HospitalInspections.org

Based on interview and record review, facility staff failed to inspect, test and maintain the fire egress doors in accordance with the 2010 Editions of NFPA 80 (Standard for Fire Doors and Other Opening Protectives) and NFPA 105 (Standard for Fire Doors and Other Opening Protectives). Facility staff failed to conduct an annual inspection of the fire egress doors. The facility census was 17.

1. Review of the facility's inspection, testing and maintenance records for the 2019 year showed the records did not contain documentation of an annual inspection of the fire egress doors during the 12-month period.

During an interview on 1/30/2020 at 1:10 P.M., the Corporate Director of Facilities and Materials confirmed the record review.

Review of NFPA 101, 2012 Edition showed the following:
-7.1.10.2.1 showed no furnishings, decorations, or other objects shall obstruct exits or their access thereto, egress therefrom, or visibility thereof.
-19.2.2.2.1 Doors complying with 7.2.1 shall be permitted.
-7.2.1.15.1* Where required by Chapters 11 through 43, the following door assemblies shall be inspected and tested not less than annually in accordance with 7.2.1.15.2 through 7.2.1.15.8:
(1) Door leaves equipped with panic hardware or fire exit hardware in accordance with 7.2.1.7;
(2) Door assemblies in exit enclosures;
(3) Electrically controlled egress doors;
(4) Door assemblies with special locking arrangements subject to 7.2.1.6.
-7.2.1.15.2 Fire-rated door assemblies shall be inspected and tested in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Smoke door assemblies shall be inspected and tested in accordance with NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives.
-7.2.1.15.3 The inspection and testing interval for fire-rated and nonrated door assemblies shall be permitted to exceed 12 months under a written performance-based program in accordance with 5.2.2 of NFPA 80, Standard for Fire Doors and Other Opening Protectives.
-7.2.1.15.4 A written record of the inspections and testing shall be signed and kept for inspection by the authority having jurisdiction.

Based on staff interview and record review, facility staff failed to inspect the fire alarm system per NFPA 72, National Fire Alarm and Signaling Code, 2010 edition. The facility census was 17.

1. Record review on 1/30/2020 did not show an annual fire alarm inspection of the sprinkler system. Record review showed the last annual inspection conducted in December of 2018.

During an interview on 1/30/2020 at 12: P.M., the Corporate Director of Facilities and Materials confirmed that the last annual fire alarm inspection was conducted in December of 2018.

Refer to NFPA 72, National Fire Alarm and Signaling Code, 2010 edition, Table 14.3.1, Table 14.4.2.2, Table 14.4.5, sections 14.4.5, 14.4.5.3.1 through section 14.4.5.4 for testing.

Based on staff interview and record review, facility staff failed to inspect the sprinkler system per NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 edition. The facility census was 17.

1. Record review on 1/30/2020 did not show an annual sprinkler inspection of the sprinkler system. Record review showed the last annual inspection conducted in December of 2018.

During an interview on 1/30/2020 at 12:14 P.M., the Corporate Director of Facilities and Materials confirmed that the last annual sprinkler inspection was conducted in December of 2018.

Refer to NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 edition, Chapters 5, 13 and 14 for additional information.

Based on facility staff interview and record review, facility staff failed to conduct fire drills on all shifts for two of four quarters reviewed. The facility census was 17 .

1. Record review on 1/30/2020 of the facility fire drill records, showed the following fire drills were not conducted:

-7 P.M.-7 A.M. shift on the 3rd quarter of 2019
-7 P.M.-7 A.M. shift on the 2nd quarter 2019
-7 A.M.-7 P.M. shift on the 3rd quarter 2019


During an interview on 1/30/2020 at 12:45 P.M., the Corporate Director of Facilities and Materials were missed.

The National Fire Protection Association 101 Life Safety Code, 2012 edition, Section 19.7.1 states:

19.7.1 Evacuation and Relocation Plan and Fire Drills.

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.

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.

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.

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.

Based on record review and facility staff interview, the facility failed to ensure that all building systems had been assigned a risk assessment category and documented per NFPA 99. The census was 17.

1. Review of the facility documents for fire safety, building system tests, and policies showed an incomplete assessment of the which systems were critical for patient safety.

2. During an interview on 1/30/2020 at 12:50 PM, the CEO said that the current risk assessment was incomplete.

Based on record review and staff interview, the facility failed to operate the emergency generator for a minimum of 30 minutes under load at least 12 times a year. In addition, the facility failed to conduct an annual load bank test for one of one emergency generators. The facility census was 17.

1. Record review on 1/30/2020 of the facility generator records showed no records, since February of 2019, of facility staff operating the emergency generator under load for at least thirty minutes.

During an interview on 1/30/2020 at 1:00 P.M., the Corporate Director of Facilities and Materials confirmed the record review.

