HospitalInspections.org

Based on observations, during a tour of the facility with facility staff, the facility failed to ensure that a means of egress was marked and illuminated as such. The findings include:
The facility did not ensure that means of egress are continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency, as required by section # 7.1.10 of the "Life Safety Code" as evidenced by inadequate signage in an area of egress.
Observation on 01/13/20 at 10:25 AM with the Director of Facilities, identified the "Center Core" of the surgical suite lacked adequate exit signage, not meeting the requirements set forth by the referenced Life Safety Code standard.

Based on observations, during a tour of the facility with facility staff, the facility failed to ensure that a wall in a biohzard room was free from penetrations to resist the passage of smoke in a fire. The findings include:
The facility did not ensure that hazardous areas protected by an automatic extinguishing system were separated by smoke resisting partitions and self-closing doors as required by 19.3.2.1.2 (walls).
Observation on 01/14/2020 at 10:45 AM with facility maintenance staff, identified the wall in the first floor bio-hazard room had mulitple holes from previously installed wall anchors in the one (1) hour fire rated wall, negating its ability to resist the passage of smoke as required by the referenced life safety code standard.

Based on observations, during a tour of the facility with facility staff, the surveyor observed that the facility failed to ensure that an automatic sprinkler system installed in accordance with NFPA 13 "Standard for the Installation of Sprinkler Systems" provided complete coverage for all portions of the building, specifically in the central sterile supply area. The findings include:
Observation on 01/13/20 at 11:25 AM with the Director of Facilities, the surveyor identified that while the facility is fully sprinklered, mechanical access areas behind the sterilizing machines and the cart wash station lacked adequate fire sprinkler coverage, not meeting the requirements set forth by NFPA 13 and NFPA 101.

Based on observations by the surveyor during a tour of the facility with Engineering Department staff, the facility did not ensure that smoke barriers were constructed to provide at least a one half hour fire resistance rating in accordance with 8.5. 19.3.7.6, 19.3.7.8, and 19.3.7.9 fo the life safety code. The findings and/or findings include:
Observations on 01/14/2020 at 11:00 AM with maintenance staff, the surveyor identified that the one (1) hour fire rated doors for the first floor mechanical room adjacent to the Engineering Office within the service corridor when released from their magnetic hold open devices, the one (1) hour fire rated doors were bound on the meeting edge, not allowing the doors to self-close in order to maintain the integrity of the barrier as required by section(s) 19.3.7.6, 19.3.7.8, and 19.3.7.9 of NFPA 101.