HospitalInspections.org

.

Based on observation and interview, the facility failed to ensure all smoke barriers were sealed to prevent the passage of smoke, as required by NFPA 101, 2003.

Observations during the morning of 02/23/16, revealed holes and unsealed pipe penetrations above the ceiling at several locations at the Corridor wall and cross-corridor doors.

In an interview during the morning of 02/23/16, the Chief Executive Officer stated that all holes and unsealed penetrations would be properly filled to prevent the passage of smoke.

.

.

Based on observation and interview, the facility failed to ensure all hazardous area walls were properly sealed to maintain a one-hour fire protection, as required by NFPA 101, 2003.

Observations during the morning of 02/23/16, revealed the holes and unsealed pipe penetrations above the ceiling at the Soiled Utility Room.

In an interview during the morning of 02/23/16, the Chief Executive Offficer stated that the one-hour rated walls at the Soiled Utility Room would be maintained.

.

.

Based on observation and interview, the facility failed to ensure the fire alarm circuit was colored red, as required by NFPA 72, 2002 which cites:

4.4.1.4.2.2 ..... Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as " FIRE ALARM CIRCUIT " .
4.4.1.4.2.3..... The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit.

Observation during the morning of 02/23/16, revealed the electrical circuit (panel and circuit number) serving the Fire Alarm Control Panel was not identified on the Annunciator Panels or the Electrical Panels.

In an interview during the morning of 02/23/16, the Chief Executive Officer stated that FACP circuit would be marked on the electrical panel and the annunciator to assist fire fighters in an emergency.

.

.

Based on record review and interview, the facility failed to ensure the fire alarm was connected to the emergency generator, as referenced by NFPA 101, 2003 and required by NFPA 99, 2002 which cites:

Reference:

NFPA 99; 2002:
4.4.2.2.2.2 ... ...The life safety branch of the emergency system shall supply power for the following lighting, receptacles and equipment:
1. Illumination of means of egress as required in NFPA 101, Life Safety Code;
2. Exit signs and exit direction signs required in NFPA 101, Life safety Code;
3. Alarm and alerting systems including the following:
a. Fire Alarms,
b. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, "Gas and Vacuum Systems;"
4. (Hospital or ASC) communication systems, where used for issuing instruction during emergency conditions;
5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location;
6. Elevator ...
7. Automatically opened doors used for building egress. No functions other than those listed above in items 1 through 7 shall be connected to the life safety branch.

Record review during the morning of 02/23/16, reflected no evidence the fire alarm was connected to the emergency generator.

In an interview during the morning of 02/23/16, the Maintenance Director stated that he was not sure if the fire alarm was connected to the generator, but would check.

.

.

Based on observation and interview, the facility failed to ensure all smoke barriers were sealed to prevent the passage of smoke, as required by NFPA 101, 2003.

Observations during the morning of 02/23/16, revealed holes and unsealed pipe penetrations above the ceiling at several locations at the Corridor wall and cross-corridor doors.

In an interview during the morning of 02/23/16, the Chief Executive Officer stated that all holes and unsealed penetrations would be properly filled to prevent the passage of smoke.

.

.

Based on observation and interview, the facility failed to ensure all hazardous area walls were properly sealed to maintain a one-hour fire protection, as required by NFPA 101, 2003.

Observations during the morning of 02/23/16, revealed the holes and unsealed pipe penetrations above the ceiling at the Soiled Utility Room.

In an interview during the morning of 02/23/16, the Chief Executive Offficer stated that the one-hour rated walls at the Soiled Utility Room would be maintained.

.

.

Based on observation and interview, the facility failed to ensure the fire alarm circuit was colored red, as required by NFPA 72, 2002 which cites:

4.4.1.4.2.2 ..... Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as " FIRE ALARM CIRCUIT " .
4.4.1.4.2.3..... The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit.

Observation during the morning of 02/23/16, revealed the electrical circuit (panel and circuit number) serving the Fire Alarm Control Panel was not identified on the Annunciator Panels or the Electrical Panels.

In an interview during the morning of 02/23/16, the Chief Executive Officer stated that FACP circuit would be marked on the electrical panel and the annunciator to assist fire fighters in an emergency.

.

.

Based on record review and interview, the facility failed to ensure the fire alarm was connected to the emergency generator, as referenced by NFPA 101, 2003 and required by NFPA 99, 2002 which cites:

Reference:

NFPA 99; 2002:
4.4.2.2.2.2 ... ...The life safety branch of the emergency system shall supply power for the following lighting, receptacles and equipment:
1. Illumination of means of egress as required in NFPA 101, Life Safety Code;
2. Exit signs and exit direction signs required in NFPA 101, Life safety Code;
3. Alarm and alerting systems including the following:
a. Fire Alarms,
b. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, "Gas and Vacuum Systems;"
4. (Hospital or ASC) communication systems, where used for issuing instruction during emergency conditions;
5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location;
6. Elevator ...
7. Automatically opened doors used for building egress. No functions other than those listed above in items 1 through 7 shall be connected to the life safety branch.

Record review during the morning of 02/23/16, reflected no evidence the fire alarm was connected to the emergency generator.

In an interview during the morning of 02/23/16, the Maintenance Director stated that he was not sure if the fire alarm was connected to the generator, but would check.

.