HospitalInspections.org

Based on observation, the facility failed to maintain its doors. This was evidenced by two doors that failed to latch. This affected one of eight smoke compartments in the Hospital and could result in the inability to contain a fire to a room.

Findings:

During a tour of the facility with staff, the doors were observed.

Hospital

1. On 7/14/14 at 10:05 a.m., the self-closing door to Surgery Room 301 failed to positive latch.

2. On 7/14/14 at 10:16 a.m., the self-closing door to the General Storage Room 384 failed to positive latch.

Based on observation, the facility failed to protect the hazardous areas. This was evidenced by a door to the hazardous area enclosure that was not equipped with a self-closing device. This affected one of eight smoke compartments in the Hospital and could result in the increased potential for the spread of fire and/or smoke to other areas of the facility.

NFPA 101, 2000
19.3.2.1 states that any hazardous areas shall have smoke-resisting doors that are self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.

Findings:

During a tour of the facility with staff, the hazardous areas were observed.

Hospital

On 7/14/14 at 10:11 a.m., the Soiled Linen Closet Room 326 was not equipped with a self-closing device.

Based on observation, testing, document review, and interview, the facility failed to provide and maintain the emergency battery back-up lights. This was evidenced by the failure to provide two battery back-up lights in the operation rooms (OR), two battery back-up lights that failed to illuminate and three battery back-up lights that were not tested for 30 seconds monthly and 90 minutes test annually. This affected two of eight smoke compartments in the Hospital and one of one smoke compartment in the Specialty Clinic, and could result in a delay in evacuation in the event of a power outage.

NFPA 101, 2000
19.2.9 Emergency Lighting
Emergency lighting shall be provided in accordance with section 7.9
19.3.2.3 Anesthetizing Locations. Anesthetizing locations shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.
39.2.10 Marking of Means of Egress. Means of egress shall have signs in accordance with Section 7.10.
7.10.5.2 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.
7.10.9.2 Exit signs connected to or provided with a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.
7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. A annual test shall be be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

NFPA 99, 1999
3-3.2.1.2, All Patient Care Areas. (5) Wiring in Anesthetizing Locations
(e) Battery-powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12(e).

Findings:

During tour, testing, document review, and interview with staff, the emergency battery back-up lights were observed and tested, and documents were requested.

Hospital

1. On 7/14/14 at 10 a.m., there was no battery back-up light installed in OR Room 310. OR Room 310 was used for endoscopy procedures.

2. On 7/14/14 at 10:01 a.m., there was no battery back-up light installed in OR Room 308. OR Room 308 was used for surgery procedures.

3. On 7/14/14 at 1:10 p.m., a battery back-up light was observed in the Generator Room. There was no documentation provided to show that the emergency battery back-up light was tested for 30 seconds monthly and 90 minutes annually. At 1:15 p.m., Staff 1 stated that the facility did not have an emergency battery back-up light testing log.

Specialty Clinic

4. On 7/15/14 at 11:43 a.m., the battery back-up light near the Women Restroom failed to illuminate when the test button was pressed.

5. On 7/15/14 at 11:51 a.m., the battery back-up light near the Medical Records File Room failed to illuminate when the test button was pressed.

6. On 7/15/14 at 1:45 p.m., there was no documentation provided to show that the emergency battery back-up lights were tested for 30 seconds monthly and 90 minutes test annually. At 1:46 p.m., Staff 1 stated that the facility did not have an emergency battery back-up light testing log.

Based on observation, testing, document review, and interview, the facility failed to maintain its emergency exit signs. This was evidenced by six exit signs that failed to illuminate and were not tested for 30 seconds monthly and 90 minutes annually. This affected one of one smoke compartment in the Specialty Clinic, and could result in a delay in evacuation in the event of a power outage.

NFPA 101, 2000
39.2.10 Marking of Means of Egress. Means of egress shall have signs in accordance with Section 7.10.
7.10.5.2 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.
7.10.9.2 Exit signs connected to or provided with a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.
7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. A annual test shall be be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Findings:

During tour, testing, document review, and interview with staff, the emergency exit signs were observed and tested, and documents were requested.

Specialty Clinic

1. On 7/15/14 at 11:40 a.m., the exit sign near Room 8 was equipped with a battery back-up. The exit sign failed to illuminate when the test button was pressed.

