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Based on observations and interview, it was determined the facility failed to maintain smoke barriers in accordance with NFPA standards. The deficiency had the potential to affect three of nine smoke compartments, patients, staff, and visitors. The facility is certified for 63 beds with a census of 40 on the day of the survey.

The findings include:

Observation on 11/14/13, between 9:00 AM and 10:00 AM, with the Executive Director revealed unsealed penetrations by pipes and wires in the smoke partitions located above the ceiling by the Operating Room (OR) Cross Corridor Doors, over Outpatient Registration, and over Emergency Room (ER) Registration.

Interview on 11/14/13 between 9:00 AM and 10:00 AM, with the Executive Director revealed he was not aware of the penetrations.

Reference: NFPA 101 (2000 Edition).



8.3 SMOKE BARRIERS
8.3.1* General.
Where required by Chapters 12 through 42, smoke barriers shall be provided to subdivide building spaces for the purpose of restricting the movement of smoke.
8.3.2* Continuity.
Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.
Exception: A smoke barrier required for an occupied space below an interstitial space shall not be required to extend through the interstitial space, provided that the construction assembly forming the bottom of the interstitial space provides resistance to the passage of smoke equal to that provided by the smoke barrier.



8.3.6.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(a) The space between the penetrating item and the smoke barrier shall
1. Be filled with a material capable of maintaining the smoke resistance of the smoke barrier, or
2. Be protected by an approved device designed for the specific purpose.
(b) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall
1. Be filled with a material capable of maintaining the smoke resistance of the smoke barrier, or
2. Be protected by an approved device designed for the specific purpose.
(c) Where designs take transmission of vibration into consideration, any vibration isolation shall
1. Be made on either side of the smoke barrier, or
2. Be made by an approved device designed for the specific purpose.

8.3.6.2 Openings occurring at points where floors or smoke barriers meet the outside walls, other smoke barriers, or fire
barriers of a building shall meet one of the following conditions:
(1) It shall be filled with a material that is capable of maintaining the smoke resistance of the floor or smoke barrier.
(2) It shall be protected by an approved device that is designed for the specific purpose.

Based on observation and interview, it was determined the facility failed to ensure cross-corridor doors located in a smoke barrier would resist the passage of smoke in accordance with NFPA standards. The deficiency had the potential to affect two of nine smoke compartments, patients, staff, and visitors. The facility is certified for 63 beds with a census of 40 on the day of the survey.

The findings include:

Observation on 11/14/13 at 9:31 AM with the Executive Director revealed the Operating Room (OR) cross-corridor doors would not close completely when tested. This was due to the doors having a coordinator that was not adjusted properly to ensure the door without the astragal would close first after the initial close.

Interview on 11/14/13 at 9:31 AM with the Executive Director revealed he was not aware to test the doors after the initial close.

NFPA Standard: NFPA 101 (2000 Edition).

19.3.7.6*. Requires doors in smoke barriers to be self-closing and resist the passage of smoke.

Reference: NFPA 80 (1999 Edition).

2-4.1 Closing Devices.
2-4.1.1 Where there is an astragal or projecting latch bolt that prevents the inactive door from closing and latching before
the active door closes and latches, a coordinating device shall be used. A coordinating device shall not be required where
each door closes and latches independently of the other.

Based on observation and interview it was determined the facility failed to ensure portable space heaters used in the facility were in accordance with NFPA standards. The deficiency had the potential to affect two of nine smoke compartments, patients, staff, and visitors. The facility is certified for 63 beds with a census of 40 on the day of the survey.

The findings include:

Observation on 11/14/13 between 9:00 AM and 3:30 PM, with the Executive Director revealed a portable space heater located in the Emergency Room (ER) Physician Lounge, the Quality/Performance Improvement Office, and the Second Floor Physician Lounge. The facility failed to provide documentation that the heating element in portable heaters did not exceed 212 degrees.

Interview on 11/14/13 between 9:00 AM and 3:30 PM with the Executive Director revealed he was not aware of the requirements for portable heaters.

Reference: NFPA 101 (2000 Edition).

19.7.8 Portable Space-Heating Devices. Portable space-heating devices shall be prohibited in all health care occupancies.
Exception: Portable space-heating devices shall be permitted to be used in non-sleeping staff and employee areas where the heating elements of such devices do not exceed 212°F (100°C).

Based on observation and interview, it was determined the facility failed to maintain exit access in accordance with NFPA standards. The deficiency had the potential to affect two of nine smoke compartments, patients, staff, and visitors. The facility is certified for 63 beds with a census of 40 on the day of the survey. The facility failed to ensure the means of egress was free of all obstructions or impediments.

