HospitalInspections.org

Based on observations and interview, the facility failed to ensure a minimum 20-minute fire protection rating in a fire barrier (a wall constructed to resist the passage of fire between sections of the building) on the first floor in accordance with 18.3.7.5 of the Life Safety Code requirements, potentially affecting staff, visitors and a census of 177 patients.

Findings included:

1. Observations on 10/17/12 at 3:00 PM showed a one-eighth inch space between the meeting edges of a pair of self-closing doors, identified by a nameplate as "Fire Door 222" and no astragal, rabbet, or bevel on either door to seal the gap and prevent the potential spread of heat and flames into an unaffected portion of the building.

During an interview on 10/17/12 at 3:00 PM, staff Y, the Director of Plant Operations stated the area had been renovated between 2006 and 2007 and had been licensed under the new 2000 edition of NFPA 101 (National Fire Protection Association). He stated that he thought the cracks between the doors did not need to be covered as long as they were less than one eighth inch wide.

Based on observation and interview, the facility failed to provide secure storage of medical gases in accordance with NFPA 99, (5.1.3.3.2(7)) with racks, chains or other fastenings to individually secure all cylinders, whether connected, unconnected, full, or empty, to prevent them from falling or inadvertently being tipped over during change-outs, potentially affecting staff, visitors and the facility census of 177 patients.

Findings included:

1. Observation on 11/17/12 at 3:38 PM showed approximately 50 H-sized cylinders of compressed non-flammable gases, standing upright on the concrete floor and chained in groups of eight to 10 cylinders. Several of the large cylinders were also connected to the manifold for medical gas serving the facility's internal medical gas system. Seven smaller cylinders containing gases for welding were also not secured and standing upright without neck protection or other storage method. (Highly compressed gasses are liquefied vapors that rapidly expand when oxidized or exposed to ambient air, causing a pressurized escape of the contents through any valve or opening. If the valve or control is knocked off or damaged, it could cause a rapid, uncontrolled release of pressure, which essentially turns the heavy metal cylinder into an unguided torpedo.)

2. During interviews on 11/17/12 at 3:45 PM the Director of Plant Operations stated that they were unclear about which edition of the NFPA 99 code was being enforced, regarding storage of the compressed gas cylinders. He stated they could re-arrange most of the cylinders and were already taking steps to have the empty cylinders removed by the supplier. He stated that the other cylinders for welding and compressed air cylinders for soda machines could be individually restrained by changing the configuration or constructing simple racks to prevent the cylinders from tipping over.

Based on observations and interview, the facility failed to ensure a minimum 20-minute fire protection rating in a fire barrier (a wall constructed to resist the passage of fire between sections of the building) on the first floor in accordance with 18.3.7.5 of the Life Safety Code requirements, potentially affecting staff, visitors and a census of 177 patients.

Findings included:

1. Observations on 10/17/12 at 3:00 PM showed a one-eighth inch space between the meeting edges of a pair of self-closing doors, identified by a nameplate as "Fire Door 222" and no astragal, rabbet, or bevel on either door to seal the gap and prevent the potential spread of heat and flames into an unaffected portion of the building.

During an interview on 10/17/12 at 3:00 PM, staff Y, the Director of Plant Operations stated the area had been renovated between 2006 and 2007 and had been licensed under the new 2000 edition of NFPA 101 (National Fire Protection Association). He stated that he thought the cracks between the doors did not need to be covered as long as they were less than one eighth inch wide.

Based on observation and interview, the facility failed to provide secure storage of medical gases in accordance with NFPA 99, (5.1.3.3.2(7)) with racks, chains or other fastenings to individually secure all cylinders, whether connected, unconnected, full, or empty, to prevent them from falling or inadvertently being tipped over during change-outs, potentially affecting staff, visitors and the facility census of 177 patients.

Findings included:

1. Observation on 11/17/12 at 3:38 PM showed approximately 50 H-sized cylinders of compressed non-flammable gases, standing upright on the concrete floor and chained in groups of eight to 10 cylinders. Several of the large cylinders were also connected to the manifold for medical gas serving the facility's internal medical gas system. Seven smaller cylinders containing gases for welding were also not secured and standing upright without neck protection or other storage method. (Highly compressed gasses are liquefied vapors that rapidly expand when oxidized or exposed to ambient air, causing a pressurized escape of the contents through any valve or opening. If the valve or control is knocked off or damaged, it could cause a rapid, uncontrolled release of pressure, which essentially turns the heavy metal cylinder into an unguided torpedo.)

2. During interviews on 11/17/12 at 3:45 PM the Director of Plant Operations stated that they were unclear about which edition of the NFPA 99 code was being enforced, regarding storage of the compressed gas cylinders. He stated they could re-arrange most of the cylinders and were already taking steps to have the empty cylinders removed by the supplier. He stated that the other cylinders for welding and compressed air cylinders for soda machines could be individually restrained by changing the configuration or constructing simple racks to prevent the cylinders from tipping over.