HospitalInspections.org

.

Based on observation and interview, the surveyor could not verify separation of the hospital from the MRI addition by a continuous 2 hour fire barrier per the requirements of:

2012 NFPA 101, 19.1.3.5, and 8.2.1.3
2012 NFPA 221, 7.2.1

Findings include:

On 04/11/2018, during a tour of the facility from 7:45 am to 3:45 pm, the surveyor could not verify that the east wall of the MRI addition was a continuous 2 hour fire barrier. The surveyor observed the gypsum board of the two hour fire rated barrier stopped just above the lay in ceiling in the MRI building. This part of the 2 hour fire barrier separating the two construction types was not continuous from the floor to the roof. The construction type of the MRI addition, type II (000) is not allowed in a partially automatic sprinklered building, the hospital.

.

.

Based on observation and interview, the facility failed to provide a building construction type permitted for a one story building with a partial automatic sprinkler system per the requirements of:

2012 NFPA 101, 19.1.6.1, and Table 19.1.6.1

This deficiency could affect 2 of 7 smoke compartments.

Findings include:

On 04/11/2018, during a tour of the facility from 7:45 am to 3:45 pm, the surveyors observed the following:
1. A structural I-beam missing the two hour rated sprayed on fire protection on the bottom of the beam and on the side facing the two hour fire rated fire barrier. This I-beam is located on the first floor above the ceiling at the bulk between the Surgical Ward and the Emergency Room Ward at the fire barrier.
2. The original plaster ceiling above the lay-in ceiling was missing in the exit discharge corridor at the MRI building at the following locations:
a. Unsealed penetrations around the hangers for the light fixtures
b. An approximately 4" x 2' piece was missing at the exit door

A member of the maintenance staff was present when this deficiency was identified.

.


39327

.

Based on review of documentation and interview, the facility failed to maintain the gauges for the automatic sprinkler system per requirements of:

2012 NFPA 101, 19.3.5.1 and 9.7.5
2011 NFPA 25, 5.3.2.1

Findings include:

On 04/11/2018, during a tour of the facility from 7:45 am to 3:45 pm, the facility failed to provide documentation of the automatic sprinkler riser gauges being replaced or calibrated within the past 5 years.

A member of the maintenance staff was present when the deficiency was found.

.

.

Based on observation and interview, the facility failed to install fire extinguishers per the requirements of:

2012 NFPA 101, 19.3.5.12, and 9.7.4.1
2010 NFPA 10, 6.1.3.8.1

Findings include:

On 04/11/2018, during a tour of the facility from 7:45 am to 3:45 pm, the surveyor observed that the fire extinguisher in the following locations were mounted higher than 5 feet:
1. Between OR Rooms 1 and 2
2. The Laboratory

A member of the maintenance staff was present when this deficiency was identified.
.

.
Based on observation and interview, the facility failed to maintain a corridor door per the requirements of:

42 CFR 483.90 (a) (1) (ii)
2012 NFPA 101, 19.3.6.3.10

Findings include:

On 04/11/2018, during a tour of the facility from 7:45 am to 3:45 pm, the surveyor observed a chair impeding the closing of the ICU Waiting Room corridor door.

A member of the maintenance staff was present when this deficiency was identified.
.

.

Based on observation and interview, the facility failed to maintain the smoke barrier doors per the requirements of:

2012 NFPA 101, 19.3.7.8, and 8.5.4.1

This deficiency could affect 4 of 7 smoke compartments.

Findings include:

On 04/11/2018, during a tour of the facility from 7:45 am to 3:45 pm, the surveyor observed the following smoke barrier doors failed to fully close during activation of the fire alarm system:

1. The 1st floor right door leaf next to the ICU Waiting Room
2. The 1st floor both door leafs next to Treatment Room 1
3. In the basement both door leafs next to the Maintenance Shop, the hardware was not being maintained
4. In the basement next to the Clean Linen Room the right door leaf had broken hardware

A member of the maintenance staff was present when this deficiency was identified.

.