HospitalInspections.org

One-story Existing Health Care Occupancy buildings of Type III (200) construction are required to be protected throughout with an automatic fire sprinkler system. 19.1.6.1

The facility failed to provide an automatic fire sprinkler system throughout the facility that meets the requirements of NFPA 13, Standard for Installation of Sprinkler Systems.

Observation determined the structural walls were concrete block and the roof assembly was constructed of combustible wood supports and wood boards. The building was not protected throughout with an automatic fire sprinkler system.

Failure to provide a building of construction Type III (200) with an automatic fire sprinkler system increases the risk of injury and death.

This deficiency affected the entire building.

Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage, and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening Protectives, except as otherwise specified in this code. 8.3.3.1.

Fire-rated door assemblies shall be inspected and tested in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. 7.2.1.15.2

The facility failed to inspect and test fire rated door assemblies throughout the facility.

Review of documentation and interview with staff determined fire rated door assemblies had not been inspected in the past year.

Failure to inspect and test fire rated door assemblies increases the risk of injury or death due to fire.

The deficiency affected numerous fire rated door assemblies throughout the facility.

Not more than 50 percent of the required number and capacity of exits comprised of smokeproof enclosures shall discharge through interior building areas on the level of exit discharge. 7.2.3.5.2

The facility failed to arrange at least 50 percent of exits to discharge directly to the exterior of the building.

Observation determined the north and south exit stairs from the basement discharged onto the first-floor corridor of the building rather than into an exit passageway or to the exterior of the building.

Failure to arrange at least 50 percent of exits to discharge directly to the exterior of the building increases the risk of injury or death due to fire.

This deficiency affected two (2) of three (3) designated exits from the basement.

Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6. 19.3.4.1

A fire alarm system required for life safety shall be installed, tested and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code. 9.6.1.3

The facility failed to test the fire alarm system as required.

Review of documentation determined device test results (alarm initiating, supervisory alarm initiating, and notification) did not provide an itemized list with the device type, address, location, and test result as required.

Failure to install, test and maintain the fire alarm system in accordance with NFPA 72 increases the risk of death or injury due to fire.

This deficiency affected one (1) of one (1) fire alarm system. The fire alarm system serves the entire facility.

In spaces served by air-handling systems, detectors shall not be located where airflow prevents operation of the detectors. Detectors should not be located in a direct airflow or closer than 36 in. from an air supply diffuser or return air opening. 19.3.4.5.1, 9.6.2.10.1.1, NFPA 72 17.7.4.1, A.17.7.4.1

The facility failed to ensure the smoke detection system was in compliance with NFPA 72, National Fire Alarm and Signaling Code.

Observation determined:

1) Two (2) smoke detectors in the Business Office were installed within 36 in. of an air supply diffuser or return air opening.

2) The smoke detector in the CT Scan Room was installed within 36 in. of an air supply diffuser or return air opening.

Failure to install the smoke detection system as required increases the risk of death or injury due to fire.

This deficiency affected three (3) of numerous smoke detectors in the facility. The smoke detection system serves the entire facility.

The facility failed to ensure corridors were separated from use areas by walls constructed with at least a ½-hour fire resistance rating.

Observation determined the corridor walls throughout the basement and main floor were not maintained as ½-hour fire resistant rated wall assemblies. The holes through the corridor walls caused by pipe, electrical conduit, air duct, and low-voltage wire penetrations were not adequately sealed with fire rated material.

Failure to ensure corridor walls have a ½-hour fire resistant rating increases the risk of injury and death.

This deficiency affected the entire facility.

The facility failed to ensure transfer grilles were not used in corridor walls.

Observation determined the Air Handler Room in the northeast basement corridor had a transfer grill in the corridor wall.

Failure to ensure transfer grilles are not used in corridor walls increases the risk of injury and death.

This deficiency affected the entire basement.

Ground-fault circuit-interruption for personnel shall be provided as required. The ground-fault circuit-interrupter shall be installed in a readily accessible location. All 125-volt, single-phase, 15- and 20-ampere receptacles located in bathrooms, kitchens, rooftops, outdoors, indoor wet locations, locker rooms with associated showering facilities, garages and where receptacles are installed within 6 ft. of the outside edge of the sink shall have ground-fault circuit-interrupter protection for personnel. 19.5.1.1, 9.1.2, NFPA 70, 210.8, 210.8(B)

The facility failed to ensure electrical wiring and electrical equipment met the requirements of NFPA 70, National Electrical Code.

Observation determined:

1) One (1) electrical receptacle in the PT Treatment Room 4 Bathroom was not ground-fault circuit-interrupter protected.

2) One (1) electrical receptacle in the PT Treatment Room 4 Shower was not ground-fault circuit-interrupter protected.

3) One (1) electrical receptacle in the Doctors Locker Bathroom was not ground-fault circuit-interrupter protected.

4) One (1) electrical receptacle in the Nurses Locker Bathroom was not ground-fault circuit-interrupter protected.

5) One (1) electrical receptacle in the Pharmacy Storage Room within 6 ft. of a sink was not ground-fault circuit-interrupter protected.

6) One (1) electrical receptacle in the OR Soiled Work Room within 6 ft. of a sink was not ground-fault circuit-interrupter protected.

7) One (1) electrical receptacle in the OR Clean Work Room within 6 ft. of a sink was not ground-fault circuit-interrupter protected.

8) One (1) electrical receptacle in the OR Manager Office within 6 ft. of a sink was not ground-fault circuit-interrupter protected.

9) One (1) electrical receptacle in ER 2 within 6 ft. of a sink was not ground-fault circuit-interrupter protected.

Failure to provide electrical wiring and equipment in accordance with NFPA 70 increases the risk of injury or death due to fire.

The deficiency affected nine (9) of numerous receptacles in the facility.

The facility failed to conduct fire drills as required.

Fire drill records review determined all fire drills did not include the simulation of an emergency phone call to the fire department.

Failure to conduct fire drills as required increases the risk of death or injury due to fire.

The deficiency affected eleven (11) of twelve (12) required drills in the past year.