2. On 7/15/14 at 11:41 a.m., the exit sign near the Doctor Office was equipped with a battery back-up. The exit sign failed to illuminate when the test button was pressed.

3. On 7/15/14 at 11:42 a.m., the exit sign near Room 1 was equipped with a battery back-up. The exit sign failed to illuminate when the test button was pressed.

4. On 7/15/14 at 11:51 a.m., the exit sign near the Entry Door was equipped with a battery back-up. The exit sign failed to illuminate when the test button was pressed.

5. On 7/15/14 at 11:52 a.m., the exit sign near the Check Out Center was equipped with a battery back-up. The exit sign failed to illuminate when the test button was pressed.

6. On 7/15/14 at 11:57 a.m., the exit sign in the Lobby was equipped with a battery back-up. The exit sign failed to illuminate when the test button was pressed.

At 1:45 p.m., there was no documentation provided showing that the exit signs were tested for 30 seconds monthly and 90 minutes annually. At 1:46 p.m., Staff 1 stated that the facility did not have an emergency exit sign testing log.

Based on document review and interview, the facility failed to ensure that fire drills were conducted one per shift per quarter. This was evidenced by one missing fire drill. This affected eight of eight smoke compartments in the Hospital, and could result in potential harm to all patients should staff members be untrained and unaware of their roles and responsibilities during a fire.

NFPA 101, 2000
19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency of 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.
Exception: Infirm or bedridden patients shall not be required to be
moved during drills to safe areas or to the exterior of the building.

Findings:

During document review and interview with staff, the fire drill documents were requested.

Hospital

On 7/14/14 at 12:50 p.m., the facility had two shifts for the fire drills. The log indicated that one of two fire drills was missing for the fourth quarter 2013. At 1 p.m., Staff 1 stated that he could not locate the missing fire drill.

Based on testing, the facility failed to maintain the fire alarm system. This was evidenced by a delay in the audible alarm when a device was activated and by a chime that failed to emit an audible sound. This affected one of eight smoke compartments in the Hospital and could potentially result in a delay in notifying the building occupants in the event of a emergency.

NFPA 101, 2000
19.3.4.3.1 Occupant Notification. Occupant notification shall be provided automatically, without delay, by internal audible alarm in accordance with 9.6.3
9.6.34 Where permitted by Chapter 11 through Chapter 42, a possible alarm sequence shall be permitted, provided that it is in accordance with NFPA 72, National Fire Alarm Code.
9.6.3.8 Audible alarm notification appliances shall be of such character and so distributed as to be effectively heard above the average ambient sound level occurring under normal conditions of the occupancy.

NFPA 72, 1999
1-5.4.2.2. Effective on January 1, 2002, actuation of alarm notification appliances or emergency voice communications and annunciation at the protected premises shall occur within 10 seconds after the activation of an initiating device.

Findings:

During testing with staff, the fire alarm devices and components were observed.

Hospital

1. On 7/14/14 between 11:11 a.m. and 11:21 a.m., four pull stations were tested. One of four pull stations that was activated did not alarm within ten seconds. The pull station in Labor and Delivery near Room 271 took approximately 16.4 seconds to activate the chime. The pull station was tested twice.

2. On 7/14/14 at 11:15 a.m., the chime in the Labor and Delivery near Room 28A failed to emit an audible sound when the pull station was activated.

Based on document review and interview, the facility failed to ensure that all fire alarm devices are tested annually. This was evidenced by incomplete testing records for the annual fire alarm inspection report. This affected eight of eight smoke compartments in the Hospital and could result in a delay in notification in the event of a fire.

NFPA 101, 2000
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system 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 NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

NFPA 72, 1999
1-6.3 Records. A complete, unalterable record of the tests and operations of each system shall be kept until the next test and for 1 year thereafter. The record shall be available for examination and, if required, reported to the authority having jurisdiction. Archiving of records by any means shall be permitted if hard copies of the records can be provided promptly when requested.
Exception: If off-premises monitoring is provided, records of all signals,
tests, and operations recorded at the supervising station shall be
maintained for not less than 1 year.

