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Based on observation, testing, and interview, the provider failed to maintain the smoke tight rating of corridor wall assemblies for three randomly observed area (the pediatric intensive care unit, plant operations suite room E0115, and gift shop). Findings include:

1. Observation and testing at 1:15 p.m. on 1/7/15 revealed a pair of corridor doors on the west end of the pediatric intensive care unit. That set of doors was in a corridor smoke partition. The doors were equipped with a door coordinator that failed to properly close one door before the other door. That condition did not allow the doors to close and latch. Interview with the director of plant operations at the time of the observation confirmed that findings.

2. Observation and testing at 10:00 a.m. on 1/6/15 revealed the corridor door to Room E0115 Plant Operations would not latch into the frame. The door was equipped with a door closer and magnetic hold-open device connected to the fire alarm system. Testing of the door revealed when released from the hold open device it would not latch under the closer power. Interview with the plant operations supervisor at the time of the observation confirmed the finding.

3. Observation and testing at 11:30 a.m. on 1/6/15 revealed the corridor door to the Gift Shop was not equipped with positive latching hardware. The door was equipped with an magnetic lock connected to the fire alarm system. That allowed the door to swing freely upon activation of the fire alarm system rendering the door unlatched. Interview with the plant operations supervisor at the time of the observation confirmed the finding.

This deficiency affected three of numerous corridor wall assemblies required to maintain a smoke tight separation.

Based on observation, testing, and interview, the provider failed to maintain the fire resistive rating of door assemblies. Two randomly observed doors would not fully close and latch into their frame upon release of the automatic door closures in one randomly observed location (basement). Findings include:

1. Observation at 8:45 a.m. on 1/7/15 revealed a set of cross-corridor doors as part of the elevator lobby in the basement. Those doors were equipped with a self-closing device and positive latching hardware. Testing of those doors revealed the west leaf would not fully close and the positive latching hardware would not latch into the door frame. That door was able to be pushed open without using the latching release push bar.

Interview with the maintenance supervisor at the time of the observation and testing confirmed that finding. He indicated that all cross-corridor doors were tested on a regular basis to ensure they functioned correctly.

This deficiency affected one of numerous door assemblies required to close and latch to maintain a fire resistive rating.

Based on observation and interview, the provider failed to maintain proper operation of magnetic hold open devices on smoke barrier doors in one randomly observed location (first floor corridor). Findings include:

1. Observation at 3:05 p.m. on 1/6/15 revealed a set of cross-corridor smoke barrier doors on the first floor. Those doors were equipped with magnetic hold open devices that would release upon activation of the fire alarm. Further observation revealed the west leaf of those doors was not held open with the approved magnetic hold open device. That door was held open with resistance from the self-closing device installed on the door. That was not an approved method for holding open smoke barrier doors as automatic closing would not occur upon activation of the fire alarm.

Interview with the plant operations supervisor at the time of observation confirmed that condition. He indicated the door was usually held open by means of the magnetic hold open device. He was not sure why it was not being utilized at the time of observation.

This deficiency has the potential to affect 100% of the occupants of the smoke compartment.

Based on observation, interview, and testing, the provider failed to ensure exits were readily accessible at all times. One randomly observed set of cross-corridor doors located between the third floor rapid admissions unit and the pediatrics department was equipped with a magnetic lock.That lock mechanism was not a delayed egress lock. That locked door also created a dead end corridor on one side of those set of doors. Findings include:

1. Observation beginning at 1:45 p.m. on 1/7/15 revealed a set of cross-corridor doors located in the two-hour rated fire wall on the third floor between the rapid admissions unit and the pediatrics department. Those doors were equipped with a magnetic lock and were marked with an exit sign indicating exiting from the rapid admissions area through the pediatric area. Testing and interview at the time of the observation revealed those doors were magnetically locked and were only unlocked by use of a key card. Those doors would not open by delayed egress. Interview with the director of plant operations at that time revealed that magnetic lock was installed to prevent access by unauthorized visitors and patients.

