HospitalInspections.org

The facility failed to ensure a complete two-hour fire resistive rated wall assembly between the hospital and the Administration Wing.

Observation determined:
1- Several electrical conduit and data cables were penetrating through the two-hour fire resistive rated wall assembly and were not sealed with fire rated material to maintain the fire rating of the wall. 2- In the Mechanical Room across from the Administration Wing, the head of wall of the two-hour fire barrier was not sealed with fire rated material.

The facility has not ensured the building construction type meets the Life Safety Code requirements.

Observation determined there were three (3) electrical conduit pipes penetrating through the floor/ceiling assembly to the floor above from the I.T. Room on the lower level. The penetrations were not sealed with fire rated material.

The facility failed to maintain the one-hour fire resistive rating of vertical shaft enclosures throughout the building.

Observation determined:
1- The elevator shaft on the lower level had an unsealed electrical conduit penetration through the wall into the corridor.
2- The fire rated doors at Elevator B, lower level, did not close and latch.
3- The lower level west stairway had several electrical conduit penetrations through the wall into the corridor that were not sealed with fire rated material.

The facility failed to separate hazardous areas from other spaces with one-hour fire resistive rated partitions and self-closing fire-rated door assemblies.

Observation determined:
1- The Laundry Room had three (3) electrical conduit pipes penetrating the floor/ceiling assembly to the floor above that were not sealed with fire rated material.
2- The south wall of the Boiler Room had an electrical conduit pipe penetrating through the wall into the corridor that was not sealed with fire rated material.
3- The door to the Soiled Linen room in the clinic did not latch into the frame.
4- The door to the Boiler Room on the lower level had several holes drilled into the door which were not sealed to maintain the fire rating of the door.

The only doors allowed into stair enclosures are from occupied spaces. The facility failed to ensure doors that accessed stair enclosures were only from occupied spaces.
Observation determined the east stair enclosure contained a door that accessed the I.T. Equipment Room.

Exits must terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge must be of required width and size to provide all occupants with safe access to a public way. 7.7.1

To ensure adequate exit capability, CMS requires asphalt or concrete surfaces from exterior exits to public ways.

The facility failed to provide an asphalt or concrete surface to a public way from one (1) of two (2) exits from the Cafeteria.

Observation determined the exit from the east side of the Cafeteria leads to a gravel path.

The facility failed to ensure the illumination of means of egress, including exit discharge, was arranged so that failure of a single lighting fixture (bulb) would not leave the area in darkness.

Observation determined four (4) of ten (10) exits had single bulb light fixtures at the exit discharge.
1- The north exit from the Kitchen.
2- The north exit from the Boiler Room.
3- The northwest exit from the main building.
4- The exit from the Lab into the courtyard.

The facility failed to ensure the fire alarm system was tested in compliance with NFPA 72, National Fire Alarm Code (Chapter 10-Inspection, Testing and Maintenance Tables 10.3.1, 10.4.2.2 and 10.4.3).

Review of records determined the fire alarm system was not tested monthly. The alarms were not tested during the months that a night time fire drill was conducted. A silent alarm fire drill was done each quarter on the night shift but the fire alarm system was not tested during those months.

The facility failed to ensure the automatic sprinkler system was continuously maintained in a reliable operating condition as required by NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems.
Observation determined:
1- A surface mount light fixture was located next to a sprinkler in the Medical Records room. The light fixture was obstructing the flow of the sprinkler.
2- Five (5) 2 'x4 ' open grates were installed in place of ceiling tile in the Lab. The grates were not dampered and were used as a return air system for the HVAC system. Heat from a fire stratifies to the ceiling and travels along the ceiling to activate the sprinkler. When ceilings are removed, it delays the activation of the automatic fire sprinkler system.

1) The facility failed to ensure electrical wiring and electrical equipment met NFPA 70 requirements. Observation determined:
a. There was an exhaust fan in the X-Ray Film Room using a flexible cord as permanent wiring to an electrical switch.
b. The water heater in the Mechanical Room was wired with a flexible cord used as permanent wiring to an outlet. The cord was spliced and taped.
c. There was a surge protector for the phone and internet equipment in the Mechanical room plugged into another surge protector.
2) Visual inspection frequencies and specific testing and maintenance frequencies for smoke detection systems are dictated by the prescriptive requirements of NFPA 72, National Fire Alarm Code (Chapter 10-Inspection, Testing and Maintenance Tables 10.3.1, 10.4.2.2 and 10.4.3). This code identifies specific inspection, testing and maintenance frequencies and methods. The facility failed to test two (2) of two (2) battery operated smoke detectors according to manufacturers' recommendations. The smoke detectors are First Alert type detectors. Manufacturers' recommendations are to test the detectors weekly. Review of records indicated the facility was testing the smoke detectors quarterly. 3) Hazardous areas including, but not limited to, areas used for general storage, boiler or furnace rooms, and maintenance shops that include woodworking and painting areas shall be protected in accordance with Section 8.4. 39.3.2.1. The facility failed to protect the general occupancy from the hazardous area. Observation determined: a. There were holes in the ceiling around the exhaust stack of the water heater in the Mechanical Room. b. There were holes in the ceiling tiles around the exhaust stack of the furnace in the Furnace Room in the Mental Health office.

Precautionary signs, readable from a distance of 5 feet, must be conspicuously displayed at the site of oxygen storage. The signs must be attached to adjacent doorways or walls leading to the area.

The facility failed to post signs at the location(s) of oxygen storage.

Observation determined there were several oxygen cylinders being stored in the Respiratory Therapy Room. A sign was not posted at the door indicating oxygen storage.

The facility failed to ensure electrical wiring and electrical equipment met NFPA 70 requirements.

Observation determined:
1- A window air conditioner unit in the Respiratory Therapy Room was plugged into an extension cord. 2- Eight (8) pumps in the Boiler Room were plugged into power strips.