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Based on observation, records review, and interview, the facility failed to have the automatic sprinkler system inspected and tested in accordance with the requirements of NFPA 25 and failed to have a licensed sprinkler suppression agent complete a five year Microbiologically Influenced Corrosion inspection of the sprinkler system internal piping. The deficient practice affected seven of seven patients.

The findings include:

The record review of the facility sprinkler inspection documentation on June 22, 2021 between the hours of 1:30 p.m. to 4:30 p.m. and June 23, 2021 between the hours of 8:00 a.m. to 10:00 a.m. revealed the facility did not have records of quarterly inspections and also lacked a record of a five (5) year MIC test of internal piping of sprinkler system.

NFPA 25: 4.3.1* Records shall be made for all inspections, tests, and maintenance of the system and its components and shall be made available to the authority having jurisdiction upon request.
NFPA 25: 4.3.2 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.
NFPA 25: 4.3.3* Records shall be maintained by the property owner.
NFPA 25: 14.2.1 Except as discussed in 14.2.1.1 and 14.2.1.4 an inspection of piping and branch line conditions shall be conducted every 5 years by opening a flushing connection at the end of one main and by removing a sprinkler toward the end of one branch line for the purpose of inspecting for the presence of foreign organic and inorganic material.
NFPA 25: 14.2.1.1 Alternative nondestructive examination methods shall be permitted.
NFPA 25: 14.2.1.2 Tubercules or slime, if found, shall be tested for indications of microbiologically influenced corrosion (MIC).
NFPA 25: 14.2.1.3* If the presence of sufficient foreign organic or inorganic material is found to obstruct pipe or sprinklers, an obstruction investigation shall be conducted as described in Section 14.3.
NFPA 25: 14.2.1.4 Non-metallic pipe shall not be required to be inspected internally.
NFPA 25: 14.2.1.5 In dry pipe systems and pre-action systems, the sprinkler removed for inspection shall be from the most remote branch line from the source of water that is not equipped with the inspector's test valve.
NFPA 25: 14.2.1.6* Inspection of a cross main is not required where the system does not have a means of inspection.
NFPA 25: 14.2.2* In buildings having multiple wet pipe systems, every other system shall have an internal inspection of piping every 5 years as described in 14.2.1.

The interview with the Maintenance Director revealed the facility was not aware of the requirement for five (5) year inspection for the sprinkler system internal piping completed by a licensed sprinkler agent.

Based on visual observation the facility failed to assure that the fire extinguishers were inspected and tested in accordance with the Life Safety Code and NFPA 10. Fire extinguishers are available to extinguish small fire or smoke emergencies. This deficient practice could potentially affect seven of seven patients.

Findings:

During the facility tour and the record review on June 22, 2021 from 1:30 p.m. to 4:30 p.m. and June 23, 2021 8:00 a.m. to 10:00 a.m. the facility's portable fire extinguishers were lacking a annual certification from a licensed fire alarm agent. The last annual certification was completed on June 3, 2020 by a licensed portable fire extinguisher agent.

NFPA 72: 10.3.2 System components shall be installed, tested, and maintained in accordance with the manufacturer's published instructions and this Code.

LRS 40:1646 (A)(B)(C) The fire marshal is authorized to cause the inspection and testing of all life safety systems and equipment in the state, whether in public or private buildings, during installation or immediately after installation to determine compliance with applicable standards. The owner of any building containing a life safety system and equipment shall cause at a minimum an annual inspection to be made of the life safety system and equipment in that building to assure compliance with applicable safety standards and to determine whether structural changes in the building or in the contents of the building mandate alteration of a system. Life safety systems and equipment includes but is not limited to fire sprinkler, fire alarm, fire suppression, special locking systems and equipment, and portable fire extinguishers.

The interview with the maintenance director revealed the facility was not aware that the annual inspection on the fire extinguishers had not been conducted.

Based on visual observation the facility failed to assure the construction of the smoke barriers walls. The walls are required to be continuous and properly protected from penetrations and gaps. Unprotected penetrations would permit the movement of smoke from one compartment to the other in the facility. The deficient practice had the potential to affect nine of nine patients with one of two smoke barriers identified as deficient.

Findings:

During the facility tour on June 22, 2021 from 1:30 p.m. to 4:30 p.m. and June 23, 2021 10:00 a.m. to 11:00 a.m. the cross corridor double door smoke barrier doors located between the nurses station and the common rehabilitation area lacked a minimum twenty minute fire rated glazing.

