HospitalInspections.org

Based on observations, staff interviews, and observations, this Condition of Participation is not met related to fire safety in regards to a two hour fire separation on two floors, egress discharge lighting for two of three exits, and trash and linen chutes, and chute discharge rooms. This could affect all patients in the facility. The total census during this visit was 264 patients.

Findings include:

During this visit on 12/06/11, a tour was conducted in the facility with Staff A, B, D, and G between 8:10 AM and 12:10 PM. Observations were conducted in the new in-patient units on the fourth and fifth floors of the new tower, Building D. Exit discharges were also observed on the main level, and linen/trash chute rooms were observed on the lower level.
The facility was unable to verify the fire resistance rating on the fire barrier doors on the fourth and fifth floor levels where the connector walkway joins existing Building C. Two of three exit discharges were observed without discharge lighting outside the exits. The linen and trash chute discharge rooms were observed with doors that failed to latch into the frame. The fusible link for the linen and trash chutes were not connected. One of two trash chute doors on the fifth floor failed to self-close and latch into the frame when tested. Refer to A709.

Based on observations, review of floor plans, and staff interviews, the facility failed to meet the provisions of the Life Safety Code related to a two hour fire separation on two floors, egress discharge lighting for two of three exits, and trash and linen chutes and chute discharge rooms.
This could affect all patients in the facility. The total census during this visit was 264 patients.

Findings include:

A tour was conducted on 12/06/11, between 8:10 AM and 12:10 AM, with Staff A, B, D, and G. Observations were conducted in the new in-patient units on the fourth and fifth floors of the new tower, Building D. Exit discharges were also observed on the main level, and linen/trash chute rooms were observed on the lower level.

During this tour, the following areas were observed:

a) Observations were conducted of the fourth and fifth floor connectors to in-patient units in existing building C. It could not be verified what the doors were fire rated due to the doors being equipped with piano hinges that went from the top to the bottom sides of the doors. Staff A, B, D, and G verified these doors lacked a visible fire rating label at the time of tour.
Refer to A710.

b) Two of three exit discharges were observed without discharge lighting outside the exits. Refer to A710.

c) The trash chute rooms on the 4th and 5th floors were each observed with two trash chute doors in each room. At 9:25 AM, when tested, one of the two chute doors failed to self-close when opened and released during testing.

Observations in the lower level, in the discharge rooms for the linen and trash chute, revealed these room doors to the hallway failed to latch into the frame when tested. The linen chute and trash chute were each equipped with a fusible link; however, observations, and interview with Staff A revealed these fusible links had not been connected due to ongoing construction. Staff A and D both verified these room doors failed to latch, and the fusible links were not connected. Refer to A710.

Based on observations, review of floor plans, and staff interviews, the facility failed to meet the provisions of the Life Safety Code, National Fire Protection Association related to fire barriers, exit discharge lighting, and linen and trash chutes. This could affect all patients in the facility. The total census during this visit was 264 patients.

Findings include:

A tour was conducted on 12/06/11, between 8:10 AM and 12:10 AM, with Staff A, B, D, and G. Observations were conducted in the new in-patient units on the fourth and fifth floors of the new tower, Building D. Exit discharges were also observed on the main level, and linen/trash chute rooms were observed on the lower level.

During this tour, the following areas were observed:

a) Observations were conducted of the fourth and fifth floor connectors to in-patient units in existing building C. A pair of double doors, each equipped with positive latches, were observed located at the end of the connector and the beginning of Building C (two hour fire rated barrier) on the fourth and fifth floors. These doors were equipped with piano hinges that went from the top to the bottom sides of the doors. There were no visible fire rating labels on the doors due to the piano hinges. Staff A, B, D, and G verified these doors lacked a visible fire rating label at the time of tour. Refer to K11.

b) Two of three exit discharges were observed without discharge lighting outside the exits. This involved the A side stairwell, and the middle stairwell which exited in the middle of the building on the main level. Observations outside these exit discharges revealed construction is currently ongoing, and these exit discharges lacked any sources of lighting. Refer to K45.

c) The trash chute rooms on the 4th and 5th floors were each observed with two trash chute doors in each room. The trash chute doors were equipped with positive latching, self-closing door mechanisms, and were observed with a label stating 1 and 1/2 hour fire resistance rating. The trash chute room was observed located by rooms D05307 and D05418. At 9:25 AM, when tested, one of the two chute doors failed to self-close when opened and released during testing.

Observations in the lower level, in the discharge rooms for the linen and trash chute, revealed these rooms were equipped with positive, self-closing doors; however, neither door closed and latched into the frame when tested. The linen chute and trash chute were each equipped with a fusible link; however, observations, and interview with Staff A revealed these fusible links had not been connected due to ongoing construction. Staff A and D both verified these room doors failed to latch, and the fusible links were not connected. Refer to K71.