HospitalInspections.org

While surveying the facility with the director of facilities management the inspector observed small sections of structural beams in the boiler room of the hospital that were missing fire proofing material. The minimum construction type classification for the facility is Type II (111) in accordance with the standard.

While surveying the facility with the director of facilities management the inspector observed that doors opening into the egress corridor on the medical-surgical wing -and- other second floor inpatient rooms located in the original hospital building failed to meet the standard as evidenced by the following findings:
1. Patient sleeping room doors that utilize active and inactive door leafs provided a horizontal gap of between 1/8'' and 1/4'' between door leaves that limited the ability of the affected doors to resist the passage of smoke as required by the standard.

While reviewing facility records pertaining to facility fire drills the inspector observed that on November 6, 2013 the facility conducted a second shift fire drill at 17:30 hours that did not use audible alarms. In accordance with NFPA 101 Life Safety Code, section 19.7.1.2 (2000 edition) only drills conducted between 21:00 hours and 06:00 hours may use coded announcements in lieu of audible alarms.

While surveying the facility with the director of facilities management the inspector observed the following deficiencies relating to the building fire sprinkler and standpipe systems:
1. The handle for the standpipe valve cabinet at the lower level south section of the building (adjacent to the plumbing room) was observed to be missing the handle for the standpipe cabinet.
2. The gauge for the fire sprinkler system valve at the lower level (south) stair requires replacement or a calibration check in accordance with NFPA 25 Inspection, Testing, and Maintenance of Water Based Fire Protection Systems, section 9-2.8.2 (1998 edition) as referenced by the standard.
3. The pendant sprinkler head in the laundry chute room (facility door tag # 0-078) requires replacement due to visible damage to the fire sprinkler head deflector.
4. The upright fire sprinkler in the cath lab equipment room was observed to be located at least 36 inches from the top of the deflector to the ceiling surface above. The upright fire sprinkler in the room must be located within one inch to six inches below the horizontal plane of the structural members in the room and a maximum of 22 inches below the ceiling in accordance with NFPA 13 Installation of Sprinkler Systems, section 5-6.4.1.2 (1999 edition) as referenced by the standard.

While reviewing facility records pertaining to facility fire drills in the ambulatory surgical practice located at 121 Medical Center Drive in Brunswick the inspector observed that fire drills conducted did not comply with the provisions of NFPA 101 Life Safety Code, section 21.7.1.2 (2000 edition) as evidenced by the following:
1. Drills conducted in the ambulatory surgical practice did not utilize audible alarms as required by the standard. (Note: Drills conducted between 21:00 hours and 06:00 hours are not required to utilize audible alarms). The frequency of drills must be at least once every quarter (three months) for each shift and infirm or bedridden patients are not required to be moved as part of the drill procedure.

While surveying the facility with the director of facilities management the inspector observed small sections of structural beams in the boiler room of the hospital that were missing fire proofing material. The minimum construction type classification for the facility is Type II (111) in accordance with the standard.

While surveying the facility with the director of facilities management the inspector observed that doors opening into the egress corridor on the medical-surgical wing -and- other second floor inpatient rooms located in the original hospital building failed to meet the standard as evidenced by the following findings:
1. Patient sleeping room doors that utilize active and inactive door leafs provided a horizontal gap of between 1/8'' and 1/4'' between door leaves that limited the ability of the affected doors to resist the passage of smoke as required by the standard.

While reviewing facility records pertaining to facility fire drills the inspector observed that on November 6, 2013 the facility conducted a second shift fire drill at 17:30 hours that did not use audible alarms. In accordance with NFPA 101 Life Safety Code, section 19.7.1.2 (2000 edition) only drills conducted between 21:00 hours and 06:00 hours may use coded announcements in lieu of audible alarms.

While surveying the facility with the director of facilities management the inspector observed the following deficiencies relating to the building fire sprinkler and standpipe systems:
1. The handle for the standpipe valve cabinet at the lower level south section of the building (adjacent to the plumbing room) was observed to be missing the handle for the standpipe cabinet.
2. The gauge for the fire sprinkler system valve at the lower level (south) stair requires replacement or a calibration check in accordance with NFPA 25 Inspection, Testing, and Maintenance of Water Based Fire Protection Systems, section 9-2.8.2 (1998 edition) as referenced by the standard.
3. The pendant sprinkler head in the laundry chute room (facility door tag # 0-078) requires replacement due to visible damage to the fire sprinkler head deflector.
4. The upright fire sprinkler in the cath lab equipment room was observed to be located at least 36 inches from the top of the deflector to the ceiling surface above. The upright fire sprinkler in the room must be located within one inch to six inches below the horizontal plane of the structural members in the room and a maximum of 22 inches below the ceiling in accordance with NFPA 13 Installation of Sprinkler Systems, section 5-6.4.1.2 (1999 edition) as referenced by the standard.

While reviewing facility records pertaining to facility fire drills in the ambulatory surgical practice located at 121 Medical Center Drive in Brunswick the inspector observed that fire drills conducted did not comply with the provisions of NFPA 101 Life Safety Code, section 21.7.1.2 (2000 edition) as evidenced by the following:
1. Drills conducted in the ambulatory surgical practice did not utilize audible alarms as required by the standard. (Note: Drills conducted between 21:00 hours and 06:00 hours are not required to utilize audible alarms). The frequency of drills must be at least once every quarter (three months) for each shift and infirm or bedridden patients are not required to be moved as part of the drill procedure.