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)

7-5.3 For supervising station fire alarm systems, records pertaining to signals received at the supervising station that result from maintenance, inspection, and testing, shall be maintained for not less than 12 months. Upon request, a hard copy record shall be provided to the authority having jurisdiction. Paper or electronic media shall be permitted
Table 7-3.2 Testing Frequencies
a. Duct Detectors - test annually

Findings:

During document review and interview with staff, the annual fire alarm inspection report was reviewed.

Hospital

On 7/15/14 at 9:40 a.m., documentation titled, "Inspection and Testing Form," dated 4/14/14 was incomplete. At 9:45 a.m., Staff 1 stated that the facility had ten duct detectors and zero heat detectors. A review of the inspection report on page three of four under the initiating and supervisory device test and inspection section, indicated that smoke, heat, waterflow, tampers, pulls, and doors were tested. There was no indications that duct detectors were tested. A review of the attached device sheets indicated that 36 smoke detectors, two waterflows, 16 pull stations, and nine doors were tested. There was no indication that the heat detector and the duct detectors were tested. At 10 a.m., Staff 1 stated that the facility did not have an inventory list for the total number of fire alarm devices.

Based on document review and interview, the facility failed to maintain its smoke detectors. This was evidenced by the failure to have the smoke detectors tested for sensitivity. This affected one of one smoke compartment at the Specialty Clinic and could result in delayed notification of a fire due to a malfunctioning smoke detector.

NFPA 101, 2000
39.3.4.2 Initiation. Initiation of the required fire alarm system shall be by manual means in accordance with 9.6.2.1(1).
Exception No. 1: Initiation shall be permitted by means of an approved
automatic fire detection system in accordance with 9.6.2.1(2)
that provides protection throughout the building.
Exception No. 2: Initiation shall be permitted by means of an approved
automatic sprinkler system in accordance with 9.6.2.1(3) that
provides protection throughout the building.
9.6.2.8 Where a complete smoke detection system is required by another section of this Code, automatic detection of smoke in accordance with NFPA 72, National Fire Alarm Code, shall be provided in all occupiable areas, common areas, and work spaces in those environments suitable for proper smoke detector operation.

NFPA 72, 1999 edition
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.
Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and table 7-2.2.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

Findings:

During document review and interview with staff, the smoke detector sensitivity report was requested.

Specialty Clinic

On 7/15/14 at 1:40 p.m., there were no records provided that indicated that the facility had its smoke detectors tested for smoke sensitivity. The last smoke detector sensitivity test was unknown. At 1:45 p.m., Staff 1 stated the Specialty Clinic did not have a smoke detector sensitivity report.

Based on testing, document review, and interview, the facility failed to ensure that its automatic sprinkler system valves were supervised so that at least a local alarm would sound when the valve was closed. This was evidenced by a post indicator valve (PIV) which did not have a supervisory switch to initiate an alarm at a 24 hour staffed location when closed. This affected eight of eight smoke compartments in the Hospital, and could potentially result in staff not being notified in the event that the automatic sprinkler system water supply is shut off.

NFPA 101, 2000
19.3.5.2* Where this Code permits exceptions for fully sprinkler
buildings or smoke compartments, the sprinkler system shall meet the following criteria:
(1) It shall be in accordance with Section 9.7.
(2) It shall be electrically connected to the fire alarm system.
(3) It shall be fully supervised.
Exception: In Type I and Type II construction, where approved by the
authority having jurisdiction, alternative protection measures shall be
permitted to be substituted for sprinkler protection in specified areas
where the authority having jurisdiction has prohibited sprinklers,
without causing a building to be classified as nonsprinklered.
9.7.2.1* Supervisory Signals. Where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.
NFPA 72, 1999
1-5.4.4 Distinctive Signals. Fire alarms, supervisory signals, and trouble signals shall be distinctively and descriptively annunciated.
3-8.3.3.1 General. The provisions of 3-8.3.3 shall apply to the monitoring of sprinkler systems, other fire suppression systems, and other systems for the protection of life and property for the initiation of a supervisory signal indicating an off-normal condition that could adversely affect the performance of the system.

Findings:

During testing, document review, and interview with staff, the PIV was tested and documents were requested.

Hospital

1. On 7/14/14 at 10:56 a.m., the locked PIV was located approximately 200 feet south of the overflow parking lot. The PIV was closed and there was no tamper alarm and/or supervisory signal initiated at the notifier panel at the Nurses Station or at the main fire alarm panel in the Penthouse. At 11 a.m., Staff 1 stated that the PIV would not send a local alarm nor was it monitored. He further indicated the project was currently under the Office of Statewide Health Planning and Development (OSHPD).

