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Based on observation, record review and staff interviews, the facility failed to assure that penetrations in the 2 hour fire separation wall between the hospital and the doctor's building are properly sealed. This deficient practice of allowing improperly sealed penetrations in a 2 hour fire wall for occupancy separation will allow smoke and fire products to move from one occupancy to the other occupancy affecting one of ten smoke zones on the 1st floor. The facility has 24 smoke zones on five floors total. The facility has a capacity of 300 with a census of 126 at the time of survey.

Findings Include:

During the tour on January 31st, 2011 beginning at 11:30 AM and February 2nd ending at 12:30 PM the following is observed:

The 2 hour fire wall separating the hospital from the doctor's building had the following inadequately sealed penetrations:

1) There is a gap around a conduit with data or phone wiring passing through the wall.
2) The end of the conduit with data or phone wiring is not properly sealed.
3) A hole was observed to be drilled through the wall.

Staff B, Staff C and Staff D were present at the time these penetrations were observed. These penetrations were sealed by staff at the time of the survey.

NFPA Standard: Additions shall be separated from any existing structure not conforming to the provisions within Chapter 19 by a fire barrier having not less than a 2-hour fire resistance rating and constructed of materials as required for the addition. Communicating openings in the fire barriers shall be permitted only in corridors and protected by approved self-closing fire doors. 2000 NFPA 101, 18/19.1.1.4.1 and 18/19.1.1.4.2.

NFPA Standard: Occupied buildings shall meet the minimum construction requirements of the occupancy chapters and NFPA 220. Additions or connected structures of different construction types shall have the ratings and classification based on: separate buildings if a 2-hour or greater vertically-aligned fire barrier wall in accordance with NFPA 221 exists between the buildings, or the least fire-resistive type of construction of the connected portions. 2000 NFPA 101, 8.2.1.

Based on observation and staff interview the facility is not ensuring that room doors latch properly. This deficient practice of not ensuring that room doors latch properly prevents the ability of the facility to properly confine fire and smoke products and to properly defend occupants in place, affecting two of four smoke zones on the 2nd floor and one of four smoke zones on the 3rd floor. The facility has 24 smoke zones on five floors total. The facility has a capacity of 300 with a census of 126 at the time of survey.

Findings Include:

During the tour on January 31st, 2011 beginning at 11:30 AM and February 2nd ending at 12:30 PM the following is observed:

Doors to rooms 220, 239, 242 on the 2nd floor and doors to rooms 312 & 315 on the 3rd floor are not latching properly

Staff B, Staff C and Staff D were present at the time of the findings. All 5 of these doors were repaired to latch by staff at the time of the survey and the repairs were confirmed by the surveyor. .

NFPA Standard: Doors in corridor walls of sprinklered buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors in non-sprinklered buildings shall have doors constructed to resist the passage of smoke for at least twenty minutes and shall be provided with suitable means of keeping the doors closed. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 19.3.6.3.1 and 19.3.6.3.

Based on observation and staff interview the facility failed to ensure proper separation of hazardous areas from other spaces. This deficient practice would allow for the spread of smoke and fire to travel into the adjacent area, affecting one of ten smoke zones on the first floor. The facility has 24 smoke zones on five floors total. The facility has a capacity of 300 with a census of 126 at the time of survey.

Findings Include:

During the tour on January 31st, 2011 beginning at 11:30 AM and February 2nd ending at 12:30 PM the following is observed:

The record storage room in the Laboratory is not equipped with a self-closing device.

Staff B, Staff C and Staff D were present during the observation and indicated that this room recently became a record storage room and a self-closing device would be added immediately.

NFPA Standard: Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1.

Based on observation, record review and staff interview, the facility failed to provide doors with the proper fire rating for stairways constructed with a 2 hour fire rating. This deficient practice of not providing doors with the proper fire rating to the stairways would allow for the spread of fire and smoke products more rapidly into the stairway, affecting 4 of 4 stairways on 2 floors. The facility has 24 smoke zones on five floors total. The facility has a capacity of 300 with a census of 126 at the time of survey.

