HospitalInspections.org

The facility failed to maintain the corridor openings per code. Findings include:

During the survey, the following is an example of what was observed:
Second Floor
The Conference Room corridor double doors were not smoke resistive. There was a gap between the double doors.

2000 NFPA 101, 19.3.6.3.1 Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.
.

The facility failed to provide smoke barriers that would provide at least a half hour fire resistance rating. Findings include: During the survey, the following are examples of what was observed:


1. Unsealed penetrations around two sections of conduit, and at the end of a sleeve, in the Smoke Barrier, at Home Care Department Second Floor.

2. Unsealed penetrations around four sections of conduit, in the Smoke Barrier, by Hospice Office Second Floor.

3. Unsealed penetrations around a group of wiring, in the Smoke Barrier, by the Elevator First Floor.

4. Unsealed penetrations around a group of wiring, in the Smoke Barrier, by Private Dining Room First Floor.

5. Unsealed penetrations around wiring, in the Smoke barrier, by Respiratory Therapy First floor.



2000 NFPA 101, 19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.
2000 NFPA 101, 8.3.2 Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.

The facility failed to provide a reliable means of egress to the public way. During the survey, the following are examples of what was observed:


1. The Exit by C-Scan was not provided with an all weather surface to the public way.

2. The Exit from Surgery was not provide with an all weather surface to the public way.


NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

NFPA 101, A.7.1.10.1 *A proper means of egress allows unobstructed travel at all times. Any type of barrier including, but not limited to, the accumulations of snow and ice in those climates subject to such accumulations is an impediment to free movement in the means of egress.

The facility failed to provide continuously illuminated exit signs. Findings include: During the survey, the following are examples of what was observed:


The exit sign was not illuminated at the Exit from Outpatient waiting room.


NFPA 101, 7.10.5 Continuous illumination of exit signs.

The facility failed to maintain the fire alarm system. Findings include: During the survey, the following are examples of waht was observed:

A) Aubible device was not provided in the corridor by Respiratory Therapy, and CCU. During the testing of the fire alarm system, when the smoke doors closed, this surveyor alone with maintanance, was not able to hear the aubible device which was located at the Nurse's Station.


27382


B) The Surgery Suite fire alarm audible device did not work when the fire alarm was tested.

2000 NFPA 101, 9.6.1.3 The provisions of Section 9.6 cover the basic functions of a complete fire alarm system, including fire detection, alarm, and communications. These systems are primarily intended to provide the indication and warning of abnormal conditions, the summoning of appropriate aid, and the control of occupancy facilities to enhance protection of life.
2000 NFPA 101, 9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.
2000 NFPA 101, 9.6.1.5 All systems and components shall be approved for the purpose for which they are installed.
.

The facility failed to provide complete sprinkler coverage to all parts of the facility.
Findings include: During the survey, the following are examples of what was observed:

Sprinkler was missing the escutcheon plate in the cooler.


2000 NFPA 13, 3-2.7.2 Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.

The facility failed to maintain the automatic sprinkler system per code. Findings include:

During the survey, the following are examples of what was observed:
Second Floor
The following areas were missing escutcheon plates for the sprinkler heads:
1. The Director of Education Office
2. The corridor (lobby) in front of the coke machine

1999 NFPA 13, 3-2.7.2 Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.
.

The facility failed to provide metal self-closing containers for disposing of cigarette butts and ashes from ashtrays. Findings include: During the survey, the following are examples of what was observed:


The designated smoking area was not provide with a metal self-closing container for disposing of cigarette butts.

NFPA 101, 19.7.4 Ashtrays of noncombustible material and safe design, and metal self-closing containers for disposing of cigarette butts and ashes from ashtrays, shall be provided.

The facility failed to maintain the means of egress per code. Findings include:

During the survey, the following is an example of what was observed:
First Floor
The Kitchen Storage Room door had a hasp lock on it.

2000 NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.
2000 NFPA 101, 19.2.2.2.4 Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side.

.

The facility failed to maintain the curtains/draperies per code. Findings include:

During the survey, the following are examples of what was observed:

The facility failed to provide flame resistance documentation for the first floor curtains/draperies in the following areas:
1. Cafeteria
2. Respiratory Room
3. Respiratory Storage Room


2000 NFPA 101, 10.3.1 Where required by the applicable provisions of this Code, draperies, curtains, and other similar loosely hanging furnishings and decorations shall be flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.
.

The facility failed to provide proper storage of oxygen cylinders. Findings include: During the survey, the following are examples of what was observed:


Approximately ten cylinders were observed unsecure, and signage for the empty cylinders were not provided.


1999 NFPA 99, 4-3.1.1.1 and 4-5.1.1.1 Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.

CGA G-4, 4.1.10, and 1999 NFPA 99, 4-3.5.2.2(b)2 and 4-5.5.2.2(b)2 Full and empty cylinders shall be stored separately, with appropriate signage.

The facility failed to provide approved electrical utilities. Findings include: During the survey, the following are examples of what was observed:

1. Two junction boxes were missing the covers in the AC Room, located outside behind the Kitchen.

2. A junction box was missing the cover, above the ceiling in the ER waiting room.

1999 NFPA 70, 370-25 and 410-12. Each box in completed installations to have a cover, face plate, or fixture canopy.

The facility failed to maintain the corridor openings per code. Findings include:

During the survey, the following is an example of what was observed:
Second Floor
The Conference Room corridor double doors were not smoke resistive. There was a gap between the double doors.

