HospitalInspections.org

NFPA 80 Standard for Fire Doors and Other Opening Protective's
4.2.1 Listed items shall be identified by a label.
4.2.2 Labels shall be applied in locations that are readily visible and convenient for identification by the AHJ after installation of the assembly.
4.2.3 The label or listing shall be considered evidence that sampling of such devices or materials have been evaluated by tests and that such devices or materials are produced under an in-plant, follow-up inspection programs.



Based on observations and interview the facility failed to ensure that 1 set of 90-minute fire rated doors could close to a latched position and 2 sets of 90-minute rated doors were equipped with listed and labeled materials.

Observations during tour on 02/05/2020 between 11:00 a.m. and 3:00 p.m. with Staff A (Assistant Facilities Director) and Staff B (Facilities Staff) revealed the following 3 sets of 90-minute fire rated door assembly locations and conditions that exist:

1. The 90-minute fire rated door assembly, located next to the SCU (Special Care Unit) nurses station, failed to close to a latched position when released from the magnetic hold open device. The top locking device, on the right hand door, was stuck in the fully extended position preventing a positive latched position when fully closed.
2. The 90-minute fire rated door assembly, identified by door assembly # 2221, located between the Hospital and the Clough Center, has non-listed wooden blocks attached to each door to extend the magnetic hold open devices away from the door.
2. The 90-minute fire rated door assembly, identified by door assembly # ML A and # ML B, located between the Hospital and the Clough Center, has non-listed wooden blocks attached to each door to extend the magnetic hold open devices away from the door.
All 4 wooden blocks are approximately 3" x 3" and 1" thick.

Interview with Staff A and Staff B confirmed the above findings and locations.

NFPA 101 Life Safety Code (2012 edition)

19.2.2.4 Smoke proof enclosures complying with 7.2.3 shall be permitted.
7.2.3.3 Enclosure.
7.2.3.3.1 A smoke proof enclosure shall be continuously enclosed by fire barriers having a 2-hour fire resistance rating from the highest point to the level of exit discharge, except as otherwise permitted in 7.2.3.3.3.

Based on observations and interview the facility failed to ensure that 3 stairwells were maintained to resist the passage of smoke or the effects from fire.

Findings include:

Observations during tour on 02/06/2020 between 10:00 a.m. and 12:00 p.m. with Staff A (Assistant Facilities Director) and Staff B (Facilities Staff) revealed 3, fire-rated stairwells with unprotected penetrations through the block walls.

These stairwells and conditions are as follows:

1. Stairwell "A", above the suspended ceiling on the upper level, has 1 unprotected penetration. The sprinkler pipe is penetrating the block wall and failed to be maintained to resist the passage of smoke or the effects from fire.
2. Stairwell "B", above the suspended ceiling on the lower level, has 3 unprotected penetrations. There are 2 electrical wires (for the fire alarm system) and 1 metal conduit is penetrating the block wall and failed to be maintained to resist the passage of smoke or the effects from fire.
3. Stairwell # 10, above the suspended ceiling on the middle level, has 2 unprotected penetrations. There is 1 electrical wire (for the fire alarm system) and 1 electrical conduit penetrating the block wall and failed to be maintained to resist the passage of smoke or the effects from fire.

Interview with Staff A and Staff B confirmed the above findings and locations.

NFPA 101 LIFE SAFETY CODE (2012 edition)
7.2.9.4 Emergency generators providing power to emergency lighting systems shall be installed, tested and maintained in accordance with NFPA 110 STANDARD for EMERGENCY and STANDBY POWER SYSTEMS (2010 edition).
7.9.3.1.1 Testing of the emergency lighting systems shall be permitted to be conducted as follows:
(1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds.
(2) The test interval shall be permitted to be extended beyond 30 days with the approval of the AHJ (Authority Having Jurisdiction).
(3) Functional testing shall be conducted annually for a minimum of 1 1/2 hours if the emergency lighting system is battery powered.
(4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1 (1) and (3).

