HospitalInspections.org

During a tour of the building on 7/07/10, the surveyor observed that not all corridor doors were suitable to provide the required separation for corridor walls which could resist the passage of smoke.

Findings include:

At 1:07 p.m. in the basement, the corridor door to the Medical Records File Room was examined by the surveyor. In the bottom half of the door, there were louvered opening approximately 18 by 18 sq. in. in total size. These louvered openings had not been sealed to prevent the passage of smoke through the openings.

Based on surveyor observations which were made during a tour of the hospital on 7/07/10, the facility failed to ensure that all self closing doors which serve fire/smoke barriers can close to positive latching when the doors were tested by the surveyor.

Findings include:

1. At 10:15 a.m., the corridor door which separates the Maintenance Department from the basement corridor was exercised by the surveyor. When the door was released, the latching bolt would not engage the door hardware once the door had closed.

2. At approximately 1:50 p.m., the fire rated door between the Purchasing Department and the Maintenance Shop was examined. When the surveyor allowed the door to close, it was discovered that the latching bolt was stuck and could not return to engage the door hardware to positive latching.

3. At 11:58 a.m. across the corridor from room #214 on the acute care wing, the self closing device for the soiled linen room door was tested by the surveyor. When the door was fully opened and released, the door did not close to positive latching when it closed.

Based on observations made by the surveyor during a tour of the interior of the Rehab Clinic on 7/07/10, it was determined that there was not an adequate number of exit signs which could indicate direction of exit travel from the building to an exit door.

Section 39.2.10 Marking of Means of Egress states that "Means of egress shall have signs in accordance with Section 7.10."

Findings include:

At 10:47 a.m. during the inspection of the Rehab Clinic, it was noted that the building is separated into a treatment area and an office area. Direction of exiting is not apparent when a person is located in the office space of the building.

Based on surveyor observations on 7/07/10, the surveyor determined that the facility failed to maintain the smoke resistance of smoke barriers at all smoke barrier locations.

Findings include:

1. At 3:30 p.m., the smoke barrier which separates the service and treatment areas from the acute care sleeping wings was examined above the ceiling. There was an unsealed penetration caused by a section of four inch conduit which contained several computer wires. The interior of the conduit and its opening had not been sealed.

2. At 4:00 p.m., the smoke barrier which separates the new addition from the existing building was examined. Above the smoke barrier doors which are at the east entrance to the emergency room, a section of conduit three to four inches in diameter passed through the barrier. The interior of the conduit had not been sealed and was filled with several wires.

Based on surveyor observations on 7/07/10, it was determined that the facility failed to ensure that all walls separating hazardous areas are maintained with fire resistant construction.

Findings include:

The Maintenance Shop and the Purchasing Department are separated by a wall which is constructed to have a fire rating of at least one hour. At approximately 3:45 a.m. above the interconnecting doorway between these two locations, there were at least two open penetrations two to three inches in diameter caused by wiring and a section of conduit which had not been sealed with an acceptable fire stop product.

Based on an observations and the testing of three dual battery light fixtures on 7/07/10, the facility failed to ensure that all battery powered emergency light fixtures were operational.

Section 39.2.9.1 of NFPA 101 states that "Emergency lighting shall be provided in accordance with Section 7.9 in any building where any one of the following conditions exists:
(1) The building is two or more stories in height above the level of exit discharge.
(2) The occupancy is subject to 100 or more occupants above or below the level of exit discharge.
(3) The occupancy is subject to 1000 or more total occupants."

Further, Section 4.6.12.2 of NFPA 101 states "Existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed."

Findings include:

At approximately 11:00 a.m., maintenance staff tested three different light fixtures within the Rehab Clinic. When the test switches were engaged, there was no illumination produced by any of the three light fixtures.

Based on surveyor observations on 7/07/10, it was determined that not all requirements of NFPA 99 regarding oxygen storage areas were being followed.

Findings include:

In accordance with Section 4-3.1.1.2 (a)7 of NFPA 99, 1999 Edition requires in part "Combustible materials, such as paper, cardboard, plastics, and fabrics, shall not be stored or kept near supply system cylinders or manifolds containing oxygen or nitrous oxide."

At 11:56 a.m., there were seven "E" cylinders of oxygen being stored in the soiled linen room on the acute care wing. This soiled linen room contained quantities of potentially combustible materials such as soiled linens and small amounts of other materials.

