HospitalInspections.org

This Standard is not met as evidenced by:

Based on observations and confirmed by the Director of Facilities during the building tour, the facility failed to ensure that egress routes are free from locked doors.

Section 19.2.2.2.1 states doors complying with 7.2.1 shall be permitted.

Section 7.2.1.5.1 states door leaves shall be arranged to be opened readily from the egress side whenever the building is occupied.

Section 7.2.1.5.3 states locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.

THE FINDINGS INCLUDE:

On 01/07/20 at 9:15 A.M. while touring the 3rd floor S5 (Respiratory) area, deadbolt locking devices were observed on the four examination room doors. Each of these doors require two separate means of action to release the door from the latched position.

This deficient practice can prevent instant patient removal in the event of an actual emergency situation where the exiting the room is required.

As a result, the facility failed to comply with section 7.2.1.5.1 requiring doors to be opened readily from the egress side.

The findings were confirmed by the Hospital's Administrative Leadership Team during the exit interview process.

This Standard is not met as evidenced by:

Based on observations and confirmed by the Director of Facilities during the building tour, the facility failed to ensure that doors held open by magnetic devices release according to section 19.2.2.2.7 with the activation of a smoke detecting device.

Section 7.2.1.8.2 states in any building of low or ordinary hazard contents, as defined in 6.2.2.2 and 6.2.2.3, or where approved by the authority having jurisdiction, door leaves shall be permitted to be automatic-closing, provided that all of the following criteria are met:
(1) Upon release of the hold-open mechanism, the leaf becomes self-closing.
(2) The release device is designed so that the leaf instantly releases manually and, upon release, becomes self-closing, or the leaf can be readily closed.
(3) The automatic releasing mechanism or medium is activated by the operation of approved smoke detectors installed in accordance with the requirements for smoke detectors for door leaf release service in NFPA 72, National Fire Alarm and Signaling Code.
(4) Upon loss of power to the hold-open device, the hold open mechanism is released and the door leaf becomes self-closing.
(5) The release by means of smoke detection of one door leaf in a stair enclosure results in closing all door leaves serving that stair.

NFPA 72 section 17.7.5.6.1 states smoke detectors that are part of an open area protection system covering the room, corridor, or enclosed space on each side of the smoke door and that are located and spaced as required by 17.7.3 shall be permitted to accomplish smoke door release service.

Section 17.7.3.2.3.1 states in the absence of specific performance-based design criteria, smooth ceiling smoke detector spacing shall be a nominal 30 ft (9.1 m).

Section 17.7.5.6.2 states smoke detectors that are used exclusively for smoke door release service shall be located and spaced as required by 17.7.5.6.

Section 17.7.5.6.3 states where smoke door release is accomplished directly from the smoke detector(s), the detector(s) shall be listed for releasing service.

Section 17.7.5.6.4 states smoke detectors shall be of the photoelectric, ionization, or other approved type.

Section 17.7.5.6.5 states the number of detectors required shall be determined in accordance with 17.7.5.6.5.1 through 17.7.5.6.5.4.

Section 17.7.5.6.5.1 states if doors are to be closed in response to smoke flowing in either direction, the requirements of 17.7.5.6.5.1(A) through 17.7.5.6.5.1(D) shall apply.
(A) If the depth of wall section above the door is 24 in. (610 mm) or less, one ceiling-mounted smoke detector shall be required on one side of the doorway only, or two wall-mounted detectors shall be required, one on each side of the doorway. Figure 17.7.5.6.5.1(A), part A or B, shall apply.
(B) If the depth of wall section above the door is greater than 24 in. (610 mm) on one side only, one ceiling-mounted smoke detector shall be required on the higher side of the doorway only, or one wall-mounted detector shall be required on both sides of the doorway. Figure 17.7.5.6.5.1(A), part D, shall apply.
(C) If the depth of wall section above the door is greater than 24 in. (610 mm) on both sides, two ceiling-mounted or wall mounted detectors shall be required, one on each side of the doorway. Figure 17.7.5.6.5.1(A), part F, shall apply.
(D) If a detector is specifically listed for door frame mounting, or if a listed combination or integral detector-door closer assembly is used, only one detector shall be required if installed in the manner recommended by the manufacturer's published instructions. Figure 17.7.5.6.5.1(A), parts A, C, and E, shall apply.

