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Based on observation, the facility failed to maintain self closing doors that would close and resist the passage of smoke. This was evidenced by doors that were tested for positive latching and failed. This affected 1 of 4 smoke compartments and had the potential to allow the spread of smoke in the event of a fire.

Findings:

During a tour of the facility with the Maintenance Staff 1 on 8/18/15, the doors with self closing devices were observed.

Building A, Existing Hospital

1. At 4:00 p.m., there was a door with a self closing device that failed to positive latch at the Interpreter Office.
2. At 4:02 p.m., there was a door to an oxygen storage closet adjacent to the nurses station that failed to positive latch.
3. At 4:04 p.m., there was a door for clean linen with a self closing device that failed to positive latch.

Based on observation and interview, the facility failed to maintain their fire alarm system as evidenced by a chime/strobe that failed during testing. This failure affected 1 of 5 smoke compartments in Building E and had the potential to delay the notification of staff in the event of a fire.

NFPA 101 Life Safety Code, 2000 Edition.
Maintaining Existing Equipment
4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

9.6.3.6 Notification signals for occupants to evacuate shall be by audible and visible signals in accordance with NFPA 72, National Fire Alarm Code, and CABO/ANSI A117.1, American National Standard for Accessible and Usable Buildings and Facilities, or other means of notification acceptable to the authority having jurisdiction shall be provided.

Section 39.3.4.3 Occupant Notification
During all times that the building is occupied (see 7.2.1.1.3), the required fire alarm system, once initiated, shall perform one of the following functions.
(a) It shall activate a general alarm in accordance with 9.6.3 throughout the building.
(b) It shall activate an alarm signal in a continuously attended location for the purpose of initiating emergency action by personnel trained to respond to emergencies. Emergency action shall be initiated by means of live voice public address system announcements originating from the attended location where the alarm signal is received. The system shall be permitted to be used for other announcements, provided that the fire alarm use takes precedence over any other use.
Exception: Any other occupant notification means permitted by 9.6.3 shall be permitted in lieu of live voice public address system announcements.

Findings:

During a tour of the facility with Maintenance Staff 1 on 8/18/15, the fire alarm system was tested and observed.

Building E, New Hospital
At 4:55 p.m., on 8/18/15, Maintenance Staff 1 stated the chime/strobe in the Radiology Department corridor failed to function during the annual certification of the fire alarm system conducted seven days ago. The malfunction was noted in the vendor report and was scheduled to be repaired.

Based on record review and interview, the facility failed to inspect their automatic sprinkler inspector test valve(ITV) quarterly. This was evidenced by no records for quarterly ITV test. This affected 5 of 5 smoke compartments in Building A and E and could result in a water flow malfunction going undetected.

NFPA 101 Life Safety Code, 2000 Edition.
19.3.5.1 Where required by 19.1.6, health care facilities shall
be protected throughout by an approved, supervised automatic
sprinkler system in accordance with Section 9.7.
Exception: In Type I and Type II construction, where approved by the
authority having jurisdiction, alternative protection measures shall be
permitted to be substituted for sprinkler protection in specified areas
where the authority having jurisdiction has prohibited sprinklers,
without causing a building to be classified as nonsprinklered.

NFPA 101 Life Safety Code, 2000 Edition.
9.7.1 Automatic Sprinklers.
9.7.1.1* 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.
Exception No. 1: NFPA 13R, Standard for the Installation of Sprinkler
Systems in Residential Occupancies up to and Including Four Stories
in Height, shall be permitted for use as specifically referenced in
Chapters 24 through 33 of this Code.
Exception No. 2: NFPA 13D, Standard for the Installation of Sprinkler
Systems in One- and Two-Family Dwellings and Manufactured
Homes, shall be permitted for use as provided in Chapters 24, 26, 32,
and 33 of this Code.

NFPA 13 Standard for the Installation of Sprinkler Systems, 1999 Edition.
2-3.3* Alarm Devices. Waterflow alarm devices including,
but not limited to, mechanical water motor gongs, vane-type
waterflow devices, and pressure switches that provide audible
or visual signals shall be tested quarterly.

