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Based on observation, the hospital failed to maintain doors protecting corridor openings to resist the passage of smoke. Failure to maintain doors protecting corridors risks the passage of smoke into the corridor thereby risking occupant ability safety exit during a fire/smoke emergency.

Findings:

During a tour of the hospital on 7/13/10, corridor doors for basement conference room A &B were found held open with door stop wedges. These doors had automatic door closures. On this same tour, a cross corridor smoke door held open with magnets inter connect to the fire alarm system did not close completely when tested. On this same tour, the laboratory door was found to not latch and the microbiology lab door was held open with a door stop wedge.

Based on observation and interview, the hospital failed to provide a fire resistive construction enclosure or seal an abandoned dumbwaiter vertical opening between floors. Failure to protect or seal vertical openings between floors, risk occupant safety from he movement of smoke and potentially fire between floors.

Findings:

During a tour of the first floor Urology Unit on 7/13/10, a dumbwaiter door was found open.

Staff stated during an interview on 7/13/10 that the dumbwaiter was not in use.

Based on observation, the hospital failed to provide emergency lighting of at least 1.5 hour duration in accordance with 7.9. Failure to provide emergency lighting risks building occupant safety and ability to exit during a power outage.

Findings:

During a tour of the hospital on 7/13/10, the emergency light in the "Administration Office was not able to perform a test and had a light indicating the battery had failed. On this same tour, an emergency light in the man corridor and in a high voltage mechanical room were not able to be tested and had a light indicating the battery had failed.

Based on interview and record review, the hospital failed to conduct fire drills as a part of the established routine at least quarterly on each shift.. Failure to implement routine fire drills for all hospital shifts places all patients on census and other building occupants at risk of inability to evacuate in the event of a fire.

Findings:

Hospital fire drill records showed not drills had been conducted during the night/graveyard shift for the first and second quarter of 2010. Similarly, no record was found for fire drills on the night/graveyard shift during the third and fourth quarter of 2009.

Hospital maintenance representative stated during and interview on 7/15/10 that s/he was not "clear that drills needed to be done during the night shift."


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Based on observation, the hospital failed to install an automatic sprinkler system in accordance with NFPA 13 in the Radioactive Storage Room. Failure to install a complete automatic sprinkler system risk spread of fire should an ignition occur.

Findings:

During a tour of the hospital basement on 7/13/10, no sprinkler was found installed in the Radioactive Storage Room.

Based on observation, review of hospital maintenance records, and interview with hospital staff, the hospital failed to maintain the automatic sprinkler system so that valves are supervises to alarm when closed [NFPA 72, 9.7.2.1]. Failure to maintain the automatic sprinkler system risks sprinkler failure to operate should the water supply be shut off.

Findings:

During a tour of the hospital on 7/13/10, the fire alarm panel in the PBX room showed "trouble."

Hospital maintenance report reviewed on 7/15/10 for the annual sprinkler system showed that four tamper switch in the system were not wired to the fire alarm control panel.

Hospital maintenance staff stated during the tour that "the water flow switch needed to be repaired and a work order with a contractor had not started."

Based on observation and review of maintenance documents, the hospital failed to maintain the FM 200 automatic fire extinguishing systems. Failure to maintain these systems risk the spread of fire if the systems failed to activate placing all building occupants at risk.

Findings:

During a tour of the hospital on 7/13/10, the FM200 systems in the telecommunications room and pharmacy had tags showing preventative maintenance in 2008. Items were stored in front of the panel and tanks in each space.

No evidence was found in hospital maintenance documents showing the systems had current prevenative maintenace.

Based on observation, the hospital failed to provide protection for cooking facilities in accordance with 9.2.3. Failure to provide protecting for cooking facilities in accordance with 9.2.3, risk uncontrolled spread of cooking fires.

Findings:

During a tour of the kitchen on 7/13/10, a deep fat fryer was in use under the hood which was not protected by a listed UL300 System. A K-class fire extinguisher was not found in the kitchen. During a follow up visit to the kitchen on 7/14/10 the deep fat fryer was found covered but still installed under the kitchen hood.

