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Based on observation, the facility failed to maintain the integrity of the building construction. This was evidenced by unsealed penetrations in the facility's walls that could result in the spread of fire and smoke. This had the potential of harming patients and staff with burns and/or smoke inhalation in the event of a fire.

Findings:

During a tour of the facility with the Safety Officer, the facility's walls and ceilings were observed.

On 2/20/2013, at 2:13 p.m., there were 12 penetrations on the wall to the medication room A33. Each penetration measured approximately 1/2-inch diameter.

Based on observation, the facility failed to maintain corridor doors. This was evidenced by doors opening into the corridor with impediments that kept them from closing and latching. This affected 2 of 4 units. This could delay the containment of smoke and fire, resulting in injury to residents, staff, and visitors.

Findings:

During a tour of the facility with the Safety Officer, the corridor doors were observed.

1. On 2/20/2013, at 1:29 p.m., the corridor door to Conference Room D27 had its latching mechanism tapped that prevented the door from positive latching.

2. On 2/20/2013, at 2:11 p.m., the corridor door to Room A49 had a door wedge that prevented the door from closing. No one was in the room during this observation.

3. On 2/20/2013, at 2:12 p.m., the corridor door to Room A50 had a door wedge that prevented the door from closing. No one was in the room during this observation.

Based on observation, the facility failed to maintain smoke barrier walls. This was evidenced by penetrations in smoke barrier walls. This had the potential to allow the spread of smoke from one smoke compartment to another smoke compartment in the event of a fire, potentially harming patients, visitors, and staff. This affected 3 of 4 units.

NFPA 101, Life Safety Code, 2000 Edition
8.3.2 Continuity. Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.

Findings:

During a tour of the facility with the Safety Officer and the Building Maintenance Supervisor, the smoke barrier walls were observed.

1. On 2/19/2013, at 11:03 a.m., the smoke barrier wall by Room 54, had a pipe sleeve penetrating the wall with no fire stop material in the tube. The pipe was located above the hard ceiling and the penetration measured approximately 2-inches diameter with cables running through it.

2. On 2/19/2013, at 11:18 a.m., the smoke barrier wall by the EPU Nursing Station, had three penetrations through the wall with no fire stop material. The penetrations were located above the tiled ceiling. Two penetrations were inside pipe sleeves that measured approximately 1-inch diameter and one penetration surrounded a pipe and it measured approximately 1/2-inch.

Based on observation and record review, the facility failed to maintain self-closing devices on fire doors. This was evidenced by rolling fire doors that were not kept in proper working condition, affected 3 of 4 units. This could result in smoke and fire to travel throughout the facility in the event of a fire in the rooms.

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 Safety Officer and the Building Maintenance Supervisor, the rolling fire doors were observed and annual inspection records were reviewed.

On 2/19/2013, at 12:07 p.m., the vendor's inspection records identified 3 of 11 rolling fire doors not checked for proper operation during an inspection. The doors included C32 in Unit C (Serial #430021), B42 in Unit B, and D40 in Unit D (Serial #430017). The fire alarm technician stated that the rolling fire doors had not been inspected because the doors required repairs.

Based on staff interviews and record review, the facility failed to ensure that staff members were aware of their duties to protect patients in the event of a fire. This was evidenced by a staff who did not know the difference between two types of fire extinguishers, a staff who did not know the difference between the building's fire alarm system and the kitchen's fire suppression system, failing to conduct fire drills under varying conditions, and incomplete fire drill records. This had the potential for staff members to not properly respond to a fire that could result in harm to patients, staff, and visitors.

NFPA 101, Life Safety Code, 2000 Edition
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.
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 Safety Officer, facility staffs were interviewed to determine their knowledge of their fire emergency procedures and usage of life safety equipments, and fire drill records were reviewed.

1. On 2/19/2013, at 4:03 p.m., kitchen staff 1 was asked how he would respond to a fire in his working area and to explain the difference between the two types of fire extinguishers located in the kitchen. Kitchen staff 1 was unable to identify what type of fire extinguisher to use during an oil or grease fire and he could not explain the difference between the K-type and the ABC-type fire extinguishers.

2. On 2/20/2013, at 8:20 a.m., kitchen staff 2 was asked how she would respond to a fire and where she would activate the fire alarm system. She pointed at the handle used to manually activate the kitchen's hood fire suppression system. Kitchen staff 2 was then asked to explain the difference between the manual fire alarm box and the hood's fire suppression system. She was unable to explain the difference between the two systems.

