HospitalInspections.org

The facility failed to ensure complete two-hour fire rated separation between the hospital and other buildings of nonconforming construction.

Manufacturers typically design 90-minute fire rated metal double doors to latch into the door frame and into the floor.

Observation determined the 90-minute fire rated double doors located between the hospital building and the clinic building were not latching into the floor.

The facility failed to ensure complete two-hour fire rated separation between the basic care facility and the clinic portions of the building.

The manufacturer designed the 90-minute fire rated door located in this separation to latch into the door frame.

Observation determined the 90-minute fire rated door located at the entry from the basic care facility did not latch into door frame. An automatic door opener disabled the original latching device.

The facility failed to ensure interior wall finishes for rooms and spaces not used for corridors had a Class A or Class B rating.

Documentation review indicated the facility did not have interior finish documentation for the wood paneling in the Mammography Procedure Room.

The facility failed to ensure water supply control valves for the automatic sprinkler system were electronically supervised by the fire alarm system.
Observation determined the tamper switch installed for the automatic sprinkler system water control valve in the kitchen "back hallway" was not interconnected to the fire alarm panel.

Testing frequencies for automatic sprinkler systems range from quarterly to annually. Inspection frequencies can be as often as weekly to as long as annually. The frequencies for testing, inspection and maintenance of automatic sprinkler systems are dictated by the requirements as outlined by Table 5-1 of NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems. NFPA 25 requires the facility to complete, maintain and make available to the authority having jurisdiction copies of records which indicate the procedure performed, by whom, the results and the date. These records are to be retained for the life of the system. The automatic sprinkler system is required to have specified maintenance.

Sprinkler record review determined the facility failed to conduct annual testing and maintenance of the sprinkler system.

Note: This is a repeat deficiency.

The facility failed to ensure electrical wiring and electrical equipment meet NFPA 70 requirements.

Observation determined the Physical Therapy Room outlet by the sink basin was not Ground Fault Circuit Interrupter (GFCI) protected.

The facility failed to ensure complete two-hour fire rated separation between the hospital and other buildings of nonconforming construction.

Manufacturers typically design 90-minute fire rated metal double doors to latch into the door frame and into the floor.

Observation determined the 90-minute fire rated double doors located between the hospital building and the clinic building were not latching into the floor.

The facility failed to ensure complete two-hour fire rated separation between the basic care facility and the clinic portions of the building.

The manufacturer designed the 90-minute fire rated door located in this separation to latch into the door frame.

Observation determined the 90-minute fire rated door located at the entry from the basic care facility did not latch into door frame. An automatic door opener disabled the original latching device.

The facility failed to ensure interior wall finishes for rooms and spaces not used for corridors had a Class A or Class B rating.

Documentation review indicated the facility did not have interior finish documentation for the wood paneling in the Mammography Procedure Room.

The facility failed to ensure water supply control valves for the automatic sprinkler system were electronically supervised by the fire alarm system.
Observation determined the tamper switch installed for the automatic sprinkler system water control valve in the kitchen "back hallway" was not interconnected to the fire alarm panel.

Testing frequencies for automatic sprinkler systems range from quarterly to annually. Inspection frequencies can be as often as weekly to as long as annually. The frequencies for testing, inspection and maintenance of automatic sprinkler systems are dictated by the requirements as outlined by Table 5-1 of NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems. NFPA 25 requires the facility to complete, maintain and make available to the authority having jurisdiction copies of records which indicate the procedure performed, by whom, the results and the date. These records are to be retained for the life of the system. The automatic sprinkler system is required to have specified maintenance.

Sprinkler record review determined the facility failed to conduct annual testing and maintenance of the sprinkler system.

Note: This is a repeat deficiency.

The facility failed to ensure electrical wiring and electrical equipment meet NFPA 70 requirements.

Observation determined the Physical Therapy Room outlet by the sink basin was not Ground Fault Circuit Interrupter (GFCI) protected.