THE FINDINGS INCLUDE:

During the morning and afternoon hours of 01/06/20 and 01/07/20 while surveying the hospital, the following items were observed regarding doors and hold open devices:

1) On 01/06/20 at 3:15 P.M. the smoke barrier door on the 3rd floor West Unit located between the Medication Room and the Clean Utility Room was observed to be held open by a magnetic device tied into the fire alarm system. There is no smoke detector provided on either side of this doorway for door release as required.
Note: The depth of the wall section above the door on each side is less than 24", requiring at a minimum one smoke detector for door release.

2) On 01/07/20 at 1:30 P.M. the 2nd floor level Auditorium doors were observed to be part of the 2-hour fire separation wall. The pair of doors are held open by magnetic devices tied into the fire alarm system. The depth of the wall section above the doors on the Auditorium side is approximately 12 feet in height. There is no smoke detector located on this room side of the doorway as required.

This deficient practice could affect all patients, as well as an undetermined amount of staff and visitors in the event of the doors not releasing and closing during an emergency situation.

As a result of the lack of a smoke detector and the doors being held open by a magnetic devices, the facility failed to comply with section 17.7.5.6.5.1 for proper smoke detection devices.

The findings were confirmed by the Hospital's Administrative Leadership Team during the exit interview process.

This Standard is not met as evidenced by:

Based on observations and confirmed by the Director of Facilities during the building tour, the facility failed to ensure that all stairwells are protected with the required fire resistance rating.

Section 19.3.1 states any vertical opening shall be enclosed or protected in accordance with Section 8.6, unless otherwise modified by 19.3.1.1 through 19.3.1.8.

Section 19.3.1.1 states where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating.

THE FINDINGS INCLUDE:

On 01/06/20 at 9:00 A.M. while reviewing the hospital floor plans and construction documents, it was observed that the stairwells in the building are identified as having a 2-hour fire resistance rating. On 01/06/20 at approximately 11:15 A.M. , the 7th floor level of "Stairwell L" was observed to be equipped with an approximate 6' door leading into the penthouse area. Although this door is no longer used, a 2" hole was observed in the door where the previous door latching assembly was located. The door was sealed from the inside (within the penthouse) with 2-layers of 5/8" gypsum. This enclosure is not accurate with the hospital plans listing the separation as 2-hours.

This deficient practice could affect all patients, as well as an undetermined amount of patients, staff and visitors in the event of an actual emergency. This stairwell door would not offer the degree of safety as indicated to prevent fire from compromising this stairwell.

As a result, the hospital failed to comply with providing a 2-hour fire separation as the plans indicate.

The findings were confirmed by the Hospital's Administrative Leadership Team during the exit interview process.

This Standard is not met as evidenced by:

Based on observations and confirmed by the Director of Facilities during the building tour, the facility failed to ensure that all required areas are protected by the automatic sprinkler system.

Section 9.7.1.1 states each automatic sprinkler system required by another section of this Code shall be in accordance with one of the following:
(1) NFPA 13, Standard for the Installation of Sprinkler Systems
(2) NFPA 13D, Standard for the Installation of Sprinkler Systems in One- and Two-Family Dwellings and Manufactured Homes
(3) NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and Including Four Stories in Height

NFPA 13 section 8.3.3.2 states where quick-response sprinklers are installed, all sprinklers within a compartment shall be quick-response unless otherwise permitted in 8.3.3.3.

Section 8.3.3.3 states where there are no listed quick-response sprinklers in the temperature range required, standard-response sprinklers shall be permitted to be used.

