HospitalInspections.org

The inspector observed, while accompanied by the Director of Maintenance, during the hours of the inspection from 8:30AM to 11:30 AM on 04/02/2015 that there were the following issues:

A) The Housekeeping / Supply Storage room was missing a door closer.

In existing construction, any hazardous areas shall be safe-guarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing - NFPA 101, 2003: 19.3.2.1 - 19.3.2.1.3.

The inspector observed, while accompanied by the Director of Maintenance, during the hours of the inspection from 8:30AM to 11:30 AM on 04/02/2015 that there were the following issues:

A) There was storage of items above an 18 inch plane below the sprinkler head shields in the Central Supply room.

" A minimum clearance of 18 inches shall be maintained between the top of storage and sprinkler deflectors " - NFPA 13, 2002: 8.5.6.1.

The inspector observed, while accompanied by the Director of Maintenance, during the hours of the inspection from 8:30AM to 11:30 AM on 04/02/2015 that there were the following issues:

A) Medical gas bottles in the outdoor storage area were not individually restrained.

" The storage of medical gases shall be provided with racks, chains, or other fastenings to individually secure all cylinders, whether connected, unconnected, full, or empty, from falling " - NFPA 99, 2002: 5.1.3.3.2(7).

The inspector observed, while accompanied by the Director of Maintenance, during the hours of the inspection from 8:30AM to 11:30 AM on 04/02/2015 that there were the following issues:

A) Water heater was placed on the " Life Safety EA " panel located in the Electric Equipment room.
B) Panel LA did not have label to facilitate identification located in the Electric Equipment room
C) In the Electric Closet room, there were electrical three panels, without any label.

NFPA 70, 1999, EES
517-32. Life Safety Branch
" No function other than those listed in (a) through (f) shall be connected to the life safety branch. The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment.
(a) Illumination of Means of Egress. Illumination of means of egress, such as lighting required for corridors, passageways, stairways, and landings at exit doors, and all necessary ways of approach to exits. Switching arrangements to transfer patient corridor lighting in hospitals from general illumination circuits to night illumination circuits shall be permitted provided only one of two circuits can be selected and both circuits cannot be extinguished at the same time.
FPN: See Life Safety Code, NFPA 101-1997, Sections 5-8 and 5-9.
(b) Exit Signs. Exit signs and exit directional signs.
FPN: See Life Safety Code, NFPA 101-1997, Section 5-10.
(c) Alarm and Alerting Systems. Alarm and alerting systems including the following:
1. Fire alarms
FPN: See Life Safety Code, NFPA 101-1997, Sections 7-6 and 12-3.4.
2. Alarms required for systems used for the piping of nonflammable medical gases
FPN: See Standard for Health Care Facilities, NFPA 99-1996, 12-3.4.1.
(d) Communications Systems. Hospital communications systems, where used for issuing instructions during emergency conditions.
(e) Generator Set Location. Task illumination battery charger for emergency battery-powered lighting unit(s) and selected receptacles at the generator set location.
(f) Elevators. Elevator cab lighting, control, communications, and signal systems. "

" Emergency panels shall be distinctively marked so that they are readily identifiable as a component of the essential electrical system. " - NFPA 70, 2002: 110-22 and 700-9(a). They shall be labeled "LIFE SAFETY", "CRITICAL", or "EQUIPMENT" as applicable.

K0130 Dietary

The inspector observed, while accompanied by the Director of Maintenance, during the hours of the inspection from 8:30AM to 11:30 AM on 04/02/2015 that there were the following issues:

A) Based on observation the facility failed to provide adequate clearance between the deep fryer and the cooking top unit.

" All deep fat fryers shall be installed with at least a 16 inch space between the fryer and surface flames form adjacent cooking equipment. " 2001 NFPA 96, 12.1.2.4.


K0130 Disaster Drills

The inspector observed, while accompanied by the Building Supervisor, during the hours of the inspection from 1:00PM to 4:00 PM on 04/02/2015 that there were the following issues:

A) Based on observation the facility failed to provide documentation of rehearsals for the last three years, in order to ensure that there was no lapse in disaster drills.

" Each organizational entity shall implement one or more specific responses of the emergency preparedness plan at least semi-annually. At least on semi-annual drill shall rehearse mass casualty response for health care facilities with emergency services, disaster receiving stations, or both. " - NFPA 99, 1999, 11-5.3.9.

The inspector observed, while accompanied by the Director of Maintenance, during the hours of the inspection from 8:30AM to 11:30 AM on 04/02/2015 that there were the following issues:

A) Based on observation the facility failed to conduct a load test of the generator every 36-48 months for at least 4 hours under full load.

" The EPSS shall be tested for the duration of its assigned class (see Section 4.2), or for a duration agreed to by the authority having jurisdiction for at least 4 hours, at least once within every 36-48 months. 1) The load shall be the EPSS system load running at the time of the test. The test shall be initiated by opening all switches or breakers supplying normal power to the EPSS. 2) A power interruption to non-EPSS loads shall not be required. " NFPA 110 (2002), 8.4.8