HospitalInspections.org

Based on observation the facility failed to ensure that corridor doors had no impediment to quick-closure, for the purpose of containing the spread of a fire.

Findings include:

On 7/23/13 at 2:55 PM, the door to Room #6 ,which opened on to a corridor, was obstructed from closing by the edge of a floor mat. At 3:00 PM a shower room door in the Physical Therapy area, which opened onto a corridor, was held open with a door wedge.

Based on observation the facility failed to ensure that one-of-five sets of smoke compartment doors were self-closing.

Findings include:

On 7/23/13 at 1:55 PM the west leaf of the smoke compartment doors, separating the Acute Care from the Physical Therapy areas, was held open with a door wedge. The magnetic holding equipment for this door was disabled.

7.10.5.1 Continuous Illumination. Every sign required to be illuminated by 7.10.6.3 and 7.10.7 shall be continuously illuminated as required under the provisions of Section 7.8.

7.10.8.1 No Exit. Any door, passage or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads as follows: NO EXIT

Based on observation, the facility failed to maintain 3 of 15 exit signs in the building, and one set of doors led to a courtyard from which there was no access to a public way.

Findings include:

On 7/23/13 at 2:10 PM two exit signs in the kitchen, heading out the rear exit, were not illuminated.

On 7/23/13 at 1:30 PM a set of glass doors, across from the Boiler Room, lead into the courtyard which could have been mistaken for an exit.

Based on record review the facility failed to ensure that the minimum number of fire drills were conducted in the past twelve months.

Findings include:

On 7/23/13 a review of the records revealed that only three fire drills were conducted in the past twelve months: 7/8/12 (11:15 AM), 2/22/13 (2:00 PM), and 5/16/13 (no time recorded).

Based on observation the facility failed to correct a nuisance, "trouble" signal on their Fire Alarm Control Panel (FACP).

Findings include:

On 7/23/13 and 7/24/13 a "Trouble" signal appeared on the facility's FACP. The Maintenance Supervisor said that it was caused by a "dead" smoke detector in the Operating Room.

19.3.4.5.1 Detection systems, where required, shall be in accordance with section 9.6.

9.6.1.4 A fire alarm system required for life safety shall be installed, tested and maintained in accordance with the applicable requirements of National Fire Protection Association (NFPA) 70, National Electric Code, and NFPA 72, National Fire Alarm Code...

NFPA 72 Chapter 10, 10.4.3.2 Sensitivity of smoke detectors and single and multiple-station smoke alarms in other than one and two-family dwellings shall be tested in accordance with 10.4.3.2.1 through 10.4.3.2.6.

10.4.3.2.1 Sensitivity shall be checked every alternate year thereafter unless other wise permitted by compliance with 10.4.3.2.3.


Based on observation, document review and staff interview the facility failed to ensure that sensitivity tests were conducted, and all smoke detectors were properly maintained.

Findings include:

On 7/23/13 a review of the facility's maintenance documents could not demonstrate that sensitivity testing had been performed. The Maintenance Supervisor was unaware that bi-annual smoke detector, sensitivity testing was required.

On 7/23/13 at 1:57 PM the battery had been partially removed from the smoke detector in the Nurses' Lounge. The monitoring light was no longer flashing, indicating that the device was no longer operable. At 3:10 PM the smoke detector in the Soiled Utility Room, across from Room 20, was missing a cover and the monitoring light was no longer flashing indicating that the device was no longer operable.

8.14.7* Exterior Roofs or Canopies.
8.14.7.1* Unless the requirements of 8.14.7.2 or 8.14.7.3 are met, sprinklers shall be installed under exterior roofs or canopies exceeding 4 ft (1.2 m) in width.

Based on observation, the facility failed to ensure that exterior canopies exceeding four feet were protected with sprinklers.

Findings include:

On 7/23/13 at 4:22 PM it was observed that the canopy over the Dietary Department's receiving dock measured 13-feet by 20-feet. There were no sprinklers present in the canopy of the dock. The Maintenance Supervisor indicated that the canopy was constructed of particle board. The canopy adjacent to the Emergency Department was sprinklered. The overhang at the entrance to the hospital was sprinklered.

NFPA 25 (1998 ed.), 2-3.2 Gauges. Gauges shall be replaced every 5 years, or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate within 3 percent of the full scale shall be recalibrated or replaced.

