HospitalInspections.org

The facility failed to provide corridor doors that would close and resist the passage of smoke. Findings include: During the survey, the following are examples of what was observed:

1. The door to the Kitchen dish washing room which opens into the corridor failed to positive latch.

2. Patient Room 103-A door failed to positive latch.


27382


3. The Biohazard Room across from Room 120 - the corridor door was not positive latching
4. The Fire Alarm Panel Room behind the Nurses' Station - the corridor door had a transfer grill in the door

________________

2000 NFPA 101, 19.3.6.3.2 Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.

2000 NFPA 101, 19.3.6.3.1 Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.
.

.
The facility failed to maintain the hazardous area per code. Findings include:

During the survey, the following is an example of what was observed:
The Record/Supply Storage Room in Radiology (over 50 sq. ft.) - the corridor door was not self-closing.

_________________

2000 NFPA 101, 19.3.2.1 Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. 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.

.

.
The facility failed to maintain the exit access per code. Findings include:

During the survey, the following was observed:
1. The doors, when fully opened projected more than 7" into the corridor.
a. Central Sterile Mechanical Room
b. Tub/Shower Room across from room 122
2. The Biohazard Room across from room 120 - had a hasp lock on the corridor side

____________________

2000 NFPA 101, 19.2.1 Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7.
2000 NFPA 101, 7.2.1.4.4 During its swing, any door in a means of egress shall leave not less than one-half of the required width of an aisle, corridor, passageway, or landing unobstructed and shall not project more than 7 in. (17.8 cm) into the required width of an aisle, corridor, passageway, or landing, when fully open. Doors shall not open directly onto a stair without a landing. The landing shall have a width not less than the width of the door. (See 7.2.1.3.)

2000 NFPA 101, 7.2.1.5.1 Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.
.

.
The facility failed to provide continuous lighting for means of egress. Findings include: During the survey, the following are examples of what was observed:


1. The Exit Discharge lighting is controlled by a switch for the Exit by Facilities Management Office.

2. The Exit Discharge lighting is controlled by a switch for the Exit by Patient room 129.

3. The Exit Discharge lighting is controlled by a switch for the Exit by Patient Room 112.

4. The Exit Discharge lighting is controlled by a switch for the Exit by Recovery Room ER.

---------------------------------
NFPA 101, 19.2.8 and 7.8.1.2 Illumination of means of egress shall be continuous.
.

.
The facility failed to conduct fire drills per code. Findings include:

During the survey, the following is an example of what was observed:
Per interview, the facility was not getting all staff to sign the participation sheet.

_________________
2000 NFPA 101, 19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. 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. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
.

.
The facility failed to provide complete/current documentation of the inspection of the fire alarm system. During the survey, the following is an example of what was observed:


Documentation was not provided for the annual inspection of the fire alarm system.
-----------------------------------
1999 NFPA 72, 7-5.2.2 and Figure 7-5.2.2 A permanent record of all inspections, testing, and maintenance shall be maintained which includes periodic tests and applicable information.
.

.
The facility failed to perform sensitivity testing of the smoke detectors. Findings include: During the survey, the following is an example of what was observed:


Documentation provided by the facility during the survey did not indicate sensitivity testing of the smoke detectors. Detector sensitivity shall be checked with one year after installation and every alternate year thereafter per 72, 7-3.2.1. (Up to 5 years permitted under certain circumstances. See 7-3.2.1).
.

Sprinkler coverage was observed during the survey not adequately provided. Findings include: During the survey, the following are examples of what was observed:

1. A 5'x 30' canopy at the Emergency Room Exit, this is a cloth material, metal framing, this provides a cover to the module building near the emergency room. Documentation was not provided for the flame resistant per NFPA 701.

2. A 6' canopy at the entrance to the Emergency Room is a cloth material, metal framing, documentation not provided for the flame resistant per NFPA 701.