Findings Include:

During the tour on January 31st, 2011 beginning at 11:30 AM and February 2nd ending at 12:30 PM the following is observed:

The doors from the corridor into the enclosed stairways have a label indicating that the doors are labeled as 45 minute fire doors. These doors are located on the 4th and 5th floors of the facility and open to the north, east, south and center stairways for a total of eight doors.

Staff B, Staff C and Staff D were present and confirmed this observation. Staff C confirmed that 1 1/2 hour fire rated doors should have been installed on these floors to the stairways with the architect and from plan review.

NFPA Standard: All inside stairs serving as an exit component shall be enclosed in accordance with 7.1.3.2 and shall be separated from other parts of the building with not less than one hour rated construction for less than four stories or two hour rated for more than three stories. 2000 NFPA 101, 7.2.2.5.1

NFPA Standard: Enclosures. All inside stairs serving as an exit or exit component shall be enclosed in accordance with 7.1.3.2. All other inside stairs shall be protected in accordance with 8.2.5.
Exception: In existing buildings, where a two-story exit enclosure connects the story of exit discharge with an adjacent story, the exit shall be permitted to be enclosed only on the story of exit discharge, provided that not less than 50 percent of the number and capacity of exits on the story of exit discharge are independent of such enclosures. 2000 NFPA 101, 7.2.2.5.1

NFPA Standard: Every opening in a fire barrier shall be protected to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. The fire protection rating for opening protectives shall be as follows:
(1) 2-hour fire barrier - 11/2-hour fire protection rating
(2) 1-hour fire barrier - 1-hour fire protection rating where used for vertical openings or exit enclosures, or 3/4-hour fire protection rating where used for other than vertical openings or exit enclosures, unless a lesser fire protection rating is specified by Chapter 7 or Chapters 11 through 42.
Exception No. 1: Where the fire barrier specified in 8.2.3.2.3.1(2) is provided as a result of a requirement that corridor walls or smoke barriers be of 1-hour fire resistance-rated construction, the opening protectives shall be permitted to have not less than a 20-minute fire protection rating when tested in accordance with NFPA 252, Standard Methods of Fire Tests of Door Assemblies, without the hose stream test. 2000 NFPA 101, 8.2.3.2.3.1

Based on observation and staff interview, the facility failed to provide means of egress that are maintained free of all obstructions or impediments to a full instant use in case of fire or other emergency. The deficient practice would prevent these exits from being arranged so that they are readily available and accessible, affecting the exit from the facility in two of ten smoke zones on the first floor and the north enclosed stairway. The facility has 24 smoke zones on five floors total. The facility has a capacity of 300 with a census of 126 at the time of survey.

Findings Include:

During the tour on January 31st, 2011 beginning at 11:30 AM and February 2nd ending at 12:30 PM the following is observed:

1) The horizontal sliding doors from the emergency department to the garage and the main lobby interior would not swing open when pressure was applied as indicated by the signs on these doors.
2) The north stairway exit discharge does not have a hard surface to a public way. This exit discharge has a hard surface landing only and then occupants must walk through a grassy area to reach another hard surface.

Staff B, Staff C and Staff D were present and are aware of the findings. Both of these horizontal sliding doors were repaired at the time of the survey and confirmed by the surveyor. Staff D acknowledged the lack of a hard surface to a public way from the north stairs.

NFPA Standard: Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. 2000 NFPA 101, 7.1.10.1

NFPA Standard: Exits shall terminate directly at a public way or an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way. 2000 NFPA 101, 7.7.1.

NFPA Standard: Horizontal sliding doors shall be permitted in means of egress, provided that the following criteria are met:
(1) The door is readily operable from either side without special knowledge or effort.
(2) The force that, when applied to the operating device in the direction of egress, is required to operate the door is not more than 15 lbf (67 N).
(3) The force required to operate the door in the direction of door travel is not more than 30 lbf (133 N) to set the door in motion and is not more than 15 lbf (67 N) to close the door or open it to the minimum required width.
(4) The door is operable with a force not more than 50 lbf (222 N) when a force of 250 lbf (1110 N) is applied perpendicularly to the door adjacent to the operating device, unless the door is an existing horizontal sliding exit access door serving an area with an occupant load of fewer than 50.
(5) The door assembly complies with the fire protection rating and, where rated, is self-closing or automatic-closing by means of smoke detection in accordance with 7.2.1.8, and is installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. 2000 NFPA 101, 7.2.1.14.

