HospitalInspections.org

Based on observations during the facility walk-through inspection on 04/02/2014 with the director of plant ops. and the COO, it was noted that the fire alarm system was not functioning as follows;
A) the visual strob signals on the second floor did not function during testing;
B) smoke barrier doors did not close when the fire alarm system was activated on the second floor;
C) tests of the corridor smoke detectors on the second floor did not activate the fire alarm system either in "trouble" or "alarm" modes.
Note that the second floor is the nursing floor for this hospital, and has been closed since the fire alarm system has been malfunctioning. Only the audio signals were functioning on the second floor during this inspection. Documentation form a licensed fire alarm contractor (dated March 2014) stated that most of the smoke detectors located in the facility were not functioning.

Based on observation during the facility walk-through inspection on 04/02/2014 with the directo plant ops., infection control office, and COO, it was noted that the facility does not comply as a fully sprinklered building under NFPA 13 (2002). Operating rooms #1, #2, #3, and the C-Section room were not protected by the fire sprinkler system. all other areas of the working hospital were proptected.

Based on observation during the walk-through inspection on 04/02/2014, with the director plant ops, and COO, it was noted that yellow tags were in place on the fire sprinkler system inspector's test valve, indicating that the flow alarm for the sprinkler system, did not activate the fire alarm system when tested on 04/05/2013. Documentation from a licensed fire alarm contractor dated March of 2014, indicated that the flow alarms were still not activating the fire alarm system.

Based on observations during the facility walk-through inspection on 04/02/2014, with the director of plant ops., COO, and infection control officer, it was noted that the kitchen range hood fire extinguisher system was not interconnected to the building fire alarm system, as required by NFPA 96 (2001) 10.6.2. Also noted was a red tag on the range hood extighuishment system, dated April 15, 2013, from a licensed contractor stating that the range hood was not connected to the building fire alarm system.
Also observed that the gas supplies to the cooking equipment under the range hood was not controlled by a solinoid to automatically shut off the gas sypply when the hood extinguishment system was activated as required by NFPA 96 (2001)10.4.

Based on observations during the facility walk-through inspection with the facility director of plant ops., COO, and CIO, the following deficiencies were noted:

a). it was noted that the main electrical switchgear room housing the main incoming electrical service, the emergency system transfer switches, and the main fire alarm control panel,had standing water on the floor of more than 50% on the room. All electrical equipment was raised on concrete curbs approximately 4" above the floor level with the standing water. However persons working on the equipment in this room would be standing in water, creating a dangerous shock hazard.

b). It was noted that the building's boilers were non-functioning (water leaking from the non-functional boilers was the cause of the standing water in the maine electrical room) . The facility had a temporary boiler located on a trailer outside the mechanical room and hooked to the building systems with surface cabling laid on the floor slab of the mechanical room.

c). It was observed that the nurse call system for the entire second floor was not working. This is the patient sleeping floor. No patients were housed on the second floor at the time of this inspection and the staff stated that the second floor had been closed since the February 2014 JACHO Survey first documented the lack of a working nurse call system.

Based on observations during the facility walk-through inspection with the Director of Plant Ops., infection control officer, COO, and CIO, on 04/02/2014, it was noted that the piped in medical gas system Master Alarm panels (2) were not functioning. Indicator ights for the various alarm functions did not activate when tested.

Based on a review of the records during the facility walk-through inspection on 04/02/2014 with the director of plant ops., COO, and CIO, it was noted that the required weekly exercising/testing of the emergency generator was not being documented.

Based on observation during the facility walk-through on 04/02/3014 with the director of plant ops. and the COO, it was observed that the main electrical switchgera room which also contained the automatic transfer switches and the main fire alarm panel, had approximately 1/2" of standing water on the floor through out eh room. All electrical switchgera were on 4" to 6" curbs, and out of the water. However anyone working in this room would be standing in water. The water was determined to be coming from a leaking and defective boiler unit located in the adjacent boiler plant.