3. A canopy approximately 18'x 40' at the Emergency Room was not provided with sprinkler coverage.

4. Corrosion build up around the link of a sprinkler above the dryers in the Laundry Room.


1999 NFPA 13, 5-13.8 Sprinklers shall be installed under exterior combustible roofs or canopies exceeding four feet in width, or over areas where combustibles are stored.

1999 NFPA 25, 2-2.1.1 and 2-4.1.2 Sprinklers that are painted, corroded or damaged shall be replaced with new listed sprinklers of the same characteristics, including orifice size, thermal response, and water distribution.


27382






5. The E.R. Patient Treatment Area - the sprinkler head was 14'-0" from the wall

_____________________
1999 NFPA 13, 5-6.3 Sprinkler Spacing (Standard Pendent and Upright Spray Sprinklers).
1999 NFPA 13, 5-6.3.2 Maximum Distance from Walls.
1999 NFPA 13, 5-6.3.2.1*
The distance from sprinklers to walls shall not exceed one-half of the allowable distance between sprinklers as indicated in Tables 5-6.2.2(a) through (d). The distance from the wall to the sprinkler shall be measured perpendicular to the wall. Where walls are angled or irregular, the maximum horizontal distance between a sprinkler and any point of floor area protected by that sprinkler shall not exceed 0.75 times the allowable distance permitted between sprinklers, provided the maximum perpendicular distance is not exceeded.

Table 5-6.2.2(b) Protection Areas and Maximum Spacing (Standard Spray Upright/Standard Spray Pendent) for Ordinary Hazard
.

The facility failed to perform the required maintenance of the facility sprinkler system. Findings include: During the survey, the following are examples of what was observed:

1. Documentation provided by the facility indicated quarterly sprinkler inspections were conducted on 1/18/2012, 4/25/2012, documentation could not be provided for inspections for 2011.

2. Documentation was not provided for the annual partial trip test, or the three year full flow trip test , for the dry riser.

3. Fire department connection did not have identification sign.
---------------------------------
NFPA 101, 4.6.12, and NFPA 25, 2-2 and Table 2-1 Requires an inspection every quarter (three months).

NFPA 25,1998 Edition, 9-5.2.3 A partial flow trip test adequate to move the valve from its seat shall be conducted annually.
NFPA 25, 1998 Edition, 9-4.4.2.2.2 Every 3 years and whenever the system is altered, the dry pipe valve shall be trip tested with the control valve fully open and the quick-opening device, if provided, in service.
NFPA 101,2000 Edition, 9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this code shall be inspected, tested, and maintained in accordance with NFPA 25, Standards for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25, 1998 Edition, 9-7.1 Fire department connections shall be inspected quarterly. The inspection shall verify the following:
(a) The fire department connections are visible and accessible.
(b) Couplings or swivels are not damaged and rotate smoothly.
(c) Plugs or caps are in place and undamaged.
(d) Gaskets are in place and in good conition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly.


27382





1. The facility could not verify if the automatic sprinkler system gauges at the risers had been calibrated or changed out in the last five years
2. The patient room closet automatic sprinkler heads were obstructed by a shelf

__________________

1998 NFPA 25, 2-3.2 Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced.
1999 NFPA 13, 5-5.6 The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.
.

.
The facility failed to provide metal self-closing containers for disposing of cigarette butts and ashes from ashtrays. Findings include: During the survey, the following are examples of what was observed:

1. The employees designated smoking area was not provided with noncombustible ashtrays, or metal containers with self-closing cover devices.

2. The patient designated smoking area was not provided with noncombustible ashtrays, or metal containers with self-closing cover devices.
-----------------------------------
NFPA 101, 19.7.4 Ashtrays of noncombustible material and safe design, and metal self-closing containers for disposing of cigarette butts and ashes from ashtrays, shall be provided.
.

A. The facility failed to maintain the dietary hood. Findings include: During the survey, the following are examples of what was observed:

Two filters in the dietary hood had approximately a 3/4 inch gap between them.