The findings include:

Observations on 11/14/13 between 9:00 AM and 3:30 PM with the Executive Director revealed two computers on wheels, and a blood pressure machine stored in the Third Floor Pulmonary Care Unit (PCU) East Corridor. Further observation revealed the storage of a scale, blood pressure machine, and an Intravenous (IV) Pump located in the Third Floor Obstetrical (OB) Hall.

Interview on 11/14/13 between 9:00 AM and 3:30 PM with the Executive Director revealed the items were routinely stored in these areas.

Reference: NFPA 101 (2000 Edition).

Means of Egress Reliability 7.1.10.1
Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Based on observation and interview, it was determined the facility failed to ensure electrical wiring was maintained in accordance with NFPA standards. The deficiency had the potential to affect four of nine smoke compartments, patients, staff, and visitors. The facility is certified for 63 beds with a census of 40 on the day of the survey.

The findings include:

Observations on 11/14/13 between 9:00 AM and 3:30 PM, with the Executive Director revealed:

-An open electrical junction box located over the ceiling by the Emergency Room (ER) Fire Door.
-A refrigerator was plugged into an extension cord located in the Emergency Room (ER) Physician Lounge.
-An extension cord was in use located in the Housekeeping Team Leader Office.
-A refrigerator was plugged into an extension cord located in the Laundry Clean Storage Room.
-A power strip was plugged into an extension cord located in the Dining Room.
-A coffee maker was plugged into an extension cord that was plugged into a power strip located in the Pharmacy.
-A refrigerator and microwave were plugged into a power strip located in the Pharmacy.
-A power strip was plugged into another power strip located in the Pharmacy.
-A power strip was plugged into another power strip located in the Respiratory Therapy Office.
-A power strip was plugged into another power strip located in the Physician Lounge on the Second Floor.
-A power strip was plugged into another power strip that was plugged into a third power strip located in the Case Management Office.


Interview on 11/14/13 between 9:00 AM and 3:30 PM, with the Executive Director revealed he was not aware of the open electrical junction box. Further interview revealed he was not aware of the misuse of power strips and extension cords.

Reference: NFPA 101 (2000 Edition).

9.1.2 Electric.
Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.


Reference: NFPA 99 (1999 Edition).

3-3.2.1.2 D

Minimum Number of Receptacles. The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.


Reference: NFPA 70 400-8.

(Extensions Cords) Uses Not Permitted.
Unless specifically permitted in 400.7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces


Reference: NFPA 70 (1999 Edition).

370.28(c) Covers.

All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Section 250-110. An extension from the cover of an exposed box shall comply with Section 370-22, Exception.

Based on observations and interview, it was determined the facility failed to maintain smoke barriers in accordance with NFPA standards. The deficiency had the potential to affect three of nine smoke compartments, patients, staff, and visitors. The facility is certified for 63 beds with a census of 40 on the day of the survey.

The findings include:

Observation on 11/14/13, between 9:00 AM and 10:00 AM, with the Executive Director revealed unsealed penetrations by pipes and wires in the smoke partitions located above the ceiling by the Operating Room (OR) Cross Corridor Doors, over Outpatient Registration, and over Emergency Room (ER) Registration.

Interview on 11/14/13 between 9:00 AM and 10:00 AM, with the Executive Director revealed he was not aware of the penetrations.

Reference: NFPA 101 (2000 Edition).



8.3 SMOKE BARRIERS
8.3.1* General.
Where required by Chapters 12 through 42, smoke barriers shall be provided to subdivide building spaces for the purpose of restricting the movement of smoke.
8.3.2* Continuity.
Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.
Exception: A smoke barrier required for an occupied space below an interstitial space shall not be required to extend through the interstitial space, provided that the construction assembly forming the bottom of the interstitial space provides resistance to the passage of smoke equal to that provided by the smoke barrier.



8.3.6.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(a) The space between the penetrating item and the smoke barrier shall
1. Be filled with a material capable of maintaining the smoke resistance of the smoke barrier, or
2. Be protected by an approved device designed for the specific purpose.
(b) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall
1. Be filled with a material capable of maintaining the smoke resistance of the smoke barrier, or
2. Be protected by an approved device designed for the specific purpose.
(c) Where designs take transmission of vibration into consideration, any vibration isolation shall
1. Be made on either side of the smoke barrier, or
2. Be made by an approved device designed for the specific purpose.

8.3.6.2 Openings occurring at points where floors or smoke barriers meet the outside walls, other smoke barriers, or fire
barriers of a building shall meet one of the following conditions:
(1) It shall be filled with a material that is capable of maintaining the smoke resistance of the floor or smoke barrier.
(2) It shall be protected by an approved device that is designed for the specific purpose.

Based on observation and interview, it was determined the facility failed to ensure cross-corridor doors located in a smoke barrier would resist the passage of smoke in accordance with NFPA standards. The deficiency had the potential to affect two of nine smoke compartments, patients, staff, and visitors. The facility is certified for 63 beds with a census of 40 on the day of the survey.