Section 8.3.3.4 states when existing light hazard systems are converted to use quick-response or residential sprinklers, all sprinklers in a compartmented space shall be changed.

Note: NFPA 13 Section 3.3.6 defines compartment as a space completely enclosed by walls and a ceiling. Each wall in the compartment is permitted to have openings to an adjoining space if the openings have a minimum lintel depth of 8 in. (200 mm) from the ceiling and the total width of the openings in each wall does not exceed 8 ft (2.4 m). A single opening of 36 in. (900 mm) or less in width without a lintel is permitted when there are no other openings to adjoining spaces.

Section 8.6.3.4.1 states unless the requirements of 8.6.3.4.2, 8.6.3.4.3, or 8.6.3.4.4 are met, sprinklers shall be spaced not less than 6 ft (1.8 m) on center.

Section 8.6.3.4.2 states sprinklers shall be permitted to be placed less than 6 ft (1.8 m) on center where the following conditions are satisfied:
(1) Baffles shall be installed and located midway between sprinklers and arranged to protect the actuating elements.
(2) Baffles shall be of noncombustible or limited-combustible material that will stay in place before and during sprinkler operation.
(3) Baffles shall be not less than 8 in. (203 mm) wide and 6 in. (152 mm) high.
(4) The tops of baffles shall extend between 2 in. and 3 in.
(51 mm and 76 mm) above the deflectors of upright sprinklers.
(5) The bottoms of baffles shall extend downward to a level at least even with the deflectors of pendent sprinklers.

Section 8.6.3.4.3 states in-rack sprinklers shall be permitted to be placed less than 6 ft (1.8 m) on center.

Section 8.6.3.4.4 Old-style sprinklers protecting fur storage vaults shall be permitted to be placed less than 6 ft (1.8 m) on center.

Section 8.6.4.1.1.1 states under unobstructed construction, the distance between the sprinkler deflector and the ceiling shall be a minimum of 1 in. (25.4 mm) and a maximum of 12 in. (305 mm) throughout the area of coverage of the sprinkler.

Section 8.15.10.1 states unless the requirements of 8.15.10.3 are met, sprinkler protection shall be required in electrical equipment rooms.

Section 8.15.10.2 states hoods or shields installed to protect important electrical equipment from sprinkler discharge shall be noncombustible.

Section 8.15.10.3 states sprinklers shall not be required in electrical equipment rooms where all of the following conditions are met:
(1) The room is dedicated to electrical equipment only.
(2) Only dry-type electrical equipment is used.
(3) Equipment is installed in a 2-hour fire-rated enclosure including protection for penetrations.
(4) No combustible storage is permitted to be stored in the room.

THE FINDINGS INCLUDE:

During the morning and afternoon hours of 01/06/20 and 01/07/20, the following items were observed regarding the installation of the automatic sprinkler system:

1) On 01/06/20 at 11:00 A.M. the IT Room located on floor 6 East was observed as not protected throughout by the sprinkler system. The floor/ceiling IT server/cable management rack is located in the middle of the room. The sprinkler head within this room is located on the front side of this rack, as a result, the rack is obstructing sprinkler protection on the rear side.

2) On 01/07/20 at approximately 3:30 P.M. when viewing the newly created Medical Gas Storage Room, it was observed that the original lay in ceiling tile system has been removed. However, the sprinkler heads protecting this location were left at this original ceiling height. As a result, the sprinkler heads are now approximately four feet (4') below the concrete deck above and not installed as required.
Note: The removed ceiling was cosmetic only and not part of the rated assembly.

3) On 01/07/20 at approximately 1:30 P.M. when viewing the Electrical closet on the 2nd floor level identified by door #12015A, it was observed to be non-sprinklered. In addition, the room was observed to not have a 2-hour separation as required if non-sprinklered.

