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Based on observation and facility staff interview, facility staff failed to provide emergency lighting not controlled by light switches. This deficient practice has the potential to affect all patients, staff and visitors within the facility. Failure to provide emergency lighting could prevent proper illumination of required areas in the event of power loss. This facility census was 75.

1. Observations on 9/18-19/19, during the Life Safety Code (LSC) tour, showed the following nurse's stations with medication refrigerators and medication carts containing light fixtures in the facility controlled by light switches:

- 4 North medication area at the nurse's station,

- 3 South medication area at the nurse's station,

- 3 North medication area at the nurse's station,

- 4 South medication area at the nurse's station.

Observations showed the medication distribution was conducted from each nurse's station.

During an interview on 9/18/2019 at 2:40 P.M., the Director of Plant Operations said the facility staff was unaware of the task illumination requirements.

NFPA 99, 2012 edition, section 6.4.2.2.4.2 states:

"6.4.2.2.4.2 The critical branch shall supply power for task illumination,
fixed equipment, select receptacles, and select power
circuits serving the following areas and functions related to patient
care:
(1) Critical care areas that utilize anesthetizing gases, task illumination,
select receptacles, and fixed equipment
(2) Isolated power systems in special environments
(3) Task illumination and select receptacles in the following:
(a) Patient care rooms, including infant nurseries, selected
acute nursing areas, psychiatric bed areas (omit receptacles),
and ward treatment rooms
(b) Medication preparation areas
(c) Pharmacy dispensing areas
(d) Nurses ' stations (unless adequately lighted by corridor
luminaires)
(4) Additional specialized patient care task illumination and
receptacles, where needed
(5) Nurse call systems
(6) Blood, bone, and tissue banks
(7)*Telephone equipment rooms and closets
(8) Task illumination, select receptacles, and select power circuits
for the following areas:
(a) General care beds with at least one duplex receptacle
per patient bedroom, and task illumination as required
by the governing body of the health care facility
(b) Angiographic labs
(c) Cardiac catheterization labs
(d) Coronary care units
(e) Hemodialysis rooms or areas
(f) Emergency room treatment areas (select)
(g) Human physiology labs
(h) Intensive care units
(i) Postoperative recovery rooms (select)
(9) Additional task illumination, receptacles, and select power
circuits needed for effective facility operation, including
single-phase fractional horsepower motors, which are permitted
to be connected to the critical branch"

Based on observation and facility staff interview, the facility staff failed to ensure the range hood was maintained in accordance with National Fire Protection Association standards. The range hood did not have a grease removal drip tray. Failure to provide a grease removal drip tray has the potential to affect all building occupants in the event of a fire. The facility census was 75.

Observation during the Life Safety Code (LSC) tour on 9/19/2019 did not show a grease removal drip tray attached to the range hood.

During an interview on 9/19/2018 at 2:41 P.M., the Director of Plant Operations stated facility staff was unaware of the grease collection tray requirements.

National Fire Protection Association (NFPA) 96, 2011 edition states:


6.2.4 Grease Drip Trays.

6.2.4.1 Grease filters shall be equipped with a grease drip tray
beneath their lower edges.

6.2.4.2 Grease drip trays shall be kept to the minimum size
needed to collect grease.

6.2.4.3 Grease drip trays shall be pitched to drain into an enclosed
metal container having a capacity not exceeding 3.8 L
(1 gal).

Based on observation, record review and facility staff interview, the facility staff did not ensure interior wall finishes met Class A or Class B flame spread requirements. The facility census was 75.

Observations on 9/19/2019, during the facility tour, showed the following areas contained painted, unrated 1/2 inch thick plywood wall covering:

-4 South seclusion room contained a 4 feet by 12 feet section of plywood wall covering,

-4 South patient rooms #422 & #416 contained a plywood window surround wall covering,

-4 North seclusion room contained a 6 feet by 8 feet section of plywood window wall covering,

-3 South designated exit corridor wall covering extending from patient room #329 down the corridor towards patient room #325,

-3 South seclusion room contained a plywood wall covering surrounding the window,


Record review did not show flame spread ratings for the 1/2 inch thick plywood.

