HospitalInspections.org

The facility failed to ensure the integrity of the two-hour fire rated occupancy separation wall between the hospital and the clinic.

Observation determined:

1) The lack of fire caulking materials around conduit through-wall penetrations in the room housing the sprinkler riser.

2) The head-of-wall joint in the room housing the sprinkler riser was not sealed with fireproofing materials.

3) The lack of fire caulking materials around conduit and water pipe through-wall penetrations in the rest room across the corridor from the room housing the sprinkler riser.

Failure to ensure the fire resistance rating of occupancy separation walls as required increases the risk of death or injury due to fire.

This deficiency affected one (1) of two (2) two-hour fire resistant rated occupancy separation walls in the facility.

Automatic fire sprinkler systems must be installed in accordance with NFPA 13.

The facility failed to install the automatic sprinkler system in accordance with NFPA 13 to provide adequate coverage for all portions of the building.

Observation determined the room housing the chemotherapy hood lacked sprinkler coverage. There was no sprinkler in the room.Failure to install the automatic sprinkler system in accordance with NFPA 13 for all portions of the building increases the risk of injury and death due to fire.

The deficiency affected one room of the facility.

Valves shall be inspected internally every 5 years to verify that all components operate properly, move freely, and are in good condition. 9-4.2.1. The facility failed to ensure the automatic sprinkler system was continuously maintained in a reliable operating condition as required by NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems.

Records review of the 06/24/2015 sprinkler inspection and test report completed by the facility's contracted service vendor determined there was no record of the required internal inspection of the sprinkler check valve in the past five (5) years. Failure to test and maintain the automatic sprinkler system in accordance with NFPA 25 increases the risk of death or injury due to fire.

The deficiency affected one of numerous required tests of the automatic sprinkler system. The automatic sprinkler system serves the entire facility.

Ref: 2000 NFPA 101 9.7.5, 1998 NFPA 25 Section 9-4.2.1.

The facility failed to ensure exit corridors were continuously maintained free of all obstructions or impediments to full instant use.

Observation determined a large scale, small scale, fan and a wheelchair were located in the exit corridor to the Same Day suite. These items restricted the use of the entire corridor width as constructed.Failure to ensure exit access was readily available at all times increases the risk of death or injury due to fire.

This deficiency affected exit access from one (1) of six (6) exits.

All Level 1 and Level 2 installations of an emergency generator must have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building. NFPA 110 Standard for Emergency and Standby Power Systems 1999 Edition.

The facility failed to ensure the emergency generator was in compliance with NFPA 110.

The generator was located inside the penthouse with no remote manual stop switch provided outside the penthouse.

Failure to ensure the emergency generator is in compliance with NFPA 110, increases the risk of death or injury due to fire.

The deficiency affected one (1) of one (1) emergency generator providing emergency power to the entire facility.

The facility failed to ensure the integrity of the two-hour fire rated occupancy separation wall between the hospital and the clinic.

Observation determined:

1) The lack of fire caulking materials around conduit through-wall penetrations in the room housing the sprinkler riser.

2) The head-of-wall joint in the room housing the sprinkler riser was not sealed with fireproofing materials.

3) The lack of fire caulking materials around conduit and water pipe through-wall penetrations in the rest room across the corridor from the room housing the sprinkler riser.

Failure to ensure the fire resistance rating of occupancy separation walls as required increases the risk of death or injury due to fire.

This deficiency affected one (1) of two (2) two-hour fire resistant rated occupancy separation walls in the facility.

Automatic fire sprinkler systems must be installed in accordance with NFPA 13.

The facility failed to install the automatic sprinkler system in accordance with NFPA 13 to provide adequate coverage for all portions of the building.

Observation determined the room housing the chemotherapy hood lacked sprinkler coverage. There was no sprinkler in the room.Failure to install the automatic sprinkler system in accordance with NFPA 13 for all portions of the building increases the risk of injury and death due to fire.

The deficiency affected one room of the facility.

Valves shall be inspected internally every 5 years to verify that all components operate properly, move freely, and are in good condition. 9-4.2.1. The facility failed to ensure the automatic sprinkler system was continuously maintained in a reliable operating condition as required by NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems.

Records review of the 06/24/2015 sprinkler inspection and test report completed by the facility's contracted service vendor determined there was no record of the required internal inspection of the sprinkler check valve in the past five (5) years. Failure to test and maintain the automatic sprinkler system in accordance with NFPA 25 increases the risk of death or injury due to fire.

The deficiency affected one of numerous required tests of the automatic sprinkler system. The automatic sprinkler system serves the entire facility.

Ref: 2000 NFPA 101 9.7.5, 1998 NFPA 25 Section 9-4.2.1.

The facility failed to ensure exit corridors were continuously maintained free of all obstructions or impediments to full instant use.

Observation determined a large scale, small scale, fan and a wheelchair were located in the exit corridor to the Same Day suite. These items restricted the use of the entire corridor width as constructed.Failure to ensure exit access was readily available at all times increases the risk of death or injury due to fire.

This deficiency affected exit access from one (1) of six (6) exits.

All Level 1 and Level 2 installations of an emergency generator must have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building. NFPA 110 Standard for Emergency and Standby Power Systems 1999 Edition.

The facility failed to ensure the emergency generator was in compliance with NFPA 110.

The generator was located inside the penthouse with no remote manual stop switch provided outside the penthouse.

Failure to ensure the emergency generator is in compliance with NFPA 110, increases the risk of death or injury due to fire.

The deficiency affected one (1) of one (1) emergency generator providing emergency power to the entire facility.