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Based on observation, the facility failed to maintain their smoke barrier doors as evidenced by the smoke barrier doors that failed to latch. This deficient practice affected 2 of 6 floors and could result in spread of smoke and fire.

Findings:

During the facility tour with staffs on 2/28/13, the smoke barrier doors were observed.

1. At 11:17 a.m., the smoke barrier door 407, FDR-190E on the fourth floor, the door was bouncing off the latching device on the door frame.

2. At 12:05 p.m., the right leaf of the smoke barrier door, FDR 135E, in the basement did not latch when closed. The right leaf landed on the upper latching device of the left leaf, FDR 134E.

Based on observation, the facility failed to maintain the integrity of the alarm system as evidenced by a broken cover of one horn strobe. This deficiency could result in delay of notification in the event of a fire, and affected 1 of 6 floors.

NFPA 101, Life Safety Code (2000) Edition
4.6.12 Maintenance and Testing
4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.
4.6.12.3 Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction.

Findings:

During a tour of the facility with staffs on 2/28/13, the alarm system was observed.

At 11:43 a.m., the horn strobe near the exit door, FDR 107, on the second floor, had a broken cover lens.

Based on observation, the facility failed to maintain its automatic sprinkler system. This was evidenced by missing escutcheon ring on the sprinklers. This could lead to the sprinklers malfunctioning in the event of a fire and affected 2 of 6 floors.

NFPA 25, 1998 Edition

2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

Exception No. 1: Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.

Exception No. 2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

2-2.1.2 Unacceptable obstructions to spray patterns shall be corrected.

2-4.1.8 Sprinklers shall not be altered in any respect or have any type of ornamentation, paint, or coatings applied after shipment from the place of manufacture.

Findings:

During a tour of the facility with staffs on 2/28/13, the sprinklers were observed.

1. At 11:19 a.m., the escutcheon ring of the sprinkler was missing in Room 409, located on the fourth floor.

2. At 11:38 a.m., the escutcheon ring of the sprinkler was missing in the Staff Resource room, OPC 3140, located on the third floor.

3. At 11:40 a.m., the escutcheon ring of the sprinkler was missing in the Recovery Nurses Station, located on the third floor.

Based on observation, the facility failed to maintain its portable fire extinguisher's signage. This was evidenced by a faded fire extinguisher sign that was posted on the door. This deficient practice could result in staff's inability to readily access the fire extinguisher in the event of a fire and affected 1 of 6 floors.

NFPA 10, 1998 Edition

1-6.3 Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas.

1-6.6 Fire extinguishers shall not be obstructed or obscured from view.
Exception: In large rooms, and in certain locations where visual obstruction cannot be completely avoided, means shall be provided to indicate the location.


Findings:

During the facility tour with staffs on 2/2//13, the signage for the fire extinguisher was observed.

At 11:12 a.m., the fire extinguisher was located inside the Elevator Machinery room, OPC 6102, on the roof of the building. The signage that posted outside the door to indicate a fire extinguisher was inside the room was faded.