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Based on observation, the facility failed to ensure the fire and smoke resistive properties of the structure were maintained. Failure to seal penetrations and maintain rated construction assemblies, has the potential to allow fire, smoke and dangerous gases to pass into unprotected spaces and between compartments. This deficient practice potentially affected all patients, staff and visitors on the date of the survey.

Findings include:

During the facility tour conducted on 7/29/21 from 12:00 -3:00 PM, observation of the interior space of the data server room, that was located in the corridor outside of the entrance into the Operating Room suite (OR), revealed the following unsealed penetrations:

- An approximately two-inch unsealed hole cut into the south wall, approximately ten feet from the floor.
- The cabling tray for the servers that was installed in a west to east orientation, approximately ten feet from the floor level, entered the ancillary space in the ceiling above the OR through an unsealed penetration, approximately four inches high by eighteen inches wide.
- Three (3) approximately three-inch diameter unsealed conduit pipes entering the ancillary attic space above.
- Walls were observed to be stamped as one-hour rated assemblies.

Actual NFPA standard:

NFPA 101

19.1.6 Minimum Construction Requirements.
19.1.6.1 Health care occupancies shall be limited to the
building construction types specified in Table 19.1.6.1, unless
otherwise permitted by 19.1.6.2 through 19.1.6.7. (See 8.2.1.)

8.2 Construction and Compartmentation.
8.2.1 Construction.
8.2.1.1 Buildings or structures occupied or used in accordance with the individual occupancy chapters, Chapters 11 through 43, shall meet the minimum construction r

Based on observation, the facility failed to ensure corridor doors would resist the passage of smoke. Installation of transfer grilles into corridor doors, has the potential to allow fire, smoke and dangerous gases to pass into the corridor, hindering the safe egress of patients during a fire event. This deficient practice affected all patients, staff and visitors on the date of the survey.

Findings include:

During the facility tour conducted on 7/29/21 from 12:30 - 3:00 PM, observation of the corridor door entering the data closet in the Specialty Clinic, revealed an approximately eight-inch by twelve-inch louvered transfer grille installed in the base of the door.

Actual NFPA standard:

NFPA 101

19.3.6 Corridors.
19.3.6.3% Corridor Doors.

19.3.6.3.1% 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) 13.4 in. (44 mm) thick, solid-bonded core wood
(2) Material that resists fire for a minimum of 20 minutes

19.3.6.4 Transfer Grilles.
19.3.6.4.1 Transfer grilles, regardless of whether they are protected by fusible link-operated dampers, shall not be used in corridor walls or doors.

Based on observation, the facility failed to ensure safe electrical installations in accordance with NFPA 70. Use of Relocatable Power Taps (RPTs) or extension cords, connected in series (daisy-chained) or as the substitution of the direct wiring of the facility, has the potential to expose patients to the risks of arc fires or electrical shock. This deficient practice affected all patients, staff and visitors on the date of the survey.

Findings include:

During the facility tour conducted on 7/29/21 from 12:30 - 3:00 PM, observation of installed electrical systems revealed the following:

- The Pharmacy office was using an extension cord to supply power to a RPT.
- The dietary station across from the main Nurse's station was using a 3-1 multiple plug adapter to supply power to a toaster and a coffee maker.
- The Specialty Clinic was using an extension cord to supply power to a mini refrigerator.
- The Laboratory was using a non-grounded plug adapter for 1 of 2 full-size refrigerators.

Actual NFPA standard:

NFPA 70

110.2 Approval. The conductors and equipment required or permitted by this Code shall be acceptable only if approved.
Informational Note: See 90.7, Examination of Equipment for Safety, and 110.3, Examination, Identification, Installation, and Use of Equipment. See definitions of Approved, Identified, Labeled, and Listed.
110.3 Examination, Identification, Installation, and Use of Equipment.
(A) Examination. In judging equipment, considerations such as the following shall be evaluated:
(1) Suitability for installation and use in conformity with the provisions of this Code
Informational Note: Suitability of equipment use may be identified by a description marked on or provided with a product to identify the suitabil

Based on record review, observation and interview, the facility failed to ensure construction activities were performed in accordance with NFPA 101. Failure to ensure rated separations are installed, alternative fire life safety measures have been evaluated, and any applicable required life safety systems not further reduced or eliminated, has the potential to expose patients to those elevated hazards and risks associated with such activities. This deficient practice affected all patients, staff and visitors on the date of the survey.

Findings include:

During review of provided maintenance and inspection records conducted on 7/29/21 from 8:30 AM - 12:30 PM, no documentation for an Interim Life Safety Measure (ILSM) assessment or daily inspection for the means of egress was available. When asked if any ILSM was in place for any remodeling or construction projects, the Maintenance Supervisor stated no documentation of an ILSM was available.

During the facility tour conducted on 7/29/21 from 12:30 - 3:00 PM, observation of the area at patient rooms 11A and 11B revealed the following:

- Patient rooms 11A and 11B were observed to be in a current state of remodel, with exposed wiring and ancillary spaces, such as the area above the exposed suspended ceiling. Both rooms were currently empty.
- A temporary wall was erected in the corridor outside of patient rooms, impacting the egress path.
- The wall was observed to constructed of metal studs with Oriented Strand Board (OSB) and a Fibre-reinforced plastic (frp) paneling attached to the corridor side surface of the OSB.
- Non-rated plastic sheeting was used as a door/separation for the entry and exit into the construction area.
- The projection into the corridor of the temporary barrier measured approximately three fe