2. On 7/14/14 at 1 p.m., a review of the event summary of the test conducted did not indicate the PIV signal was received. A review of the OSHPD building permit application indicated that the facility had wanted to add a wireless supervisory device to the PIV. At 1:30 p.m., Staff 2 stated that the wireless PIV monitoring device did not work; therefore, the project would be ongoing. The OSHPD PIV monitor project number was S140683-06-00. Staff 2 stated that the facility was currently making daily inspections of the locked PIV until the OSHPD project was completed.

Based on observation, document review, and interview, the facility failed to maintain the integrity of the automatic sprinkler system and components. This was evidenced by sprinkler heads that were painted and two missing waterflow tests for two inspector test valves (ITV). This affected eight of eight smoke compartments in the Hospital, and could result in the ineffective operation of the automatic sprinkler system in the event of a fire.

NFPA 101, 2000
19.7.6 Maintenance and Testing (see 4.6.12)
4.6.12 Maintenance and Testing. Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provision of this code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction

NFPA 25, 1998
1-8*. Records of inspections, tests, and maintenance of the system and its components shall be made available to the authority having jurisdiction upon request. Typical records include, but are not limited to, valve inspections; flow, drain, and pump tests; and trip tests of dry pipe, deluge, and pre-action valves.
1-8.1 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.
2-1. The minimum requirements for annual routine inspection, testing, and maintenance of sprinkler systems shall conform to Table 2-1 that shall be used to determine the system components to be tested and the minimum required frequencies for inspection, testing, and maintenance.
2-2.1.1*. Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.
2-2.6 Alarm Devices. Alarm devices shall be inspected quarterly to verify that they are free of physical damage.
2-3.3* Alarm Devices. 2 Waterflow alarm devices including,but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.

NFPA 13, 1999
3-2.6.3 Unless applied by the manufacture, sprinklers shall not be painted, and any sprinklers that have been painted shall be replaced with new listed sprinklers of the same characteristics, including orifice size, thermal response, and water distribution.

Findings:

During tour, document review, and interview, the sprinkler heads were observed and documents were requested.

Hospital

1. On 7/14/14 at 10:05 a.m., the sprinkler head in Cabinet 2 was observed with paint on seven spokes of the deflector plate in the Surgery Department.

2. On 7/14/14 at 10:06 a.m., the sprinkler head in Cabinet 3 was observed with paint that completely covered the deflector plate in the Surgery Department.

3. On 7/14/14 at 10:10 a.m., the sprinkler head in the Soil Linen Closet was observed with paint that completely covered the deflector plate in the Surgery Department.

4. On 7/14/14 at 2:25 p.m., the facility has two inspector test valves (ITV). The ITV were located in the Administrative Conference Room and an outside Storage Room. The facility failed to provide two 2013 fourth quarter sprinkler test reports. At 2:40 p.m., Staff 1 stated that the vendor did not come out for the fourth quarter 2013.

Based on observation, document review, and interview, the facility failed to comply with the regulations regarding portable space heating devices. This was evidenced by the failure to follow the manufacturer's specifications and to test the portable space heaters to insure that they do not exceed 212 degrees fahrenheit. This affected one of eight smoke compartments in the Hospital and could result in the ignition of fire.

NFPA 101, 2000
19.5.1 Utilities. Utilities shall comply with the provisions of section 9.1
9.1.2 Electric. Electrical wiring and equipment shall be in
accordance with NFPA 70, National Electrical Code, unless existing
installations, which shall be permitted to be continued in
service, subject to approval by the authority having jurisdiction.

19.7.6 Maintenance and Testing (see 4.6.12)
4.6.12 Maintenance and Testing. Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provision of this code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

NFPA 70, 1999
110-3 Examination, Identification, Installation and use of Equipment
(b) Installation and use. Listed or labeled equipment shall be installed and used in accordance with any instructions included in the listing or labeling.