4) While conducting the facility tour on 1/06/20 at approximately 2:10 P.M., observations revealed the presence of a quick response sprinkler head approximately fifty inches (50") apart from a standard response sprinkler head in room #470 on the fourth floor of the "Usen Building".
In addition to being to close to each other, regulations prohibit the installation of quick response and standard response sprinkler heads within the same compartmented space.
To ensure compliance with NFPA 13 regulations, the standard head sprinkler located approximately 50" from the quick response head must be removed. Note: All other sprinkler heads within the observed compartmented space (room #470) are of the quick response type

NOTE: The hospital is self identifying as being a fully sprinklered building in all required locations. In addition, the hospital is utilizing various exceptions from the LSC Chapter 19 requiring full sprinkler protection.

This deficient practice could affect all patients, as well as an undetermined amount of staff and visitors in the event of an actual emergency situation where fire was to threaten these locations.

As a result, the facility failed to comply with the various sections of NFPA 13 and the installation of the automatic sprinkler system.

The findings were confirmed by the Hospital's Administrative Leadership Team during the exit interview process.

Based on observations and confirmed the Maintenance Director, the facility failed to ensure compliancy with required NFPA (National Fire Protection Association) regulations.
-Section 7.1.1.2 of the 2010 edition of NFPA 13 "Standard For The Installation of Sprinkler Systems" states pressure gages shall be installed above and below each alarm check valve or system riser check valve where such devices are present.
-Section 5.2.4.1 of the 2011 edition of NFPA 25 "Standard For The Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems" states that gages on wet pipe sprinkler systems shall be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained.

Findings Include:

On 01/07/20 at approximately 2:10 P.M. it was observed that there is no pressure gauge installed on the street/supply side of the backflow preventer.

As a result of the finding the facility is found to be non-compliant with NFPA 13 Section 7.1.1.2 and NFPA 25 Section 5.2.4.1.

The finding was confirmed by the facility's head electrician and reviewed with the Director of Facilities, Engineering and other Hospital Administrative staff during the exit conference.

This Standard is not met as evidenced by:

Based on observations and confirmed by the Facility's maintenance staff during the building tour, the facility failed to ensure compliancy with sections of the 2011 edition of NFPA 25 "Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems"
-Section 5.2.1.1.1* states sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall).
- Section 5.2.1.1.2 states any sprinkler that shows signs of any of the following shall be replaced:
(1) Leakage
(2) Corrosion
(3) Physical damage
(4) Loss of fluid in the glass bulb heat responsive element
(5)*Loading
(6) Painting unless painted by the sprinkler manufacturer

Findings Include:

While conducting the facility tour on 1/06/20 at approximately 2:30 P.M., observations revealed the existence of a damaged sprinkler head positioned in the ceiling near room #424 of the area identified as "Usen West". The damaged head is of the concealed type with a drop down deflector which rides on guide rails when activated. At time of observation, the sprinkler head was found to be missing its cover and the deflector guide rails were bent and misaligned.

As a result of the finding, the facility failed to ensure compliance with Section 5.2.1.1.2 of NFPA 25 which requires damaged sprinkler heads to be replaced.

The findings were confirmed by the Hospital's Administrative Leadership Team during the exit interview process.

This Standard is not met as evidenced by:

Based on observations and confirmed by the Director of Facilities during the building tour, the facility failed to ensure that corridor separation is provided as required.

Section 19.3.6.1 subsection (7) states spaces other than patient sleeping rooms, treatment rooms, and hazardous areas, shall be permitted to be open to the corridor and unlimited in area, provided that all of the following criteria are met:

(a) The space and the corridors onto which it opens, where located in the same smoke compartment, are
protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4.
(b) Each space is protected by automatic sprinklers, or the furnishings and furniture, in combination with all
other combustibles within the area, are of such minimum quantity and arrangement that a fully developed
fire is unlikely to occur.
(c) The space does not obstruct access to required exits.