During an interview on 9/19/2019 at 2:35 P.M., the Director of Plant Operations said the facility believed the plywood met flame spread requirements for a partially sprinklered building.

19.3.3.2* Interior Wall and Ceiling Finish. Existing interior
wall and ceiling finish materials complying with Section 10.2
shall be permitted to be Class A or Class B.

10.2.8 Automatic Sprinklers.
10.2.8.1 Other than as required in 10.2.4, where an approved
automatic sprinkler system is installed in accordance with Section
9.7, Class C interior wall and ceiling finish materials shall
be permitted in any location where Class B is required, and
Class B interior wall and ceiling finish materials shall be permitted
in any location where Class A is required.

10.2.5 Trim and Incidental Finish.
10.2.5.1 General. Interior wall and ceiling trim and incidental
finish, other than wall base in accordance with 10.2.5.2 and
bulletin boards, posters, and paper in accordance with
10.2.5.3, not in excess of 10 percent of the aggregate wall and
ceiling areas of any room or space shall be permitted to be
Class C materials in occupancies where interior wall and ceiling
finish of Class A or Class B is required.

Based on observation and facility staff interview, facility staff failed to ensure areas open to the corridor contain smoke detection
per NFPA 72, National Fire Alarm and Signaling Code, 2010 edition. This deficient practice has the potential to effect all facility patients, staff and visitors. This deficient practice could delay fire and emergency personnel response in the event of a fire. The facility census was 75.

Observations on 9/19/2019, during the facility tour, showed the 4 North nurse's station open to the designated exit corridors requiring smoke detection. Observation did not show a smoke detector within the nurse's station.

During an interview on 9/19/2019 at 2:20 P.M., the Director of Plant Operations said he/she believed the fire alarm inspection company installed the fire alarm system per code requirements.

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

Refer to NFPA 72, National Fire Alarm and Signaling Code, 2010 edition, sections 17.6.3 Location and Spacing and 17.6.3.3.1 Spacing for additional information.

Based on observation, record review and facility staff interview, the facility staff failed to ensure the sprinkler supervisory alarms were installed and monitored per NFPA 72, National Fire Alarm and Signaling Code, 2010 edition. The facility census was 75.


Observations on 9/19/2019, during the facility tour, showed the following sprinkler system control valves connected to the facility sprinkler system water supply in the hospital without electronic supervision:

-East stairwell 2nd floor landing,

-South stairwell 2nd floor landing.


Record review of the annual fire alarm inspection dated 11/07/2018 did not show a connection function test for the sprinkler system control valves located on the East stairwell 2nd floor landing or the South stairwell 2nd floor landing.

During an interview on 9/19/2019 at 2:15 P.M., the Director of Plant Operations said the facility believed the sprinkler installation company installed the sprinkler system per code requirements.

NFPA 101, 2012 edition, Section 9.7.2 states:

"9.7.2 Supervision.

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 and
Signaling Code, and a distinctive supervisory signal shall be provided
to indicate a condition that would impair the satisfactory
operation of the sprinkler system. 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."


Please refer to NFPA 72, 2010 ed. Table 14.4.5 (15L), Table 14.4.2.2 (14I) for testing requirements.

Based on record review, facility staff failed to inspect the one wet sprinkler system per NFPA 25, Standard for the Inspection, Testing, and maintenance of Water-Based Fire Protection Systems, 2011 edition. The facility census was 75.

1) Record review on 9/18/2019 did not show the following inspections:

-five (5) year internal pipe inspections/testing for the one wet sprinkler system and one dry pipe system (Chapter 14);

-five year check valve/backflow interior inspections for the west stairwell 1st floor check valve, 1st floor landing FDC check valve and the 2nd floor landing check valve;

-annual backflow inspections for the west stairwell 1st floor check valve, 1st floor landing FDC check valve and the 2nd floor landing check valve;

During an interview on 9/19/2019 at 2:15 P.M., the Director of Plant Operations said he/she believed the sprinkler inspection company inspected the sprinkler system per code requirements.

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.

13.4.2 Check Valves.
13.4.2.1 Inspection. Valves shall be inspected internally every
5 years to verify that all components operate correctly, move
freely, and are in good condition.


