HospitalInspections.org

Based on observations and interview, the facility failed to ensure door frames in fire walls and smoke barriers throughout the facility displayed a legible label attesting that they offered a minimum 20-minute fire protection rating in accordance with 19.3.6.3.1 (requirements for existing construction); and failed to ensure two sets of doors in a fire wall dividing the med/surg wing offered protection from smoke and fire in accordance with 18.3.7.8 (requirements for new construction), potentially affecting the staff, visitors and patient census of the 25 bed hospital. The facility census was 12.

Findings included:

1. Observations on 12/28/11 at 8:30 AM through 12/28/11 at 3:00 PM showed paint obscured the fire rating labels on all rated corridor door frames of janitor's closets, equipment storage rooms, electrical and data closets soiled utility rooms, and patient rooms on the second floor made the labels unreadable. The stamped rating on the labels affixed to corridor door frames in smoke and fire barriers throughout the first floor were obscured in like manner by paint that rendered the labels unreadable.

2. Observations on 12/28/11 at 9:00 AM showed gaps of one eighth inch width not covered or sealed with an astragal (a molding attached to one of two leafs of a double door that creates a smoke tight barrier) on two sets of doors in a north-south fire wall subdividing the second floor's 22-bed med/surg wing.

Record review showed the double doors were installed during the 2010 renovations and equipped with a built-in expansion strip which was activated by the heat of a fire. However, the expansion strip is not activated by smoke and does not meet the intent of the regulation to prevent smoke from spreading form one compartment.

During an interview on 12/28/11 at 3:00 PM, Staff A, Director of Maintenance stated he initially thought that maintaining a minimum gap and use of the expanding strips would serve the purpose, but agreed the heat sensitive strips do not prevent smoke from passing through the openings. He stated that he was pretty sure all of the rated door frames throughout the facility had been painted over, because they were all done by the same contractor during same period of time, as part of the renovation and reconstruction.

Based on observation and interview, the facility failed to maintain a clear width and work area in one of two electrical rooms in accordance with NFPA 70, 12.5.3 which specifies a working space of at least 30 inches horizontally where rear or side access is required to work on de-energized parts of enclosed equipment and to ensure workers have adequate room to avoid contacting grounded components or incurring injury when retreating. The facility census was 12.

Findings included:

1. Observation on 12/28/11 at 8:40 AM through 9:30 AM showed six, one-gallon cans of nonflammable latex paint, a large empty, cardboard box that had held ceiling tiles for the suspended ceilings, numerous strips and scraps of wiring, and a contractor's tool chest in an electrical closet on second floor.

During an interview on 12/28/11, at 11:00 AM Staff A, the Director of Maintenance stated he would have his people check all electrical rooms and contact the construction foreman to ensure all items were removed from each electrical room.

Based on observations and interview, the facility failed to ensure door frames in fire walls and smoke barriers throughout the facility displayed a legible label attesting that they offered a minimum 20-minute fire protection rating in accordance with 19.3.6.3.1 (requirements for existing construction); and failed to ensure two sets of doors in a fire wall dividing the med/surg wing offered protection from smoke and fire in accordance with 18.3.7.8 (requirements for new construction), potentially affecting the staff, visitors and patient census of the 25 bed hospital. The facility census was 12.

Findings included:

1. Observations on 12/28/11 at 8:30 AM through 12/28/11 at 3:00 PM showed paint obscured the fire rating labels on all rated corridor door frames of janitor's closets, equipment storage rooms, electrical and data closets soiled utility rooms, and patient rooms on the second floor made the labels unreadable. The stamped rating on the labels affixed to corridor door frames in smoke and fire barriers throughout the first floor were obscured in like manner by paint that rendered the labels unreadable.

2. Observations on 12/28/11 at 9:00 AM showed gaps of one eighth inch width not covered or sealed with an astragal (a molding attached to one of two leafs of a double door that creates a smoke tight barrier) on two sets of doors in a north-south fire wall subdividing the second floor's 22-bed med/surg wing.

Record review showed the double doors were installed during the 2010 renovations and equipped with a built-in expansion strip which was activated by the heat of a fire. However, the expansion strip is not activated by smoke and does not meet the intent of the regulation to prevent smoke from spreading form one compartment.

During an interview on 12/28/11 at 3:00 PM, Staff A, Director of Maintenance stated he initially thought that maintaining a minimum gap and use of the expanding strips would serve the purpose, but agreed the heat sensitive strips do not prevent smoke from passing through the openings. He stated that he was pretty sure all of the rated door frames throughout the facility had been painted over, because they were all done by the same contractor during same period of time, as part of the renovation and reconstruction.

Based on observation and interview, the facility failed to maintain a clear width and work area in one of two electrical rooms in accordance with NFPA 70, 12.5.3 which specifies a working space of at least 30 inches horizontally where rear or side access is required to work on de-energized parts of enclosed equipment and to ensure workers have adequate room to avoid contacting grounded components or incurring injury when retreating. The facility census was 12.

Findings included:

1. Observation on 12/28/11 at 8:40 AM through 9:30 AM showed six, one-gallon cans of nonflammable latex paint, a large empty, cardboard box that had held ceiling tiles for the suspended ceilings, numerous strips and scraps of wiring, and a contractor's tool chest in an electrical closet on second floor.

During an interview on 12/28/11, at 11:00 AM Staff A, the Director of Maintenance stated he would have his people check all electrical rooms and contact the construction foreman to ensure all items were removed from each electrical room.