THE FINDINGS INCLUDE:

On 01/07/20 at approximately 1:15 P.M. while touring the 2nd floor level, the egress corridor located outside of Stair J was observed to be used as an employee use area. Although the corridor is approximately 12' in width at this location, wall mounted computer cubicles were observed. During the entire survey process, these computer stations were in constant use by hospital employees. This corridor is not equipped with smoke detecting devices as required to allow open spaces to the corridor.

This deficient practice could affect all patients, as well as an undetermined amount of staff and visitors in the event of an actual emergency situation where smoke detectors for early detection are required to warn of smoke and/or fire.

As a result, the facility failed to comply with section 19.3.6.1 regarding rooms open to the corridor.

The findings were confirmed by the Hospital's Administrative Leadership Team during the exit interview process.

This Standard is not met as evidenced by:

Based on observations and confirmed by the Director of Facilities during tour, the facility failed to ensure compliance with specific requirements of the 2012 edition of NFPA 101 Life Safety Code.

Section 19.3.6.3.1 states doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be doors constructed to resist the passage of smoke and shall be constructed of materials such as the following:
(1) 1-3/4 in. (44 mm) thick, solid-bonded core wood

(2) Material that resists fire for a minimum of 20 minutes
Section 19.3.6.3.2 states that the requirements of 19.3.6.3.1 shall not apply where otherwise permitted by either of the following:

(1) Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain
flammable or combustible materials shall not be required to comply with 19.3.6.3.1.

(2) In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.7, the door construction materials requirements of 19.3.6.3.1 shall not be mandatory, but the doors shall be constructed to resist the passage of smoke.

Section 19.3.6.3.5 states that corridor doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction, and the device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door.

Findings Include:

During the morning and afternoon hours of 01/06/20 the following items were observed:

1. On 01/06/20 at approximately 11:00 A.M. the "South" Building's sixth floor level MGH pediatric area:
a.) The Nursing Director's Office was held open by a wood floor wedge,
b.) Exam Room #9 had an approximate 1/2" unsealed gap between the door face and door stop along the header.

2. On 01/06/20 at 3:45 P.M. the third floor level, identified as outpatient Dietary and Psychiatric office spaces, Office # 10 B utilized a wood floor wedge to hold the door open.

3. On 01/06/20 at approximately 4:10 P.M the Usen Building's third floor level occupied unit, the two (2) Interview Room's corridor doors each were equipped with the total hinge, and no door stops along the header, the hinge side and latch side jam.
(Facility staff stated that it is a way to access room in the event of a hostile patient). Neither one of the frames are equipped with door stops rendering the doors less than smoke resistant.

4. On 01/06/20 at approximately 11:40 A.M. the set of double doors leading into the 6th floor NICU were observed to have an approximate 1/4" gap between the two door leaves.

5. On 01/06/20 at 4:15 P.M., all of the patient room doors on the 3rd floor West Unit were observed as being obstructed. These room doors were unable to close and latch as a soiled linen cart and/or trash container were preventing each of these doors from closing. The rooms are designed with a an approximate 10" wall on the latching side of the door, when these carts and/or containers are placed in this wall location, they prohibit the doors from closing.

As a result of the finding the facility is found to be non-compliant with section 19.3.6.3.2(2) and section 19.3.6.3.5.

The finding was confirmed by the facility's head electrician and reviewed with the Director of Facilities, Engineering and other Hospital Administrative staff during the exit conference.

This Standard is not met as evidenced by:

Based on observations and confirmed by the Director of Facilities during the building tour, the facility failed to ensure that smoke compartments are maintained as smoke tight as required. This deficient practice could affect all current residents, as well as an undetermined amount of staff and visitors in the event of an actual emergency situation where the transmission of smoke could travel from compartment to compartment.

Section 19.3.7.3 states any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a minimum 1/2-hour fire resistance rating, unless otherwise permitted by one of the
following:

(1) This requirement shall not apply where an atrium is used, and both of the following criteria also shall apply:
(a) Smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with 8.6.7(1)(c).
(b) Not less than two separate smoke compartments shall be provided on each floor.

