HospitalInspections.org

Based on observation, the facility failed to properly arrange exit discharge in accordance to NFPA 101 sections 19.2.7, 7.7.1, and S&C letter 05-38. These deficiencies practice affected one (1) of six (6) exits in the facility on the day of survey.

Findings include:

On February 2, 2017 at 10:50 AM, observation revealed the 2nd floor West Hall exit discharge was not leading all-weather surfaces to the public way.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview.

Based on observations the facility failed to provide the required fire resistance rating for the exit stairwell in accordance with NFPA 101 19.3.1.1, 8.6. This deficient practice affected one (1) of two (2) exits on the 2nd floor of the facility on the day of survey.
Findings include:
On February 2, 2017 at 11:10 AM, observations revealed unsealed 5 inch open gap at the stairwell interior walls to the concrete deck above. Observation also revealed cables and conduits penetrating 5 inch open gap opening in the stairwell interior wall.
The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview.

Based on observations the facility failed to provide the required 1 hour fire resistance rating for the hazardous area (laboratory) in accordance with NFPA 101 19.3.2.1 (8). This deficient practice has the potential of affecting two (2) of five (5) smoke comparments in the facility on the day of survey.
Findings include:
On February 2, 2017 at 12:20 PM, observation revealed open and unsealed penetrations in the concrete deck above the lay-in ceiling of the Laboratory of the facility.
The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview.

Based on observation and testing, the facility failed positive alarm sequence for the fire alarm system in accordance to NFPA 101 sections 19.3.4.3, 9.6.3.4, and NFPA 72 section 18.5.4.3.2(4). This deficient practice affected one (1) of five (5) smoke comparments in the facility on day of survey.
Findings include:
On February 2, 2017 at 11:20 AM, observation revealed unsychronized emergency strobes lights in the Emergency Department of the facility.
The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview.

Based on observations, the facility failed to provide the safety requirements for area open to the main corridor of the facility in accordance with 19.3.6.1 (7). This deficient practice has the potential of affecting three (3) of five (5) smoke compartments in the facility on the day of survey.

Findings include:

On 2-2-17 at 10:55 AM, observation revealed the following areas could not resist the passage of smoke, were open to the main corridor of the facility and were not electrically supervised by an automatic detection system:

1. 1st Floor Nourishment Room
2. 2nd Floor Ice Machine Room
3. 2nd Floor Ambulance Service Office

The administrator and maintenance director were notified during the survey and in the exit conference.

Based on observation and interview, the facility failed to provide corridor partitions that resist the passage of smoke in a non sprinkled building in accordance to NFPA 101 19.3.6.2. These deficiencies practice affected the entire facility on the day of survey.

Findings include:
On February 2, 2017 at 9:50 AM, observation revealed open penetrations in all corridor walls on the 1st and 2nd floors of the facility.
The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview.

Based on observations the facility failed to provide the required 30 minute fire resistance rating for smoke barrier walls in accordance with NFPA 101 19.3.7.3, 8.5, 8.5.6. These deficient practices have the potential of affecting five (5) of five (5) smoke compartments in the facility on the day of survey.
On February 2, 2017 at 10:30 AM, observations revealed unsealed penetrations and unapproved foam spray in the two (2) smoke barrier walls on the 1st floor of the facility. Observation also revealed open and unsealed penetrations in the smoke barrier on the 2nd floor of the facility.
The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview.