HospitalInspections.org

Based on observation and staff interview, the facility failed to maintain latching stairwell doors for vertical separation in 2 of 5 stairwells. This condition had the potential to allow smoke and fire to migrate into stairwell exits, hindering exit capabilities.

Findings are:
Observations during the facility tour on 1/18/11, from 2:16 pm to 3:21 pm revealed:
1. The stairwell doors by the Laundry failed to latch when swung shut by the closure.
2. The 1st Floor North Stairwell door failed to latch when swung shut by the closure.
In an interview conducted at the time of observations, (1/18/11, from 2:16 pm to 3:21 pm), Maintenance A acknowledged the findings.

Based on observation and staff interview, the facility failed to separate hazardous storage rooms in 2 of 9 smoke compartments. This condition had the potential to allow smoke and fire to spread from the storage room with high combustible loads to the exit corridor.

Findings are:
Observation during the facility tour on 1/18/11, from 1:36 pm to 2:34 pm revealed:
1. The Bio-Storage Room measured over 50 square feet with hazmat supplies such as gloves, tarps and over items in packaging. The facility failed to install a closure on the door.
2. The Oxygen Supplies Storage Room revealed the room measured over 50 square feet with shelf storage of nasal canulas and various oxygen items in combustible packaging. The facility failed to separate the storage room from the corridor with a smoke resisting door. A wood accordion door with no latching hardware failed to provide the smoke resisting partition.
In an interview conducted at the time of observation (1/18/11, from 1:36 pm to 2:34 pm), Maintenance A acknowledged the findings.

Based on record review and staff interview, the facility failed to test battery backup emergency lights routinely for the elevator and 2 of 2 Operating Rooms. This condition had the potential to leave occupants in darkness during the loss of power.

Findings are:
Record review of battery backup emergency light testing revealed:
1. Monthly inspections for the battery backup emergency lights for the Elevator failed to be current. Documentation of an annual 90 minute test failed to be made available for review.
2. The facility failed to document monthly inspections of the emergency lights in Operating Rooms 1 and 2. The lights are not yet a year old, but will require a 90 minute annual test.
In an interview conducted at the time of record review, (1/18/11, at 11:16 am), Maintenance A acknowledged the documentation failed to be current and that the Operating Room lights failed to be tested.

Based on record review and staff interview, the facility failed to conduct fire drills quarterly for 3 of 3 shifts. This condition would not provide the necessary training for staff response to a fire emergency.

Findings are:
Record review of fire drills revealed:
1. The facility failed to document a fire drill for the 1st Shift in the 3rd Quarter of 2010.
2. The facility failed to document a fire drill for the 3rd Shift in the 1st Quarter of 2010.
3. When fire drill reports were compared to the central receiving station log, it was revealed that the facility failed to sound the fire alarm during three 2nd shift fire drills and one 1st shift fire drill during 2010; not successfully simulating fire conditions.
In an interview conducted at the time of record review (1/18/11, at 11:56 am), Maintenance A acknowledged the missing fire drills and that the fire alarm failed to be sounded during all 1st and 2nd shift fire drills.

Actual NFPA Standard:
NFPA 101, 19.7.1.2*
Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency 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.

Based on observation and staff interview, the facility failed to install fire alarm components in accordance with NFPA 72 in 2 of 9 smoke compartments. This condition had the potential for fire alarm components to not react to smoke to alert occupants.

Findings are:
Observations during the facility tour on 1/18/11, from 1:06 pm to 2:12 pm revealed:
1. The facility installed magnetic hold-open devices for both South Lab Doors and failed to install smoke detection within 5 foot of each door for door release. Smoke detectors were not installed every 30 feet in the corridor.
2. The smoke detector in Electrical Room B126 for protection of a fire alarm amplifier failed to be installed within 12 inches of the ceiling.
3. A plastic bag covered the smoke detector in the MRI Equipment Room. The facility removed the bag during the survey.
4. The smoke detector in the Food Service Office hung by its wires and appeared to have been installed in the ceiling by a type of plastic clip.
In an interview conducted at the time of observations, (1/18/11, from 1:06 pm to 2:12 pm), Maintenance A acknowledged the findings.

Actual NFPA Standard:
NFPA 72, 2-10.6.5.1.1
If the depth of wall section above the door is 24 in. (610 mm) or less, one ceiling-mounted detector shall be required on one side of the doorway only. Figure 2-10.6.5.1.1, parts B and D, shall apply.
NFPA 72, 2-3.4.3.1
Spot-type smoke detectors shall be located on the ceiling not less than 4 in. (100 mm) from a sidewall to the near edge or, if on a sidewall, between 4 in. and 12 in. (100 mm and 300 mm) down from the ceiling to the top of the detector.

Based on record review and staff interview, the facility failed to have the hood and duct system inspected for contamination by deposits from grease-laden vapors on a semiannual basis. This condition had the potential to restrict exhaust air flow or allow fire to grow beyond the limitations of the suppression system.