(2) Smoke dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating,
and air-conditioning systems where an approved, supervised automatic sprinkler system in accordance with
19.3.5.8 has been provided for smoke compartments adjacent to the smoke barrier.

Section 8.5.2.1 states 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 by use of a combination thereof.

Section 8.5.2.2 states smoke barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.

THE FINDINGS INCLUDE:

During morning and afternoon hours of 01/07/20 the following deficiencies but not limited to were observed regarding smoke barrier walls:

1) On 01/07/20 at 9:00 A.M. the 3rd floor level smoke barrier wall by S8 was checked for structural integrity during the facility tour. An electronic smoke damper was observed directly above smoke barrier door #33,000. Upon closer examination, the smoke damper was observed to be located in the middle (between studs) of the actual wall, and not on one side as it should be. As a result of the placement of this damper, the wall was observed as having an approximate 8" x 8" non-sealed penetration. With the location of this smoke damper, it would not be possible to be smoke tight as there are moving components of the mechanism.

2) On 01/07/20 at 11:00 A.M. the smoke barrier wall on the 2nd floor level between S6 and S7 was checked for structural integrity during the facility tour. Numerous non-sealed penetrations were noted throughout this wall, these include voids around conduits, piping, wiring, and electrical components ranging in size from approximately 1"x2" to 2"x4".

3) On 01/07/20 from 10:50 A.M. to 11:10 A.M. the smoke barrier wall separating smoke compartment SC-2G from smoke compartment SC-2A was checked for structural integrity during the facility tour. Numerous non-sealed penetrations ranging in size from approximately 2"x2" to 6"x6". These include but are not limited to the following locations:
a) Above the cross-corridor smoke barrier door leading into Suite #9.
b) Above the layed in ceiling tiles of the office area located adjacent to the corridor that leads to Suite #9.
c) Above the layed in ceiling tiles of the "Usen CDC staff breakroom".

As result, the facility failed to ensure compliance with section 8.5.2.1 requiring smoke barrier walls to be tight from outside wall to outside wall.

The findings were confirmed by the Hospital's Administrative Leadership Team during the exit interview process.

This Standard is not met as evidenced by:

Based on observations and confirmed by the Director of Facilities during the building tour, the facility failed to ensure that smoke barrier doors are maintained and equipped as required.

Section 19.3.7.8 states doors in smoke barriers shall comply with 8.5.4 and all of the following:
(1) The doors shall be self-closing or automatic-closing in accordance with 19.2.2.2.7.
(2) Latching hardware shall not be required
(3) The doors shall not be required to swing in the direction of egress travel.

Section 8.5.4.1 states doors in smoke barriers shall close the opening, leaving only the minimum clearance necessary for proper operation, and shall be without louvers or grilles. The clearance under the bottom of a new door shall be a maximum of 3/4 in. (19 mm).

Section 8.5.4.4 states doors in smoke barriers shall be self-closing or automatic-closing in accordance with 7.2.1.8 and shall comply with the provisions of 7.2.1.

Section 7.2.1.8.2 states in any building of low or ordinary hazard contents, as defined in 6.2.2.2 and 6.2.2.3, or where approved by the authority having jurisdiction, door leaves shall be permitted to be automatic-closing, provided that all of the following criteria
are met:
(1) Upon release of the hold-open mechanism, the leaf becomes self-closing.
(2) The release device is designed so that the leaf instantly releases manually and, upon release, becomes self-closing, or the leaf can be readily closed.
(3) The automatic releasing mechanism or medium is activated by the operation of approved smoke detectors installed in accordance with the requirements for smoke detectors for door leaf release service in NFPA 72, National Fire Alarm and Signaling Code.
(4) Upon loss of power to the hold-open device, the hold open mechanism is released and the door leaf becomes self-closing.
(5) The release by means of smoke detection of one door leaf in a stair enclosure results in closing all door leaves serving that stair.