During a tour of the kitchen on 7/13/10, no gas shut off interlocked with the under hood water fire suppression system was installed. Hospital maintenance documents confirmed no gas shut off when the alarm was tested.

Based on observation, the hospital failed to maintain egress corridors clear and free of obstructions to exiting. Failure to maintain clear and unobstructed exit pathway risks the ability of building occupants to exit during a fire or smoke event.

Findings:

During a tour of the Central Supply area on 7/13/10, storage bins and shed bins were observed in the corridor.

During a tour of the Emergency Department on 7/14/10, supply carts, gurneys and charging vital signs monitors were observed in the corridor.

During a tour of the 4th floor patient unit on 7/14/10, wheel chairs, large water bottles, and 50 gal paper shred containers were found in the corridor.

Based on observation, the hospital failed to store trash collection containers greater than 32 gal capacity in a room protected as a hazardous area when not attended. Failure to store trash collection containers in a protected area when not in use risk proliferation of smoke fire should ignition occur.

Findings:

During a tour of the corridor near Central Supply on 7/13/10 3- 50 gallon paper shredding containers were found.

During a tour of the 4th Floor on 7/14/10, a 50 gallon paper shredding container was in the corridor

Based on observation, the hospital failed to protect pipe and conduits penetrations in smoke barriers to maintain the smoke resistance of the barrier [reference NFPA 101 8.3.6]. Failure to maintain the smoke resistance of a required smoke barrier risks hospital occupant exposure to smoke while defending in place.

Findings:

During a tour of the hospital on 7/13/10, unsealed penetrations were found in the fire/smoke wall at 1 East outside the pathology area. On this same tour, holes were observed in the corridor wall of the Radioactive Storage Room.

During a tour of the hospital 7/14/10, unsealed penetrations were found around new pipe in the 1st floor mechanical room wall. On this same tour, unsealed penetrations were found in the 3rd floor electrical room wall.

Based on observation, the hospital failed to maintain doors protecting corridor openings to resist the passage of smoke. Failure to maintain doors protecting corridors risks the passage of smoke into the corridor thereby risking occupant ability safety exit during a fire/smoke emergency.

Findings:

During a tour of the hospital on 7/13/10, corridor doors for basement conference room A &B were found held open with door stop wedges. These doors had automatic door closures. On this same tour, a cross corridor smoke door held open with magnets inter connect to the fire alarm system did not close completely when tested. On this same tour, the laboratory door was found to not latch and the microbiology lab door was held open with a door stop wedge.

Based on observation and interview, the hospital failed to provide a fire resistive construction enclosure or seal an abandoned dumbwaiter vertical opening between floors. Failure to protect or seal vertical openings between floors, risk occupant safety from he movement of smoke and potentially fire between floors.

Findings:

During a tour of the first floor Urology Unit on 7/13/10, a dumbwaiter door was found open.

Staff stated during an interview on 7/13/10 that the dumbwaiter was not in use.

Based on observation, the hospital failed to provide emergency lighting of at least 1.5 hour duration in accordance with 7.9. Failure to provide emergency lighting risks building occupant safety and ability to exit during a power outage.

Findings:

During a tour of the hospital on 7/13/10, the emergency light in the "Administration Office was not able to perform a test and had a light indicating the battery had failed. On this same tour, an emergency light in the man corridor and in a high voltage mechanical room were not able to be tested and had a light indicating the battery had failed.

Based on interview and record review, the hospital failed to conduct fire drills as a part of the established routine at least quarterly on each shift.. Failure to implement routine fire drills for all hospital shifts places all patients on census and other building occupants at risk of inability to evacuate in the event of a fire.

Findings:

Hospital fire drill records showed not drills had been conducted during the night/graveyard shift for the first and second quarter of 2010. Similarly, no record was found for fire drills on the night/graveyard shift during the third and fourth quarter of 2009.

