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CHILDRENS MERCY HOSPITAL
LIFE SAFETY CODE STANDARD
Tag No.: K0027
Based on observation and interview, the facility failed to ensure separation between the corridor smoke compartment and surgical suites in accordance with 18.3.7.8, which requires smoke doors in newly constructed areas to be equipped with rabbets, bevels or astragals at the meeting edges. This deficient practice potentially affects staff, visitors and patients in beds of the second floor. The patient census was 207 patients.
Findings included:
Observation of walls and doors protecting the 2-south surgical suite on 5/11/10 at 1:20 P.M. showed a missing astragal from the double doors labled 2301.900, located outside of the Cath Lab Operating Room. The wood doors were fire rated 1.5 hour doors and located in a one hour wall finished to the concrete roof deck.
During an interview on 5/11/10 at 1:30 P.M., the Director of Plant Engineering said the doors were added as part of new construction that was completed in November and December of 2009. He said they would check all doors in areas of new construction or renovation to ensure they were appropriately smoke tight and equipped with astragals, rabbets or bevels at the meeting edges.
LIFE SAFETY CODE STANDARD
Tag No.: K0076
Based on observation, the facility failed to ensure that all tanks containing compressed medical gasses were individually secured for 12 tanks in the laboratory area. This affects all employees in the laboratory area.
Findings included:
During tour of the laboratory area on 5/13/2010 at approximately 1:30 p.m. 12 tanks of compressed gasses were observed secured by chains to the wall of a laboratory suite. There were three groups of two tanks each held in place by a chain around the two tanks. A separate group of six tanks was secured by one chain around the group of tanks. None of the tanks were individually secured.
Chapter 5.1.3.3.2 of the 2002 edition of the Life Safety Code (NFPA 99) published by the National Fire Protection Association states that locations for the central supply systems and the storage of medical gas shall meet the following requirements: (7) be provided with racks, chains or other fastenings to individually secure all cylinders, whether connected, unconnected, full, or empty from falling.