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Based on observation and interview, the facility failed to maintain self-closing devices on fire doors. This was evidenced by a rolling fire door that was not kept in proper working condition. This could result in injury to patients, staff, or visitors. This affected 1 of 11 emergency exits.

NFPA 80, Standard for Fire Doors and Fire Windows, 1999 Edition
15-1.4 Repairs. Repairs shall be made and defects that could interfere with operation shall be corrected immediately.
15-2.4.1 Self-closing devices shall be kept in proper working condition at all times.
15-2.4.3 All horizontal or vertical sliding and rolling fire doors shall be inspected and tested annually to check for proper operation and full closure. Resetting of the release mechanism shall be done in accordance with the manufacturer's instructions. A written record shall be maintained and shall be made available to the authority having jurisdiction.

Findings:

During a tour of the facility with the Lead Engineer, two Operations Managers, and the Area Director of Plant Operations on 12/3/2013, a rolling fire door was observed and the annual inspection record was requested.

At 2:02 p.m., the roll down door in the loading dock was observed to contain two rusted fusible links. The roll down door was located in an area used as an emergency exit from the kitchen and dining room areas. The Area Director of Plant Operations stated that he could not provide any evidence to show that the roll down doors had been checked for proper operation and he had no inspection records.

Based on observation, the facility failed to maintain their fire doors to prevent the passage of smoke. This was evidenced by cross corridor fire doors at smoke/fire barrier separations that failed to close and positive latch upon activation of the fire alarm system. This could result in the spread of smoke and fire and increase the risk of injury to patients, visitors and staff in the event of a fire. This affected 3 of 7 smoke compartments in the Hospital Building.

NFPA 101, Life Safety Code, 2000 Edition
7.2.1.9.2 Doors Required to Be Self-Closing. Where doors are required to be self-closing and (1) are operated by power upon the approach of a person or (2) are provided with power-assisted manual operation, they shall be permitted in the means of egress under the following conditions:
(1) Doors can be opened manually in accordance with 7.2.1.9.1 to allow egress travel in the event of power failure.
(2) New doors remain in the closed position unless actuated or opened manually.
(3) When actuated, new doors remain open for not more than 30 seconds.
(4) Doors held open for any period of time close - and the power-assist mechanism ceases to function - upon operation of approved smoke detectors installed in such a way as to detect smoke on either side of the door opening in accordance with the provisions of NFPA 72, National Fire Alarm Code.
(5) Doors required to be self-latching are either self-latching or become self-latching upon operation of approved smoke detectors per 7.2.1.9.2(4).
(6) New power-assisted swinging doors comply with BHMA/ANSI A156.19, American National Standard for Power Assist and Low Energy Power Operated Doors.

Findings:

During a tour of the facility with the Lead Engineer, two Operations Managers, and the Area Director of Plant Operations on 12/3/2013, the fire doors at the smoke/fire barrier separations were observed.


1. At 2:33 p.m., the cross corridor fire doors (#M3-13) failed to close and positive latch 2 of 2 leaf doors upon activation of the fire alarm system. The doors were equipped with an automatic door closer system and latching mechanisms.

2. At 2:35 p.m., the cross corridor fire doors (#M2-69) failed to close and positive latch 1 of 2 leaf doors upon activation of the fire alarm system. The doors were equipped with an automatic door closer system and latching mechanisms.

Based on observation and record review, the facility failed to maintain the battery powered emergency lights. This was evidenced by emergency lights that failed to illuminate when tested, no documentation for the testing of the battery powered emergency lights that failed, and no 90-minutes testing completed at least annually for all battery powered emergency lights. This could result in the failure of the emergency lights in the event of a power outage. This affected the emergency power to the Hospital Building.

NFPA 101, Life Safety Code, 2000 Edition.
19.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9.
7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed at 30-day intervals.

Findings:

During a tour of the facility with the Lead Engineer, two Operations Managers, and the Area Director of Plant Operations from 12/3/2013 through 12/4/2013, the battery powered emergency lights were observed and records for the testing of the emergency lights were requested.

1. On 12/3/2013, at 1:23 p.m., the battery powered emergency lights installed in the Cardiopulmunary Services Storage Room failed to illuminate when pushing down on the test button.

2. On 12/3/2013, at 2:05 p.m., two of two battery powered emergency lights installed by the generator failed to illuminate when pushing down on the test button.

3. On 12/4/2013, at 9:00 a.m., there were no record/s that showed that the battery powered emergency lights that had failed in the Cardiopulmunary Services Storage Room and in the generator area had been checked monthly.

4. On 12/4/2013, at 9:01 a.m., there was no record that showed that the battery powered emergency lights had been tested for 90-minutes at least once a year.