During a tour of the building on 7/07/10, the surveyor observed that not all corridor doors were suitable to provide the required separation for corridor walls which could resist the passage of smoke.

Findings include:

At 1:07 p.m. in the basement, the corridor door to the Medical Records File Room was examined by the surveyor. In the bottom half of the door, there were louvered opening approximately 18 by 18 sq. in. in total size. These louvered openings had not been sealed to prevent the passage of smoke through the openings.

Based on surveyor observations which were made during a tour of the hospital on 7/07/10, the facility failed to ensure that all self closing doors which serve fire/smoke barriers can close to positive latching when the doors were tested by the surveyor.

Findings include:

1. At 10:15 a.m., the corridor door which separates the Maintenance Department from the basement corridor was exercised by the surveyor. When the door was released, the latching bolt would not engage the door hardware once the door had closed.

2. At approximately 1:50 p.m., the fire rated door between the Purchasing Department and the Maintenance Shop was examined. When the surveyor allowed the door to close, it was discovered that the latching bolt was stuck and could not return to engage the door hardware to positive latching.

3. At 11:58 a.m. across the corridor from room #214 on the acute care wing, the self closing device for the soiled linen room door was tested by the surveyor. When the door was fully opened and released, the door did not close to positive latching when it closed.

Based on observations made by the surveyor during a tour of the interior of the Rehab Clinic on 7/07/10, it was determined that there was not an adequate number of exit signs which could indicate direction of exit travel from the building to an exit door.

Section 39.2.10 Marking of Means of Egress states that "Means of egress shall have signs in accordance with Section 7.10."

Findings include:

At 10:47 a.m. during the inspection of the Rehab Clinic, it was noted that the building is separated into a treatment area and an office area. Direction of exiting is not apparent when a person is located in the office space of the building.

Based on surveyor observations on 7/07/10, the surveyor determined that the facility failed to maintain the smoke resistance of smoke barriers at all smoke barrier locations.

Findings include:

1. At 3:30 p.m., the smoke barrier which separates the service and treatment areas from the acute care sleeping wings was examined above the ceiling. There was an unsealed penetration caused by a section of four inch conduit which contained several computer wires. The interior of the conduit and its opening had not been sealed.

2. At 4:00 p.m., the smoke barrier which separates the new addition from the existing building was examined. Above the smoke barrier doors which are at the east entrance to the emergency room, a section of conduit three to four inches in diameter passed through the barrier. The interior of the conduit had not been sealed and was filled with several wires.

Based on surveyor observations on 7/07/10, it was determined that the facility failed to ensure that all walls separating hazardous areas are maintained with fire resistant construction.

Findings include:

The Maintenance Shop and the Purchasing Department are separated by a wall which is constructed to have a fire rating of at least one hour. At approximately 3:45 a.m. above the interconnecting doorway between these two locations, there were at least two open penetrations two to three inches in diameter caused by wiring and a section of conduit which had not been sealed with an acceptable fire stop product.

Based on an observations and the testing of three dual battery light fixtures on 7/07/10, the facility failed to ensure that all battery powered emergency light fixtures were operational.

Section 39.2.9.1 of NFPA 101 states that "Emergency lighting shall be provided in accordance with Section 7.9 in any building where any one of the following conditions exists:
(1) The building is two or more stories in height above the level of exit discharge.
(2) The occupancy is subject to 100 or more occupants above or below the level of exit discharge.
(3) The occupancy is subject to 1000 or more total occupants."

Further, Section 4.6.12.2 of NFPA 101 states "Existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed."

Findings include:

At approximately 11:00 a.m., maintenance staff tested three different light fixtures within the Rehab Clinic. When the test switches were engaged, there was no illumination produced by any of the three light fixtures.

Based on surveyor observations on 7/07/10, it was determined that not all requirements of NFPA 99 regarding oxygen storage areas were being followed.

Findings include:

In accordance with Section 4-3.1.1.2 (a)7 of NFPA 99, 1999 Edition requires in part "Combustible materials, such as paper, cardboard, plastics, and fabrics, shall not be stored or kept near supply system cylinders or manifolds containing oxygen or nitrous oxide."

At 11:56 a.m., there were seven "E" cylinders of oxygen being stored in the soiled linen room on the acute care wing. This soiled linen room contained quantities of potentially combustible materials such as soiled linens and small amounts of other materials.