HospitalInspections.org

Based on observation and interview, the hospital failed to install exit signage in the kitchen area. This failure had the potential to affect all hospital occupants that used the kitchen area. The hospital census was 10.

Observation during the Life Safety Code tour on 05/20/25 between 9:00 A.M. and 4:00 P.M., showed there were no exit signs located in the kitchen area to identify the route of exit in the event of an emergency.

During an interview on 05/21/25 at 10:20 A.M., Staff V, Maintenance Director, stated that he did not know why there were no exit signs in the kitchen area.

The National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, states:
- 7.10.2 Directional Signs.
- 7.10.2.1 A sign complying with 7.10.3, with a directional indicator showing the direction of travel, shall be placed in every location where the direction of travel to reach the nearest exit is not apparent.
- 7.10.2.2 Directional exit signs shall be provided within horizontal components of the egress path within exit enclosures as required by 7.10.1.2.2.

Based on interview and record review, the hospital staff failed to inspect and test the fire alarm system in accordance with the 2010 edition of NFPA 72 (National Fire Alarm and Signaling Code), when the staff failed to provide complete and verifiable documentation for 100 percent inspection and testing of the fire alarm system semi-annually. Failure to inspect and test the fire alarm system in accordance with the standard had the potential to prevent the proper function of the fire alarm system and delay response procedures in the event of an emergency. The hospital census was 10.

Review of the hospital's fire alarm system inspection, testing and maintenance records, dated May 2023 through May 2025, showed no documentation of a semi-annual fire alarm system inspection.

During an interview on 05/21/25 at 10:20 A.M., Staff V, Maintenance Director, stated that he was responsible for ensuring the fire alarm system was inspected as required and that he was unaware a semi-annual inspection was required.

Review of The National Fire Protection Association (NFPA) 72, 2010 edition, stated:
14.3.1* Unless otherwise permitted by 14.3.2 visual inspections shall be performed in accordance with the schedules in Table 14.3.1 or more often if required by the authority having jurisdiction.
14.4.5* Unless otherwise permitted by other sections of this Code, testing shall be performed in accordance with the schedules in Table 14.4.5, or more often if required by the authority having jurisdiction.

Based on observation, interview and record review, the hopsital staff failed to conduct monthly fire fighter operation testing. This failure had the potential to place all building occupants who used the elevators at risk for their safety. The hospital census was 10.

Observation during the Life Safety Code tour on 05/20/25 between 9:00 A.M. and 4:00 P.M., showed the hospital featured two passenger elevators that were equipped with fire fighter operation.

Review of the hospital's elevator inspection records showed no documentation of monthly fire fighter operation testing.

During an interview on 05/21/25 at 10:20 A.M., Staff V, Maintenance Director, state that he did not know that monthly fire fighter testing for the elevators was required.

Review of The National Fire Protection Association (NFPA) 101, 2012 edition, Section 9.4.6.1 showed elevators shall be subject to periodic inspections and tests as specified in ASME A17.1/CSA B44, Safety Code for Elevators and Escalators.

Based on observation, interview and record review, the hospital failed to ensure two of two operating rooms were equipped with Line Isolation Monitors (LIMs). This failure had the potential to affect all building occupants who used the operating rooms. The hospital census was 10.

Observation during the Life Safety Code tour on 05/20/25 between 9:00 A.M. and 4:00 P.M., showed the hospital featured two operating rooms.

Record review of the hopital's maintenance records showed no documentation of LIMs testing.

During interview on 05/21/25 at 10:20 A.M., Staff V, Maintenance Director, stated that the hospital had never had LIMs in the operating rooms and that he did not know why they had never been installed.

Review of the 2012 edition of The National Fire Protection Association (NFPA) 99, showed the following:
3.3.138* Patient Care Room. Any room of a health care facility wherein patients are intended to be examined or treated. (MED)
3.3.138.1* Basic Care Room. Room in which the failure of equipment or a system is not likely to cause injury to the patients or caregivers but can cause patient discomfort. (Category 3). (MED)
3.3.138.2* Critical Care Room. Room in which failure of equipment or a system is likely to cause major injury or death of patients or caregivers (Category 1). (MED)
3.3.138.3* General Care Room. Room in which failure of equipment or a system is likely to cause minor injury to patients or caregivers (Category 2). (MED)
3.3.138.4* Support Room. Room in which failure of equipment or a system is not likely to have a physical impact on patients or caregivers (Category 4). (MED)
6.4.1.1.4 Essential electrical systems shall have a minimum of the following two independent sources of power: a normal source generally supplying the entire electrical system and one or more alternate sources for use when the normal source is interrupted.
6.4.1.1.5 Where the normal source consists of generating units on the premises, the alternate source shall be either another generating set or an external utility service.
6.4.1.1.6 General. Generator sets installed as an alternate source of power for essential electrical systems shall be designed to meet the requirements of such service.
NFPA 70 (NEC):
Patient Bed Location. The location of a patient sleeping bed, or the bed or procedure table of a critical care area. [99:3.3.137]

517.19 Critical Care Areas.
(A) Patient Bed Location Branch Circuits. Each patient bed location shall be supplied by at least two branch circuits, one or more from the emergency system and one or more circuits from the normal system. At least one branch circuit from the emergency system shall supply an outlet(s) only at that bed location. All branch circuits from the normal system shall be from a single panelboard. Emergency system receptacles shall be identified and shall also indicate the panelboard and circuit number supplying them.
The branch circuit serving patient bed locations shall not be part of a multi-wire branch circuit.