2000 NFPA 101, 19.3.6.3.1 Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.
.

The facility failed to provide smoke barriers that would provide at least a half hour fire resistance rating. Findings include: During the survey, the following are examples of what was observed:


1. Unsealed penetrations around two sections of conduit, and at the end of a sleeve, in the Smoke Barrier, at Home Care Department Second Floor.

2. Unsealed penetrations around four sections of conduit, in the Smoke Barrier, by Hospice Office Second Floor.

3. Unsealed penetrations around a group of wiring, in the Smoke Barrier, by the Elevator First Floor.

4. Unsealed penetrations around a group of wiring, in the Smoke Barrier, by Private Dining Room First Floor.

5. Unsealed penetrations around wiring, in the Smoke barrier, by Respiratory Therapy First floor.



2000 NFPA 101, 19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.
2000 NFPA 101, 8.3.2 Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.

The facility failed to provide a reliable means of egress to the public way. During the survey, the following are examples of what was observed:


1. The Exit by C-Scan was not provided with an all weather surface to the public way.

2. The Exit from Surgery was not provide with an all weather surface to the public way.


NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

NFPA 101, A.7.1.10.1 *A proper means of egress allows unobstructed travel at all times. Any type of barrier including, but not limited to, the accumulations of snow and ice in those climates subject to such accumulations is an impediment to free movement in the means of egress.

The facility failed to provide continuously illuminated exit signs. Findings include: During the survey, the following are examples of what was observed:


The exit sign was not illuminated at the Exit from Outpatient waiting room.


NFPA 101, 7.10.5 Continuous illumination of exit signs.

The facility failed to maintain the fire alarm system. Findings include: During the survey, the following are examples of waht was observed:

A) Aubible device was not provided in the corridor by Respiratory Therapy, and CCU. During the testing of the fire alarm system, when the smoke doors closed, this surveyor alone with maintanance, was not able to hear the aubible device which was located at the Nurse's Station.


27382


B) The Surgery Suite fire alarm audible device did not work when the fire alarm was tested.

2000 NFPA 101, 9.6.1.3 The provisions of Section 9.6 cover the basic functions of a complete fire alarm system, including fire detection, alarm, and communications. These systems are primarily intended to provide the indication and warning of abnormal conditions, the summoning of appropriate aid, and the control of occupancy facilities to enhance protection of life.
2000 NFPA 101, 9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.
2000 NFPA 101, 9.6.1.5 All systems and components shall be approved for the purpose for which they are installed.
.

The facility failed to provide complete sprinkler coverage to all parts of the facility.
Findings include: During the survey, the following are examples of what was observed:

Sprinkler was missing the escutcheon plate in the cooler.


2000 NFPA 13, 3-2.7.2 Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.

The facility failed to maintain the automatic sprinkler system per code. Findings include:

During the survey, the following are examples of what was observed:
Second Floor
The following areas were missing escutcheon plates for the sprinkler heads:
1. The Director of Education Office
2. The corridor (lobby) in front of the coke machine

1999 NFPA 13, 3-2.7.2 Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.
.

The facility failed to provide metal self-closing containers for disposing of cigarette butts and ashes from ashtrays. Findings include: During the survey, the following are examples of what was observed:


The designated smoking area was not provide with a metal self-closing container for disposing of cigarette butts.

NFPA 101, 19.7.4 Ashtrays of noncombustible material and safe design, and metal self-closing containers for disposing of cigarette butts and ashes from ashtrays, shall be provided.

The facility failed to maintain the means of egress per code. Findings include:

During the survey, the following is an example of what was observed:
First Floor
The Kitchen Storage Room door had a hasp lock on it.

2000 NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.
2000 NFPA 101, 19.2.2.2.4 Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side.

.

The facility failed to maintain the curtains/draperies per code. Findings include:

During the survey, the following are examples of what was observed:

The facility failed to provide flame resistance documentation for the first floor curtains/draperies in the following areas:
1. Cafeteria
2. Respiratory Room
3. Respiratory Storage Room


2000 NFPA 101, 10.3.1 Where required by the applicable provisions of this Code, draperies, curtains, and other similar loosely hanging furnishings and decorations shall be flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.
.

The facility failed to provide proper storage of oxygen cylinders. Findings include: During the survey, the following are examples of what was observed:


Approximately ten cylinders were observed unsecure, and signage for the empty cylinders were not provided.


1999 NFPA 99, 4-3.1.1.1 and 4-5.1.1.1 Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.

CGA G-4, 4.1.10, and 1999 NFPA 99, 4-3.5.2.2(b)2 and 4-5.5.2.2(b)2 Full and empty cylinders shall be stored separately, with appropriate signage.

The facility failed to provide approved electrical utilities. Findings include: During the survey, the following are examples of what was observed:

1. Two junction boxes were missing the covers in the AC Room, located outside behind the Kitchen.

2. A junction box was missing the cover, above the ceiling in the ER waiting room.

1999 NFPA 70, 370-25 and 410-12. Each box in completed installations to have a cover, face plate, or fixture canopy.