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PAUL OLIVER MEMORIAL HOSPITAL
Cooking Facilities
Tag No.: K0324
Based on observation and interview, the facility failed to ensure cooking facilities are protected in accordance with NFPA 96, unless meeting the requirements of 19.3.2.5.2, 19.3.2.5.3 or 19.3.2.4.4, as required by 19.3.2.5.1 through 19.3.2.5.5, 9.2.3 and TIA 12-2. This deficient practice could affect all occupants in the event of fire emergency.
Findings Include:
On 05/18/22 at approximately 9:26 AM, observation revealed the baffles for the kitchen hood system had approximately 1/4" gap between two baffles. The baffles did not make a tight seal to filter correctly.
This finding was confirmed by interview with Facility Maintenance Staff #1 at the time of observation.
Corridor - Doors
Tag No.: K0363
Based on observation and interview, the facility failed to provide corridor doors that would close and resist the passage of smoke in accordance with LSC Section 19.3.6.3. This deficient practice could potentially affect 8 occupants of the facility in the event of a fire not being contained to the smoke compartment.
Findings Include:
On 5/18/22 at 11:03am, observation revealed the inactive leaf on the Dialysis Water room door had an upper manual latching device and the bottom of the door had an automatic flush mount latch/release. The two different devices do not work together and the inactive leaf did not automatically latch and release as required in LSC 19.3.6.3.8.
This finding was confirmed by Facility Maintenance Staff #1 at the time of the observation.
Subdivision of Building Spaces - Smoke Barrie
Tag No.: K0372
Based on observation and interview, the facility failed to ensure smoke barriers were constructed to a minimum 1/2-hour fire resistance rating in accordance with 8.5, as required by 19.3.7.3 and 8.6.7.1(1). This deficient practice could affect 8 occupants in the event of smoke/fire was not contained to the smoke compartment.
Findings Include:
On 5/18/22 at 10:04 am, observation revealed an open penetration around a copper pipe above the cross corridors leading into the Cardiac Unit which is a violation of LSC 8.5.6.2.
This finding was confirmed by Facility Maintenance Staff #1 at the time of the observation.