HospitalInspections.org

Based on observation and facility staff interview, facility staff failed to ensure areas open to the corridor contain smoke detection per NFPA 72, National Fire Alarm and Signaling Code, 2010 edition. This deficient practice has the potential to effect all facility patients, staff and visitors. This facility census was three.

1. Observation on 8/17/21 showed the following areas open to the corridor. Observation showed the areas did not have smoke detectors:

- Reception Area;
- Pharmacy.

During an interview on 8/17/21 at 8:58 A.M., the Facilities Manager confirmed the observations.

19.3.4.1 General. Health care occupancies shall be provided
with a fire alarm system in accordance with Section 9.6.

Refer to NFPA 72, National Fire Alarm and Signaling Code, 2010 edition, sections 17.6.3 Location and Spacing and 17.6.3.3.1 Spacing for additional information.

Based on observation and facility staff interview, facility staff failed to ensure corridor doors resisted the passage of smoke. This deficient practice has the potential to affect all patients, staff and visitors. Failure to ensure corridor doors positively latched when closed has the potential to prevent or delay evacuation out of the building in the event of a fire or other emergency by allowing smoke, fumes and the products of fire from entering the exit corridors in the event of a fire. The facility census was three.

1. Observation on 8/17/21, during the building tour, showed 19 of 19 patient room doors on the secure unit contained wicket (a door within a door) doors. Observation showed a three quarter inch gap around the perimeter of the wicket doors.

During an interview on 8/17/21 at 10:02 A.M., the Facilities Manager said that the wicket doors were installed to monitor patients.

NFPA 101, 2012 edition, Section 19.3.6.3 states:

"19.3.6.3* Corridor Doors.
19.3.6.3.1* Doors protecting corridor openings in other than
required enclosures of vertical openings, exits, or hazardous
areas shall be doors constructed to resist the passage of smoke
and shall be constructed of materials such as the following:
(1) 13.4 in. (44 mm) thick, solid-bonded core wood
(2) Material that resists fire for a minimum of 20 minutes

19.3.6.3.2 The requirements of 19.3.6.3.1 shall not apply
where otherwise permitted by either of the following:
(1) Doors to toilet rooms, bathrooms, shower rooms, sink
closets, and similar auxiliary spaces that do not contain
flammable or combustible materials shall not be required
to comply with 19.3.6.3.1.

(2) In smoke compartments protected throughout by an approved,
supervised automatic sprinkler system in accordance
with 19.3.5.7, the door construction materials requirements
of 19.3.6.3.1 shall not be mandatory, but the doors
shall be constructed to resist the passage of smoke.

19.3.6.3.10* Doors shall not be held open by devices other
than those that release when the door is pushed or pulled.

19.3.6.3.5* Doors shall be provided with a means for keeping
the door closed that is acceptable to the authority having jurisdiction,
and the following requirements also shall apply:
(1) The device used shall be capable of keeping the door fully
closed if a force of 5 lbf (22 N) is applied at the latch edge
of the door.
(2) Roller latches shall be prohibited on corridor doors in
buildings not fully protected by an approved automatic
sprinkler system in accordance with 19.3.5.7.

19.3.6.3.13 Dutch doors shall be permitted where they conform
to 19.3.6.3 and meet all of the following criteria:
(1) Both the upper leaf and lower leaf are equipped with a
latching device.
(2) The meeting edges of the upper and lower leaves are
equipped with an astragal, a rabbet, or a bevel.
(3) Where protecting openings in enclosures around hazardous
areas, the doors comply with NFPA80, Standard for Fire

Based on observation and facility staff interview, the facility staff failed to ensure the building ventilation system was installed according to NFPA 90B, Standard for the Installation of Warm Heating and Air-Conditioning and Ventilating Systems, 2012 edition and NFPA 90A Standard for the Installation of Air-Conditioning and Ventilating Systems, 2012 edition. The census was three.

1. Observation on 8/17/21 , during the building tour, showed an electric dryer secure unit soiled linen room. Additional observation showed the warm air exhaust flexible duct penetrated the suspended ceiling and exhausted the air into the interstitial space between the ceiling and the floor deck. Observation showed an accumulation of lint in the interstitial space.

During an interview on 8/17/21 at 10:05 A.M., the Facilities Manager said he did not know the vent emptied into the interstitial space.

NFPA 101, 2012 edition, Section 19.5.2 states:

"19.5.2 Heating, Ventilating, and Air-Conditioning.
19.5.2.1 Heating, ventilating, and air-conditioning shall comply
with the provisions of Section 9.2 and shall be installed in
accordance with the manufacturer ' s specifications, unless otherwise
modified by 19.5.2.2."

9.2 Heating, Ventilating, and Air-Conditioning.
9.2.1 Air-Conditioning, Heating, Ventilating Ductwork, and
Related Equipment. Air-conditioning, heating, ventilating
ductwork, and related equipment shall be in accordance with
NFPA 90A, Standard for the Installation of Air-Conditioning and
Ventilating Systems, or NFPA 90B, Standard for the Installation of
Warm Air Heating and Air-Conditioning Systems, as applicable, unless
such installations are approved existing installations,
which shall be permitted to be continued in service.

Refer to NFPA 90A, Standard for the Installation of Air-Conditioning and
Ventilating Systems, 2012 edition, Section 4.2.4 thru 4.2.4.2 and Section 4.3.3.1 for additional information.

Based on observation and interview the facility failed to provide window blinds that were flame resistant in accordance with provisions of NFPA 101, 10.3. The facility census was three.

1. Observations on 8/17/21 , during the Life Safety Code tour, showed the window blinds throughout the facility did not have identification that showed them as being flame retardant.

During an interview on 8/17/21 at 9:20 A.M., the Facilities Manager said he did not know if the blinds had a rating.

NFPA Standard: Draperies, curtains, and other similar loosely hanging furnishings and decorations shall be flame resistant as /demonstrated by testing in accordance with NFPA 701. 2012 NFPA 101.