The findings include:

Observation on 11/14/13 at 9:31 AM with the Executive Director revealed the Operating Room (OR) cross-corridor doors would not close completely when tested. This was due to the doors having a coordinator that was not adjusted properly to ensure the door without the astragal would close first after the initial close.

Interview on 11/14/13 at 9:31 AM with the Executive Director revealed he was not aware to test the doors after the initial close.

NFPA Standard: NFPA 101 (2000 Edition).

19.3.7.6*. Requires doors in smoke barriers to be self-closing and resist the passage of smoke.

Reference: NFPA 80 (1999 Edition).

2-4.1 Closing Devices.
2-4.1.1 Where there is an astragal or projecting latch bolt that prevents the inactive door from closing and latching before
the active door closes and latches, a coordinating device shall be used. A coordinating device shall not be required where
each door closes and latches independently of the other.

Based on observation and interview it was determined the facility failed to ensure portable space heaters used in the facility were in accordance with NFPA standards. The deficiency had the potential to affect two of nine smoke compartments, patients, staff, and visitors. The facility is certified for 63 beds with a census of 40 on the day of the survey.

The findings include:

Observation on 11/14/13 between 9:00 AM and 3:30 PM, with the Executive Director revealed a portable space heater located in the Emergency Room (ER) Physician Lounge, the Quality/Performance Improvement Office, and the Second Floor Physician Lounge. The facility failed to provide documentation that the heating element in portable heaters did not exceed 212 degrees.

Interview on 11/14/13 between 9:00 AM and 3:30 PM with the Executive Director revealed he was not aware of the requirements for portable heaters.

Reference: NFPA 101 (2000 Edition).

19.7.8 Portable Space-Heating Devices. Portable space-heating devices shall be prohibited in all health care occupancies.
Exception: Portable space-heating devices shall be permitted to be used in non-sleeping staff and employee areas where the heating elements of such devices do not exceed 212°F (100°C).

Based on observation and interview, it was determined the facility failed to maintain exit access in accordance with NFPA standards. The deficiency had the potential to affect two of nine smoke compartments, patients, staff, and visitors. The facility is certified for 63 beds with a census of 40 on the day of the survey. The facility failed to ensure the means of egress was free of all obstructions or impediments.

The findings include:

Observations on 11/14/13 between 9:00 AM and 3:30 PM with the Executive Director revealed two computers on wheels, and a blood pressure machine stored in the Third Floor Pulmonary Care Unit (PCU) East Corridor. Further observation revealed the storage of a scale, blood pressure machine, and an Intravenous (IV) Pump located in the Third Floor Obstetrical (OB) Hall.

Interview on 11/14/13 between 9:00 AM and 3:30 PM with the Executive Director revealed the items were routinely stored in these areas.

Reference: NFPA 101 (2000 Edition).

Means of Egress Reliability 7.1.10.1
Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Based on observation and interview, it was determined the facility failed to ensure electrical wiring was maintained in accordance with NFPA standards. The deficiency had the potential to affect four of nine smoke compartments, patients, staff, and visitors. The facility is certified for 63 beds with a census of 40 on the day of the survey.

The findings include:

Observations on 11/14/13 between 9:00 AM and 3:30 PM, with the Executive Director revealed:

-An open electrical junction box located over the ceiling by the Emergency Room (ER) Fire Door.
-A refrigerator was plugged into an extension cord located in the Emergency Room (ER) Physician Lounge.
-An extension cord was in use located in the Housekeeping Team Leader Office.
-A refrigerator was plugged into an extension cord located in the Laundry Clean Storage Room.
-A power strip was plugged into an extension cord located in the Dining Room.
-A coffee maker was plugged into an extension cord that was plugged into a power strip located in the Pharmacy.
-A refrigerator and microwave were plugged into a power strip located in the Pharmacy.
-A power strip was plugged into another power strip located in the Pharmacy.
-A power strip was plugged into another power strip located in the Respiratory Therapy Office.
-A power strip was plugged into another power strip located in the Physician Lounge on the Second Floor.
-A power strip was plugged into another power strip that was plugged into a third power strip located in the Case Management Office.


Interview on 11/14/13 between 9:00 AM and 3:30 PM, with the Executive Director revealed he was not aware of the open electrical junction box. Further interview revealed he was not aware of the misuse of power strips and extension cords.

Reference: NFPA 101 (2000 Edition).

9.1.2 Electric.
Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.


Reference: NFPA 99 (1999 Edition).

3-3.2.1.2 D

Minimum Number of Receptacles. The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.


Reference: NFPA 70 400-8.

(Extensions Cords) Uses Not Permitted.
Unless specifically permitted in 400.7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces


Reference: NFPA 70 (1999 Edition).

370.28(c) Covers.

All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Section 250-110. An extension from the cover of an exposed box shall comply with Section 370-22, Exception.