Based on record review and staff interview, the facility is not conducting fire drills as required quarterly on each shift and properly recording the results and facts relating to the fire drills. This deficient practice affects the ability of the staff to properly respond in the event of an actual emergency and affects twenty-four of twenty-four smoke zones. The facility has 24 smoke zones on five floors total. The facility has a capacity of 300 with a census of 126 at the time of survey.

Findings Include:

During the tour on January 31st, 2011 beginning at 11:30 AM and February 2nd ending at 12:30 PM the following is observed:

1) Review of the facility's fire drill records for the previous 12 months revealed that fire drills conducted on the 3rd shift during the last four quarters revealed that all four occurred between 11:34 PM and 11:47 PM.

Staff E indicated that he conducts the drills and he did not realize that he was establishing a pattern for these drills.

NFPA Standard: 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.

Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building. 2000 NFPA 101, 19.7.1.2.

Based on observation and interview the facility fails to insure that the facility is protected throughout by an automatic sprinkler system installed in accordance with the 1999 NFPA 13. This deficient practice prevents the facility from being adequately provided with a sprinkler system as required, increasing the risk of fire in two of ten smoke zones on the 1st floor and one of three on the 5th floor. The facility has 24 smoke zones on five floors total. The facility has a capacity of 300 with a census of 126 at the time of survey.

Findings Include:

During the tour on January 31st, 2011 beginning at 11:30 AM and February 2nd ending at 12:30 PM the following is observed:

1) The following areas are not provided with sprinkler protection on the 1st floor:
a. Emergency department's northeast electrical closet containing electrical panel label 1EHK.
b. Day surgery department's environmental services closet.
c. Radiology department diagnostic room 2 and 4, including closets. These rooms are also known as chest X-ray rooms.
2) The following areas are not provided with sprinkler protection on the 5th floor:
a. Two electrical closets in the center zone.
b. A closet in the center zone used for form storage and dispersal.

Staff B acknowledged the areas were lacking sprinkler protection.

NFPA Standard: Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. 2000 NFPA 101, 9.7.1.1.

NFPA Standard:Automatic sprinkler systems installed to make use of an alternative permitted by this Code shall be considered required systems and shall meet the provisions of this Code that apply to required systems. 2000 NFPA 101, 9.7.1.4.

NFPA Standard: The requirements for spacing, location, and position of sprinklers shall be based on the following principles:
(1) Sprinklers installed throughout the premises
(2) Sprinklers located so as not to exceed maximum protection area per sprinkler
(3) Sprinklers positioned and located so as to provide satisfactory performance with respect to activation time and distribution
Exception No. 1: For locations permitting omission of sprinklers, see 5-13.1, 5-13.2, and 5-13.9.
Exception No. 2: When sprinklers are specifically tested and test results demonstrate that deviations from clearance requirements to structural members do not impair the ability of the sprinkler to control or suppress a fire, their positioning and locating in accordance with the test results shall be permitted.
Exception No. 3: Clearance between sprinklers and ceilings exceeding the maximum specified in 5-6.4.1, 5-7.4.1, 5-8.4.1, 5-9.4.1, 5-10.4.1, and 5-11.4.1 shall be permitted provided that tests or calculations demonstrate comparable sensitivity and performance of the sprinklers to those installed in conformance with these sections. 1999 NFPA 13, 5-1.1.

NFPA Standard: Electrical Equipment. Sprinkler protection shall be required in electrical equipment rooms. Hoods or shields installed to protect important electrical equipment from sprinkler discharge shall be noncombustible.
Exception: Sprinklers shall not be required where all of the following conditions are met:
(a) The room is dedicated to electrical equipment only.
(b) Only dry-type electrical equipment is used.
(c) Equipment is installed in a 2-hour fire-rated enclosure including protection for penetrations.
(d) No combustible storage is permitted to be stored in the room. 1999 NFPA 13, 5-13.11.