NFPA 110 STANDARD for EMERGENCY and STANDBY POWER SYSTEMS (2010 edition)
7.3 Lighting
7.3.1 The level 1 or level 2 EPS (Emergency Power Supply) equipment locations shall be provided with battery powered emergency lighting.
This requirement shall not apply to units located outdoors in enclosures that do not include walk in access.



Based on observations and interview the facility failed to ensure that battery powered emergency lighting is installed at the level 1, Emergency Power Supply equipment location containing 2 ATS's (Automatic Transfer Switches).

Findings include:

Observations during tour on 02/05/2020 between 11:00 a.m. and 11:15 a.m. with Staff A (Assistant Facilities Director) and Staff B (Facilities Staff) revealed that the Emergency Power Equipment room, containing the ATS for the 800 KW emergency generator and the ATS for the 300 KW emergency generator, failed to be equipped with battery powered emergency lighting.

Interview with Staff A and Staff B confirmed the above findings and location.

Based on observations and interview the facility failed to ensure that 2 hazardous areas could resist the passage of smoke or the effects from fire.

Findings include:

Observations during tour on 02/05/2020 between 2:00 p.m. and 2:30 p.m. with Staff A (Assistant Facilities Director) and Staff B (Facilities Staff) revealed that 2 hazardous areas, with unprotected penetrations through the 1-hour smoke/fire barrier wall. These 2 locations and conditions are as follows:

1. The Emergency Electrical Room, located off the lower level Utilities Corridor, had at least 1 cinder block removed from the wall, above an Electrical Distribution Panel, to permit access for at least 6 metal electrical conduit's, to pass through the barrier wall. The conduits range in size from (approximately) 3/4" - 2 1/2", creating an unprotected penetration that will not resist the passage of smoke or the effects from fire.
2. The Main Boiler room, located off the lower level Utilities Corridor, have at least 3 metal electrical conduit's, (approximately 1") passing through the wall between the corridor and the Boiler room, creating unprotected penetration's that will not resist the passage of smoke or the effects from fire.

Interview with Staff A and Staff B confirmed the above findings and locations.

NFPA 72 National Fire Alarm and Signaling Code (2010 edition)

29.4.3 The performance of fire-warning equipment discussed in this chapter shall depend on such equipment being properly selected, installed, operated, tested and maintained in accordance with the provisions of this code and with the manufacturer's published instructions provided with the equipment.

Based on observations and interview the facility failed to ensure that 1 smoke detector was properly installed and maintained in an exit enclosure.

Findings include:

Observations during tour on 02/06/2020 between 11:30 a.m. and 11:45 a.m. with Staff A (Assistant Facilities Director) and Staff B (Facilities Staff) revealed that 1 actively powered and connected smoke detector, was found laying on its side, still attached to a mounting bracket, on top of a new suspended ceiling tile, located on the upper level of Stairwell # 3. The concealed space above the ceiling (in the stairwell) is approximately 30" tall. Documentation of when the new suspended ceiling tiles were installed failed to be available for review and documentation of the last inspection/testing date of this device could not be confirmed.

Interview with Staff A and Staff B confirmed the above findings, condition, and location of this smoke detection device.

Based on observations and interview the facility failed to ensure that 1 smoke detector was properly installed and maintained in an exit enclosure.

Findings include:

Observations during tour on 02/06/2020 between 11:30 a.m. and 11:45 a.m. with Staff A (Assistant Facilities Director) and Staff B (Facilities Staff) revealed that 1 actively powered and connected smoke detector, was found laying on its side, still attached to a mounting bracket, on top of a new suspended ceiling tile, located on the upper level of Stairwell # 3. The concealed space above the ceiling (in the stairwell) is approximately 30" tall. Documentation of when the new suspended ceiling tiles were installed failed to be available for review and documentation of the last inspection/testing date of this device could not be confirmed.

Interview with Staff A and Staff B confirmed the above findings, condition, and location of this smoke detection device.

NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems (2011 edition)

6.3.4.1 Gauges shall be replaced every 5 years or tested every 5 years by a comparison with a calibrated gauge.
6.3.4.2 Gauges not accurate to within 3 percent of the full scale shall be recalibrating or replaced.
10.3.4.3.1 The water discharge pattern from all of the open spray nozzles shall be observed to ensure that patterns are not impeded by plugged nozzles, to ensure that nozzles are correctly positioned, and to ensure that obstructions do not prevent discharge patterns from wetting surfaces to be protected.

Based on observations and interview the facility failed to ensure that 2 sprinkler pressure gauges were replaced every 5 years or recalibrated every 5 years and that 1 sprinkler head was not blocked from discharge patterns.

Findings include:

Observations during tour on 02/05/2020 between 11:45 a.m. and 1:00 p.m. with Staff A (Assistant Facilities Director) and Staff B (Facilities Staff) revealed that 2 sprinkler system pressure gauges, located in the lower level Sprinkler Riser Room, 1 gauge installed on each of the 2 sprinkler risers, are dated 2012 (approximately 8 years old) and documentation of a recalibration test or an install date after 2015 failed to be available for review, additionally 1 sprinkler head, located in the middle of the Main Kitchen Storage room, was blocked from a discharge pattern with a large box (Approximately 30" x 36") placed directly under (approximately 4") the sprinkler head.

Interview with Staff A and Staff B confirmed the above findings and locations.

NFPA 80 Standard for Fire Doors and Other Opening Protective's (2010 edition)

5.2 Inspections
5.2.1 Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ (Authority Having Jurisdiction).

5.2.4 Swinging Doors with Builders Hardware or Fire Door Hardware
5.2.4.1 Fire door assemblies shall be visually inspected from both side to assess the overall condition of the door assembly.
5.2.4.2 As a minimum, the following items shall be verified:
(1) No open holes or breaks exist in surfaces of either the door or frame.
(2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped.
(3) The door, frame, hinges, hardware, and non-combustible threshold are secured, aligned, and in working order with no visible signs of damage.
(4) No parts are missing or broken.
(5) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7.
(6) The self closing device is operational; that is, the active door completely closes when operated from the full open position.
(7) If a coordinator is installed, the inactive leaf closes before the active leaf.
(8) Latching hardware operates and secures the door when it is in the closed position.
(9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame.
(10) No field modifications to the door assembly have been performed that void the label.
(11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity.


Based on observations and interview the facility failed to ensure that at least 7 out of 25 patient room doors, for corridor access, could resist the passage of smoke or the effects from fire.

Findings include:

Observations during tour on 02/05/2020 between 1:00 p.m. and 4:00 p.m. with Staff A (Assistant Facilities Director) and Staff B (Facilities Staff) revealed that 7 patient room doors failed to be able to close to a latched position.

The following 7 doors failed to be maintained operational: room # 111, #112, # 113, # 115, #117, # 119, and # 121 will not resist the passage of smoke or the effects from fire.

NFPA 70 National Electrical Code (2011 edition)

110.26 Spaces About Electrical Equipment.
Access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment.

(A) Working Space for equipment operating at 600 volts, nominal, or less to ground and likely to require examination, adjustment, servicing, or maintenance while energized shall comply with the dimensions of 110.26 (A) (1).

110.26 Working Space
Condition 1 Condition 2
0 - 150 volts 3 ft. 3 ft.
151-600 volts 3 ft. 3 ft.

Based on observations and interview the facility failed to ensure that a least 2 electrical panels were not blocked from instant access.

Findings include:

Observations during tour on 02/05/2020 between 1:00 p.m. and 1:15 p.m. with Staff A (Assistant Facilities Director) and Staff B (facilities Staff) revealed that 1 Electrical Distribution panel and 1 FACP (Fire Alarm Control Panel), located in the lower level Electrical Room, next to the lower level Elevator Machine Room, were blocked with storage boxes, house keeping supplies, and computer equipment.

Interview with Staff A and Staff B confirmed the above findings and location.