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

Observation determined:

1) The two-hour barrier had pipe, electrical conduit, and low-voltage wire penetrations above the door from the hospital to the Clinic Lobby that were not fire caulked in accordance with the manufacturer's UL listing.

2) The head-of-wall joint on the hospital side of the two-hour wall was not sealed with fire rated material to meet the requirements of a two-hour fire resistive rated wall assembly.

3) The gypsum board on the north side of the 90-minute fire rated door between the hospital and the Clinic Lobby abutted the door frame rather than into the gypsum board stops that are part of the fire rated door frame assembly.

4) The 90-minute fire rated door between Physical Therapy and Pool Room did not self-close to the latched position and was missing the fire rated smoke seal.

5) The gypsum board on the north side of the 90-minute fire rated door between Physical Therapy and Pool Room abutted the door frame rather than into the gypsum board stops that are part of the fire rated door frame assembly.

6) The west door leaf of the 90-minute fire rated double door between the Kitchen Service Corridor and the Clinic was not equipped with a self-closing device and an astragal that would seal the gap between the door leaves.

7) The gypsum board on the north side of the 90-minute fire rated double door between the Kitchen Service Corridor and the Clinic abutted the door frame rather than into the gypsum board stops that are part of the fire rated door frame assembly.

8) The 90-minute fire rated door between the hospital and the assisted living building was missing the fire rated smoke gasket on the hinge side of the door frame.

One story buildings of Type II (000) construction are required to be protected throughout with an automatic sprinkler system.

The facility failed to ensure Type II (111) building construction without an automatic sprinkler system.

Observation determined steel members supporting the roof were not protected throughout the facility. The original construction for the building was altered from Type II (111) to Type II (000) when the monolithic ceiling was removed.

The facility failed to provide interior finish rating documentation for the suspended ceiling tile used throughout the exit corridor system.

Review of documentation determined the facility did not have the interior finish rating of the suspended ceiling tiles that were installed in the exit corridor system.

The facility failed to provide interior finish rating documentation for the suspended ceiling tile used in rooms and spaces not used for corridors throughout the facility.

Review of documentation determined the facility did not have the interior finish rating of the suspended ceiling tiles that were installed in rooms and spaces not used for corridors throughout the facility.

The facility failed to provide corridors separated from use areas by walls with at least 1/2-hour fire resistance rating.

Observation determined the exit corridor walls throughout most of the building were not constructed with 30-minute fire rated material. The exit corridor walls were not fire resistive construction from the floor to the roof deck. The corridor walls were not plastered on both sides of the metal studs. Approximately 12 - 18 inches of the walls (above the suspended ceilings) had exposed metal studs on the corridor side.

Note:

Corridor walls in health care occupancies that are protected with an automatic fire sprinkler system can stop at a suspended ceiling.

The facility failed to ensure the corridor doors were constructed of 1 ?-in. thick, solid-bonded core wood, resisted the passage of smoke, and were provided with hardware to keep the door closed.

Observation determined:

1) The gap between the door to Patient Room 18 and the door frame was more than 1/2 inch and would allow the passage of smoke.

2) The door to Patient Room 21 was removed during remodeling of the area.

3) The doors to Patient Rooms 16 and 24 would not latch into the door frame.

4) The corridor doors to the DON Office and the Lab were propped open with rubber and wooden wedges.

1) In existing health care occupancies protected throughout with a sprinkler system, hazardous areas need to be smoke resistant with self-closing doors. At the time of the Life Safety Code survey, the sprinkler system in the Boiler Room was not operational.

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:

a) The south wall of the Boiler Room had two pipe penetrations that were not sealed with fire rated material.

b) The ceiling of the Boiler Room had numerous holes that have not been sealed with fire rated material.

2) In new health care occupancies (Ambulance Bay Addition) hazardous areas are required to be both sprinklered and separated from the rest of the facility by one-hour fire resistive construction.

The facility failed to provide a minimum of one-hour fire resistive rated partitions and fire rated self-closing fire-rated door assemblies.

Observation determined:

a) An electrical conduit penetration through the west wall of the Ambulance Bay was not sealed with fire rated material.

b) The 90-minute fire rated double doors to the Ambulance Bay would not self-close to the latched position and the gap between the doors were not sealed with an astragal and fire rated smoke gasket.

The width of corridors (clear and unobstructed) serving as exit access in hospitals and nursing homes must be maintained.

The facility failed to maintain clear and unobstructed exit corridors.