Based on observation, record review and staff interview the facility failed to inspect and test the dry sprinkler system and supply an adequate stock of spare sprinklers in the sprinkler cabinet in accordance with NFPA 25. This deficient practice does not ensure that the dry sprinkler systems is being maintained in a reliable condition, in the kitchen zone on the 1st floor and the exterior canopy and does not provide adequate spare sprinkler heads to return the system operating condition after sprinkler head activation. The facility has 24 smoke zones on five floors total. The facility has a capacity of 300 with a census of 126 at the time of survey.

Findings Include:

During the tour on January 31st, 2011 beginning at 11:30 AM and February 2nd ending at 12:30 PM the following is observed:

1) Record review did not produce a sprinkler inspection and test that indicates that a full trip test of the dry sprinkler system had been performed within the last 3 years.
2) The spare head cabinet contains only 6 spare heads and there are not two of each type found within the facility. No quick response pendant sprinkler heads were found and the stock of spare sprinklers are fewer than required.

Staff D and Staff E were present at record review and are aware of the finding.

NFPA Standard: Every 3 years and whenever the system is altered, the dry pipe valve shall be trip tested with the control valve fully open and the quick-opening device, if provided, in service. 1998 NFPA 25, 9-4.4.2.2.1.

NFPA Standard: A supply of at least six spare sprinklers shall be stored in a cabinet on the premises for replacement purposes. The stock of spare sprinklers shall be proportionally representative of the types and temperature ratings of the system sprinklers. A minimum of two sprinklers of each type and temperature rating installed shall be provided. The cabinet shall be so located that it will not be exposed to moisture, dust, corrosion, or a temperature exceeding 100°F (38°C).
Exception: Where dry sprinklers of different lengths are installed, spare dry sprinklers shall not be required, provided that a means of returning the system to service is furnished. 1998 NFPA 25, 2-4.1.4.

NFPA Standard: The stock of spare sprinklers shall be as follows:
(a) For protected facilities having under 300 sprinklers -no fewer than 6 sprinklers
(b) For protected facilities having 300 to 1000 sprinklers - no fewer than 12 sprinklers
(c) For protected facilities having over 1000 sprinklers -no fewer than 24 sprinklers 1998 NFPA 25, 2-4.1.5.

Based on observation, record review and interview the facility does not assure a fire watch procedure and policy is written and available for implementation when the fire sprinkler system is out of service for more than 4 hours in a 24-hour period, for 12 of 12 months of records reviewed, for 2010. This deficient practice would allow facility exposure to undetected smoke and/or fire without an automatic sprinkler compensatory provision when it occurred, and without appropriately prepared staff response, affecting twenty-four of twenty-four smoke zones. The facility has 24 smoke zones on five floors total. The facility has a capacity of 300 with a census of 126 at the time of survey.

Findings Include:

During the tour on January 31st, 2011 beginning at 11:30 AM and February 2nd ending at 12:30 PM it is observed during record review that no written fire watch policy and procedures are available for when the fire sprinkler systems are out of service as required.

Staff D acknowledged that the facility's fire watch policy does not include wording indicating that a fire watch will be implemented when the fire sprinkler system is out of service for more than 4 hours in a 24-hour period.

NFPA Standard: Where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the AHJ shall be notified, and the building shall be evacuated or an approved fire watch shall be provided until the sprinkler system has been returned to service. 2000 NFPA 101, 9.7.6.1

NFPA Standard: The following procedures shall be implemented: the extent and expected duration of the impairment shall be determined; the area or buildings involved shall be inspected and the increased risks determined; and recommendations submitted to management or building owner/manager. Where a required fire protection system is out of service for more than 4 hours in a 24-hour period, the impairment coordinator shall arrange for one of the following: evacuation of the building affected by the system out of service; an approved fire watch; establishment of a temporary water supply; implementation of a program to eliminate potential ignition sources and limit the amount of fuel available; notification of the fire department; the insurance carrier, the alarm company, building owner/manager, and other AHJ ' s; notification of the supervisors in the affected areas; a tag impairment system has been implemented; all necessary tools and materials have been assembled on the site for preplanned impairments. A fire watch should consist of trained personnel who continuously patrol the effected area, with ready access to fire extinguishers and the ability to promptly notify the fire department. During the patrol of the area, the person should be looking for fire, and other fire protection features of the building such as egress routes and alarm systems are available and functioning properly. 1998 NFPA 25, 11-5

Based on observation, record review and staff interviews, the facility failed to assure that penetrations in the 2 hour fire separation wall between the hospital and the doctor's building are properly sealed. This deficient practice of allowing improperly sealed penetrations in a 2 hour fire wall for occupancy separation will allow smoke and fire products to move from one occupancy to the other occupancy affecting one of ten smoke zones on the 1st floor. The facility has 24 smoke zones on five floors total. The facility has a capacity of 300 with a census of 126 at the time of survey.