13.4 System Valves.
13.4.1 Inspection of Alarm Valves. Alarm valves shall be inspected
as described in 13.4.1.1 and 13.4.1.2.


13.4.1.2* Alarm valves and their associated strainers, filters,
and restriction orifices shall be inspected internally every
5 years unless tests indicate a greater frequency is necessary.

13.7 Fire Department Connections.
13.7.1 Fire department connections shall be inspected quarterly
to verify the following:
(1) The fire department connections are visible and accessible.
(2) Couplings or swivels are not damaged and rotate
smoothly.
(3) Plugs or caps are in place and undamaged.
(4) Gaskets are in place and in good condition.
(5) Identification signs are in place.
(6) The check valve is not leaking.
(7) The automatic drain valve is in place and operating properly.
(8) The fire department connection clapper(s) is in place
and operating properly.


5.3.2* Gauges.
5.3.2.1 Gauges shall be replaced every 5 years or tested every
5 years by comparison with a calibrated gauge.

Based on record review and facility staff interview, the facility staff failed to provide completed fundamental risk assessments and formally documented risk assessment procedures for all building systems categories are determined by a performed by qualified personnel. Failure to have the building systems risk assessments completed puts patients at risk for a potential negative outcome if category one systems (Category 1 system in which a failure of such equipment or system is likely to cause major injury or death of patients or caregivers) fail with no plan on how to respond if the system fails. The facility census was 75.


1. Review of the facility documents for fire safety, building system tests, and policies did not show how the categorical risk assessment scores for the building systems were determined.

2. During an interview on 9/30/2019 at 8:54 A.M., the Director of Plant Operations said he/she believed the hospital determined the categorical risk assessment scores per code requirements.

The National Fire Protection Association 99 Health Care Facilities Code, 2012 edition, Chapter 4 states:

"Chapter 4 Fundamentals

4.1* Building System Categories. Building systems in health
care facilities shall be designed to meet system Category 1
through Category 4 requirements as detailed in this code.

4.1.1* Category 1. Facility systems in which failure of such equipment
or system is likely to cause major injury or death of patients
or caregivers shall be designed to meet system Category 1 requirements
as defined in this code.

4.1.2* Category 2. Facility systems in which failure of such equipment
is likely to cause minor injury to patients or caregivers shall
be designed to meet system Category 2 requirements as defined
in this code.

4.1.3 Category 3. Facility systems in which failure of such equipment
is not likely to cause injury to patients or caregivers, but can
cause patient discomfort, shall be designed to meet system Category
3 requirements as defined in this code.

4.1.4 Category 4. Facility systems in which failure of such equipment
would have no impact on patient care shall be designed to
meet system Category 4 requirements as defined in this code.

4.2* Risk Assessment. Categories shall be determined by following
and documenting a defined risk assessment procedure.

4.3 Application. The Category definitions in Chapter 4 shall
apply to Chapters 5 through 11."

A.4.2 Risk assessment should follow procedures such as those
outlined in ISO/IEC 31010, Risk Management-Risk Assessment
Techniques, NFPA 551, Guide for the Evaluation of Fire Risk Assessments,
Guide for the Evaluation of Fire Risk Assessments, SEMI S10-
0307E, Safety Guideline for Risk Assessment and Risk Evaluation
Process, or other formal process. The results of the assessment
procedure should be documented and records retained.

Based on observation and facility staff interview, the facility staff failed to provide a remote annunciator panel (a panel providing information on the condition and problems with the emergency generator) for one of one emergency generators at a constantly attended location. The census was 75.

1. Observation on 9/19/2019 during the facility tour, did not show a remote annunciator panel for the emergency generator in a constantly attended location.

During an interview on 9/19/2019 at 2:33 P.M., the Director of Plant Operations said the generator annunciator panel requirement was missed.