NFPA 101: 8.3.4.2* The fire protection rating for opening protectives in fire barriers, fire-rated smoke barriers, and fire-rated smoke partitions shall be in accordance with Table 8.3.4.2 Smoke barriers fire-rated glazing marking door vision panel maximum size tested D-20 or D-W-20

The interview with the maintenance personnel revealed the facility was not aware the smoke barrier cross corridor double door vision window was required to have a minimum twenty minute fire rated glazing.

Based on visual observation and record review the facility failed to maintain a written plan for emergency evacuations. A plan of action provides staff confidence, resident's safety and a smooth transition in the event of an emergency. This deficiency has the potential to affect seven of seven patients.

Findings:

During the record review on June 22, 2021 between the hours of 1:30 p.m. to 4:30 p.m. and June 23, 2021 between the hours of 8:00 a.m. to 10:00 a.m. was unable to locate a documented fire emergency event evacuation and relocation plan.

NFPA 101:19.7.1.1 The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary.
NFPA 101:19.7.1.2 All employees shall be periodically instructed and kept informed with respect to their duties under the plan required by 19.7.1.1.
NFPA 101:19.7.1.3 A copy of the plan required by 19.7.1.1 shall be readily available at all times in the telephone operator's location or at the security center.
NFPA 101:19.7.1.4* Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions.
NFPA 101:19.7.1.5 Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.
NFPA 101:19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.
NFPA 101:19.7.1.7 When drills are conducted between 9:00 p.m. and 6:00 a.m. (2100 hours and 0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
NFPA 101:19.7.1.8 Employees of health care occupancies shall be instructed in life safety procedures and devices.
NFPA 101:19.7.2.1.1 For health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel.
NFPA 101:19.7.2.1.2 The basic response required of staff shall include the following:
(1) Removal of all occupants directly involved with the fire emergency
(2) Transmission of an appropriate fire alarm signal to warn other building occupants and summon staff
(3) Confinement of the effects of the fire by closing doors to isolate the fire area
(4) Relocation of patients as detailed in the health care occupancy's fire safety plan
NFPA 101:19.7.2.2 Fire Safety Plan. A written health care occupancy fire safety plan shall provide for all of the following:
(1) Use of alarms
(2) Transmission of alarms to fire department
(3) Emergency phone call to fire department
(4) Response to alarms
(5) Isolation of fire
(6) Evacuation of immediate area
(7) Evacuation of smoke compartment
(8) Preparation of floors and building for evacuation
(9) Extinguishment of fire

The interview with maitenance director revealed the facility was not aware that the evacuation plan did not contain all of the required components.

Based on visual observation and record review the facility failed to maintain documentation for fire drills conducted during each quarter on each shift. Fire drills provide training in procedures in cases of emergency. The deficient practice had the potential to affect seven of seven patients. There were three of the four quarters in 2020-2021 were deficient.

Findings:

During the record review on June 22, 2021 between the hours of 1:30 p.m. to 4:30 p.m. and June 23, 2021 between the hours of 8:00 a.m. to 10:00 a.m. the facility lacked documented fire drills for the 6:00 a.m. to 6:00 p.m. shift for the second and third quarter of the year 2020. The facility also lacked documented fire drills for the second, third and fourth quarters of the 2020.

NFPA 101:19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.

The interview with the maintenance director revealed the facility was not aware the fire drills were not being held for each work shift of each quarter.

Based on visual observation, the facility failed to assure that the policy on smoking required all smoking areas to be supplied with a metal, self-closing container. Cigarette butts shall be extinguished in an approved container in order to prevent accidental combustion. This deficient practice could potentially affect seven of seven patients.

Findings:

During the facility tour on June 22, 2021 between the hours of 1:30 p.m. to 4:30 p.m. and June 23, 2021 between the hours of 8:00 a.m. to 10:00 a.m. the designated smoking area lacked a noncombustible readily available metal container with a self closing cover device into which ashtrays can be emptied.

NFPA 101:19.7.4* Smoking. Smoking regulations shall be adopted and shall include not less than the following provisions:

(1) Smoking shall be prohibited in any room, ward, or individual enclosed space where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.

(2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.

(3) Smoking by patients classified as not responsible shall be prohibited.

(4) The requirement of 19.7.4(3) shall not apply where the patient is under direct supervision.

(5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.

(6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.

The interview with maintenance director revealed the facility was not aware the containers in the smoking area did not meet the requirements.

Based on record review the facility failed to provide annual fire door testing documentation. Written annual records demonstrate all fire doors are properly being maintained to ensure protection for life and property. The deficiency has the potential to affect seven of seven patients.

