 Edition
19.5.1 Utilities.
19.5.1.1 Utilities shall comply with the provisions of Section 9.1.
9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service.


NFPA 70, National Electrical Code, 2011 Edition
110.26 Spaces About Electrical Equipment. Access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment.
(2) Width of Working Space. The width of the working space in front of the electrical equipment shall be the width of the equipment or 762 mm (30 in.), whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of equipment doors or hinged panels.


Findings:

During a tour of the facility and interview with the CFF and BTS on 8/9/17, the electrical equipment was observed.

1. At 9:30 a.m., access to electrical panels AB and A in Room 103A were obstructed by two recycling bins. The recycling bins were placed directly in front of the electrical panels. This finding was confirmed by the CFF and BTS.

Based on observation and interview, the facility failed to maintain the Oxygen Storage location. This was evidenced by the failure to segregate empty cylinders from full cylinders. This affected one of three smoke compartments, and could result in confusion in access in the event of an emergency.


NFPA 99, Health Care Facilities Code, 2012 Edition
11.6.5.2 If empty and full cylinders are stored within the same enclosure, empty cylinders shall be segregated from full cylinders.

Findings:

During a tour of the facility and interview with CFF, FF1, and BTS on 8/9/17, the oxygen storage location was observed.

1. At 9:23 a.m., the oxygen cylinders was observed in Room 119A. There were four empty E-cylinder tanks that were stored in the same rack with two full E-cylinder tanks. The empty cylinders were not segregated from full cylinders. This finding was confirmed by CFF.