HospitalInspections.org

Based upon observation, interview and document review, the building construction types are not separated in accordance with Code requirements. Failure to separate the different construction types can expose the lesser construction type to failure from the effects of a fire originating in the greater construction type.

Findings include:

On 6/13/17 at 9:30am while in the company of the DPO it was observed above the cross corridor doors at the top of the ramp corridor south of the main lobby that the indicated 3-hour barrier separating the different construction types was not complete to the bottom of the roof deck to comply with 8.2.1.3(3). The fully sprinklered 1-story with basement structure of Type II (000) construction type is permitted but must be separated from the fully sprinklered 3-story structure of Type I (332) construction type because Type II (000) is not permitted by 19.1.6.1 for a 3-story structure.

Based on observation, means of egress is not maintained free of obstructions to reach the public way or area of refuge away from the building. Failure to provide an unobstructed path can compromise occupants ability to reach the area of safety.

Findings include:

On 6/13/17 at 10:05am while in the company of the DPO it was observed that the south exit door from the 1st floor leads through the smoker's fenced patio which is equipped with a gate which has a latching device which has an unfamiliar system of operation under all lighting conditions and is hard to operate to release the gate to comply with 7.2.1.5.10. The gate is not free-swinging to the full open position and is obstructed by overgrown landscaping in noncompliance with 7.2.1.4.1.

Based upon observation, patient sleeping room corridor doors are provided with locking hardware which does not permit egress from the room side. Failure to provide means of egress from the rooms can prevent occupants from leaving the room to reach an exit or place of safety during a fire/smoke event.

Findings include:

On 6/12/17 at 8:15am while in the company of the DPO it was observed that typical patient sleeping room doors on the 3rd floor (and the 2nd floor also) are equipped with both a latchset and a separate dead bolt lock which is only operable with a key from the corridor side. The dead bolt thumbturn device on the room side of the door has been disabled so as not to be in compliance with 19.2.2.2.4 or the provisions of 19.2.2.2.5.

Based upon observation and staff interview, egress doors are provided with locking hardware which does not permit egress from the building for non-clinical need occupants. Failure to provide means of egress from the building can prevent occupants from reaching an exit or place of safety during a fire/smoke event.

Findings include:

On 6/13/17 at 10:45am while in the company of the DPO it was observed that the 1st floor was equipped with locking devices on the means of egress doors. Doors throughout the facility have locks, including exits, which require the use of a key carried by staff. During interview with the DPO and RTC Administrator, the RTC (Resident Treatment Center) unit on the 1st floor was indicated to house residents that are not clinical need patients. Locks on the 1st floor means of egress doors do not comply with the provisions of 19.2.2.2.4 and 19.2.2.2.5.2(2) because a total (complete) smoke detection system is not provided for the 1st floor or all locked doors cannot be remotely unlocked at an approved, constantly attended location within the locked space of the 1st floor.

Based upon observation, doors required to be self-closing are held open with non-approved devices. Failure to provide self-closing doors can permit a delay in activation of protective systems and the spread of fire and smoke to other parts of the building.

Findings include:

On 6/13/17 at 10:15am it was observed while in the company of the DPO that the Kitchen "office" used as a storage room and identified on the life safety drawings as a hazardous area had the door propped open with a wedge in non-compliance with 19.2.2.2.7.

Based upon observation, exit stair enclosures are not maintained to meet their required fire resistance rating. Failure to maintain the fire resistance rated enclosure of the exits can compromise the level of safety the exit is expected to provide.

Findings include:

On 6/13/17 at 8:45am it was observed in the company of the DPO that the 2nd floor Stair #2 door was not fire resistance rated labeled to comply with 7.1.3.2.1, 8.3.3.1 and 8.3.3.2.3.

Based on observation and staff interview, illumination of the exit discharge portion of the means of egress is not provided to maintain illumination of the means of egress in the event of failure of the normal power supply. Failure to maintain illumination of the means of egress can affect all persons in the facility required to utilize the exit(s) by preventing safe and unimpeded access to the public way.

Findings include:

On 6/13/17 at 10:05am while in the company of the DPO, it was observed that typical exit discharge lighting was not of the instant-on type to provide illumination within the required 10 second period to comply with 19.2.8, 19.2.9 and 7.8 & 7.9.1.3. Not all exit discharge locations were provided with multiple fixtures (or fixtures with multiple lamps) to comply with 7.8.1.4.