Findings Include:

During the tour on January 31st, 2011 beginning at 11:30 AM and February 2nd ending at 12:30 PM the following is observed:

The 2 hour fire wall separating the hospital from the doctor's building had the following inadequately sealed penetrations:

1) There is a gap around a conduit with data or phone wiring passing through the wall.
2) The end of the conduit with data or phone wiring is not properly sealed.
3) A hole was observed to be drilled through the wall.

Staff B, Staff C and Staff D were present at the time these penetrations were observed. These penetrations were sealed by staff at the time of the survey.

NFPA Standard: Additions shall be separated from any existing structure not conforming to the provisions within Chapter 19 by a fire barrier having not less than a 2-hour fire resistance rating and constructed of materials as required for the addition. Communicating openings in the fire barriers shall be permitted only in corridors and protected by approved self-closing fire doors. 2000 NFPA 101, 18/19.1.1.4.1 and 18/19.1.1.4.2.

NFPA Standard: Occupied buildings shall meet the minimum construction requirements of the occupancy chapters and NFPA 220. Additions or connected structures of different construction types shall have the ratings and classification based on: separate buildings if a 2-hour or greater vertically-aligned fire barrier wall in accordance with NFPA 221 exists between the buildings, or the least fire-resistive type of construction of the connected portions. 2000 NFPA 101, 8.2.1.

Based on observation and staff interview the facility is not ensuring that room doors latch properly. This deficient practice of not ensuring that room doors latch properly prevents the ability of the facility to properly confine fire and smoke products and to properly defend occupants in place, affecting two of four smoke zones on the 2nd floor and one of four smoke zones on the 3rd floor. The facility has 24 smoke zones on five floors total. The facility has a capacity of 300 with a census of 126 at the time of survey.

Findings Include:

During the tour on January 31st, 2011 beginning at 11:30 AM and February 2nd ending at 12:30 PM the following is observed:

Doors to rooms 220, 239, 242 on the 2nd floor and doors to rooms 312 & 315 on the 3rd floor are not latching properly

Staff B, Staff C and Staff D were present at the time of the findings. All 5 of these doors were repaired to latch by staff at the time of the survey and the repairs were confirmed by the surveyor. .

NFPA Standard: Doors in corridor walls of sprinklered buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors in non-sprinklered buildings shall have doors constructed to resist the passage of smoke for at least twenty minutes and shall be provided with suitable means of keeping the doors closed. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 19.3.6.3.1 and 19.3.6.3.

Based on observation and staff interview the facility failed to ensure proper separation of hazardous areas from other spaces. This deficient practice would allow for the spread of smoke and fire to travel into the adjacent area, affecting one of ten smoke zones on the first floor. The facility has 24 smoke zones on five floors total. The facility has a capacity of 300 with a census of 126 at the time of survey.

Findings Include:

During the tour on January 31st, 2011 beginning at 11:30 AM and February 2nd ending at 12:30 PM the following is observed:

The record storage room in the Laboratory is not equipped with a self-closing device.

Staff B, Staff C and Staff D were present during the observation and indicated that this room recently became a record storage room and a self-closing device would be added immediately.

NFPA Standard: Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1.

Based on observation, record review and staff interview, the facility failed to provide doors with the proper fire rating for stairways constructed with a 2 hour fire rating. This deficient practice of not providing doors with the proper fire rating to the stairways would allow for the spread of fire and smoke products more rapidly into the stairway, affecting 4 of 4 stairways on 2 floors. The facility has 24 smoke zones on five floors total. The facility has a capacity of 300 with a census of 126 at the time of survey.

