HospitalInspections.org

Based on observation and interview, the facility failed to maintain grease filters of the kitchen range hood in accordance with NFPA 96, 5.1.4 and 6.2.3.3.

This failure could allow grease buildup in the kitchen range exhaust hood assembly and affect the safety of the building's inhabitants in the event of a fire or emergency.

Findings included:

During observation of the commercial range exhaust hood in the kitchen on 02/20/24, there was an approximate 5 inch gap between grease filters over the deep fryer. Additionally, there was no grease tight seal in the inner corner of the hood. The Director of Plant Operations confirmed the observations in the kitchen exhaust hood.

.

Based on observation, interview, and record review, the facility failed to maintain the fire alarm system free of system errors, in accordance with NFPA 72, 10.19.

This failure could affect the reliability of the building's fire protection system and affect the safety of the building's inhabitants in the event of a fire or emergency.

Findings included:

During observations of the fire alarm control panel on 02/20/24 and 02/21/24, the panel visually indicated a trouble signal. The Director of Plant Operations said the signal was due to a tamper switch on a fire sprinkler valve on the first floor near the emergency room admission area that couldn't be reset and cleared. Observations of the fire sprinkler valve on the first floor at the aforementioned location revealed the sprinkler valve's electronic monitoring device indicator was lit up red. The facility's most recent fire alarm inspection report dated 10/16/23 (conducted by a contracted vendor) indicated a "trouble on panel due to bad tamper".

.

Based on observation and interview, the facility failed to maintain fire sprinkler heads free of foreign material in the kitchen, in accordance with NFPA 25, 5.2.1.1.2(5).

This failure could affect the reliability of the building's fire protection system and affect the safety of the building's inhabitants in the event of a fire or emergency.

Findings included:

During observation in the kitchen on 02/20/24, three fire sprinkler heads in the vicinity of the cooking range hood had dust on their deflectors and response elements. The Director of Emergency Project Management confirmed the observations of the sprinkler heads.

.

Based on observation and interview, the facility failed to ensure the smoke barrier wall on the 1st floor (1 of 9 hospital floors) was constructed to a ½ hour fire resistance rating in accordance with NFPA 101, 19.3.7.3 and 8.5.

This failure could compromise the integrity of the smoke barrier wall and permit smoke/fire to transfer from one smoke compartment to another in the event of a fire and affect the safety of the patients.

Findings included:

During observation and interview on 02/21/24, the portion of the 1st floor smoke barrier wall located above the ceiling of the chapel had an unsealed hole around a conduit penetration. Along the first floor smoke barrier wall above the ceiling near emergency room timeclock, there was a 16-inch by 10-inch scab patch attached to the wall. The Director of Plant Operations confirmed the observations in the smoke barrier walls.

.

Based on observation, interview, and record review, the facility failed to ensure an air handler unit shut down upon detection of smoke, in accordance with NFPA 90A, 6.4.3.1 as referenced by NFPA 101, 19.5.2.1. and 9.2.

This failure could allow smoke to recirculate in the duct system the event of a fire and affect the safety of the patients.

Findings included:

Review of the facility's most recent fire alarm inspection report dated 10/16/23 revealed two of three duct detectors for AHU-26 (air handler unit 26) failed to shut the unit down.

During observation and interview on 02/21/24 in the mechanical room on the 7th floor, the plant operations unit director tested the two duct detectors (one for supply and one for return) on AHU-26. The detectors' status lit up red, but the air handler unit failed to shut down up detection of smoke. The test was repeated twice with the same result. The Director of Plant Operations confirmed the result and said their vendor would need to resolve the issue.

.