Findings:

During the record of review on June 22, 2021 between the hours of 1:30 p.m. to 4:30 p.m. and June 23, 2021 between the hours of 8:00 a.m. to 10:00 a.m. the facility lacked annual fire door inspection documentation.

NFPA 80: 5.2.4.1* Periodic inspections and testing shall be performed not less than annually.

A.5.2.4.1 Doors subject to high-volume use and abuse might warrant an increased frequency of inspection. Components including, but not limited to, hinges, catches, closers, latches, and stay rollers are especially subject to wear.

The interview with the maintenance director revealed the facility was not aware annual fire door inspections were required to be conducted annually.

Based on record review, the facility failed to assure that a polarity, ground and retention resident / patient room electrical receptacle test had been conducted and documented. When the correct protocols are routinely completed by qualified personnel to the resident / patient electrical receptacle outlets chances of creating a unsafe electrical event or possible fire emergency are reduced or possibly eliminated. The deficient practice had the potential to affect nine of nine patients.

Findings:

During the record of review on June 22, 2021 from 1:30 p.m. to 4:30 p.m. and June 23, 2021 10:00 a.m. to 11:00 a.m. revealed the facility lacked polarity, ground and retention testing documentation for all patient rooms.

NFPA 99 6.3.3.2 Receptacle Testing in Patient Care Rooms 6.3.3.2.1
6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection.
6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified.
6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall not be less than 115 g (4oz.)
Section 3-3 Section 3-3.4.3.1 A record shall be maintained of the tests required by this chapter and associated repairs of modifications. At a minimum, this record shall contain date, the rooms or areas tested and an indication of which items have met or have failed to meet the performance requirements of the chapter.
6.3.4.1 Maintenance and Testing of Electrical System.
6.3.4.1.1 Where hospital-grade receptacles are required at patient bed locations and in locations where deep sedation or general anesthesia is administered, testing shall be performed after initial installation, replacement, or servicing of the device.
6.3.4.1.2 Additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data.
6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months.

The interview with the maintenance personnel revealed the facility was not aware that all documentation was not complete regarding the inspection/testing of the resident / patient electrical receptacles.

Based on record review, the facility failed to assure that a polarity, ground and retention resident / patient room electrical receptacle test had been conducted and documented. When the correct protocols are routinely completed by qualified personnel to the resident / patient electrical receptacle outlets chances of creating a unsafe electrical event or possible fire emergency are reduced or possibly eliminated. The deficient practice had the potential to affect seven of seven patients.

Findings:

During the record of review on June 22, 2021 between the hours of 1:30 p.m. to 4:30 p.m. and June 23, 2021 between the hours of 8:00 a.m. to 10:00 a.m. revealed the facility lacked polarity, ground and retention testing documentation for all patient rooms.

NFPA 99 6.3.3.2 Receptacle Testing in Patient Care Rooms 6.3.3.2.1
6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection.
6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified.
6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall not be less than 115 g (4oz.)
Section 3-3 Section 3-3.4.3.1 A record shall be maintained of the tests required by this chapter and associated repairs of modifications. At a minimum, this record shall contain date, the rooms or areas tested and an indication of which items have met or have failed to meet the performance requirements of the chapter.
6.3.4.1 Maintenance and Testing of Electrical System.
6.3.4.1.1 Where hospital-grade receptacles are required at patient bed locations and in locations where deep sedation or general anesthesia is administered, testing shall be performed after initial installation, replacement, or servicing of the device.
6.3.4.1.2 Additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data.
6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months.

The interview with maintenance director revealed the facility was not aware that all documentation was not complete regarding the inspection/testing of the resident / patient electrical receptacles.

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 seven of seven patients.

Findings:

During the facility tour on June 22, 2021 between the hours of 1:30 p.m. to 4:30 p.m. and June 23, 2021 between the hours of 8:00 a.m. to 10:00 a.m. 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 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.

NFPA 110:5.6.5.6.1 The remote manual stop station shall be labeled.

(2) The weekly generator inspection logs lacking from the previous year of service.

NFPA 110:8.3.7* Storage batteries, including electrolyte levels or battery voltage, used in connection with systems shall be inspected weekly and maintained in full compliance with manufacturer's specifications.

NFPA 110:8.4.1* EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly.

NFPA 110:A.8.4.1 Weekly inspection does not require running of the EPS. Running unloaded generators as part of this weekly inspection can result in long-term problems such as wet stacking. See Figure A.8.4.1(a) and Figure A.8.4.1(b).

The interview with the maintenance director revealed the facility was not aware that documented weekly generator inspections identifying specific components had been inspected and a remote manual stop locate outside the weatherproof enclosure for emergency generators was required.