Findings Include:

During the tour on January 31st, 2011 beginning at 11:30 AM and February 2nd ending at 12:30 PM the following is observed:

The doors from the corridor into the enclosed stairways have a label indicating that the doors are labeled as 45 minute fire doors. These doors are located on the 4th and 5th floors of the facility and open to the north, east, south and center stairways for a total of eight doors.

Staff B, Staff C and Staff D were present and confirmed this observation. Staff C confirmed that 1 1/2 hour fire rated doors should have been installed on these floors to the stairways with the architect and from plan review.

NFPA Standard: All inside stairs serving as an exit component shall be enclosed in accordance with 7.1.3.2 and shall be separated from other parts of the building with not less than one hour rated construction for less than four stories or two hour rated for more than three stories. 2000 NFPA 101, 7.2.2.5.1

NFPA Standard: Enclosures. All inside stairs serving as an exit or exit component shall be enclosed in accordance with 7.1.3.2. All other inside stairs shall be protected in accordance with 8.2.5.
Exception: In existing buildings, where a two-story exit enclosure connects the story of exit discharge with an adjacent story, the exit shall be permitted to be enclosed only on the story of exit discharge, provided that not less than 50 percent of the number and capacity of exits on the story of exit discharge are independent of such enclosures. 2000 NFPA 101, 7.2.2.5.1

NFPA Standard: Every opening in a fire barrier shall be protected to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. The fire protection rating for opening protectives shall be as follows:
(1) 2-hour fire barrier - 11/2-hour fire protection rating
(2) 1-hour fire barrier - 1-hour fire protection rating where used for vertical openings or exit enclosures, or 3/4-hour fire protection rating where used for other than vertical openings or exit enclosures, unless a lesser fire protection rating is specified by Chapter 7 or Chapters 11 through 42.
Exception No. 1: Where the fire barrier specified in 8.2.3.2.3.1(2) is provided as a result of a requirement that corridor walls or smoke barriers be of 1-hour fire resistance-rated construction, the opening protectives shall be permitted to have not less than a 20-minute fire protection rating when tested in accordance with NFPA 252, Standard Methods of Fire Tests of Door Assemblies, without the hose stream test. 2000 NFPA 101, 8.2.3.2.3.1

Based on observation and staff interview, the facility failed to provide means of egress that are maintained free of all obstructions or impediments to a full instant use in case of fire or other emergency. The deficient practice would prevent these exits from being arranged so that they are readily available and accessible, affecting the exit from the facility in two of ten smoke zones on the first floor and the north enclosed stairway. The facility has 24 smoke zones on five floors total. The facility has a capacity of 300 with a census of 126 at the time of survey.

Findings Include:

During the tour on January 31st, 2011 beginning at 11:30 AM and February 2nd ending at 12:30 PM the following is observed:

1) The horizontal sliding doors from the emergency department to the garage and the main lobby interior would not swing open when pressure was applied as indicated by the signs on these doors.
2) The north stairway exit discharge does not have a hard surface to a public way. This exit discharge has a hard surface landing only and then occupants must walk through a grassy area to reach another hard surface.

Staff B, Staff C and Staff D were present and are aware of the findings. Both of these horizontal sliding doors were repaired at the time of the survey and confirmed by the surveyor. Staff D acknowledged the lack of a hard surface to a public way from the north stairs.

NFPA Standard: Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. 2000 NFPA 101, 7.1.10.1

NFPA Standard: Exits shall terminate directly at a public way or an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way. 2000 NFPA 101, 7.7.1.

NFPA Standard: Horizontal sliding doors shall be permitted in means of egress, provided that the following criteria are met:
(1) The door is readily operable from either side without special knowledge or effort.
(2) The force that, when applied to the operating device in the direction of egress, is required to operate the door is not more than 15 lbf (67 N).
(3) The force required to operate the door in the direction of door travel is not more than 30 lbf (133 N) to set the door in motion and is not more than 15 lbf (67 N) to close the door or open it to the minimum required width.
(4) The door is operable with a force not more than 50 lbf (222 N) when a force of 250 lbf (1110 N) is applied perpendicularly to the door adjacent to the operating device, unless the door is an existing horizontal sliding exit access door serving an area with an occupant load of fewer than 50.
(5) The door assembly complies with the fire protection rating and, where rated, is self-closing or automatic-closing by means of smoke detection in accordance with 7.2.1.8, and is installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. 2000 NFPA 101, 7.2.1.14.