NFPA 99, 1999
2-1 Labeled. Equipment or materials to which has been attached a label, symbol, or other identifying mark of an organization that is acceptable to the authority having jurisdiction and concerned with product evaluation, that maintains periodic inspection of production of labeled equipment or materials, and by whose labeling the manufacturer indicates compliance with appropriate standards or performance in a specified manner.
9-2.1.8.1 Manuals. The manufacturer of the appliance shall furnish operator's maintenance, and repair manuals with all units. These manuals shall include operating instructions, maintenance details, and testing procedures. The manuals shall include the following where applicable:
(d) Step-by-step procedures for proper use of the appliance
(e) Safety considerations in application and in servicing.

Findings:

During tour, document review, and interview with staff, the portable space heaters were observed and documents were requested.

Hospital

1. On 7/14/14 at 9:16 a.m., a portable space heater was observed underneath a desk. The heater was plugged into a power strip, in Cubicle 4 in the Business Office.

2. On 7/14/14 at 9:18 a.m., a portable space heater was observed underneath a desk. The heater was plugged into a power strip in Cubicle 3 in the Business Office.

3. On 7/14/14 at 9:19 a.m., a portable space heater was observed underneath a desk. The heater was plugged into a power strip in Cubicle 2 in the Business Office.

There was no documentation provided showing inspection or testing of the portable space heaters to insure that they did not exceed the maximum temperature requirement. The manufacturer's specification indicated under operation, "insert the plug into a suitable wall outlet," and under the warning label it indicated, "to always unplug the unit when not in use." Staff 2 stated that the heaters were not acceptance tested to make sure that the portable space heaters did not exceed 212 degree.

Based on document review and interview, the facility failed to provide a written policy for relative humidity (RH). This was evidenced by no written policy electing to use the categorical waiver to maintain the RH between 20-60 percent. This affected one of eight smoke compartments in the Hospital and could result in an increased risk of fire.

S&C 13-25, Relative Humidity (RH). Waiver of Life Safety Code (LSC) Anesthetizing Location Requirements. This letter permit new and existing ventilation systems supplying hospital and critical access hospital (CAH) anesthetizing locations to operate with a RH at 20 percent, instead of 35 percent. Hospitals and CAH facilities are expected to have written documentation that they have elected to use the waiver. At the entrance conference for any survey assessing the LSC compliance, a facility that has elected to use this waiver must notify the survey team.

Findings:

During document review and interview, the RH policy was requested.

Hospital

On 7/15/14 at 9:10 a.m., the facility failed to provide a written policy electing to use the categorical waiver to maintain the RH between 20-60 percent. At 9:15 a.m., Staff 1 stated that the facility did not have a written policy to maintain the RH between 20-60 percent.

Based on observation, the facility failed to maintain its electrical wiring and connections. This was evidenced by the use of extension cords, power strips chained together, suspended power strips, and power strips mounted on walls. This affected three of eight smoke compartments in the Hospital and could result in an increased risk of an electrical fire.

NFPA 101, 2000
19.5.1 Utilities. Utilities shall comply with the provisions of section 9.1
9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 70, 1999
110-12 Mechanical Execution of Work. Electrical equipment shall be installed in a neat and workmanlike manner.
(c) Integrity of Electrical Equipment and Connections. Internal parts of electrical equipment, including busbars, wiring terminals, insulators, and other surfaces, shall not be damaged or contaminated by foreign materials such as paint, plaster, cleaners, abrasives, or corrosive residues. There shall be no damaged parts that may adversely affect safe operation or mechanical strength of the equipment such as parts that are broken; bent; cut; or deteriorated by corrosion, chemical action, or overheating.
210-23 In no case shall the load exceed the branch-circuit ampere rating. An individual branch circuit shall be permitted to supply any load for which it is rated. A branch circuit supplying two or more outlets or receptacles shall supply only the loads specified according to its size as specified in (a) through (d) and as summarized in Section 210-24. A 15 or 20-ampere branch circuit shall be permitted to supply lighting units or other utilization, or a combination of both. The rating of any one cord and plug-connected utilization equipment shall not exceed 80 percent of the branch-circuit ampere rating. The total rating of utilization equipment fastened in place, other than lighting fixtures, shall not exceed 50 percent of the branch circuit ampere rating where lighting units, cord and plug-connected utilization equipment not fastened in place, or both, are also supplied.
400-8 Unless specifically permitted in Section 400-7, flexible cord and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors.
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code.
400-10. Flexible cords and cables shall be connected to devices and to fittings so that tension will not be transmitted to joints or terminals.
406.6 Receptacle Faceplates (Cover Plates). Receptacle faceplates shall be installed so as to completely cover the opening and seat against the mounting surface. Receptacle faceplates mounted inside a box having a
recess-mounted receptacle shall effectively close the opening and seat against the mounting surface.

