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Based upon observation and interview the facility failed to ensure doors in hazardous area separations would self close upon activation of the fire sprinkler and smoke detection system. This deficient practice would allow fire products to move unconstrained through fire/smoke separations.

Findings include:

During the facility tour on 5-18-2011 between 9:00 AM and 10:30 AM, observation of the fire separation doors in Materials Management revealed the double doors were propped open by improvised means and would not self close. Interview with the Chief Engineer indicated he was unaware the doors were being propped open, and immediately implemented interim life safety measures. Additional doors were found to be propped open in Human Resources and the gift shop storage room.

Actual NFPA standard:

LSC 101, 2000 Edition

18.2.2.2.6*
Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure (except boiler rooms, heater rooms, and mechanical equipment rooms) shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.

Based upon observation and interview it was determined that the facility failed to ensure exit discharge was unobstructed to a public way. Failure to provide accessible exit discharge prevents egress to a safe area by wheelchairs, beds and mobility impaired persons.

Findings include:

During the facility tour on May 17, 2011 at approximately 4:30 PM, observation revealed the level one North corridor exit (near the OR suite) discharge did not connect to a public way or parking area, there was approximately 30 feet of landscaped surface to cross before a hard surface area was available. This was observed by the surveyor and acknowledged as a potential problem during snow and wet weather by the Chief Engineer.

Actual NFPA Standard:

LSC 101 - 2000

18.2.1 General.
Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7.
Exception: As modified by 18.2.2 through 18.2.11.
7.7.1*
Exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way.
Exception No. 1: This requirement shall not apply to interior exit discharge as otherwise provided in 7.7.2.
Exception No. 2: This requirement shall not apply to rooftop exit discharge as otherwise provided in 7.7.6.
Exception No. 3: Means of egress shall be permitted to terminate in an exterior area of refuge as provided in Chapters 22 and 23.

Based upon observation and interview the facility failed to ensure smoke barrier penetrations were effectively sealed to prevent or impede the transfer of smoke between compartments. Failure to limit the products of combustion could affect patient safety.

Findings include:

During the facility tour and above ceiling inspection conducted on May 17 & 18, 2011, observation revealed several penetrations of smoke barriers, corridors and hazardous areas enclosures.

Observation of the smoke barrier above the cross corridor doors near ED/Fast Track revealed two- four inch electrical conduits, not filled to prevent the passage of smoke, observation of the barriers at rooms CC2-121 and C1-528 also revealed unsealed conduits.

Actual NFPA Standard:

LSC 101-2000

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:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) 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 meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Based upon observation and interview the facility failed to ensure use of adequate electrical circuits thereby preventing the need for extension cords and multi plug adaptors. Failure to ensure the proper circuitry is used can overload circuits endangering surgical patients and/or cause a fire.

Findings include:

During the facility tour on May 17, 2011 at approximately 4:10 PM; observation revealed a heavy duty extension cord plugged into a single circuit on the equipment boom in operating room (OR) #8. That cord powered a relocatable power tap (RPT) labeled "ACE", which powered another heavy duty extension cord, which powered a 3:1 multiplug adaptor, which powered a Neptune 2 waste management unit. Observation revealed 10 duplex receptacles powered by six different circuits within reach of the Neptune unit cord.

The same electrical cord setup was also observed in OR # 6 & OR # 5 during the OR tour within the next 15 minutes. When the OR Manager was interviewed at approximately 4:30 PM, he stated that this cord use was a standard setup, and that staff had not gotten used to the additional power circuits being available, he stated he would correct the situation that evening.

Actual NFPA Standard:

NFPA 70, National Electrical Code, 1999 Edition

110.3 Examination, Identification, Installation, and Use of Equipment.
(A) Examination. In judging equipment, considerations such as the following shall be evaluated:
(1) Suitability for installation and use in conformity with the provisions of this Code
FPN: Suitability of equipment use may be identified by a description marked on or provided with a product to identify the suitability of the product for a specific purpose, environment, or application. Suitability of equipment may be evidenced by listing or labeling.
(2) Mechanical strength and durability, including, for parts designed to enclose and protect other equipment, the adequacy of the protection thus provided
(3) Wire-bending and connection space
(4) Electrical insulation
(5) Heating effects under normal conditions of use and also under abnormal conditions likely to arise in service
(6) Arcing effects
(7) Classification by type, size, voltage, current capacity, and specific use
(8) Other factors that contribute to the practical safeguarding of persons using or likely to come in contact with the equipment
(B) Installation and Use. Listed or labeled equipment shall be installed and used in accordance with any instructions included in the listing or labeling.