HospitalInspections.org

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The facility failed to provide corridor doors that would close and resist the passage of smoke. Findings include:During the survey, the following is an example of what was observed:

The break room door failed to positive latch, and a hole observed above and below the handle approximately the size of a dime. This room is located across the corridor from Patient Room 204.
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NFPA 101, 19.3.6.3.1 Exception No.2. In the smoke compartments protected throughout by an approved, supervised automatic sprinkler system, doors in corridor walls shall be constructed to resist the passage of smoke and be provided with suitable means of keeping the doors closed.

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The facility failed to provide smoke barriers that would provide at least a half hour fire resistance rating. Findings include: During the survey, the following are examples of what was observed:

1. Unsealed penetrations at the end of a sleeve, and around a bar joint,group of wiring, in the smoke barrier, by Radiology/Ultrasound.

2. Unsealed penetrations around a group of wiring, in the smoke barrier, by BMA Office.
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NFPA 101, 19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.

NFPA 101, 8.3.2 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.

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The facility failed to provide separation of hazardous areas. Findings include: During the survey, the following is an example of what was observed:

A office located in the Lab is being used for combustible storage, room is 80 sq feet, door does not have a self-closing device.
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NFPA 101, 19.3.2.1 and 8.4.1 Hazardous areas to be provided with smoke-resisting partitions and doors when protection consists of an automatic extinguishing system. Doors shall be self-closing with positive latching hardware.

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The facility failed to provide proper emergency lighting: Findings include: During the survey, the following is an example of what was observed:

The maintenance director was not able to verify if the exit discharge lighting was on the generators.
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NFPA 101, 7.9.2.3 Emergency generators providing power to emergency lighting systems to be installed per NFPA 110.

7.9.1.1* Emergency lighting facilities for means of egress shall be provided in accordance with Section 7.9 for the following:
(1) Buildings or structures where required in Chapters 11 through 42
(2) Underground and windowless structures as addressed in Section 11.7
(3) High-rise buildings as required by other sections of this Code
(4) Doors equipped with delayed egress locks
(5) The stair shaft and vestibule of smokeproof enclosures, which shall be permitted to include a standby generator that is installed for the smokeproof enclosure mechanical ventilation equipment and used for the stair shaft and vestibule emergency lighting power supply
For the purposes of this requirement, exit access shall include only designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit. For the purposes of this requirement, exit discharge shall include only designated stairs, ramps, aisles, walkways, and escalators leading to a public way.

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The facility failed to perform sensitivity testing of the smoke detectors. Findings include:

Documentation provided by the facility during the survey did not indicate sensitivity testing of the smoke detectors. Detector sensitivity shall be checked with one year after installation and every alternate year thereafter per 72, 7-3.2.1. (Up to 5 years permitted under certain circumstances. See 7-3.2.1).

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The facility failed to perform the required maintenance of the facility sprinkler system. Findings include:

Documentation provided during the survey indicated quarterly (three months) sprinkler system inspections were conducted as follows: 4/20/12, 8/7/2012, 11/7/2012. The facility failed to have sprinkler inspections in 7/2012, and 2/2013.
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NFPA 101, 4.6.12, and NFPA 25, 2-2 and Table 2-1 Requires an inspection every quarter (three months).

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The facility failed to provide required height for fire extinguishers. Findings
include: During the survey, the following are examples of what was observed:

1. The K-Extinguisher in the Kitchen was mounted 67" from the the floor to the top of the gauge.

2. The Dry Chemical extinguisher in the Kitchen was mounted 69" from the floor to the top of the gauge.

3. There were serveral other extinguishers throught out the facility that exceeded the height requirement.
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1998 NFPA 10, 1-6.10 Fire extinguishers weighting not more than 40 lb. (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb. (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 31/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).

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The facility failed to provide metal self-closing containers for disposing of cigarette butts and ashes from ashtrays. Findings include: During the survey, the following is an example of what was observed:

Metal self-closing container was not provided in the visitors designated smoking area, East patio at the end of the Hospital. This surveyor observed hospital staff smoking in this area also.
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NFPA 101, 19.7.4 Ashtrays of noncombustible material and safe design, and metal self-closing containers for disposing of cigarette butts and ashes from ashtrays, shall be provided.

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The facility had improper heating devices. Findings include: During the survey, the following is an example of what was observed:

Two portable heating devices were observed in the Sleep/Lounge for the Doctor's.
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NFPA 101, 19.7.8, prohibits the use of portable space heating devices in all health care occupancies. Except it shall be permitted to be used in non-sleeping staff and employee areas where the heating elements of such devices do not exceed 212F (100C).

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The facility failed to provide proper storage of oxygen cylinders. Findings include: During the survey, the following is an example of what was observed:

Two unsecured oxygen cylinders in the Director of Respiratory Care Office.
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1999 NFPA 99, 4-3.1.1.1 and 4-5.1.1.1 Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.

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The facility failed to maintain the emergency lighting: Findings include: During the survey, the following is an example of what was observed:

Documentation was not provided for the monthly or annual test of the emergency lighting.
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NFPA 101, 7.9.3 A documented monthly test of battery-powered emergency lighting for at least 30 seconds, and an annual test for a duration of 1-1/2 hours, with equipment being fully operational for the duration of the test.

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The facility failed to provide approved electrical utilities. Findings include: During the survey, the following is an example of what was observed:


A junction box was missing the cover in Boiler Room # One.
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1999 NFPA 70, 370-25 and 410-12. Each box in completed installations to have a cover, face plate, or fixture canopy.

