HospitalInspections.org

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Based on the observation on 6/18/2015, the facility failed to maintain smoke barriers to limit the spread of fire and restrict the movement of smoke. Findings include:

Unsealed penetrations around a section of conduit, in the smoke barrier above the doors, and 3 unsealed openings approximately 2"x 2", in the barrier access from the Lobby.

The deficiency impacted 1 of 3 smoke compartments.
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NFPA 101, 19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.

NFPA 101, 8.3.2 Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.
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Based on the observation on 6/18/2015, the facility failed to maintain fire barriers to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. Findings include:

Unsealed penetrations around wiring in 2 different locations of the fire barrier by the Cafeteria.

The deficiency impacted 1 of 2 fire barriers.
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NFPA 101, 19.2.2.5 and 7.2.4.3 Openings in fire barriers shall be constructed to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other.
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Based on the observation on 6/18/2015, the facility failed to provide continuous illumination for means of egress. Findings include:

The exit discharge lighting is controlled by a switch located next to the exit by housekeeping.

The deficiency impacted 1 of 3 smoke compartments.
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NFPA 101, 19.2.8 and 7.8.1.2 Illumination of means of egress shall be continuous.
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Based on the review of the documentation on 6/18/2015, the facility failed to perform sensitivity testing for smoke detectors. Findings include:

Last documentation provided by the facility indicated last sensitivity testing of the smoke detectors was conducted on 6/21/2012.

The deficiency impacted 5 of 5 smoke compartments.
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Detector sensitivity shall be checked with one year after installation and every alternate year thereafter per 72, 7-3.2.1. (Up to 5 years permitted under certain circumstances. See 7-3.2.1).
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Based on the observation on 6/18/2015, the facility failed to maintain the automatic sprinkler system. Findings include:

1. Last date the gauges were replaced for the wet riser was 4/6/2010.

2. Emergency Room Pharmacy had blue/cream color wiring attached to the sprinkler branch lines.

The deficiency impacted 3 of 3 smoke compartments.
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NFPA 25, 9-2.8.2: Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced.

1998 NFPA 25, 2-2.2* Pipe and Fittings. Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.
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Based on the observation on 6/18/2015, the facility failed to maintain the fire extinguishers. Findings include:

Documentation was not provided for the 2015 May monthly inspection for the fire extinguisher located in the mechanical room/riser room. The tag attached indicated annual service was conducted in March of 2015, space for May monthly was blank.

The deficiency impacted 1 of 3 smoke compartments.
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1998 NFPA 10, 4-3.1 Fire extinguishers shall be inspected when placed in service and thereafter at approximately 30-day intervals.
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Based on the observation on 6/18/2015, the facility failed to maintain the dietary hood. Findings include:

1. The provided documentation for the monthly inspection of the hood system was the inspection card attached to the pull station of the hood extinguishing system. This card was observed with space on the reverse side to date and initial each month an inspection was conducted by facility staff. This side of the inspection card was blank for the month of April, and May of 2015. The last six month inspection was conducted on 3/5/2015.

2. The K-extinguisher in the kitchen was not provided with a placard.

3. The location of the stove, and the shelf attached to the top of the stove, during the survey failed to provide adequate nozzle coverage for the back eyes of the stove.

The deficiency impacted 5 of 5 smoke compartments.
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NFPA 17, 9-2.1- On a monthly basis, inspection shall be conducted in accordance with the manufacturer 's listed installation and maintenance manual or owner 's manual. As a minimum,
this "quick check " or inspection shall include verification of the following:
(a) The extinguishing system is in its proper location.
(b) The manual actuators are unobstructed.
(c) The tamper indicators and seals are intact.
(d) The maintenance tag or certificate is in place.
(e) The system shows no physical damage or condition that might prevent operation.
(f) The pressure gauge(s), if provided, is in operable range.
(g) The nozzle blow-off caps, where provided, are intact and undamaged.
(h) Neither the protected equipment nor the hazard has been replaced, modified, or relocated.

NFPA 96 7-2.1.1 A placard identifying the use of the extinguisher as a secondary backup means to the automatic fire suppression system shall be conspicuously placed near each portable fire extinguisher in the cooking area.

Review of 1998 NFPA 17 (7-3.2), 1998 NFPA 17a (3-1.1).
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Based on the observation on 6/18/2015 the facility had in use improper heating device. Findings include:

A portable heating device was in use during the survey in the Doctors sleep lounge.

The deficiency impacted 1 of 3 smoke compartments.
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NFPA 101, 19.7.8, Prohibits the use of portable space heating devices.
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Based on the observation on 6/18/2015, the facility failed to maintain the remote annunciator for the generator. Findings include:

When the generator was placed under load, the remote annunciator panel did not indicate EPS Supplying load. The lamp test was conducted by maintenance before the transfer of the generator and the generator EPS lamp did function.

The deficiency impacted 5 of 5 smoke compartments.
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1999 NFPA 99, 3-6.1.1 Generators shall conform to 3-4.1.1
1999 NFPA 99, 3-4.1.1.15 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:
(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load
2. When the battery charger is malfunctioning
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed

Where a regular work station 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 in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually.
[110: 3-5.5.2]
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(A) Based on the observation on 6/18/2015, the facility failed to assure that equipment used for the care of patients, was not plugged into circuit breaker protected power strips. Findings include:

The following is a list of equipment used for the care of a patient, that was plugged into a circuit breaker power strip (an extension cord) in the OR Room:

Olympus monitor, OR bed, Electrosurgical generator, Drying fan for scopes, and Olympus tower.

The facility is not provided with adequate number of receptacles for appliances in this room.

The deficiency impacted 1 of 3 the smoke compartments.
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Review of 1999 NFPA 70, 400-7 and 400-8, HCFA Transmittal Notice 22-99, and Interpretative Guidelines for
F 0323 Extension cords should not be used to take the place of adequate wiring in a facility. If extension cords are used, the cords should be properly secured and not be placed overhead, under carpets or rugs, or anywhere that the cord can cause trips, falls, or overheat. Extension cords should be connected to only one device to prevent overloading of the circuit. The cord itself should be of a size and type for the expected electrical load and made of material that will not fray or cut easily. Electrical cords including extension cords should have proper grounding if required and should not have any grounding devices removed or not used if required.
Power strips may not be used as a substitute for adequate electrical outlets in a facility. Power strips may be used for a computer, monitor, and printer. Power strips are not designed to be used with medical devices in patient care areas. Precautions needed if power strips are used include: installing internal ground fault and over-current protection devices; preventing cords from becoming tripping hazards; and using power strips that are adequate for the number and types of devices used. Overload on any circuit can potentially cause overheating and fire. The use of ground fault circuit interruption (GFCIs) may be required in locations near water sources to prevent electrocution of staff or residents.

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(B) Based on observation on 6/18/2015, the facility failed to maintain the electrical equipment. Findings include:

1. Junction box was missing the cover above the ceiling near the fire barrier, in front of the elevator.

2. Open blank in the electrical panel in the generator set control room.

3. A refrigerator and microwave was plugged into a surge protector (extension cord) in Central Supply.
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1999 NFPA 70, 370-25 and 410-12. Each box in completed installations to have a cover, face plate, or fixture canopy.

1999 NFPA 70, 373-4 Unused opening shall be effectively closed to afford protection substantially equivalent to that of the enclosures.

1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99. The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. lt is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip.
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