HospitalInspections.org

Based on observations made during the survey of the facility while accompanied by the Dir. Plant Ops it was observed that the facility was not in compliance with the following:
Hazardous areas are protected by a fire barrier having a 1-hour fire resistance rating (with ¾ hour fire-rated doors) or an automatic fire extinguishing system in accordance with 8.7.1. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.

REMARKS:
" The non-compliant general location within the facility is the Normal Power MAIN ELECTRICAL ROOM.
o While the room's interior hollow metal door opening assembly (with closer hardware) has a 90-minute fire resistance rating - the construction of the room's 1-hour fire resistance rated drywall partitions & 1-hour fire resistance rated CMU masonry walls are non-compliant regarding the following:
" Drywall partitions are not continuously fire-sealed along the top and bottom as required for both sides of the rated walls.
" Drywall tape embedment work is entirely missing at the rated walls.
" There are multiple unsealed penetrations into and thru the rated walls.
" CMU masonry walls had 4 openings that were not repaired and/or sealed as required.

Based on observations made during the survey of the facility while accompanied by the Dir. Plant Ops it was observed that the facility was not in compliance with the following:

NFPA 99, 2002: 5.1.2 "Nature of Hazards of Gas and Vacuum Systems. Potential fire and explosion hazards associated with medical gas central piping systems and medical-surgical vacuum systems shall be considered in the design, installation, testing, operation, and maintenance of these systems."


REMARKS:
NOTE: There are 2 separate bulk oxygen tank locations on the Hospital site.
" The main bulk oxygen tank used for the Hospital's primary/overall patient care Oxygen usage which was installed initially.
" Then a separate Hyperbaric bulk oxygen tank which was added later which covers just the Hyperbaric patient care needs.

The Surveyor observed and noted that the Hyperbaric bulk oxygen tank is currently unprotected from vehicles driving by it. The tank is very close to an adjacent vehicular drive, located between an exterior wall of the Hospital building, and the commonly used vehicular drive used by the public when driving on-site. The provision of bollards or other protective means is required.