HospitalInspections.org

Based on observation and interview, it was determined the facility failed to ensure hazardous areas were protected according to National Fire Protection Association (NFPA) standards.

The findings include:

Observation on 03/29/2011 at 1:39 PM, with the Engineering Director, revealed the door leading into the Dry Goods Storage did not have a self closer. The area was used to storage large quantities of food supplies packed in cardboard boxes.

Interview on 03/29/2011 at 1:39 PM, with the Engineering Director, revealed the area was marked as a hazardous area on the Life Safety Plans and did need a self closer.

Reference: NFPA 101 (2000 edition)
19.3.2.1 Hazardous Areas. Any hazardous areas shall be safeguarded
by a fire barrier having a 1-hour fire resistance rating
or shall be provided with an automatic extinguishing system in
accordance with 8.4.1. The automatic extinguishing shall be
permitted to be in accordance with 19.3.5.4. Where the sprinkler
option is used, the areas shall be separated from other
spaces by smoke-resisting partitions and doors. The doors
shall be self-closing or automatic-closing. Hazardous areas
shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including
repair shops, used for storage of combustible supplies
and equipment in quantities deemed hazardous by the
authority having jurisdiction
(8) Laboratories employing flammable or combustible materials
in quantities less than those that would be considered
a severe hazard.
Exception: Doors in rated enclosures shall be permitted to have nonrated,
factory- or field-applied protective plates extending not more
than 48 in. (122 cm) above the bottom of the door.

Based on observation and interview, it was determined the facility failed to ensure proper signage was maintained for fire extinguishers according to National Fire Protection Association (NFPA) standards.

The findings include:

Observation on 03/29/2011 at 1:45 PM, with the Engineering Director, revealed a K type extinguisher located in the kitchen area did not have the required signage.

Interview on 03/29/2011 at 1:45 PM, with the Engineering Director, revealed the extinguisher had been in place for approximately two (2) years and the sign had never been in place.

Reference: NFPA 96 (1998 edition)
7-2.1.1 A placard identifying the use of the extinguisher as
a secondary backup means to the automatic fire suppression
system shall be conspicuously placed near each portable fire
extinguisher in the cooking area.

Based on observation and interview, it was determined the facility failed to ensure portable space heaters used in the facility were approved, according to National Fire Protection Association (NFPA) standards.

The findings include:

Observation on 03/29/2011 at 11:03 AM, revealed portable space heaters in use at the following locations: front desk registration and registration offices room two (2), room three (3), room four (4), and room five (5). The observation was confirmed with the Engineering Director.

Interview on 03/29/2011 at 11:03 AM, with the Engineering Director, revealed the hospital has a policy allowing portable space heaters to be used in offices but could not produce documentation stating the heating elements do not exceed 212 °F for the portable space heaters. Further interview, with the engineering Director, revealed he had misread the requirements for portable space heater use in health care facilities.

Reference: NFPA 101 (2000 edition)]
19.7.8 Portable Space-Heating Devices. Portable space-heating
devices shall be prohibited in all health care occupancies.
Exception: Portable space-heating devices shall be permitted to be used
in nonsleeping staff and employee areas where the heating elements of
such devices do not exceed 212°F (100°C).

Based on observation and interview, it was determined the facility failed to ensure hazardous areas were protected according to National Fire Protection Association (NFPA) standards.

The findings include:

Observation on 03/29/2011 at 1:39 PM, with the Engineering Director, revealed the door leading into the Dry Goods Storage did not have a self closer. The area was used to storage large quantities of food supplies packed in cardboard boxes.

Interview on 03/29/2011 at 1:39 PM, with the Engineering Director, revealed the area was marked as a hazardous area on the Life Safety Plans and did need a self closer.

Reference: NFPA 101 (2000 edition)
19.3.2.1 Hazardous Areas. Any hazardous areas shall be safeguarded
by a fire barrier having a 1-hour fire resistance rating
or shall be provided with an automatic extinguishing system in
accordance with 8.4.1. The automatic extinguishing shall be
permitted to be in accordance with 19.3.5.4. Where the sprinkler
option is used, the areas shall be separated from other
spaces by smoke-resisting partitions and doors. The doors
shall be self-closing or automatic-closing. Hazardous areas
shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including
repair shops, used for storage of combustible supplies
and equipment in quantities deemed hazardous by the
authority having jurisdiction
(8) Laboratories employing flammable or combustible materials
in quantities less than those that would be considered
a severe hazard.
Exception: Doors in rated enclosures shall be permitted to have nonrated,
factory- or field-applied protective plates extending not more
than 48 in. (122 cm) above the bottom of the door.

Based on observation and interview, it was determined the facility failed to ensure proper signage was maintained for fire extinguishers according to National Fire Protection Association (NFPA) standards.

The findings include:

Observation on 03/29/2011 at 1:45 PM, with the Engineering Director, revealed a K type extinguisher located in the kitchen area did not have the required signage.

Interview on 03/29/2011 at 1:45 PM, with the Engineering Director, revealed the extinguisher had been in place for approximately two (2) years and the sign had never been in place.

Reference: NFPA 96 (1998 edition)
7-2.1.1 A placard identifying the use of the extinguisher as
a secondary backup means to the automatic fire suppression
system shall be conspicuously placed near each portable fire
extinguisher in the cooking area.

Based on observation and interview, it was determined the facility failed to ensure portable space heaters used in the facility were approved, according to National Fire Protection Association (NFPA) standards.

The findings include:

Observation on 03/29/2011 at 11:03 AM, revealed portable space heaters in use at the following locations: front desk registration and registration offices room two (2), room three (3), room four (4), and room five (5). The observation was confirmed with the Engineering Director.

Interview on 03/29/2011 at 11:03 AM, with the Engineering Director, revealed the hospital has a policy allowing portable space heaters to be used in offices but could not produce documentation stating the heating elements do not exceed 212 °F for the portable space heaters. Further interview, with the engineering Director, revealed he had misread the requirements for portable space heater use in health care facilities.

Reference: NFPA 101 (2000 edition)]
19.7.8 Portable Space-Heating Devices. Portable space-heating
devices shall be prohibited in all health care occupancies.
Exception: Portable space-heating devices shall be permitted to be used
in nonsleeping staff and employee areas where the heating elements of
such devices do not exceed 212°F (100°C).