HospitalInspections.org

Based on visual observation and record review the facility failed to assure that semi-annual inspections and routine cleanings were conducted by a licensed contractor on the commercial hood/suppression system. The removal of grease laden vapors from the air is essential to decrease the risk of fire and maintain the air flow within the hood system. The deficient practice had the potential to affect 16 of 16 patients

Findings:

During the facility tour on 8/14/2018 between the hours of 12:00 pm to 2:45 pm and on 8/15/2018 between the hours of 9:30 am to 2:00 pm it was observed the kitchen Hood Suppression System was providing one nozzle for covering a six burner cooktop and adjacent two burner cooktop.

NFPA 96: 10.1.2* Cooking equipment that produces grease-laden vapors and that might be a source of ignition of grease in the hood, grease removal device, or duct shall be protected by fire-extinguishing equipment.

Interview with Maintenance revealed the facility was not aware the appliances in the kitchen were not covered on the hoop suppression system.

Based on visual observation the facility failed to assure that the building had a complete, supervised, automatic sprinkler system installed in accordance with NFPA 13. Activation of the sprinkler system shall trigger notification of the emergency to the fire alarm system within 90 seconds, which results in protection of life and property. This deficiency has the potential to affect 16 of 16 residents.

Findings:

During the facility tour on 8/14/2018 between the hours of 12:00 pm to 2:45 pm and on 8/15/2018 between the hours of 9:30 am to 2:00 pm the following items were observed deficient:

(1) The concealed pendant sprinkler heads located on each side of the cross corridor smoke barrier corridor ceiling nearest patient room number 322 were obstructed by a surface mounted light fixture on each side of the smoke barrier cross corridor double doors.

NFPA 13: 8.6.4 Deflector Position (Standard Pendent and Upright Spray Sprinklers).
NFPA 13:8.6.4.1 Distance Below Ceilings.
NFPA 13:8.6.4.1.1 Unobstructed Construction.
NFPA 13:8.6.4.1.1.1 Under unobstructed construction, the distance between the sprinkler deflector and the ceiling shall be a minimum of 1 in. (25.4 mm) and a maximum of 12 in. (305 mm) throughout the area of coverage of the sprinkler.

NFPA 13:8.6.5.2 Obstructions to Sprinkler Discharge Pattern Development.
NFPA 13:8.6.5.2.1 General.
NFPA 13:8.6.5.2.1.1 Continuous or noncontinuous obstructions less than or equal to 18 in. (457 mm) below the sprinkler deflector that prevent the pattern from fully developing shall comply with 8.6.5.2.

Table 8.6.5.1.2 Positioning of Sprinklers to Avoid Obstructions to Discharge [Standard Spray
Upright/Standard Spray Pendent (SSU/SSP)]
Distance from Sprinklers to Side of Obstruction (A)
Maximum Allowable Distance of Deflector
Above Bottom of Obstruction (in.) (B)
Less than 1 ft 0
1 ft to less than 1 ft 6 in. 21?2
1 ft 6 in. to less than 2 ft 31?2
2 ft to less than 2 ft 6 in. 51?2
2 ft 6 in. to less than 3 ft 71?2
3 ft to less than 3 ft 6 in. 91?2
3 ft 6 in. to less than 4 ft 12
4 ft to less than 4 ft 6 in. 14
4 ft 6 in. to less than 5 ft 161?2
5 ft to less than 5 ft 6 in. 18
5 ft 6 in. to less than 6 ft 20
6 ft to less than 6 ft 6 in. 24
6 ft 6 in. to less than 7 ft 30
7 ft to less than 7 ft 6 in. 35
For SI units, 1 in. = 25.4 mm; 1 ft = 0.3048 m.
Note: For A and B, refer to Figure 8.6.5.1.2(a).

(2) The fire pump room was lacking a proper fire stopping material for the one hour fire barrier and a 45 minute fire door with a self closure.

NFPA 20: 4.12.1.1.2 states, "Indoor fire pump rooms in non-high-rise buildings or in separate fire pump buildings shall be physically separated or protected by fire-rated construction in accordance with Table 4.12.1.1.2."