THE FINDINGS INCLUDE:

During the afternoon hours of 01/06/20 and 01/07/20 while touring the hospital, it was observed that smoke barrier doors are not properly maintained or equipped. The following items but not limited to were observed regarding smoke barrier doors:

1) On 01/06/20 at 10:40 A.M. the pair of smoke barrier doors on the 6th floor corridor located at S3 were observed to have an approximate 1/4" gap between the two door leaves.

2) On 01/06/20 at 3:15 P.M. the smoke barrier door on the 3rd floor West Unit located between the Medication Room and the Utility Room was observed as not closing as required. The door appears to be out of adjustment preventing full closure as required. The door had an approximate 1/4" gap along the latch side of the door jamb when tested for operation.

3) On 01/06/20 at 4:15 P.M. the smoke barrier door on the 3rd floor East Unit located between the X-Ray Control Room and Exam Room 1 was found to be wedged (wood wedge) in the open position. This door wedge was immediately removed by hospital staff.

4) On 01/07/20 at 2:20 P.M. the second floor smoke barrier door which separates SC-2A from SC-2G was observed to be deficient as follows.

a) It is equipped with a non-rated vision panel.

b) It was being held open by a releasing device which requires manual activation to close the door. As section 7.2.1.8.2 requires, smoke barrier doors shall only be allowed to be held in the open position by use of an automatic releasing device that is actuated by the fire alarm system. This self closing device has the ability to lock in the open position, resulting in non-release upon activation of the alarm system.

This deficient practice could affect all patients, as well as an undetermined amount of staff and visitors in the event of an actual emergency situation where the transmission of smoke from one compartment to another must be contained.

As a result, the facility failed to comply with section 19.3.7.8 and 8.5.4 requiring smoke barrier doors to self close and be smoke tight.

The findings were confirmed by the Hospital's Administrative Leadership Team during the exit interview process.

This Standard is not met as evidenced by:

Based on observations and confirmed by the Director of Facilities during the building tour, the facility failed to ensure that the Heating Ventilation Air Conditioning (HVAC) System is installed as required.. Section 19.5.2.1 states heating, ventilating, and air-conditioning shall comply with the provisions of Section 9.2 and shall be installed in accordance with the manufacturer's specifications, unless otherwise modified by 19.5.2.2.

Section 9.2.1 states Air-Conditioning, Heating, Ventilating Ductwork, and Related Equipment. Air-conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, as applicable, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 90A section 5.3.1.1 states an approved fire dampers shall be provided where air ducts penetrate or terminate at openings in walls or partitions required to have a fire resistance rating of 2 hours or more.

NFPA 90A section 4.3.5.1 states a service opening shall be provided in air ducts adjacent to each fire damper, smoke damper, combination fire/smoke damper, and any smoke detectors that need access for installation, cleaning, maintenance, inspection, and testing.

Section 4.3.5.1.1 states the opening shall be large enough to permit maintenance and resetting of the device.

Section 4.3.5.2 states service openings shall be identified with letters having a minimum height of 12.7 mm (1.2 in.) to indicate the location of the fire protection device(s) within.

Section 5.4.8.1 states fire dampers and ceiling dampers shall be maintained in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.

Section 4.3.5.1.1 states the opening shall be large enough to permit maintenance and resetting of the device.

Section 4.3.5.2 states service openings shall be identified with letters having a minimum height of 12.7 mm (1.2 in.) to indicate the location of the fire protection device(s) within.

NFPA 80 section 19.4.1 states each damper shall be tested and inspected 1 year after installation.

Section 19.4.1.1 states the test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years.

Section 19.4.3 states full unobstructed access to the fire or combination fire/ smoke damper shall be verified and corrected as required.

Section 19.4.4 states if the damper is equipped with a fusible link, the link shall be removed for testing to ensure full closure and lock-inplace if so equipped.

Section 19.4.5 states the operational test of the damper shall verify that there is no damper interference due to rusted, bent, misaligned, or damaged frame or blades, or defective hinges or other moving parts.