Based on record review and observation the facility failed to ensure that the gauges on the riser pipe were replaced or calibrated as required.

Findings include:

On 7/23/13 at 2:30 PM it was observed that the gauges on the riser pipe appeared to be the original equipment. They were made by the Star Sprinkler Corporation of Philadelphia, PA. This is the same company who made the castings of the riser plumbing joints. The cornerstone on building indicated that this part of the facility was constructed in 1971. The gauges were in brass cases, with old paint splatter on them. The Maintenance Supervisor did not know when the gauges were last replaced. There was no documentation which would indicate that the gauges had ever been replaced.

Based on observation, the facility failed to ensure that two of 25 fire extinguishers were in good working condition.

Findings include:

On 7/23/13 one fire extinguisher in the corridor near the radiology department and one fire extinguisher in the Riser Room, were equipped with pressure indicators which were out of the "green" area, which meant that they contained less-than-optimal pressure. The annual fire extinguisher inspection was due 7/26/13.

NFPA 90 A, Chapter 3 Integration of a Ventilation and Air-Conditioning System(s) with Building Construction. 3.4.7 Maintenance. At least every 4 years, fusible links (where applicable) shall be removed: all dampers shall be operated to verify that they fully close; the latch, shall be checked; and moving parts shall be lubricated as necessary.

Based on record review, and staff interview, the facility failed to ensure that smoke/fire dampers were inspected on a four-year frequency.

Findings include:

On 7/23/13 during a review of the facility's maintenance records, no documentation could be found to indicate that damper testing had ever been performed. The Maintenance Supervisor was unaware that dampers had to be inspected every four years. The facility's blueprints indicated the location of each smoke/fire damper in the building.

Based on observation, the facility failed to ensure that the corridors were free of equipment which constricted the width of the means of egress.

Findings include:

On 7/23/13 and 7/24/13 an inversion table and an abdominal exerciser were observed restricting an eight-foot corridor down to just 5.5 feet.

Based on observation the facility failed to ensure that a hazardous quantity of oxygen cylinders were stored in a room which was rated as having one-hour fire separation.

Findings include:

On 7/24/13 at 10:30 AM it was revealed that the facility was using a converted shower room for the storage of oxygen cylinders. There were 49 "E" cylinders in this room along with 9 "H" cylinders for a total of 3,925 cubic feet of oxygen. The converted shower room had a drop-in ceiling, an un-rated door opening onto the corridor, and it was unknown if the room was equipped with a smoke/fire damper.

Based on observation the facility failed to ensure that hazardous quantities of flammable liquids were safely stored.

Findings include:

On 7/24/13 at 7:15 AM, four, gallon containers were observed in a cabinet, under a counter in the Laboratory. The cabinet was made of a combustible material. The containers were made of a translucent plastic. All containers were partially full. Two containers were labeled "Methanol", one container was labeled "Ethanol" and one container was labeled "Acetone".

NFPA 110, 8.4.2.3* Diesel-powered EPS installations that do not meet the requirements of 8.4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.

NFPA 110, 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 Emergency Power Supply (EPS) service room at a work site readily observable by personnel.

Based on observation, staff interview and record review, the facility failed to ensure that required load-bank testing was being performed, and that remote alarm panel was located where personnel could monitor the status of the EPS.

Findings include:

On 7/23/13 at 7:50 AM power was intentionally dropped to the building. Power transferred within three seconds. The amperage reading on the generator set was 5-30 A. The generator was a 124 kW, diesel "Lima Magna". The Maintenance Supervisor indicated that the generator was operating far below 30% of capacity. Record review revealed no documentation of load-bank testing. The Maintenance Supervisor was unaware that annual load-bank testing of the generator was required.

On 7/23/13 during a tour of the facility, no remote EPS alarm panel could be found. The Maintenance Supervisor indicated that the only monitoring panel for the EPS was located outside with the EPS.

Based on observation the facility failed to ensure that Alcohol Based Hand Rub (ABHR) dispensers were installed safely.

Findings include:

On 7/23/13 at 1:57 PM an ABHR dispenser was observed to be installed directly over a light switch in the Nurses' Lounge. At 3:00 PM an ABHR dispenser was mounted directly over a light switch in the Physical Therapy Room.