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The facility failed to provide corridor doors that would close and resist the passage of smoke. Findings include:During the survey, the following is an example of what was observed:

The break room door failed to positive latch, and a hole observed above and below the handle approximately the size of a dime. This room is located across the corridor from Patient Room 204.
------------------------------------------------

NFPA 101, 19.3.6.3.1 Exception No.2. In the smoke compartments protected throughout by an approved, supervised automatic sprinkler system, doors in corridor walls shall be constructed to resist the passage of smoke and be provided with suitable means of keeping the doors closed.

.
The facility failed to provide smoke barriers that would provide at least a half hour fire resistance rating. Findings include: During the survey, the following are examples of what was observed:

1. Unsealed penetrations at the end of a sleeve, and around a bar joint,group of wiring, in the smoke barrier, by Radiology/Ultrasound.

2. Unsealed penetrations around a group of wiring, in the smoke barrier, by BMA Office.
------------------------------------------------

NFPA 101, 19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.

NFPA 101, 8.3.2 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.

.
The facility failed to provide separation of hazardous areas. Findings include: During the survey, the following is an example of what was observed:

A office located in the Lab is being used for combustible storage, room is 80 sq feet, door does not have a self-closing device.
-------------------------------------------------

NFPA 101, 19.3.2.1 and 8.4.1 Hazardous areas to be provided with smoke-resisting partitions and doors when protection consists of an automatic extinguishing system. Doors shall be self-closing with positive latching hardware.

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The facility failed to provide proper emergency lighting: Findings include: During the survey, the following is an example of what was observed:

The maintenance director was not able to verify if the exit discharge lighting was on the generators.
-------------------------------------
NFPA 101, 7.9.2.3 Emergency generators providing power to emergency lighting systems to be installed per NFPA 110.

7.9.1.1* Emergency lighting facilities for means of egress shall be provided in accordance with Section 7.9 for the following:
(1) Buildings or structures where required in Chapters 11 through 42
(2) Underground and windowless structures as addressed in Section 11.7
(3) High-rise buildings as required by other sections of this Code
(4) Doors equipped with delayed egress locks
(5) The stair shaft and vestibule of smokeproof enclosures, which shall be permitted to include a standby generator that is installed for the smokeproof enclosure mechanical ventilation equipment and used for the stair shaft and vestibule emergency lighting power supply
For the purposes of this requirement, exit access shall include only designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit. For the purposes of this requirement, exit discharge shall include only designated stairs, ramps, aisles, walkways, and escalators leading to a public way.

.

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The facility failed to perform sensitivity testing of the smoke detectors. Findings include:

Documentation provided by the facility during the survey did not indicate sensitivity testing of the smoke detectors. Detector sensitivity shall be checked with one year after installation and every alternate year thereafter per 72, 7-3.2.1. (Up to 5 years permitted under certain circumstances. See 7-3.2.1).

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The facility failed to perform the required maintenance of the facility sprinkler system. Findings include:

Documentation provided during the survey indicated quarterly (three months) sprinkler system inspections were conducted as follows: 4/20/12, 8/7/2012, 11/7/2012. The facility failed to have sprinkler inspections in 7/2012, and 2/2013.
------------------------------------------

NFPA 101, 4.6.12, and NFPA 25, 2-2 and Table 2-1 Requires an inspection every quarter (three months).

.
The facility failed to provide required height for fire extinguishers. Findings
include: During the survey, the following are examples of what was observed:

1. The K-Extinguisher in the Kitchen was mounted 67" from the the floor to the top of the gauge.

2. The Dry Chemical extinguisher in the Kitchen was mounted 69" from the floor to the top of the gauge.

3. There were serveral other extinguishers throught out the facility that exceeded the height requirement.
-----------------------------------------------

1998 NFPA 10, 1-6.10 Fire extinguishers weighting not more than 40 lb. (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb. (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 31/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).

.
The facility failed to provide metal self-closing containers for disposing of cigarette butts and ashes from ashtrays. Findings include: During the survey, the following is an example of what was observed:

Metal self-closing container was not provided in the visitors designated smoking area, East patio at the end of the Hospital. This surveyor observed hospital staff smoking in this area also.
----------------------------------------------------

NFPA 101, 19.7.4 Ashtrays of noncombustible material and safe design, and metal self-closing containers for disposing of cigarette butts and ashes from ashtrays, shall be provided.

.
The facility had improper heating devices. Findings include: During the survey, the following is an example of what was observed:

Two portable heating devices were observed in the Sleep/Lounge for the Doctor's.
-------------------------------------------

NFPA 101, 19.7.8, prohibits the use of portable space heating devices in all health care occupancies. Except it shall be permitted to be used in non-sleeping staff and employee areas where the heating elements of such devices do not exceed 212F (100C).

.
The facility failed to provide proper storage of oxygen cylinders. Findings include: During the survey, the following is an example of what was observed:

Two unsecured oxygen cylinders in the Director of Respiratory Care Office.
-------------------------------------------------
1999 NFPA 99, 4-3.1.1.1 and 4-5.1.1.1 Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.

.
The facility failed to maintain the emergency lighting: Findings include: During the survey, the following is an example of what was observed:

Documentation was not provided for the monthly or annual test of the emergency lighting.
----------------------------------------------

NFPA 101, 7.9.3 A documented monthly test of battery-powered emergency lighting for at least 30 seconds, and an annual test for a duration of 1-1/2 hours, with equipment being fully operational for the duration of the test.

.
The facility failed to provide approved electrical utilities. Findings include: During the survey, the following is an example of what was observed:


A junction box was missing the cover in Boiler Room # One.
-----------------------------------------

1999 NFPA 70, 370-25 and 410-12. Each box in completed installations to have a cover, face plate, or fixture canopy.