3. On 2/20/2013, at 3:45 p.m., the fire drill record reviewed for the past 12 months did not show that a fire alarm signal was transmitted for drills conducted during 7 a.m. to 9 p.m..

4. On 2/20/2013, at 3:50 p.m., the fire drill record reviewed for the past 12 months did not show that drills were done in varying times. Drills were recorded to be done in the morning at 7 a.m. for the first, second, third, and fourth quarters and at 4 p.m. for the first, third, and fourth quarters.

Based on observation, interview, and record review, the facility failed to ensure that their fire alarm system was installed appropriately. This was evidenced by access controlled egress doors that that failed to unlock automatically upon activating the fire alarm system. This affected 2 of 4 units. This could result in delays during a fire evacuation, resulting in injury to patients, staff, and visitors.

NFPA 101, Life Safety Code, 2000 Edition
7.2.1.6.2 Access-Controlled Egress Doors. Where permitted in Chapters 11 through 42, doors in the means of egress shall be permitted to be equipped with an approved entrance and egress access control system, provided that the following criteria are met.
(d) Activation of the building fire-protective signaling system, if provided, shall automatically unlock the doors in the direction of egress, and the doors shall remain unlocked until the fire-protective signaling system has been manually reset.
(e) Activation of the building automatic sprinkler or fire detection system, if provided, shall automatically unlock the
doors in the direction of egress and the doors shall remain unlocked until the fire-protective signaling system has been manually reset.

Findings:

During a tour of the facility with the Safety Officer and the fire alarm technician, the fire alarm system and the sprinkler system were observed and records were reviewed.

1. On 2/20/2013 at 8:45 a.m., the cross corridor Access-Controlled Egress Doors by Room B51 failed to unlock upon activating a smoke detector in the area. An exit sign was displayed by the door.

2. On 2/20/2013, at 8:46 a.m., the cross corridor Access-Controlled Egress Doors by Room B47 failed to unlock upon activating a smoke detector in the area. An exit sign was displayed by the door.

3. On 2/20/2013, at 8:50 a.m., the cross corridor Access-Controlled Egress Doors by Room B65 failed to unlock upon activating a smoke detector in the area. An exit sign was displayed by the door.

4. On 2/20/2013, at 9:02 a.m., the cross corridor Access-Controlled Egress Doors by Room C73 failed to unlock upon activating a smoke detector in the area. An exit sign was displayed by the door.

The Safety Officer stated that the Access-Controlled Egress Doors is an ongoing project through the Office of Statewide Health Planning & Development (OSHPD). The fire alarm technician stated that change orders had been submitted and that OSHPD is planning on doing a field visit. OSHPD's citizen access website had indicated that a building permit had been issued on 1/31/2012.

Based on document review and interview, the facility failed to maintain operational integrity of the fire alarm system. This was evidenced by 40 of 370 fire alarm smoke detectors that failed sensitivity testing and duct detectors that failed to shutdown equipments in 2 of 4 units. This had the potential to have a fire alarm system not function and result in a delayed response to a fire, increasing the risk of injury to patients, visitors, and staff.

NFPA 101, Life Safety Code, 2000 Edition
9.6.1.7 To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code.

NFPA 72, National Fire Alarm Code, 1999 Edition
2-10.3.2 If smoke detectors are used to initiate selectively the operation of equipment to control smoke spread, the requirements of 2-10.4.2.2 shall apply.

7-3.2.1 Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In
zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer ' s calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.

7-5.2.2 A permanent record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 7-5.2.2.
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business address, and telephone number
(6) Name, address, and representative of approving agency(ies)
(7) Designation of the detector(s) tested, for example, " Tests performed in accordance with Section __________. "
(8) Functional test of detectors
(9) *Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type heat detectors
(12) Other tests as required by equipment manufacturers
(13) Other tests as required by the authority having jurisdiction
(14) Signatures of tester and approved authority representative
(15) Disposition of problems identified during test (for example, owner notified, problem corrected/successfully retested, device abandoned in place)

Findings:

During a tour of the facility with the Safety Officer and the fire alarm technician, the fire alarm systems were tested, observed, and documents were reviewed.