Based on record review and staff interview, the facility is not conducting fire drills as required quarterly on each shift and properly recording the results and facts relating to the fire drills. This deficient practice affects the ability of the staff to properly respond in the event of an actual emergency and affects twenty-four of twenty-four smoke zones. The facility has 24 smoke zones on five floors total. The facility has a capacity of 300 with a census of 126 at the time of survey.

Findings Include:

During the tour on January 31st, 2011 beginning at 11:30 AM and February 2nd ending at 12:30 PM the following is observed:

1) Review of the facility's fire drill records for the previous 12 months revealed that fire drills conducted on the 3rd shift during the last four quarters revealed that all four occurred between 11:34 PM and 11:47 PM.

Staff E indicated that he conducts the drills and he did not realize that he was establishing a pattern for these drills.

NFPA Standard: 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.

Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building. 2000 NFPA 101, 19.7.1.2.

Based on observation and interview the facility fails to insure that the facility is protected throughout by an automatic sprinkler system installed in accordance with the 1999 NFPA 13. This deficient practice prevents the facility from being adequately provided with a sprinkler system as required, increasing the risk of fire in two of ten smoke zones on the 1st floor and one of three on the 5th floor. The facility has 24 smoke zones on five floors total. The facility has a capacity of 300 with a census of 126 at the time of survey.

Findings Include:

During the tour on January 31st, 2011 beginning at 11:30 AM and February 2nd ending at 12:30 PM the following is observed:

1) The following areas are not provided with sprinkler protection on the 1st floor:
a. Emergency department's northeast electrical closet containing electrical panel label 1EHK.
b. Day surgery department's environmental services closet.
c. Radiology department diagnostic room 2 and 4, including closets. These rooms are also known as chest X-ray rooms.
2) The following areas are not provided with sprinkler protection on the 5th floor:
a. Two electrical closets in the center zone.
b. A closet in the center zone used for form storage and dispersal.

Staff B acknowledged the areas were lacking sprinkler protection.

NFPA Standard: Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. 2000 NFPA 101, 9.7.1.1.

NFPA Standard:Automatic sprinkler systems installed to make use of an alternative permitted by this Code shall be considered required systems and shall meet the provisions of this Code that apply to required systems. 2000 NFPA 101, 9.7.1.4.

NFPA Standard: The requirements for spacing, location, and position of sprinklers shall be based on the following principles:
(1) Sprinklers installed throughout the premises
(2) Sprinklers located so as not to exceed maximum protection area per sprinkler
(3) Sprinklers positioned and located so as to provide satisfactory performance with respect to activation time and distribution
Exception No. 1: For locations permitting omission of sprinklers, see 5-13.1, 5-13.2, and 5-13.9.
Exception No. 2: When sprinklers are specifically tested and test results demonstrate that deviations from clearance requirements to structural members do not impair the ability of the sprinkler to control or suppress a fire, their positioning and locating in accordance with the test results shall be permitted.
Exception No. 3: Clearance between sprinklers and ceilings exceeding the maximum specified in 5-6.4.1, 5-7.4.1, 5-8.4.1, 5-9.4.1, 5-10.4.1, and 5-11.4.1 shall be permitted provided that tests or calculations demonstrate comparable sensitivity and performance of the sprinklers to those installed in conformance with these sections. 1999 NFPA 13, 5-1.1.

NFPA Standard: Electrical Equipment. Sprinkler protection shall be required in electrical equipment rooms. Hoods or shields installed to protect important electrical equipment from sprinkler discharge shall be noncombustible.
Exception: Sprinklers shall not be required where all of the following conditions are met:
(a) The room is dedicated to electrical equipment only.
(b) Only dry-type electrical equipment is used.
(c) Equipment is installed in a 2-hour fire-rated enclosure including protection for penetrations.
(d) No combustible storage is permitted to be stored in the room. 1999 NFPA 13, 5-13.11.