Findings:

During document review with Maintenance Staff 1 on 8/19/15, the records for quarterly sprinkler flow test were reviewed.

At 11:00 a.m., there were no records of quarterly inspectors test valve(ITV)testing. Maintenance Staff 1 stated his understanding was ITV testing was done during the annual certification.

Based on observation, the facility failed to maintain their automatic sprinkler system in accordance with NFPA 13, 1999 Edition. This was evidenced by missing "E" rings that created penetrations in the ceiling around the sprinklers. This affected 4 of 5 smoke compartments in Building A and Building E and could result in the spread of smoke in the event of a fire.

NFPA 101 Life Safety Code, 2000 Edition.
NFPA 101, 2000 Edition. Life Safety Code.
9.7.1.1* 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.
Exception No. 1: NFPA 13R, Standard for the Installation of Sprinkler
Systems in Residential Occupancies up to and Including Four Stories
in Height, shall be permitted for use as specifically referenced in
Chapters 24 through 33 of this Code.
Exception No. 2: NFPA 13D, Standard for the Installation of Sprinkler
Systems in One- and Two-Family Dwellings and Manufactured
Homes, shall be permitted for use as provided in Chapters 24, 26, 32,
and 33 of this Code.

NFPA 13, 1999 Edition. Standard for the Installation of Sprinkler Systems.
3-2.7 Escutcheon Plates.
3-2.7.1 Nonmetallic escutcheon plates shall be listed.
3-2.7.2* Escutcheon plates used with a recessed or flush-type
sprinkler shall be part of a listed sprinkler assembly.


Findings:

During a tour of the facility with Maintenance Staff 1 on 8/18/15, the sprinklers were observed.

Building A, Existing Hospital
1. At 4:05 p.m., there was a sprinkler assembly missing the escutcheon ring at the entrance to the Performance Improvement Coordinators office.

2. At 4:34 p.m., there was a sprinkler assembly missing the escutcheon ring in the H.I.S. Analyst office.

Building E, New Hospital
3. At 7:26 a.m., on 8/19/15, there was a sprinkler missing the escutcheon ring in the equipment room in the OR area.

Based on observation, the facility failed to maintain self closing doors that would close and resist the passage of smoke. This was evidenced by doors that were tested for positive latching and failed. This affected 1 of 4 smoke compartments and had the potential to allow the spread of smoke in the event of a fire.

Findings:

During a tour of the facility with the Maintenance Staff 1 on 8/18/15, the doors with self closing devices were observed.

Building A, Existing Hospital

1. At 4:00 p.m., there was a door with a self closing device that failed to positive latch at the Interpreter Office.
2. At 4:02 p.m., there was a door to an oxygen storage closet adjacent to the nurses station that failed to positive latch.
3. At 4:04 p.m., there was a door for clean linen with a self closing device that failed to positive latch.

Based on observation and interview, the facility failed to maintain their fire alarm system as evidenced by a chime/strobe that failed during testing. This failure affected 1 of 5 smoke compartments in Building E and had the potential to delay the notification of staff in the event of a fire.

NFPA 101 Life Safety Code, 2000 Edition.
Maintaining Existing Equipment
4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

9.6.3.6 Notification signals for occupants to evacuate shall be by audible and visible signals in accordance with NFPA 72, National Fire Alarm Code, and CABO/ANSI A117.1, American National Standard for Accessible and Usable Buildings and Facilities, or other means of notification acceptable to the authority having jurisdiction shall be provided.

Section 39.3.4.3 Occupant Notification
During all times that the building is occupied (see 7.2.1.1.3), the required fire alarm system, once initiated, shall perform one of the following functions.
(a) It shall activate a general alarm in accordance with 9.6.3 throughout the building.
(b) It shall activate an alarm signal in a continuously attended location for the purpose of initiating emergency action by personnel trained to respond to emergencies. Emergency action shall be initiated by means of live voice public address system announcements originating from the attended location where the alarm signal is received. The system shall be permitted to be used for other announcements, provided that the fire alarm use takes precedence over any other use.
Exception: Any other occupant notification means permitted by 9.6.3 shall be permitted in lieu of live voice public address system announcements.