Based on record review, the facility failed to ensure that staff members were periodically instructed on their duties to protect patients in the event of a fire. This was evidenced by fire drills not completed for every shift at least quarterly and fire drills not done under varied times and conditions. This had the potential for staff members to not properly respond to a fire that could result in harm to patients, staff, and visitors. This affected 1 of 2 shifts in 2 of 4 quarters.

NFPA 101, Life Safety Code, 2000 Edition
19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.

19.7.2.1 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 warn 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 detailed in the health care occupancy's fire safety plan.

19.7.2.3 All health care occupancy personnel shall be instructed in the use of and response to fire alarms. In addition, they shall be instructed in the use of the code phrase to ensure transmission of an alarm under the following conditions:
(1) When the individual who discovers a fire must immediately go to the aid of an endangered person
(2) During a malfunction of the building fire alarm system
Personnel hearing the code announced shall first activate the building fire alarm using the nearest manual fire alarm box and then shall execute immediately their duties as outlined in the fire safety plan.

Findings:

During a tour of the facility with the two Operations Managers and the Area Director of Plant Operations on 12/4/2013, the fire drill documents were reviewed.

1. At 11:21 a.m., there was no records that showed that fire drills had been done during the 2nd shift (7 p.m. to 7 a.m.) in the second quarter (April, May, or June) in 2013 and the 2nd shift in the fourth quarter (October, November, December) in 2012 or 2013. The Chief Executive Officer stated that the facility has only two shifts: "first shift is from 7 a.m. to 7 p.m. and the second shift is from 7 p.m. to 7 a.m."

2. At 11:25 a.m., the fire drills were not done under varied times and conditions. 8 of 11 fire drills in the past 12-months were done within a 5-hour time period (between 8:30 a.m. to 1:30 p.m.).

Based on observation, the facility failed to maintain their automatic sprinkler system. This was evidenced by a sprinkler without an escutcheon ring. Sprinkler heads and scutcheon rings are listed to respond to a calculated ceiling temperature and a missing or detached escutcheon ring could allow heat and smoke to affect other areas in the building. This affected 1 of 7 smoke compartments in the Hospital Building.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition.
2.2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

NFPA 13, Standard for the Installation of Sprinkler Systems, 1999 Edition
3-2.7.2 Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.

Findings:

During a tour of the facility with the Lead Engineer, two Operations Managers, and the Area Director of Plant Operations on 12/3/2013, the sprinkler system was observed.

At 1:36 p.m., the sprinkler head installed on the ceiling in the Intensive Care Unit by Bed 6 did not have an escutcheon ring.

Based on observation, the facility failed to maintain their building service equipment. This was evidenced by gas lines to a steam boiler that were not installed properly. This could cause structural damage and result in injury to patients, staff, and visitors. This affected 1 of 7 smoke compartments in the Hospital Building.

NFPA 101, Life Safety Code, 2000 Edition
9.2.2 Ventilating or Heat-Producing Equipment. Ventilating or heat-producing equipment shall be in accordance with NFPA 91, Standard for Exhaust Systems for Air Conveying of Vapors,Gases, Mists, and Noncombustible Particulate Solids; NFPA 211, Standard for Chimneys, Fireplaces, Vents, and Solid Fuel-Burning Appliances; NFPA 31, Standard for the Installation of Oil-Burning Equipment; NFPA 54, National Fuel Gas Code; or NFPA 70, National Electrical Code, as applicable, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.
NFPA 54, National Fuel Gas Code, 1999 Edition
3.3.6 Hangers, Supports, and Anchors.
(a) Piping shall be supported with pipe hooks, metal pipe straps, bands, brackets, or hangers suitable for the size of piping, of adequate strength and quality, and located at intervals so as to prevent or damp out excessive vibration. Piping shall be anchored to prevent undue strains on connected equipment and shall not be supported by other piping. Pipe hangers and supports shall conform to the requirements of ANSI/MSS SP-58, Pipe Hangers and Supports - Materials, Design and Manufacture.
(b) Spacings of supports in gas piping installations shall not be greater than shown in Table 3.3.6.
(c) Supports, hangers, and anchors shall be installed so as not to interfere with the free expansion and contraction of the piping between anchors. All parts of the supporting equipment shall be designed and installed so they will not be disengaged by movement of the supported piping.

Findings:

During a tour of the facility with the Lead Engineer, two Operations Managers, and the Area Director of Plant Operations on 12/3/2013, the building service equipments were observed.

At 2:14 p.m., the gas lines to steam boiler #1 was observed to contain a natural gas fuel line that was not properly anchored and secured in place. The gas line was approximately 1-foot off the ground, it had two 90-degrees pipe fitting elbows that ran the fuel line horizontally and vertically, and it ran for more than 8-feet in length with no supports and no anchorage.