2. Observation at that same time revealed there was not an exit sign on the opposite side of those doors. The corridor from that set of doors to the next available egress corridor was approximately 50 feet. That distance was in excess of the 30 feet allowed for a dead end corridor. The locked doors at the end of that 50 foot long corridor created a dead end corridor. Interview at the time of the observation revealed that magnetic lock system has been installed to prevent elopements from the pediatrics unit with an infant wearing a security system band. This deficiency has the potential to affect all persons in the smoke compartment located on the pediatrics department side of that door.

Based on observation and record review, the provider failed to maintain the integrity of two hour horizontal exits. Randomly observed sets of horizontal exit doors located throughout the patient tower portion excluding the ninth and tenth floor of the building were not labeled as ninety minute fire rated doors. Findings include:

1. Random observations on 1/6/15 revealed eight foot tall by four feet wide metal cross-corridor horizontal exit doors randomly located throughout the patient tower portion of the building excluding the ninth and tenth floors. Those doors did not have a manufacturer's label on them indicating a fire resistive rating of at least ninety minutes. Record review of the providor's life safety drawings dated 8/28/14 indicated the fifth, sixth, seventh, and eight floors had horizontal exit conditions on those floors. Record review of previous FSES worksheets revealed that condition.

The building meets the FSES dated 1/9/15. Please mark an "F" in the completion date column to indicate the provider's intent to correct the deficiencies identified in K000.

Based on observation and interview, the provider failed to maintain the automatic sprinkler system in reliable operating condition. Random observation of sprinklers in the basement mechanical room revealed a corroded sprinkler head. The provider must comply with the National Fire Protection Association (NFPA-13) Standard for the Installation of Sprinkler Systems section 18, System Inspection, Testing, and Maintenance. Findings include:

1. Observation at 3:45 p.m. on 1/6/15 revealed one standard-response sprinkler in the mechanical room located in the basement with corrosion build-up. That condition had the potential to affect the reliability of operation of that sprinkler. Interview with the plant operations supervisor at the time of the observation confirmed that condition. Sprinkler heads are inspected annually by Western States Fire Protection.

This deficiency affected one component of the buildings fire protection system.

Based on observation and interview, the provider failed to ensure the commercial cooking facility was protected in accordance with NFPA 96 in one of two commercial cooking locations (serving kitchen). Findings include:

1. Observation at 9:25 a.m. on 1/7/15 revealed a serving kitchen on the east side of the main kitchen. That kitchen was equipped with a grill protected by UL 300 commercial kitchen hood. Further protection of that grill required a K type fire extinguisher within 30 feet of the main source of a fire hazard. An ABC type fire extinguisher was provided near the grill. That type of extinguisher was not appropriate for the extinguishment of grease laden fires produced by commercial cooking operations. Interview with the director of plant operations at the time of the observation revealed he was not aware of that condition and agreed with that requirement.

This deficiency affected one of numerous components of the commercial kitchen fire protection requirements.

Based on observation, testing, and interview, the provider failed to maintain ninety minute horizontal exit doors in operating condition. One randomly observed cross-corridor horizontal exit door on the eight floor did not latch when closed with the closer. The door was in the two hour fire-resistive wall located in the center of the elevator lobby. Findings include:

1. Observation and testing at 10:45 a.m. on 1/6/15 revealed the cross-corridor horizontal exit door located in the eight floor elevator lobby did not fully close and latch when closed under the power of the door closer. Testing the door several times under the power of the door closer revealed the door was obstructed at the top of the door frame at the latching mechanism. This obstruction did not allow the door to be pulled into the frame. Interview with the supervisor of security at the time of the observation and testing confirmed that finding. He further stated the door hardware would be adjusted or repaired as soon as possible. This deficiency had the potential to affect two of two smoke compartments located on that floor.