HospitalInspections.org

Based on observation, record review and facility staff interview, the facility failed to provide a 1-hour rated separation between a hazardous area (areas that pose a degree of hazard greater than normal to the general occupancy of the building such as areas used for storage or use of combustibles or flammables, toxic, noxious, or corrosive materials, or heat producing appliances) and two designated exit corridors in the facility per NFPA (National Fire Protection Association) requirements. Failure to separate the designated exits and provide the one hour rated separation walls and provide a fire rated door equipped with a self-closing device puts all patients, staff and visitors at risk of injury or death from a fire by not containing the fire and smoke within the hazardous area and eliminating the two required means of egress. The facility census was 427.


1. Observation on 1/27/2016 at 4:15 PM, during the facility tour, showed:

- a deep fryer in operation in the Servery. Observation showed the fryer was not enclosed by one hour rated walls and a fire rated door equipped with a self-closing device creating a hazardous area. Observation showed the fryer open to the corridor running thru the Servery.

-a designated exit stairwell number 4A discharged into the open compartment Servery containing the deep fryer requiring staff, patients and visitors to pass thru a hazardous area to reach the exit to get out of the building in the event of a fire.

-a designated North exit from the hospital corridor exited into the
Servery and discharged into the open compartment containing the deep fryer requiring staff, patients and visitors to pass thru a hazardous area to reach the exit to get out of the building in the event of a fire.

2. Record review of a facility layout of the ground floor showed the Servery located in smoke compartment (SC), labeled G-4 Health Care, measured approximately 17,851 square feet.

3. During an interview on 1/28/16 at 11:00 AM, Staff SSS, Plant Operations, acknowledged the finding and stated the facility opened the Servery 1/27/2016. Additionally he said that he did not know the deep fryer had an influence on the use of the corridor.

NFPA 101, 2000 edition, section 19.3.2.1 states: "Hazardous Areas. Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors. The doors shall be self-closing or automatic closing. Hazardous areas shall include, but shall not be restricted to, the following:

(1) Boiler and fuel fired heater rooms
(2) Central/bulk laundries larger than 100 (square) ft (9.3m squared)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 (square) feet (4.6m squared), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.

Exception: Doors in rated enclosures shall be permitted to have non-rated, factory- or field- applied protective plates extending not more than 48 in. (122 cm) above the bottom of the door."

Based on observation and facility staff interview, the facility failed to provide a complete fire alarm system in accordance with NFPA (National Fire Protection Association) 72, National Fire Alarm Code, 1999 Edition requirements. The facility staff failed to ensure smoke detector installation complied with NFPA 72 requirements. This deficient practice has the potential to affect all facility patients, visitors and staff by potentially delaying the detector response time, emergency response time and exposing them to smoke and fumes in the event of a fire. Failure to ensure correct smoke detector placement according to NFPA 72 could delay the detector's response time which would delay the fire alarm notifying building occupants of a fire. This deficient practice could effect the fire alarm systems ability to operate properly in 46 of 46 smoke compartments. The facility census was 427.

Findings include:

1. Observations made from 1/25/2016 through 1/27/2016, during the facility tour, showed the following corridor and corridor smoke compartment areas did not contain smoke detectors spaced at 30 feet between detectors:

- Smoke detectors spaced 50 feet apart in Old Physical Therapy Gym on 6th floor
- Smoke detectors spaced over 70 feet apart on 6th floor West
- Smoke detectors spaced 42 feet apart in the 5th floor East Neonatal Intensive Care Unit
-Smoke detectors spaced 60 feet apart and 79 feet apart in the 4th floor West Intensive Care Unit Visitors Hall
-Smoke detectors spaced approximately 100 feet apart from patient room #462 extending through the compartment to the Nurse's Station
-Smoke detectors spaced 63 feet apart, 65 feet apart, and 50 feet apart on the 3rd floor in 3 West and Telemetry corridors
-Smoke detectors spaced 50 feet apart in 2 West corridor on the 2nd floor
-No smokes detectors in corridor smoke compartment between patient rooms #260-252 on 2 East on 2nd floor
-One smoke detector in the Doctor's Lounge exit corridor measuring approximately 100 feet long on the 1st floor
-One smoke detector in the Same Day Surgery exit corridor measuring approximately 90 feet long on the 1st floor
-No smokes detectors in corridor smoke compartment of the Laboratory on the 1st floor
-One smoke detector 75 feet from end the end of the Same Day Surgery South Ramp exit corridor extending by rooms #10-18 on the 1st floor


Observation on 1/27/2016 at 1:25 PM did not show a smoke detector in the center core of the Emergency Department Nurse's Station with an approximately 4 feet elevation change between the surrounding ceiling and Center Core ceiling heights.

