HospitalInspections.org

One-story Existing Health Care Occupancy buildings of Type III (200) construction are required to be protected throughout with an automatic sprinkler system.

The facility failed to provide an automatic fire sprinkler system throughout the facility that meets the requirements of NFPA 13, Standard for Installation of Sprinkler Systems.

Observation determined the structural walls were concrete block and the roof assembly was constructed of combustible wood supports and wood boards. The building was not protected throughout with an automatic sprinkler system.

The facility failed to ensure corridors were separated from use areas by walls constructed with at least a 1/2-hour fire resistance rating.

Observation determined the corridor walls throughout the basement and main floor were not maintained as 1/2-hour fire resistant rated wall assemblies. The holes through the corridor walls caused by pipe, electrical conduit, air duct, and low-voltage wire penetrations, were not adequately sealed with fire rated material.

The facility failed to separate hazardous areas from other spaces with one-hour fire resistive rated partitions and self-closing fire-rated door assemblies.

Observation determined:

1) The new 90-minute fire rated wood door to the Medical Records Storage Room was not equipped with intumescent and fire rated smoke gaskets.

2) The door to Medical Records was held in the open position with a small cabinet.

3) A hole through the Medical Records Room door above the door latch was not repaired.

4) An air duct penetration through the one-hour ceiling of the Medical Records Room was not equipped with a fire damper.

5) A hole in the southeast corner of the Medical Records Room ceiling was not sealed with fire rated material.

6) The self-closing device on the east door to the Maintenance Storage Room was disconnected and the door would not self-close to the latched position.

The facility failed to ensure that exit stairways were enclosed with construction having a fire resistance rating of at least one-hour to provide a continuous path of escape with protection provided against fire or smoke from other parts of the building.

Observation determined the north and south exit stairs from the basement discharged onto the main floor and were not arranged to provide a continuous fire resistant enclosure to the exterior of the building.

The fire alarm system must be in compliance with NFPA 72.

The facility failed to ensure the fire alarm system was maintained, inspected and tested in accordance with the manufacturer's specifications.

Review of the fire alarm test records indicated the number of fire alarm initiating devices tested during the 2010 and 2011 inspections differed. The number of smoke detectors, heat detectors and pull stations were different on the two reports. This lack of consistent testing indicates not all devices have been tested each year.

Visual inspection frequencies and specific testing and maintenance frequencies for smoke detection systems are dictated by the prescriptive requirements of NFPA 72, National Fire Alarm Code (Chapter 10-Inspection, Testing and Maintenance Tables 10.3.1, 10.4.2.2 and 10.4.3). This code identifies specific inspection, testing and maintenance frequencies and methods.

Sensitivity testing of smoke detectors is to be completed for all smoke detectors during the first year in service, and the alternate year following. After the second required calibration test, if the detector has remained within its listed and marked sensitivity range, the length of time between calibration tests may be extended, not to exceed five years.

The facility failed to ensure smoke detectors were maintained, inspected and tested in accordance with NFPA 72.

Review of the fire alarm test results indicated the smoke detection system was not sensitivity tested at frequencies in compliance with the minimum requirements of NFPA 72. If the smoke detection system does not meet the allowance for five (5) years between testing, the system must be tested at least every two (2) years.

The 9-29-05 smoke detector sensitivity test was the only test on record. The facility was unable to provide documentation to verify a 2-year testing interval and exceeded the maximum 5-year interval.

1) Transfer switches must be subjected to a maintenance program including connections, inspection or testing for evidence of overheating and excessive contact erosion, removal of dust and dirt, and replacement of contacts when required. NFPA 110, Standard for Emergency and Standby Power Systems

The facility failed to provide documentation of a preventive maintenance program for the emergency generator electrical transfer switch.

2) Records review indicated the facility failed to provide evidence of maintenance of fire dampers in a reliable operating condition as required by NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems. Maintenance of fire dampers is required at least every 6 years. Maintenance of fire dampers includes:

(a) Fusible links shall be removed.
(b) All dampers shall be operated to verify that they close fully.
(c) The latch, if provided, shall be checked.
(d) Moving parts shall be lubricated as necessary.