THE FINDINGS INCLUDE:

On 01/07/20 at approximately 10:45 A.M. while touring the 3rd floor level, the fire/smoke combination wall by S8 was checked for structural integrity. Above the ceiling within the men's bathroom, a 6" x 6" duct was observed as penetrating the wall. This duct was not equipped with an access panel to determine if the fire damper was present. In addition, as no access panel is present, inspection of the fire damper if present could not be verified.

This deficient practice could affect all residents, as well as an undetermined amount of staff and visitors in the event of an actual emergency situation where the dampers are required to activate.

As a result, the facility failed to comply with section 9.2 requiring the maintenance of Heating Ventilation and Air Conditioning (HVAC) Systems.

The findings were confirmed by the Hospital's Administrative Leadership Team during the exit interview process.

This Standard is not met as evidenced by:

Based on observations and confirmed by the Facility's Maintenance Staff during the building tour, the facility failed to ensure compliance with Chapter 19 Section 19.7.8 of the 2012 edition of NFPA 101 " Life Safety Code ".

Section 19.7.8 " Portable Space Heating Devices " states the following. Portable space heating-devices shall be prohibited in all health care occupancies, unless both of the following criteria are met:
(1) Such devices are used only in non-sleeping staff and employee areas.
(2) The heating elements of such devices do not exceed 212 degrees F (100 degrees C).

Findings Include:

During 01/06/20 while touring the facility, observations revealed the existence of a portable electric space heaters with heating elements capable of exceeding 212 degrees F (100 degrees C) at the following locations:

1. On 01/06/20 at 10:40 A.M. on the sixth floor level at the MGH Outpatient Checkout / Reception desk.

2. On 01/06/20 at approximately 2:10 P.M. on the third floor level outpatient Dietary and Psychiatric office spaces at: office # 13 B, Social Service(s) Workers office, office #12 B, office #11 B, and the Care Coordinator Office #4.

As a result, the facility failed to comply with section 19.7.8 allowing the use of portable electric heaters.

The finding was confirmed by the facility's head electrician and reviewed with the Director of Facilities, Engineering and other Hospital Administrative staff during the exit conference.

This Standard is not met as evidenced by:

Based on observations and confirmed by the Facility's Maintenance Staff during the building tour, the facility failed to ensure that the electrical wiring is in accordance with NFPA 99, (Health Care Facilities Code) 2012 edition. NFPA 99 section 6.3.2.1 states installation shall be in accordance with NFPA 70, (National Electrical Code) 2011 edition.

NFPA 70 section 590.3 has the following time constraints for temporary wiring.
(A) During the Period of Construction. Temporary electric power and lighting installations shall be permitted during
the period of construction, remodeling, maintenance, repair, or demolition of buildings, structures, equipment, or
similar activities.
(B) 90 Days. Temporary electric power and lighting installations shall be permitted for a period not to exceed 90 days for holiday decorative lighting and similar purposes.
(C) Emergencies and Tests. Temporary electric power and lighting installations shall be permitted during emergencies
and for tests, experiments, and developmental work.
(D) Removal. Temporary wiring shall be removed immediately upon completion of construction or purpose for which
the wiring was installed.

Findings Include:

On 1/6/20 at approximately 2:10 P.M., an extension cord was observed as being utilized to supplement power to a non-conforming quartz type portable electric space heater and a cell phone charger on the third floor level, outpatient Dietary and Psychiatric office spaces, at the Care Coordinator Office #4 (opposite office #17).
Note: Please refer to ID Prefix Tag K781 for the deficiency regarding the non-conforming electrical heater.

The facility's head electrician, who also noted this, immediately removed the space heater and cord and placed them in a locked closet.

As a result, the facility failed to comply with NFPA 70 section 590.3 regarding the use of extension cords.

The finding was confirmed by the facility's head electrician and reviewed with the Director of Facilities, Engineering and other Hospital Administrative staff during the exit conference.