Findings:

During a tour of the facility with Maintenance Staff 1 on 8/18/15, the fire alarm system was tested and observed.

Building E, New Hospital
At 4:55 p.m., on 8/18/15, Maintenance Staff 1 stated the chime/strobe in the Radiology Department corridor failed to function during the annual certification of the fire alarm system conducted seven days ago. The malfunction was noted in the vendor report and was scheduled to be repaired.

Based on record review and interview, the facility failed to inspect their automatic sprinkler inspector test valve(ITV) quarterly. This was evidenced by no records for quarterly ITV test. This affected 5 of 5 smoke compartments in Building A and E and could result in a water flow malfunction going undetected.

NFPA 101 Life Safety Code, 2000 Edition.
19.3.5.1 Where required by 19.1.6, health care facilities shall
be protected throughout by an approved, supervised automatic
sprinkler system in accordance with Section 9.7.
Exception: In Type I and Type II construction, where approved by the
authority having jurisdiction, alternative protection measures shall be
permitted to be substituted for sprinkler protection in specified areas
where the authority having jurisdiction has prohibited sprinklers,
without causing a building to be classified as nonsprinklered.

NFPA 101 Life Safety Code, 2000 Edition.
9.7.1 Automatic Sprinklers.
9.7.1.1* 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.
Exception No. 1: NFPA 13R, Standard for the Installation of Sprinkler
Systems in Residential Occupancies up to and Including Four Stories
in Height, shall be permitted for use as specifically referenced in
Chapters 24 through 33 of this Code.
Exception No. 2: NFPA 13D, Standard for the Installation of Sprinkler
Systems in One- and Two-Family Dwellings and Manufactured
Homes, shall be permitted for use as provided in Chapters 24, 26, 32,
and 33 of this Code.

NFPA 13 Standard for the Installation of Sprinkler Systems, 1999 Edition.
2-3.3* Alarm Devices. Waterflow alarm devices including,
but not limited to, mechanical water motor gongs, vane-type
waterflow devices, and pressure switches that provide audible
or visual signals shall be tested quarterly.

Findings:

During document review with Maintenance Staff 1 on 8/19/15, the records for quarterly sprinkler flow test were reviewed.

At 11:00 a.m., there were no records of quarterly inspectors test valve(ITV)testing. Maintenance Staff 1 stated his understanding was ITV testing was done during the annual certification.

Based on observation, the facility failed to maintain their automatic sprinkler system in accordance with NFPA 13, 1999 Edition. This was evidenced by missing "E" rings that created penetrations in the ceiling around the sprinklers. This affected 4 of 5 smoke compartments in Building A and Building E and could result in the spread of smoke in the event of a fire.

NFPA 101 Life Safety Code, 2000 Edition.
NFPA 101, 2000 Edition. Life Safety Code.
9.7.1.1* 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.
Exception No. 1: NFPA 13R, Standard for the Installation of Sprinkler
Systems in Residential Occupancies up to and Including Four Stories
in Height, shall be permitted for use as specifically referenced in
Chapters 24 through 33 of this Code.
Exception No. 2: NFPA 13D, Standard for the Installation of Sprinkler
Systems in One- and Two-Family Dwellings and Manufactured
Homes, shall be permitted for use as provided in Chapters 24, 26, 32,
and 33 of this Code.

NFPA 13, 1999 Edition. Standard for the Installation of Sprinkler Systems.
3-2.7 Escutcheon Plates.
3-2.7.1 Nonmetallic escutcheon plates shall be listed.
3-2.7.2* Escutcheon plates used with a recessed or flush-type
sprinkler shall be part of a listed sprinkler assembly.


Findings:

During a tour of the facility with Maintenance Staff 1 on 8/18/15, the sprinklers were observed.

Building A, Existing Hospital
1. At 4:05 p.m., there was a sprinkler assembly missing the escutcheon ring at the entrance to the Performance Improvement Coordinators office.

2. At 4:34 p.m., there was a sprinkler assembly missing the escutcheon ring in the H.I.S. Analyst office.

Building E, New Hospital
3. At 7:26 a.m., on 8/19/15, there was a sprinkler missing the escutcheon ring in the equipment room in the OR area.