HospitalInspections.org

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Based on observation and interview, the facility failed to ensure all doors located at corridors latched into the frames, as required by NFPA 101, 2003: 18.3.6.3.5.

Observations during the morning of 02/25/16, revealed the doors at the Men's Locker and the Emergency Room Security did not latch into the frame.

In and interview during the morning of 02/25/16, the Facility Engineer stated that he would adjust the closers at the two observed doors to assure positive latching to prevent the passage of smoke and would verify that all corridor doors were equipped with latching hardware that functioned correctly.


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Based on observation and interview, the facility failed to ensure that there were no unsealed penetrations at all rated walls, as required by NFPA 101, 2003: 8.3.5.1.

Observations during the morning of 02/25/16, revealed there were unsealed holes and penetrations above the ceiling in the fire rated walls of the Soiled Linen Room and Janitor's Closet of the Medical/Surgery Unit.

In an interview during the morning of 02/25/16, the Facility Engineer stated that the holes and penetrations would be properly sealed to achieve the required fire rating and that the entire facility would be checked.

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Based on observation and interview, the facility failed to ensure the fire alarm circuit was colored red, as required by NFPA 72, 2002 which cites:

4.4.1.4.2.2 ..... Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as " FIRE ALARM CIRCUIT " .
4.4.1.4.2.3..... The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit.

Observation during the morning of 02/25/16, revealed the electrical circuit (panel and circuit number) serving the Fire Alarm Control Panel was not identified on the Annunciator Panels or the Electrical Panels.

In an interview during the morning of 02/25/16, the Facility Engineer stated that identification of the FACP circuit would be completed and that it was a good idea to assist fire fighters in an emergency.

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.

Based on observation and interview, the facility failed to ensure all doors located at corridors latched into the frames, as required by NFPA 101, 2003: 18.3.6.3.5.

Observations during the morning of 02/25/16, revealed the doors at the Men's Locker and the Emergency Room Security did not latch into the frame.

In and interview during the morning of 02/25/16, the Facility Engineer stated that he would adjust the closers at the two observed doors to assure positive latching to prevent the passage of smoke and would verify that all corridor doors were equipped with latching hardware that functioned correctly.


.

.

Based on observation and interview, the facility failed to ensure that there were no unsealed penetrations at all rated walls, as required by NFPA 101, 2003: 8.3.5.1.

Observations during the morning of 02/25/16, revealed there were unsealed holes and penetrations above the ceiling in the fire rated walls of the Soiled Linen Room and Janitor's Closet of the Medical/Surgery Unit.

In an interview during the morning of 02/25/16, the Facility Engineer stated that the holes and penetrations would be properly sealed to achieve the required fire rating and that the entire facility would be checked.

.

.

Based on observation and interview, the facility failed to ensure the fire alarm circuit was colored red, as required by NFPA 72, 2002 which cites:

4.4.1.4.2.2 ..... Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as " FIRE ALARM CIRCUIT " .
4.4.1.4.2.3..... The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit.

Observation during the morning of 02/25/16, revealed the electrical circuit (panel and circuit number) serving the Fire Alarm Control Panel was not identified on the Annunciator Panels or the Electrical Panels.

In an interview during the morning of 02/25/16, the Facility Engineer stated that identification of the FACP circuit would be completed and that it was a good idea to assist fire fighters in an emergency.

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