1. On 2/19/2013, at 12:20 p.m., the fire alarm annual report, dated 1/11/2013 and 1/10/2012, showed that the duct detectors failed to shut down air flow equipments in air ducts located in Unit B and Unit C. There was no record that showed the replacement or repair of these equipments. The fire alarm technician stated that the repairs had not been completed. The Assistant Administrator stated that Unit B is currently inactive and Unit C is active with the potential of serving up to 34 patients.

2. On 2/19/2013, at 12:40 p.m., the log showing the smoke detector sensitivity test identified 40 of 370 smoke detectors out of range. There was no documentation for repair or replacement of the smoke detector. The fire alarm technician stated that he had compiled the list through quarterly inspections he had conducted in the past year, beginning on 3/14/2012.

3. On 2/19/2013, the fire alarm system inspection and testing records did not include testing all the items listed in section 7-5.2.2 of NFPA 72.

Based on observation, the facility failed to ensure that portable heaters not be used in patient care areas. This was evidenced by a portable space heater found in an exam room. This affected 1 of 4 units. This had the potential for causing fire and/or injuring patients.

Findings:

During a tour of the facility with the Safety Officer, patient areas were observed.

On 2/20/2013, at 1:48 p.m., a portable heater was observed in the exam room C43. The heater was not on and no patients were in the room during this observation.

Based on observation, interview, and record review, the facility failed to maintain their Emergency Power System (EPS) in accordance with NFPA 101 and NFPA 110. This was evidenced by failing to provide a functional remote alarm annunciator in a constantly attended area and by no battery-powered emergency lighting unit found by the generator. This had the potential for not being able to monitor the condition of the generator and the inability of troubleshooting a failure of the generator during the loss of power and darkness.

NFPA 101, Life Safety Code, 2000 Edition
7.9.2.3 Emergency generators providing power to emergency lighting systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. Stored electrical energy systems, where required in this Code, shall be installed and tested in accordance with NFPA 111, Standard on Stored Electrical Energy Emergency and Standby Power Systems.

NFPA 110, Standard for Emergency and Standby Power Systems, 1999 Edition
3-5.5.2 An automatic control and safety panel shall be a part of the EPS and shall contain the following equipment or possess the following characteristics, or both:
(d) Battery-powered individual alarm indication to annunciate visually at the control panel the occurrence of any of the conditions in Table 3-5.5.2(d); additional contacts or circuits for a common audible alarm that signals locally and remotely when any of the itemized conditions occurs. A lamp test switch(es) shall be provided to test the operation of all alarm lamps listed in Table 3-5.5.2(d).

3-5.6 Remote Controls and Alarms.
3-5.6.1 A remote, common audible alarm powered by the storage battery shall be provided as specified in 3-5.5.2(d). This remote alarm shall be located outside of the EPS service room at a work site readily observable by personnel.

5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.

Findings:

During a tour of the facility with the Safety Officer and the Building Maintenance Supervisor, the generator and its components were observed.

1. On 2/19/13, at 11:28 a.m., the remote alarm annunciator for the generator was observed to be installed in the corridor of the administration building. The Building Maintenance Supervisor confirmed that the remote annunciator was not functioning and the maintenance records did not show that it had been tested. The one line diagram showed that the generator may be used as a secondary power source during a power outage, including but not limited to the following electrical equipments: emergency lights, exits signs, emergency receptacle wall outlets, and the fire alarm system.

2. On 2/19/13, at 11:42 a.m., the area where the generator was located did not have a battery-powered emergency lighting unit. The Building Maintenance Supervisor confirmed that there was no battery-powered lighting unit.

Based on document review and interview, the facility failed to maintain record of electrical system checks. This was evidenced by no record of tension and polarity testing done on all receptacle wall outlets, affected 4 of 4 units. This had the potential to not be able to determine if all the outlets had been checked, increasing risk of electrical fire and electrical shock, injuring patients, visitors, and staff.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
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 Safety Officer and the Building Maintenance Supervisor, the documentation for the inspection of receptacle wall outlets were requested and electrical equipment were observed.

On 2/20/13, at 7:50 a.m.,the Building Maintenance Supervisor stated that they had no records available that showed the listing of all the receptacle wall outlets inspected for integrity, tension, and polarity within the past 12 months. The record showing that the receptacle wall outlets had been inspected was dated 3/30/2010.