During an interview on 1/28/16 at 10:15 AM, Staff SSS, Plant Operations, acknowledged the findings and stated that the facility installed a new complete fire alarm system replacement project started in 2013 and was completed in 2014. He said that the previous Team Leader of Plant Operations trusted that the vendor installed the new fire alarm system per code requirements.

NFPA 101, 2000 edition, section 9.6.2.9 states: "Where a partial smoke detection system is required by another section of this Code, automatic detection of smoke in accordance with NFPA 72, National Fire Alarm Code, shall be provided in all common areas and work spaces, such as corridors, lobbies, storage rooms, equipment rooms, and other tenantless spaces in those environments suitable for proper smoke detector operation. Selective smoke detection unique to other sections of this Code shall be provided as required by those sections."

NFPA 72, National Fire Alarm Code, 1999 edition, Section 2-1.4.2.2 states: "Partial Coverage. If required, partial detection systems shall be provided in all common areas and work spaces, such as corridors, lobbies, storage rooms, equipment rooms, and other tenantless spaces in those environments suitable for proper detector operation in accordance with this code."


NFPA 72, 1999 Edition, Section 2-3.4.5.1.1 states: "On smooth ceilings, spacing of 30 ft (9.1 m) shall be permitted to be used as a guide. In all cases, the manufacturer's documented instructions shall be followed. Other spacing shall be permitted to be used depending on ceiling height, different conditions, or response requirements. For the detection of flaming fires, the guidelines in Appendix B shall be permitted to be used."


NFPA 72, 1999 Edition, Section 2-3.4.6.1 states: "Flat Ceilings. For ceiling heights of 12 ft (3.66 m) or lower, and beam or solid joist depths of 1 ft (0.3 m) or less, smooth ceiling spacing running in the direction parallel to the run of the beams or solid joists shall be used and one-half the smooth ceiling spacing shall be in the direction perpendicular to the run of the beams or solid joists. For beams over 1 ft (0.3 m) in depth, spot type detectors shall be permitted to be located either on the ceiling or on the bottom of the beams.

For beam depths exceeding 1 ft (0.3 m) or for ceiling heights exceeding 12 ft (3.66 m), spot-type detectors shall be located on the ceiling in every beam pocket.
For solid joists, the detectors shall be located on the bottom of the joists."

NFPA 101, 2000 Edition, Section 18.1.1.1.1 states: "General. The requirements of this chapter apply to the following:

(1) New buildings or portions thereof used as health care occupancies (see 1.4.1)
(2) Additions made to, or used as, a health care occupancy (see 4.6.6 and 18.1.1.4)

Exception: The requirement of 18.1.1.1.1 shall not apply to additions classified as occupancies other than health care that are separated from the health care occupancy in accordance with 18.1.2.1(2) and conform to the requirements for the specific occupancy in accordance with Chapters 12 through 17 and Chapters 20 through 42, as appropriate.

(3) Alterations, modernizations, or renovations of existing health care occupancies (see 4.6.7 and 18.1.1.4)

(4) Existing buildings or portions thereof upon change of occupancy to a health care occupancy (see 4.6.11)

Exception:* Facilities where the authority having jurisdiction has determined equivalent safety has been provided in accordance with Section 1.5."

NFPA 101, 2000 Edition, Section 4.6.7 states: "Modernization or Renovation. Any alteration or any installation of new equipment shall meet, as nearly as practicable, the requirements for new construction. Only the altered, renovated, or modernized portion of an existing building, system, or individual component shall be required to meet the provisions of this Code that are applicable to new construction. If the alteration, renovation, or modernization adversely impacts required life safety features, additional upgrading shall be required. Existing life safety features that do not meet the requirements for new buildings, but that exceed the requirements for existing buildings, shall not be further diminished. In no case shall the resulting life safety features be less than those required for existing buildings."

