HospitalInspections.org

Citation Text for Tag 0311, Regulation K307, Bld 01
Based on direct observation, not all stair doors are maintained to provide protection of the exit enclosure. This deficiency could affect patients, staff and visitors if the stair door did not provide the proper protection during a fire emergency.

The finding is:

On November 6, 2024 at 12:30pm, while in the company of the DOE it was observed that the East Exit Stair door on the 3rd floor failed to self-close and self-latch. The door leaf was observed to drag along the door frame to prevent closure. This does not comply with the requirements of Table 8.3.4.2 and NFPA 80, 2010 6.4.1.1.

Based on direct observation, hazardous areas are not properly separated from the remainder of the occupancy and the means of egress. Failure to properly separate hazardous area from required means of egress paths can compromise the safety of all occupants.

Findings include:

A. November 6, 2024 at 1:00pm, while in the company of DOE it was observed that the room on the north side of the corridor at the end of the 2nd floor east wing is used for storage, and the doors serving the room are not selfclosing fire rated door assemblies. Therefore, this hazardous area failed to comply with 19.3.2.

B. November 6, 2024 at 1:05pm, while in the company of DOE it was observed that an above ceiling penetration in the soiled utility room adjacent to the 2nd floor east wing nurses' station was not sealed against fire in the fire barrier as shown on the Life Safety plans provided by the facility. This penetration does not comply with 8.3.5.1.

Based on document review the fire alarm system is not being inspected, tested and maintained in accordance with code requirements. Failure to properly inspect, test and maintain the fire alarm system can result in failure of the system to operate as intended to warn occupants of a fire/smoke event.

Findings include:

On Novemebr 6, 2024, at 12::00pm while in the company of the DOE, it was observed that the October 15, 2024 annual fire alarm inspection indicated that 7 initiating devices tested outside the manufacturer's specified sensitivity ranges. No evidence was presenbted to indicate corrective action had occured. Therefore, the system is not maintained in accordance with NFPA 72-2010.

Based on document review the facility failed to perform the required sprinkler system maintenance. Failure to maintain the sprinkler system can result in failure or dimminished system performance during a fire event risking the safety of patients, staff and visitors.

The finding is:

On Novemebr 6, 2024, at 11:45pm while in the company of the DOE, review of the October 15, 2024 annual inspection indicated 4 deficiencies in the sprinkler system; 1 deficiency cited incorrect installation of sprinkler heads, 1 deficiency cited no hose valve inspection, and 2 deficiencies cited gauge replacement/recalibration. No evidence of corrective action was presented for review. Therefore, the system is not maintained in accordance with NFPA 25-2011.

Based on observation and document review the facility failed to maintain life safety code protective devices. This deficient practice may affect all patients, staff and visitors within the building should a component of an essential system fail during a fire event.

The finding is:

On Novemebr 6, 2024 at 11:30am, while in the company of the DOE no documentation or evidence of inspection or testing within the previous six years was available for review to comply with NFPA 80-2010, 19.4 and NFPA 105-2010, 6.6.3.

Based on direct observation the facility lacks complete electrical bonding of the medical gas piping system. Failure to install and maintain this installation could potentially result in the piping system becoming electrically energized. This deficient practice could affect patients, staff and visitors.

Findings include:

On November 6, 2024, at 2:30pm while in the company of the DOE, it could not be confirmed through direct observation that electrical bonding of the facility's medical gas piping system has been completed. This is not in compliance with NFPA 70-2011 Edition, Section 250.104 (B).

Based on direct observation the generators are not installed as required. This deficient practice could affect patients, staff, and visitors in the building if the generators are not capable of being safely operated as required in an emergency event.

The finding is:

On Novmeebr 6, 2024, at 2:00pm while accompanied by the DOE it was observed that a manual emergency stop station for generator #2 was remotely located from the prime mover, however, a manual emergency stop station for generator #1 was not observed remotely located from the prime mover as required. This does not comply with NFPA 101-2010, Section 5.6.5.6.