NFPA 20: Table 4.12.1.1.2 Equipment Protection
Pump Building(s) Exposing Required
Room/House Pump Room /House Separation

Not sprinklered Not sprinklered 2 hour fire-rated
Not sprinklered Fully sprinklered or
Fully sprinklered Not sprinklered 50 ft (15.3 m)


Fully sprinklered Fully sprinklered 1 hour fire-rated
or
50 ft (15.3 m)

Interview with Maintenance revealed the facility was not aware the automatic sprinkler system was not complete.

Based on visual observation the facility failed to assure that the complete, supervised, automatic sprinkler system was inspected and tested in accordance with the requirements of NFPA 13. Activation of the sprinkler system shall trigger notification of the emergency to the fire alarm system within 90 seconds, which results in protection of life and property. This deficiency has the potential to affect 16 of 16 residents.

Findings:

During the facility tour on 8/14/2018 between the hours of 12:00 pm to 2:45 pm and on 8/15/2018 between the hours of 9:30 am to 2:00 pm the following items were observed deficient:

(1) The fire pump had been yellow tagged by the licensed agent on 2/7/2018 and on 7/30/2018 for the fire pump run alarm, power fail alarm and phase reversal not reporting to the panel.

(2) The sprinkler system inspections by a qualified person were lacking for the week and quarters from the previous year.

Interview with Maintenance revealed the facility was not aware that the annual and/or quarterly inspections were not complete and maintenance was unaware the fire pump deficiensies had not been corrected.

Based on visual observation the facility failed to assure that the emergency generator was maintained and tested in accordance with NFPA 110. In cases of a power outage the emergency generator powers essential life safety equipment for the facility. The deficient practice had the potential to affect 13 of 20 residents.

Findings:

During the facility tour on 8/14/2018 between the hours of 12:00 pm to 2:45pm and on 8/15/2018 between the hours of 9:30 am to 2:00 pm the following items were observed as deficient:

(1) The generator was not provided with a remote manual stop and remote manual signage located outside the weatherproof enclosure.

NFPA 110:5.6.5.6 states, "All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building".

(2) The generator was lacking a complete two hour fire barrier assembly surrounding the indoor 500 KW and the indoor 750 KW generator.

NFPA 110:7.2.1 state, "Indoor EPS Installations. The EPS shall be installed in a separate room for Level 1 installations. NFPA 110:7.2.1.1 The EPS room shall be separated from the rest of the building by construction with a 2-hour fire resistance rating".
NFPA 110: 7.2.1.2 states, "EPSS equipment shall be permitted to be installed in the EPS room".
NFPA 110: 7.2.1.3 states, "No other equipment, including architectural appurtenances, except those that serve this space, shall be permitted in the EPS room".

Interview with the Maintenance Director revealed the facility was not aware that a remote manual stop for emergency generators was required.

Based on visual observation, the facility failed to assure outdoor cryogenic oxygen containers in compliance with NFPA 99. A properly installed cryogenic oxygen tank is important to protect essential life and property..

Findings:

During the facility tour on 8/14/2018 between the hours of 12:00 pm to 2:45pm and on 8/15/2018 between the hours of 9:30 am to 2:00 pm it was observed the oxygen gas tank and the cryogenic oxygen tank located outside the facility is within the minimum distance of fifteen feet from a shipping container being used to store combustible paper products.

NFPA 99:5.1.3.3.1.9 Central supply systems for oxygen with a total capacity connected and in storage of 566,335 L (20,000 ft3) or more outside of the facility at standard temperature and pressure (STP) shall comply with NFPA 55, Compressed Gases and Cryogenic Fluids Code.

NFPA 55: TABLE 8.7.2 Minimum Separation Distances Between Stationary Cryogenic Containers and Exposures
Exposure Feet
(1) Buildings, regardless of construction type 1
(2) Wall Openings 1
(3) Air intakes 10
(4) Property Lines 5
(5) Places of Public Assembly Occupancy 50
(6) Nonambulatory Patient Ares 50
(7) Combustible Materials (paper, leaves, weeds, dry grass) 15
(8) Incompatible hazardous materials 20
(9) Building Exits 10

Interview with Maintenance revealed the facility was not aware that the outdoor oxygen tanks were required to be a minimum distance from combustible materials.