Hospital maintenance representative stated during and interview on 7/15/10 that s/he was not "clear that drills needed to be done during the night shift."


.

Based on observation, the hospital failed to install an automatic sprinkler system in accordance with NFPA 13 in the Radioactive Storage Room. Failure to install a complete automatic sprinkler system risk spread of fire should an ignition occur.

Findings:

During a tour of the hospital basement on 7/13/10, no sprinkler was found installed in the Radioactive Storage Room.

Based on observation, review of hospital maintenance records, and interview with hospital staff, the hospital failed to maintain the automatic sprinkler system so that valves are supervises to alarm when closed [NFPA 72, 9.7.2.1]. Failure to maintain the automatic sprinkler system risks sprinkler failure to operate should the water supply be shut off.

Findings:

During a tour of the hospital on 7/13/10, the fire alarm panel in the PBX room showed "trouble."

Hospital maintenance report reviewed on 7/15/10 for the annual sprinkler system showed that four tamper switch in the system were not wired to the fire alarm control panel.

Hospital maintenance staff stated during the tour that "the water flow switch needed to be repaired and a work order with a contractor had not started."

Based on observation and review of maintenance documents, the hospital failed to maintain the FM 200 automatic fire extinguishing systems. Failure to maintain these systems risk the spread of fire if the systems failed to activate placing all building occupants at risk.

Findings:

During a tour of the hospital on 7/13/10, the FM200 systems in the telecommunications room and pharmacy had tags showing preventative maintenance in 2008. Items were stored in front of the panel and tanks in each space.

No evidence was found in hospital maintenance documents showing the systems had current prevenative maintenace.

Based on observation, the hospital failed to provide protection for cooking facilities in accordance with 9.2.3. Failure to provide protecting for cooking facilities in accordance with 9.2.3, risk uncontrolled spread of cooking fires.

Findings:

During a tour of the kitchen on 7/13/10, a deep fat fryer was in use under the hood which was not protected by a listed UL300 System. A K-class fire extinguisher was not found in the kitchen. During a follow up visit to the kitchen on 7/14/10 the deep fat fryer was found covered but still installed under the kitchen hood.

During a tour of the kitchen on 7/13/10, no gas shut off interlocked with the under hood water fire suppression system was installed. Hospital maintenance documents confirmed no gas shut off when the alarm was tested.

Based on observation, the hospital failed to maintain egress corridors clear and free of obstructions to exiting. Failure to maintain clear and unobstructed exit pathway risks the ability of building occupants to exit during a fire or smoke event.

Findings:

During a tour of the Central Supply area on 7/13/10, storage bins and shed bins were observed in the corridor.

During a tour of the Emergency Department on 7/14/10, supply carts, gurneys and charging vital signs monitors were observed in the corridor.

During a tour of the 4th floor patient unit on 7/14/10, wheel chairs, large water bottles, and 50 gal paper shred containers were found in the corridor.

Based on observation, the hospital failed to store trash collection containers greater than 32 gal capacity in a room protected as a hazardous area when not attended. Failure to store trash collection containers in a protected area when not in use risk proliferation of smoke fire should ignition occur.

Findings:

During a tour of the corridor near Central Supply on 7/13/10 3- 50 gallon paper shredding containers were found.

During a tour of the 4th Floor on 7/14/10, a 50 gallon paper shredding container was in the corridor

Based on observation, the hospital failed to protect pipe and conduits penetrations in smoke barriers to maintain the smoke resistance of the barrier [reference NFPA 101 8.3.6]. Failure to maintain the smoke resistance of a required smoke barrier risks hospital occupant exposure to smoke while defending in place.

Findings:

During a tour of the hospital on 7/13/10, unsealed penetrations were found in the fire/smoke wall at 1 East outside the pathology area. On this same tour, holes were observed in the corridor wall of the Radioactive Storage Room.

During a tour of the hospital 7/14/10, unsealed penetrations were found around new pipe in the 1st floor mechanical room wall. On this same tour, unsealed penetrations were found in the 3rd floor electrical room wall.