Findings:

During a tour of the facility with staff, the electrical wiring and connections were observed.

Hospital

1. On 7/14/14 at 9:13 a.m., a power strip was suspended off the floor with items plugged into it near Cubicle 1 in the Business Office.

2. On 7/14/14 at 9:14 a.m., a bundle of wire was observed inside a junction box. The junction box was missing a cover plate near Cubicle 2 in the Business Office.

3. On 7/14/14 at 9:15 a.m., a water dispensing machine was plugged into a power strip near Cubicle 3 in the Business Office.

4. On 7/14/14 at 9:17 a.m., a black extension cord was plugged into a power strip near Cubicle 6 in the Business Office.

5. On 7/14/14 at 9:19 a.m., a black extension cord was plugged into a power strip near Cubicle 3 in the Business Office.

6. On 7/14/14 at 9:20 a.m., a mounted power strip was connected to another power strip that was suspended off the floor with items plugged into it in the Gift Shop.

7. On 7/14/14 at 9:21 a.m., a microwave machine was plugged into a power strip in the Intensive Care Unit (ICU).

8. On 7/14/14 at 9:30 a.m., a hearing screen machine was plugged into a power strip in the Maternity Neonatal Intensive Care Unit (NICU).

9. On 7/14/14 at 9:40 a.m., an IV pump machine was plugged into a power strip that was mounted on the wall near Labor and Delivery Room 28B.

10. On 7/14/14 at 9:50 a.m., a mounted power strip was connected to another power strip, in the Emergency (ER) Department.

11. On 7/14/14 at 9:55 a.m., a microwave and a toaster were plugged into a power strip in the Lab Break Room.

12. On 7/14/14 at 10:05 a.m., a refrigerator was plugged into a power strip that was mounted on the wall in Room 378, adjacent to the ER Office.

13. On 7/14/14 at 10:20 a.m., a microwave was plugged into a three plug adapter in the X-Ray Department.

14. On 7/14/14 at 10:22 a.m., a water dispenser was plugged into a power strip in the Administrative Office.

Based on document review and interview, the facility failed to provide a written protocol to ensure that if the automatic sprinkler system was out of service for four or more hours in a 24 hour period that the authority having jurisdiction (AHJ) would be notified. This was evidenced by a lack of documentation and staff knowledge for this requirement. This affected eight of eight smoke compartments in the Hospital and could potentially result in the AHJ being unable to exercise oversight in the event of an automatic sprinkler system shut down.

NFPA 101, 2000
19.3.5.1 Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
Exception: In Type I and Type II construction, where approved by the
authority having jurisdiction, alternative protection measures shall be
permitted to be substituted for sprinkler protection in specified areas
where the authority having jurisdiction has prohibited sprinklers,
without causing a building to be classified as nonsprinklered.

Findings:

During document review and interview with staff, the automatic sprinkler system fire watch policy was reviewed.

Hospital

On 7/14/14 at 1:50 p.m., the documentation provided for an approved fire watch for the automatic sprinkler system did not include guidance for the notification of the Department of Public Health if the automatic sprinkler system was out of service for four or more hours in a 24 hour period. At 1:51 p.m., Staff 1 stated that the facility was unaware of the requirement.

Based on document review and interview, the facility failed to provide a written protocol to ensure that if the fire alarm system was out of service for four or more hours in a 24 hour period that the authority having jurisdiction (AHJ) would be notified. This was evidenced by a lack of documentation and staff knowledge for this requirement. This affected eight of eight smoke compartments in the Hospital and could potentially result in the AHJ being unable to exercise oversight in the event of a fire alarm system shut down.

NFPA 101, 2000
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.

Findings:

During document review and interview with staff, the fire alarm system fire watch policy was reviewed.

Hospital

On 7/14/14 at 1:50 p.m., the documentation provided for an approved fire watch for the fire alarm system did not include guidance for the notification of the Department of Public Health if the fire alarm system was out of service for four or more hours in a 24 hour period. At 1:51 p.m., Staff 1 stated that the facility was unaware of the requirement.