Based upon observation, Exit signage is not provided to accurately identify access to Exits. Failure to accurtely identify exit paths can confuse occupants and delay occupants from accessing the safety of an exit.

Findings include:

A. On 6/13/17 at 9:00am it was observed on the 2nd floor that directional exit signs identified patient room doors or directions as the access to exits when they are not. Directional signs provided in accordance with 7.10.1.5.1 and 7.10.2.1 misdirect/misidentify the required path of travel.

B. On 6/13/17 at 10.35am it was observed that exit signage is not provided at the north end of the east corridor of the 1st floor in the "Acute" unit to comply with 19.2.5.4 and 7.10.1.5.

Based upon observation, vertical openings are not constructed and maintained to provide separation of floor levels in accordance with requirements. Failure to protect vertical openings can permit the effects of a fire/smoke event to expose and compromise the safety of occupants on other floor levels.

Findings include:

On 6/12/17 at 3:30pm while in the company of the DPO it was observed in the basement level Mechanical Equipment room (near fire pump) that multiple penetrations through the floor above were not protected in accordance with 19.3.1 and 8.3.5.1.

Based upon observation, hazardous areas are not protected in accordance with Code requirements. Failure to provide protection of areas with a higher degree of hazard than normal to the remaining occupancy can compromise the safety of all occupants during a fire/smoke event originating within the hazardous area.

Findings include:

On 6/13/17 at 8:30am while in the company of the DPO it was observed that the 3rd floor east soiled utility room fire rated corridor door did not self-close to a latched condition to comply with 19.3.2.1, 8.4.3.5 and 19.3.6.3.5.

Based upon document review and staff interview, fire alarm system components are not tested and maintained to document required testing of system components. Failure to maintain fire alarm system components may result in failure of devices to provide effective early notification of a developing fire/smoke event which can affect the safety of building occupants.

Findings include:

A. On 6/12/17 at 2:00pm while in the company of the DPO during record document review, it was noted that annual fire alarm system testing available for review did not document that sensitivity testing of the smoke detection devices had been done within the last five years to comply with NFPA 72-2010, 14.4.5.3.3.

B. On 6/12/17 at 2:30pm while in the company of the DPO during record document review of the sprinkler system/fire pump testing and maintenance records, it was noted that the 6/7/16 and 9/15/16 reports of FE Moran indicated that an exterior alarm had intermittant operation. The subsequent reports of 12/5/16 and 3/15/17 by Illini indicated exterior alarms to be "NA". No documentation was available to resolve the deficiency noted in the FE Moran reports and it was not clear why the Illini report was "not applicable". Testing and maintenance records that accurately assess the condition of the system is not being maintained to comply with NFPA 25-2011, 4.3 and NFPA 72-2010, 14.6.

C. On 6/13/17 at 9:45am while in the company of the DPO it was observed at the 1st floor LS electrical panel that not all breakers serving the fire alarm system were marked in red and provided with lock-on devices to comply with NFPA 72-2010, 10.5.5.2.3 & 10.5.5.2.4.

Based on observation, smoke barriers are not maintained to provide subdivision of building floors in accordance with Code requirements. Failure to maintain smoke barrier separations can compromise occupant safety during a fire/smoke event by not providing horizontal movement on a floor level to an area of safety.

Findings include:

On 6/13/17 at 8:20am while in the company of the DPO it was observed that the designated 3rd floor smoke barrier cross corridor double egress doors which are normally held open, did not self-close to a position which would resist the passage of smoke to comply with 19.3.7.6, 19.3.7.8 and 8.5.4.

Based upon observation of record documents and staff interview, documentation of testing of the Essential Electrical Systems (EES) is not maintained in accordance with Code requirements. Failure to maintain testing documentation for the EES can result in failure of the system to perform and provide electrical power as required during loss of normal power.

Finding include:

On 6/12/17 at 2:45pm while in the company of the DPO it was observed that the facility conducted monthly testing under load documentation indicated that the minimum 30% of generator nameplate rating required by NFPA 110-2010, 8.4.2 was not being met and that annual load bank testing to comply with NFPA 110-2010, 8.4.2.3 was performed. However, the 7/8/16 copy of a carbon copy of the report available on site for review was not readable to confirm compliance with NFPA 110-2010, 8.3.4.