Based on record review and interview, the facility failed to protect their cooking facility in accordance with NFPA 96. This was evidenced by a time lapse of greater than six months between inspection of the kitchen's suppression system. This affected 1 of 7 smoke compartments and had the potential for the failure to maintain the exhaust system and kitchen suppression system. This could result in an increased risk of fire and injury to patients, staff, and visitors.

NFPA 96, Standard for Ventilation Control and and Fire Protection of Commercial Cooking Equipment, 1998 Edition
8.2 An inspection and servicing of the fire-extinguishing system and listed exhaust hoods containing a constant or fire-actuated water system shall be made at least every 6 months by properly trained and qualified persons.
8-3.1.2 When a vent cleaning service is used, a certificate showing date of inspection or cleaning be maintained on the premises. After cleaning is completed, the vent cleaning contractor shall place or display within the kitchen area a label indicating the date cleaned and the name of the servicing company. It shall also indicate areas not cleaned.

Findings:

During a tour of the facility with the two Operations Managers and the Area Director of Plant Operations on 12/4/2013, the documentation for the kitchen fire suppression system was requested.

At 8:55 a.m., the records for the inspection of the two suppression systems in the kitchen showed that the system had not been inspected at a minimum of every 6-months. The Area Director of Plant Operations stated that he could not provide any evidence to show that the two suppression systems in the kitchen had been inspected prior to 11/7/2013.

Based on observation and record review, the facility failed to maintain the integrity of the fire rated construction of the smoke/fire barrier walls. This was evidenced by a penetration in the rated barrier walls. This could result in the reduction in the staffs ability to protect in place and increase the risk of injury to the the patients due to smoke and fire. This affected 1 of 7 smoke compartments in the Hospital Building.

NFPA 101, Life Safety Code (2000 Edition)
8.2.2.2 Fire compartments shall be formed with fire barriers that are continuous from outside wall to outside wall, from one fire barrier to another, or a combination thereof, including continuity through all concealed spaces, such as those found above a ceiling, including interstitial spaces. Walls used as fire barriers shall comply with Chapter 3 of NFPA 221, Standard for Fire Walls and Fire Barrier Walls. The NFPA 221 limitation on percentage width of openings shall not apply.

NFPA 221, Standard for Fire Walls and Fire Barrier Walls.
4-2 Penetration Seals. All through-penetration protection systems shall be tested and rated in accordance with ASTM E814, Standard Test Method for Fire Tests of Through-Penetration Fire Stops. The positive pressure difference between the exposed and unexposed surfaces of the test assembly shall not be less than 0.01 in. (2.5 Pa) water gauge. A through-penetration protection system shall have an F rating (as defined by ASTM E814) not less than the required fire resistance rating of the fire wall or fire barrier wall.

NFPA 101 Life Safety Code 2000 Edition:
8.3.6.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet on of the following condition:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where the designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following condition:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

During a tour of the facility with the two Operations Managers and the Area Director of Plant Operations on 12/4/2013, the smoke/fire barrier walls were observed.

At 11:30 a.m., the rated fire barrier wall that was observed above the ceiling tiles and directly above the fire doors by the Lobby had a penetration through the wall. The penetration measured approximately 2-inches in diameter and had cables running through it. The facility drawings reviewed showed that the wall was rated for 2-hours, and it was the seperation between the hospital and the Medical Office Building (MOB).

Based on record review and interview, the facility failed to maintain electrical safety. This was evidenced by failing to perform inspection of electrical outlets. This had the potential for increasing the risk of electrical fire and electrical shock that may result in the injury to patients, visitors, and staff. This affected 7 of 7 smoke compartments in the Hospital Building.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
3-3 Electrical System Requirements
3-3.3.2.5 Test Equipment. Electrical safety test instruments shall be tested periodically, but not less than annually, for acceptable performance.
3-3.3.3 Receptacle Testing in Patient Care Areas.
(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 15g (4oz).
3-3.4.3 Recordkeeping.
3-3.4.3.1 General. A record shall be maintained of the tests required by this chapter and associated repairs or modification. At a minimum, this record shall contain the date, the rooms or area tested, and an indication of which items have met or have failed to meet the performance requirements of this chapter.

Findings:

During a tour of the facility with the two Operations Managers and the Area Director of Plant Operations on 12/4/2013, the records for the inspection of receptacle wall outlets was requested.

At 9:03 a.m., there were no records available to review that showed the listing of all the receptacle wall outlets inspected for integrity, grounding, tension, and polarity. The Area Director of Plant Operations stated that he could not provide any evidence to show that the receptacle wall outlets had been inspected.