NFPA 99, 2012 edition, section 6.4.1.1.17 states:

"6.4.1.1.17 Alarm Annunciator. A remote annunciator that is
storage battery powered shall be provided to operate outside of
the generating room in a location readily observed by operating
personnel at a regular work station (see 700.12 of NFPA 70, National
Electrical Code). The annunciator shall be hard-wired to indicate
alarm conditions of the emergency or auxiliary power
source as follows:
(1) Individual visual signals shall indicate the following:
(a) When the emergency or auxiliary power source is operating
to supply power to load
(b) When the battery charger is malfunctioning
(2) Individual visual signals plus a common audible signal to
warn of an engine-generator alarm condition shall indicate
the following:
(a) Low lubricating oil pressure
(b) Low water temperature (below that required in
6.4.1.1.11)
(c) Excessive water temperature
(d) Low fuel when the main fuel storage tank contains
less than a 4-hour operating supply
(e) Overcrank (failed to start)
(f) Overspeed

6.4.1.1.17.1* A remote, common audible alarm shall be provided
as specified in 6.4.1.1.17.4 that is powered by the storage
battery and located outside of the EPS service room at a work
site observable by personnel. [110:5.6.6]

6.4.1.1.17.2 An alarm-silencing means shall be provided, and
the panel shall include repetitive alarm circuitry so that, after
the audible alarm has been silenced, it reactivates after the
fault condition has been cleared and has to be restored to its
normal position to be silenced again. [110:5.6.6.1]

6.4.1.1.17.3 In lieu of the requirement of 5.6.6.1 of NFPA110, a
manual alarm-silencing means shall be permitted that silences
the audible alarm after the occurrence of the alarm condition,
provided such means do not inhibit any subsequent alarms from
sounding the audible alarm again without further manual action.
[110:5.6.6.2]

6.4.1.1.17.4 Individual alarm indication to annunciate any of
the conditions listed in Table 6.4.1.1.16.2 shall have the following
characteristics:
(1) It shall be battery powered.
(2) It shall be visually indicated.
(3) It shall have additional contacts or circuits for a common
audible alarm that signals locally and remotely when any
of the itemized conditions occurs.
(4) It shall have a lamp test switch(es) to test the operation of
all alarm lamps.

6.4.1.1.17.5 Acentralized computer system (e.g., building automation
system) shall not be permitted to be substituted for
the alarm annunciator in 6.4.1.1.17 but shall be permitted to
be used to supplement the alarm annunciator.

6.4.1.2 Battery. Battery systems shall meet all requirements of
Article 700 of NFPA 70, National Electrical Code.


Table 6.4.1.1.16.2 Safety Indications and Shutdowns
Level 1
Indicator Function (at Battery Voltage) CV S RA
(a) Overcrank X X X
(b) Low water temperature X - X
(c) High engine temperature pre-alarm X - X
(d) High engine temperature X X X
(e) Low lube oil pressure pre-alarm X - X
(f) Low lube oil pressure X X X
(g) Overspeed X X X
(h) Low fuel main tank X - X
(i) Low coolant level X O X
(j) EPS supplying load X - -
(k) Control switch not in automatic
position
X - X
(l) High battery voltage X - -
(m) Low cranking voltage X - X
(n) Low voltage in battery X - -
(o) Battery charger ac failure X - -
(p) Lamp test X - -
(q) Contacts for local and remote
common alarm
X - X
(r) Audible alarm-silencing switch - - X
(s) Low starting air pressure X - -
(t) Low starting hydraulic pressure X - -
(u) Air shutdown damper when used X X X
(v) Remote emergency stop - X -
CV: Control panel-mounted visual. S: Shutdown of EPS indication.
RA: Remote audible. X: Required. O: Optional.
Notes:
(1) Item (p) shall be provided, but a separate remote audible signal shall
not be required when the regular work site in 5.6.6 of NFPA110, Standard
for Emergency and Standby Power Systems, is staffed 24 hours a day.
(2) Item (b) is not required for combustion turbines.
(3) Item (r) or (s) is required only where used as a starting method.
(4) Item (j): EPS ac ammeter shall be permitted for this function.
(5) All required CV functions shall be visually annunciated by a remote,
common visual indicator.
(6) All required functions indicated in the RAcolumn shall be annunciated
by a remote, common audible alarm as required in 5.6.5.2(4) of
NFPA 110.
(7) Item (i) requires a low gas pressure alarm on gaseous systems.
(8) Item (b) must be set at 11°C (20°F) below the regulated temperature
determined by the EPS manufacturer, as required in 5.3.1 of
NFPA 110."