Section 6.4.4.1.1.4 (A) of the National Fire Protection Association (NFPA 99) states: Generator sets shall be tested 12 times a year, with testing intervals of not less than 20 days nor more than 40 days. Generator sets serving essential electrical systems systems shall be tested in accordance with NFPA 110, Standards for Emergency and Standby Power Systems, Chapter 8.

2. Record review on 1/30/2020 of the facility generator records did not show records of annual testing with the available building electrical load at a minimum of 30% of the generator nameplate rating or load bank records.

During an interview on 1/30/2020 at 1:00 P.M., the Corporate Director of Facilities and Materials said the facility last conducted an annual load bank test on 6/19/2018.


NFPA 110, Standard for Emergency and Standby Power Systems, 2010 edition states:

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.

5.6.5.6.1 The remote manual stop station shall be labeled.

8.4.2* Diesel generator sets in service shall be exercised at
least once monthly, for a minimum of 30 minutes, using one
of the following methods:
(1) Loading that maintains the minimum exhaust gas temperatures
as recommended by the manufacturer
(2) Under operating temperature conditions and at not less
than 30 percent of the EPS nameplate kW rating

8.4.2.1 The date and time of day for required testing shall be
decided by the owner, based on facility operations.

8.4.2.2 Equivalent loads used for testing shall be automatically
replaced with the emergency loads in case of failure of
the primary source.

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 shall be exercised annually with supplemental
loads at not less than 50 percent of the EPS nameplate kW
rating for 30 continuous minutes and at not less than 75 percent
of the EPS nameplate kWrating for 1 continuous hour for a total
test duration of not less than 1.5 continuous hours.

8.3 Maintenance and Operational Testing.

8.3.1* The EPSS shall be maintained to ensure to a reasonable
degree that the system is capable of supplying service within the
time specified for the type and for the time duration specified for
the class.

8.3.2 A routine maintenance and operational testing program
shall be initiated immediately after the EPSS has passed
acceptance tests or after completion of repairs that impact the
operational reliability of the system.

8.3.2.1 The operational test shall be initiated at an ATS and
shall include testing of each EPSS component on which maintenance
or repair has been performed, including the transfer of
each automatic and manual transfer switch to the alternate
power source, for a period of not less than 30 minutes under
operating temperature.

8.3.3 A written schedule for routine maintenance and operational
testing of the EPSS shall be established.

8.3.4 A permanent record of the EPSS inspections, tests, exercising,
operation, and repairs shall be maintained and readily
available.

8.3.4.1 The permanent record shall include the following:
(1) The date of the maintenance report
(2) Identification of the servicing personnel
(3) Notation of any unsatisfactory condition and the corrective
action taken, including parts replaced
(4) Testing of any repair for the time as recommended by the
manufacturer

8.3.5* Transfer switches shall be subjected to a maintenance and
testing program that includes all of the following operations:
(1) Checking of connections
(2) Inspection or testing for evidence of overheating and excessive
contact erosion
(3) Removal of dust and dirt
(4) Replacement of contacts when required

8.3.6 Paralleling gear shall be subject to an inspection, testing,
and maintenance program that includes all of the following
operations:
(1) Checking of connections
(2) Inspection or testing for evidence of overheating and excessive
contact erosion
(3) Removal of dust and dirt
(4) Replacement of contacts when required

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.

8.3.7.1 Maintenance of lead-acid batteries shall include the
monthly testing and recording of electrolyte specific gravity. Battery
conductance testing shall be permitted in lieu of the testing
of specific gravity when applicable or warranted.

8.3.7.2 Defective batteries shall be replaced immediately
upon discovery of defects.

8.3.8 A fuel quality test shall be performed at least annually
using tests approved by ASTM standards.

8.4 Operational Inspection and Testing.

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

8.4.6 Transfer switches shall be operated monthly.

8.4.6.1 The monthly test of a transfer switch shall consist of
electrically operating the transfer switch from the standard position
to the alternate position and then a return to the standard
position.

7.2.4* Minimizing the possibility of damage resulting from interruptions
of the emergency source shall be a design consideration
for EPSS equipment.

A.7.2.4 When installing the EPSS equipment and related
auxiliaries, environmental considerations should be given,
particularly with regard to the installation of the fuel tanks
and exhaust lines, or the EPS building, or both.
To protect against disruption of power in the facility, it is recommended
that the transfer switch be located as close to the load
as possible. The following are examples of external influences:
(1) Natural conditions
(a) Storms
(b) Floods
(c) Earthquakes
(d) Tornadoes
(e) Hurricanes
(f) Lightning
(g) Ice storms
(h) Wind
(i) Fire
(2) Human-caused conditions
(a) Vandalism
(b) Sabotage
(c) Other similar occurrences
(3) Material and equipment failures
For natural conditions, EPSS design should consider the
"100-year storm" flooding level or the flooding level predicted
by the Sea, Lake, and Overland Surges from Hurricanes