Findings are:
Record review of range hood documentation revealed no semi-annual cleaning documentation.
In an interview conducted at the time of record review (1/18/11, at 11:21 am), Maintenance A confirmed the cleaning had not been set up because the facility was not aware of the requirement.

NFPA 96, 8-3.1.1. Upon inspection, if found to be contaminated with deposits from grease-laden vapors, the entire exhaust system shall be cleaned by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Section 8-3.
System Inspection Schedule:
Type or Volume of Cooking Frequency
Frequency:
Systems serving solid fuel cooking operations: Monthly
Systems serving high-volume cooking operations such as 24-hour cooking, charbroiling or wok cooking: Quarterly
Systems serving moderate-volume cooking operations: Semiannually
Systems serving low-volume cooking operations, such as churches, day camps, seasonal businesses, or senior centers: Annually
NFPA 96, 8-3.1. Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Table 8-3.1.

1 Based on record review and staff interview, the facility failed to ensure that 3 of 3 boilers had a current boiler certificate. This condition increased the potential of boiler failure.

Findings are:
Record review of boiler certificates revealed the most recent boiler inspection certificate expired 8/31/2010.
In an interview conducted at the time of record review, (1/18/11 at 11:13 am), Maintenance A acknowledged the findings.

Nebraska's Boiler Inspection Act, Sections 48-701 through 48-743.


2. Based on record review and staff interview, the facility failed to conduct final testing of the clean agent suppression system and its enclosure in accordance with NFPA 2001. This condition had the potential for the system to not activate in the case of a fire or for the agent to leak out of the room and not contain a fire.

Findings are:
Record review of the Fenwal 732 Clean Agent Suppression System revealed no documentation of a final approval by the Nebraska State Fire Marshal ' s Office or a test of the enclosure.
In an interview conducted at the time of record review, (1/18/11, at 1:53 pm), Maintenance A confirmed that the testing had not been completed. Information Technology Staff A stated that the system had been installed approximately 6 months from the date of the survey.

Actual NFPA Standard:
NFPA 2001, 4-7.1 General.
The completed system shall be reviewed and tested by qualified personnel to meet the approval of the authority having jurisdiction. Only listed equipment and devices shall be used in the systems. To determine that the system has been properly installed and will function as specified, the following tests shall be performed.
NFPA 2001, 4-7.2.3* Review Enclosure Integrity.
All total flooding systems shall have the enclosure examined and tested to locate and then effectively seal any significant air leaks that could result in a failure of the enclosure to hold the specified agent concentration level for the specified holding period. The currently preferred method is using a blower door fan unit and smoke pencil. Quantitative results shall be obtained and recorded to indicate that the specified agent concentration for the specified duration of protection is in compliance with Section 3-6, using an approved blower fan unit or other means as approved by the authority having jurisdiction.

Based on record review and staff interview, the facility failed to test and maintain the facility emergency generator in accordance with NFPA 110. This condition increased the potential of generator failure.

Findings are:
Record review of generator testing revealed:
1. The facility failed to run the generator at 30 percent of the nameplate rating on 12/10 at 28%, 5/10 at 28% and 4/10 documentation failed to be available for review. Documentation of a load bank test did not exist.
2. The facility failed to provide documentation of weekly testing for 7/10.
In an interview conducted at the time of record review, (1/18/11 at 12:02 pm), Maintenance A acknowledged the missing documentation.

Actual NFPA Standard:
NFPA 110, 6-4.2*
Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
The date and time of day for required testing shall be decided by the owner, based on facility operations.
NFPA 110, 6-4.2.2
Diesel-powered EPS installations that do not meet the requirements of 6-4.2 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, 6-4.1*
Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.

Based on observation and staff interview, the facility failed to use electrical wiring in accordance with NFPA 70 for 3 of 9 smoke compartments. This condition had the potential to overload a circuit, which would cause an electrical fire.

Findings are:
Observation during the facility tour on 1/18/11, from 1:47 pm to 2:54 pm revealed:
1. A power strip plugged into a power strip for a fan in Cardiac Rehab.
2. A 6-outlet power tap fastened to a wall outlet in the Pharmacy for chargers and a radio.
3. A coffee maker plugged into an extension cord in Office 244.
In an interview conducted at the time of observation (1/18/11, from 1:47 pm to 2:54 pm), Maintenance A acknowledged the use of the electrical equipment.

Actual NFPA Standard:
NFPA 1, 11.1.5.2.2 The relocatable power taps shall be directly connected to a permanently installed receptacle.

Based on observation and staff interview, the facility failed to not install alcohol based hand sanitizers directly adjacent to electrical sources in 1 of 9 smoke compartments. This failure had the potential to ignite the hand sanitizer when coming into contact with an electrical source due to the alcohol found in the sanitizer.

Findings are:
Observation during the facility tour on 1/18/11, at 2:46 pm revealed a alcohol based hand sanitizers installed within 12 inches of electrical sources throughout the OB Wing.
In an interview conducted at the time of observation (1/18/11, at 2:46 pm), Maintenance A confirmed the location of the sanitizers.

Nebraska State Fire Marshal Official Interpretation 05-04