Improper Installation of ABHR Dispensers Near Ignition Sources
Penalty
Summary
The facility was found to be non-compliant with the 2012 NFPA 101 Life Safety Code regarding the installation of alcohol-based hand rub (ABHR) dispensers. During a recertification survey, it was observed that ABHR dispensers were installed directly above ignition sources, specifically electrical outlets, in several locations within the facility. These locations included corridors on the second to fourth floors near specific room numbers, as well as in the corridor outside of the kitchen on the first floor. This installation violates the requirement that ABHR dispensers should not be placed directly over or within one inch of ignition sources. The deficiency was confirmed through staff interviews during the survey process.
Plan Of Correction
Plan of Correction: Approved March 29, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Immediate Corrective Action The alcohol-based hand rub dispensers on first floor near kitchen, on second floor near room [ROOM NUMBER], on third floor near 309, on fourth floor near 409 were removed and placed away from ignition sources (3/14/25). Identification of others All residents have the potential to be affected by this deficient practice. A complete audit of the entire building was completed to ensure that the alcohol-based hand rub (ABHR) dispensers were not installed directly over or within 1 inch of ignition sources (3/14/25). No other issues were identified. All Maintenance Staff will be in serviced on the importance of ensuring that all Alcohol Based Dispensers shall not be installed above an ignition source within a 1 in. radius from an ignition source (3/31/25). Systematic Changes The Maintenance Director and Administrator reviewed the NFPA 101 manual and created a policy on placement of Alcohol-Based Hand-Rub Dispensers. Alcohol-based hand-rub dispensers shall be protected in accordance with 8.7.3.1. All Maintenance staff will be in serviced on the importance of ensuring that appropriate placement of the Alcohol Based Hand-Rub Dispensers. All Alcohol Based Dispensers shall not be installed in the following locations: (a) Above an ignition source within a 1 in. (25 mm) horizontal distance from each side of the ignition source (b) To the side of an ignition source within a 1 in. (25mm) horizontal distance from the ignition source (c) Beneath an ignition source within a 1 in. (25 mm) vertical distance from the ignition source (3/31/25). QA The Maintenance Director and Administrator developed an audit tool to ensure that the alcohol-based hand rub (ABHR) dispensers were not installed directly over or within 1 inch of ignition sources complying with requirements of 2012 NFOA 101. There will be a visual check of all alcohol-based hand rub (ABHR) dispensers weekly for 3 months. All negative findings will be brought to the Maintenance Director and reported to the Administrator and addressed immediately. All findings will be reported to the QA committee quarterly. The QA committee will determine a schedule for ongoing audits if deemed necessary. Date of correction/responsible person Maintenance Director is responsible. 4/25/25- date of correction.