-------------------------------------
NFPA 96, 3-2.3 Grease filters shall be listed and constructed of steel or listed equivalent material and shall be of rigid construction that will not distort or crush under normal operation, handling, and cleaning conditions. Filters shall be tight fitting and firmly held in place.




B. The facility failed to adequately perform testing and inspection of the dietary hood extinguishment system. Findings include:

During survey, the provided documentation for the monthly inspection of the hood system was the inspection card attached to the pull station of the hood extinguishing system. This card was observed with space on the reverse side to date and initial each month an inspection was conducted by facility staff. This side of the inspection card was blank.
---------------------------------------
NFPA 17, 9-2.1- On a monthly basis, inspection shall be conducted in accordance with the manufacturer 's listed installation and maintenance manual or owner 's manual. As a minimum, this "quick check " or inspection shall include verification of the following:
(a) The extinguishing system is in its proper location.
(b) The manual actuators are unobstructed.
(c) The tamper indicators and seals are intact.
(d) The maintenance tag or certificate is in place.
(e) The system shows no physical damage or condition that might prevent operation.
(f) The pressure gauge(s), if provided, is in operable range.
(g) The nozzle blow-off caps, where provided, are intact and undamaged.
(h) Neither the protected equipment nor the hazard has been replaced, modified, or relocated.

.
The facility failed to provide proper storage of oxygen cylinders. Findings include: During the survey, the following is an example of what was observed.

Six unsecured oxygen cylinders in the oxygen storage room.
----------------------------------------
1999 NFPA 99, 4-3.1.1.1 and 4-5.1.1.1 Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.
.

.
The facility failed to provide proper signage for the above ground diesel tank. Findings include: During the survey, the following are examples of what was observed:

Two diesel tanks were not identified for fire hazard and its contents.
-------------------------------------
NFPA 30 2-9.3, Unsupervised aboveground storage tanks shall be secured and marked in such a manner as to identify the fire hazards of the tank and its contents to the general public. The area in which the tank is located shall be protected from tampering or trespassing, where necessary.
.

.
The facility failed to maintain the emergency generators per code. Findings include:

During the survey, the following is an example of what was observed:
The facility failed to provide documentation of weekly inspections on the two emergency generators

____________________

1999 NFPA 110, 6-4.1 Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
.

A. The facility failed to provide receptacles for appliances. Findings include: During the survey, the following are examples of what was observed:

1. A junction box was missing the cover in the ceiling of the cooler located in the kitchen.

2. A junction box was missing the cover in the maintenance shop.

3. A junction box was missing the cover in the boiler room.

4. Microwave and refrigerator was plugged into a surg protector in the maintenance shop.
----------------------------------
1999 NFPA 70, 370-25 and 410-12. Each box in completed installations to have a cover, face plate, or fixture canopy.

Appliances, such as air conditioners, refrigerators, and microwaves shall plug directly into a receptacle. 1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99.


27382





B. The facility failed to maintain the electrical wiring and equipment per code. Findings include:

During the survey, the following are examples of what was observed:
1. The Breakroom for Radiology had a refrigerator plugged into a surge protector
2. The E.R. Pantry had a refrigerator and a microwave plugged into a surge protector
3. The O.R. did not have any emergency electrical outlets indicated
4. The O.R. had patient care equipment plugged into a surge protector
5. The Lab. had two extension cords plugged into a surge protector
6. The Nurses' Station had a homemade extension cord in use

_____________________

1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip.

1999 NFPA 70, 517-33
(a) Receptacle Identification. The receptacles or the faceplates for receptacles supplied by the critical branch shall have a distinctive color or marking so as to be readily recognizable.

1999 NFPA 70, 400-7 (b) Attachment Plugs. Where used as permitted in subsections (a)(3), (a)(6), and (a)(8), each flexible cord shall be equipped with an attachment plug and shall be energized from a receptacle outlet.