Based on observation, record review and staff interview the facility failed to inspect and test the dry sprinkler system and supply an adequate stock of spare sprinklers in the sprinkler cabinet in accordance with NFPA 25. This deficient practice does not ensure that the dry sprinkler systems is being maintained in a reliable condition, in the kitchen zone on the 1st floor and the exterior canopy and does not provide adequate spare sprinkler heads to return the system operating condition after sprinkler head activation. The facility has 24 smoke zones on five floors total. The facility has a capacity of 300 with a census of 126 at the time of survey.

Findings Include:

During the tour on January 31st, 2011 beginning at 11:30 AM and February 2nd ending at 12:30 PM the following is observed:

1) Record review did not produce a sprinkler inspection and test that indicates that a full trip test of the dry sprinkler system had been performed within the last 3 years.
2) The spare head cabinet contains only 6 spare heads and there are not two of each type found within the facility. No quick response pendant sprinkler heads were found and the stock of spare sprinklers are fewer than required.

Staff D and Staff E were present at record review and are aware of the finding.

NFPA Standard: Every 3 years and whenever the system is altered, the dry pipe valve shall be trip tested with the control valve fully open and the quick-opening device, if provided, in service. 1998 NFPA 25, 9-4.4.2.2.1.

NFPA Standard: A supply of at least six spare sprinklers shall be stored in a cabinet on the premises for replacement purposes. The stock of spare sprinklers shall be proportionally representative of the types and temperature ratings of the system sprinklers. A minimum of two sprinklers of each type and temperature rating installed shall be provided. The cabinet shall be so located that it will not be exposed to moisture, dust, corrosion, or a temperature exceeding 100°F (38°C).
Exception: Where dry sprinklers of different lengths are installed, spare dry sprinklers shall not be required, provided that a means of returning the system to service is furnished. 1998 NFPA 25, 2-4.1.4.

NFPA Standard: The stock of spare sprinklers shall be as follows:
(a) For protected facilities having under 300 sprinklers -no fewer than 6 sprinklers
(b) For protected facilities having 300 to 1000 sprinklers - no fewer than 12 sprinklers
(c) For protected facilities having over 1000 sprinklers -no fewer than 24 sprinklers 1998 NFPA 25, 2-4.1.5.

Based on observation, record review and interview the facility does not assure a fire watch procedure and policy is written and available for implementation when the fire sprinkler system is out of service for more than 4 hours in a 24-hour period, for 12 of 12 months of records reviewed, for 2010. This deficient practice would allow facility exposure to undetected smoke and/or fire without an automatic sprinkler compensatory provision when it occurred, and without appropriately prepared staff response, affecting twenty-four of twenty-four smoke zones. The facility has 24 smoke zones on five floors total. The facility has a capacity of 300 with a census of 126 at the time of survey.

Findings Include:

During the tour on January 31st, 2011 beginning at 11:30 AM and February 2nd ending at 12:30 PM it is observed during record review that no written fire watch policy and procedures are available for when the fire sprinkler systems are out of service as required.

Staff D acknowledged that the facility's fire watch policy does not include wording indicating that a fire watch will be implemented when the fire sprinkler system is out of service for more than 4 hours in a 24-hour period.

NFPA Standard: Where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the AHJ shall be notified, and the building shall be evacuated or an approved fire watch shall be provided until the sprinkler system has been returned to service. 2000 NFPA 101, 9.7.6.1

NFPA Standard: The following procedures shall be implemented: the extent and expected duration of the impairment shall be determined; the area or buildings involved shall be inspected and the increased risks determined; and recommendations submitted to management or building owner/manager. Where a required fire protection system is out of service for more than 4 hours in a 24-hour period, the impairment coordinator shall arrange for one of the following: evacuation of the building affected by the system out of service; an approved fire watch; establishment of a temporary water supply; implementation of a program to eliminate potential ignition sources and limit the amount of fuel available; notification of the fire department; the insurance carrier, the alarm company, building owner/manager, and other AHJ ' s; notification of the supervisors in the affected areas; a tag impairment system has been implemented; all necessary tools and materials have been assembled on the site for preplanned impairments. A fire watch should consist of trained personnel who continuously patrol the effected area, with ready access to fire extinguishers and the ability to promptly notify the fire department. During the patrol of the area, the person should be looking for fire, and other fire protection features of the building such as egress routes and alarm systems are available and functioning properly. 1998 NFPA 25, 11-5