Rick Patrick
rick@greenepublishing.com
This is the third of a series of articles on the findings of deficiencies at Lake Park of Madison. These deficiencies were noted in inspection reports obtained by Greene Publishing, Inc. The reports were provided by the Agency for Health Care Administration (AHCA).
During an inspection at Lake Park of Madison on Thursday, Feb. 25, inspectors from the Agency for Health Care Administration (AHCA) with the State of Florida, found a number of deficiencies, many of which were related to patient and staff safety, specifically fire safety. One of these findings was in regards to the fire alarm system. Regulations call for, “A fire alarm system, installed with systems and components in accordance with NFPA 70, National Electric Code and NFPA 72, National Fire Alarm Code to provide effective warning of fire in any part of the building. In areas not continuously occupied, detection is installed at each fire alarm control unit. In new occupancy, detection is also installed at notification appliance circuit power extenders and supervising station transmitting equipment. Fire alarm system wiring or other transmission paths are monitored for integrity.” According to the report, this requirement was not met by Lake Park. This was evidenced by “observation and interview with the Maintenance Director.” The report states that, “the facility failed to provide audible appliances in the therapy room area which could negatively affect those within the room by not alerting them to an emergency situation, resulting in the potential endangerment of the occupants of the room in the event of an emergency.”
Lake Park's response was, “the facility will maintain an electrically supervised fire alarm, which provides emergency forces notification, is available to warn occupants, and operate protective systems shall be provided in accordance with NFPA 101 Life Safety Code (2012 edition). The physical therapy room will have an audible appliance installed. The appliance has been ordered and the facility is awaiting the installation. No other area has been identified to need audible appliances for emergency forces notification.”
The report also states that Lake Park failed to maintain the fire alarm system, as required. The report further states that Lake Park failed to “provide evidence of the annual duct detector airstream sampling using a method acceptable to the manufacturer or their published instructions. An interview was conducted with the Maintenance Director concurrent with the observations and confirmed the findings. Documentation indicated the last time the system was tested was July of 2019.”
Lake Park responded by saying that, “the facility will provide evidence of the annual duct detector airstream sampling using a method acceptable to the manufacturer or their published instructions. The duct detector airstream sampling was completed and documentation is available. The testing indicated that two duct smoke detectors failed. The detectors have been ordered through an outside vendor and will be installed upon the delivery of the detectors.”
There is a requirement for the inspection, maintenance and testing of the automatic and standpipe sprinkler systems. The AHCA report stated that these requirements were not met, based on observation and interview with the Maintenance Director. The AHCA inspection further revealed that sprinkler heads in the laundry room area were observed covered with foreign material. According to NFPA regulations, “Sprinklers shall not show signs of leakage, shall be free of corrosion, foreign materials, paint and physical damage. And shall be installed in the correct orientation. Any sprinkler that shows signs of any of the following shall be replaced: leakage, corrosion, physical damage, loss of fluid in the glass bulb heat responsive element, loading [or] painting unless painted by the sprinkler manufacturer.
Lake Park responded to this item by stating, “the facility will provide inspection, maintenance and testing of the fire sprinkler system in accordance with NFPA. The laundry area sprinkler heads are now free of foreign matter. All other sprinkler heads have been inspected to ensure they do not show signs of leakage, are free of corrosion, foreign matter, paint and physical damage. Any noted during the inspection were corrected. The Maintenance Director will be responsible for the monthly tests and for scheduling all quarterly and annual testing and will report issues directly to the Executive Director.
There are specific regulations from the CFR and NFPA that deal with doors and the containment of smoke, fire and gasses that could prove dangerous in the event of a fire. Doors located in fully sprinkled smoke compartments are only required to resist the passage of smoke. Hold open devices are permitted so long as the device releases when the door is pushed or pulled. The AHCA report states that Lake Park did not meet the requirements in regards to the proper maintenance of fire/smoke doors. During the fire and life safety tour of Lake Park, there were several smoke doors that were not closing properly. One door was delaminating which could allow smoke, fire and gasses to enter the compartment. A visitation room exit door was not closing or latching. The door was also rubbing on the frame, which could allow fire, smoke and fire gasses to enter the compartment. Another door frame was broken at the top right corner, which could allow fire, smoke and gasses to enter the compartment. Another set of self-closing doors were delaminating which could allow fire, smoke and gasses to enter the compartment. At another self-closing door, a wooden wedge was used to hold the door open.
Lake Park of Madison responded by stating that all doors identified in the report would be measured and ordered by a vendor in Valdosta, Ga. The doors were to be replaced upon arrival. All other doors were inspected by the Maintenance Director to determine they were closing properly. Annual inspections will be conducted by the Maintenance Director to determine that all smoke doors close properly. The Executive Director will review the results of the annual inspections to determine compliance.
There were other areas of concern where smoke barriers had not been fire stopped or smoke sealed according to the requirements of NFPA. These could allow fire and smoke to travel from one compartment to another, which could endanger occupants of the facility. These included a hole in the wall of the clean linen room and a vent falling from the ceiling of the beauty shop. There was also a separation between the wall and ceiling in the copy room.
Lake Park responded by saying that the facility will repair the existing fire/smoke penetrations according to the requirements of NFPA. Lake Park also stated that the Maintenance Director has completed a walk-through of the entire facility in order to identify other problem areas. Monthly inspections have also been added to the regular preventive maintenance plan.
It is a requirement that smoking regulations include the provision that “metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.” According to the inspection report, “the facility failed to provide metal containers with self-closing cover devices into which ashtrays can be emptied in the designated smoking areas. This could result in a fire, smoke and fire gasses permeating the building and jeopardizing patients and staff.”
Lake Park responded with, “the facility has provided metal containers with self-closing cover devices into which ashtrays can be emptied to both the resident and staff designated smoking areas. Ashtrays of noncombustible material and safe design and the metal containers with self-closing cover devices are now in all areas identified for smoking.
There is a regulation regarding the use of space heaters which states: “Portable space heating devices shall be prohibited in all health care occupancies, except, unless used in non-sleeping staff and employee areas where the heating elements do not exceed 212 degrees Fahrenheit (100 degrees Celsius).” During the fire and life safety tour of the facility a portable space heater was located in an office on the west wing. The facility failed to provide evidence that heating elements of the heater did not exceed 212 degrees Fahrenheit. Radiant heaters can be a source of ignition and as such can be a danger to staff and occupants of the building.
Lake Park responded by removing the space heater from the office at the time of the survey. The Executive Director inspected the facility for any other portable space heaters and had them removed. It was stated that portable space heaters are not allowed in the facility, by policy. It was stated that staff members would be reminded of this policy during fire safety training each year.
As stated earlier, these deficiencies are from an inspection performed on Thursday, Feb. 25. There could be more information forthcoming as it is released from the AHCA. Information about the AHCA and Florida's nursing facilities can be found at https://ahca.myflorida.com/.