Based on observation and staff interview, the facility failed to ensure the correct application of sprinkler heads for the entire building. The facility failed to ensure all sprinkler heads were not obstructed and quick response sprinkler heads and regular response sprinkler heads were not mixed together in the same compartment/area. Two areas contained the mix of sprinkler type heads and one room contained a blocked sprinkler head. These deficient practices have the potential to affect all facility patients, visitors and staff by potentially delaying the sprinkler system response time, emergency response time and exposing them to smoke and fumes in the event of a fire. The facility census was 427.

1. Observation on 1/26/2016 at 1:28 PM, during the Life Safety Code tour, showed two quick response sprinkler heads mixed with regular response sprinkler heads in the 6th floor three car elevator lobby compartment.

2. Observation on 1/27/2016 at 10:45 AM, during the Life Safety Code tour, showed one regular response sidewall sprinkler head mixed with quick response sprinkler heads in the Doctor's Lounge exit corridor on the 1st floor.

3. Observation on 1/27/2016 at 1:40 PM, during the Life Safety Code tour, showed two quick response sprinkler heads mixed with regular response sprinkler heads in the Radiation Oncology compartment over the Linear Accelerator Operations desk on the 1st floor.

4. Observation on 1/27/2016 at 1:40 PM, during the Life Safety Code tour, showed one recessed quick response sprinkler head blocked by an examination light gantry frame in Catheter Lab Room A on the 1st floor.

During an interview on 1/28/16 at 10:18 AM, Staff SSS, Plant Operations, acknowledged the findings and stated that he did not know that the zones contained a mix of quick and standard sprinkler heads. Additionally, he said that he did not know about the blocked sprinkler head in the Catheter lab.

NFPA 13, Installation of Sprinkler Systems, 1999 Edition, Section 5-3.1.5.2 states: "When existing light hazard systems are converted to use quick-response or residential sprinklers, all sprinklers in a compartment space shall be changed."

The National Fire Protection Association 13, Installation of Sprinkler Systems, 1999 edition, section 5-6.5.2.1 states: "Continuous or noncontinuous obstructions less than or equal to 18 in. (457 mm) below the sprinkler deflector that prevent the pattern from fully developing shall comply with this section. Regardless of the rules of this section, solid continuous obstructions shall meet the requirements of 5-6.5.1.2."

Based on observation and facility staff interview, the facility failed to maintain one of one range hood in accordance with National Fire Protection Association (NFPA) 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 1998 edition requirements. Failure to maintain a range hood in accordance with NFPA 96 has the potential to affect all patients, staff and visitors. This deficient practice could spread a grease fire throughout the kitchen. This deficient practice has the potential to effect all patients, staff and visitors by creating conditions which increase the quantity of flammable material available to burn and by spreading the flammable cooking grease within the kitchen area beyond the range hood extinguishing system's area of coverage. Failure to maintain the range hood per NFPA code requirements could effect the range hood's ability to contain a grease fire in the event of a fire. The facility census was 427.

Observation on 1/27/2016 at 3:45 PM, during the facility tour, showed the range hood equipped with two separate grease drip trays (a gutter installed under the range hood to collect grease and direct it into catch pans for removal). Observation showed each drip tray contained two rags placed into the grease drip trays. Observation showed the rags soaked with grease and water from the range hood. Additional observation showed the rags blocked the grease and water collected in the drip trays from running out of the drip trays and into the catch pans. Observation showed a large accumulation of grease and water pooled in the drip trays increasing the amount of combustible fluid above the open flames of the gas fueled grill and the boiling grease of the deep fryer. Observation showed the catch pans filled to capacity with grease and water. Observation showed an accumulation of grease and water mixture dripping from the lowest edge of the drip trays over the stoves, grills, deep fryer and floor under the drip trays. Observation of the grease drip trays showed a gap in each tray measuring approximately one inch wide. Observation showed the grease and water mixture dripping from the gaps in each drip tray onto the kitchen floor beyond the edges of the range hood extinguishing system's coverage area. Observation showed a grease and water mixture from the drip trays draining into pans containing beef and chicken on one side of the range hood and a large cauldron of boiling water on the opposite side of the range hood.

During an interview on 1/28/16 at 11:00 AM, Staff SSS, Plant Operations, acknowledged the findings and stated that the facility and outside vendors have been working on the range hood issue but have not resolved the problem.


NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 1998 edition, section 3-2.6 states: "Filters shall be equipped with a drip tray beneath their lower edges. The tray shall be kept to the minimum size needed to collect grease and shall be pitched to drain into an enclosed metal container having a capacity not exceeding 1 gal (3.785 L)".