Observation determined:

1) The corridor width by the Nurses Station was obstructed by a card table and a temporary roller stand that was being used for the storage of electronic equipment.

2) Construction supplies were being stored in the Acute Wing corridor.

3) An extension cord was run across the Acute Wing corridor.

4) A sheet of poly was draped across the Acute Wing corridor.

The emergency illumination lighting system must be arranged to provide the required illumination automatically. 7.9.2.2

Note: CMS allows a light fixture equipped with a single long-life bulb with a quick strike feature to illuminate exit discharge.

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 the exterior of two (2) of four (4) exits was illuminated with a single-bulb light fixture. The light fixtures that illuminated the two signed exit discharge areas from the Ambulance Bay were single-bulb light fixtures without the quick strike feature.

Exits must be marked by approved signage that is readily visible from any direction of exit access and that obviously and clearly identifies the exit. 7.10.1.2

The facility failed to mark the exit paths with readily visible signage. If permanent exit signs are removed during the remodeling of an occupied building, temporary exit signs must be installed so occupants of the building can identify the exit path.

Observation determined the exit signage that was attached to the suspended ceiling at the Main Nurses Station was removed with the suspended ceiling.

The administration of health care facilities is to develop and distribute to all supervisory personnel written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. All employees are to be periodically instructed and kept informed with respect to their duties under the plan. 19.7.2.

Review of policies/procedures indicated the facility failed to provide a written evacuation plan that indicates safe exiting in the event of a fire. The facility's Evacuation Plan was not changed or altered to accommodate changes to the exit system throughout the remodeling project.

The fire alarm system must be in compliance with NFPA 72. Whenever devices are added to or alterations are made to a fire alarm system, all initiating devices and signaling devices must be tested to ensure the fire alarm panel recognizes and addresses each device.

The facility failed to ensure the fire alarm system was maintained, inspected and tested in accordance with the manufacturer's specifications.

1) Review of the fire alarm test records indicated the facility failed to ensure the fire alarm system was operating properly. The June 2011 fire alarm test report indicated that three devices failed the test but were not replaced.

2) Observation indicated that smoke detectors have been removed and/or covered during the remodeling project.

3) Observation indicated that several new signaling devices were added and others appear to be attached to temporary wiring.

4) Heat and smoke rises to the ceiling and stratifies at that elevation. When the suspended ceiling is partially removed, it delays the activation of smoke detectors and the fire alarm system. Ceiling assemblies need to be maintained intact as much as possible and all suspended ceiling tile that can be reinstalled at the end of the construction day should be installed.

Newly introduced upholstered furniture in non-sprinklered portions of the facility must be tested in accordance with NFPA 261, Standard Method of Test for Determining Resistance to Mock-up Upholstered Furniture Material Assemblies to Ignition by Smoldering Cigarettes and ASTM E 1537, Standard Method for Fire Testing of Real Scale Upholstered Furniture Items.

The facility failed to provide documentation to ensure all upholstered furniture meets these standards.

Records review determined documentation was not available for the upholstered furniture located in the Day Room (three chairs and a couch) to verify the fire resistance rating or the date the furniture was purchased.

Enclosures shall be provided for supply systems cylinder storage or manifold locations for oxidizing agents such as oxygen and nitrous oxide. Such enclosures shall be constructed of an assembly of building materials with a fire-resistive rating of at least 1 hour and shall not communicate directly with anesthetizing locations. Other nonflammable (inert) medical gases may be stored in the enclosure. Flammable gases shall not be stored with oxidizing agents. Storage of full or empty cylinders is permitted. Such enclosures shall serve no other purpose. NFPA 99, Standard for Health Care Facilities 4-3.1.1.2

The facility failed to maintain a 1-hour fire-resistance rated enclosure for the oxygen manifold location within the building.

Observation determined the 60-minute door to the Oxygen Room was missing the center hinge. All components of the rated door assembly must be present and functioning to maintain the door rating.

NFPA 241 Section 8.6.2 Temporary Separation Walls.

a) Protection shall be provided to separate an occupied portion of the structure from a portion of the structure undergoing alteration, construction, or demolition operations when such operations are considered as having a higher level of hazard than the occupied portion of the building.

b) Walls shall have at least a 1-hour fire resistance rating.

c) Opening protection shall have at least a 45-minute fire protection rating.

The facility failed to provide fire rated partitions between the occupied spaces and the construction areas.

Observation determined that a one-hour fire rated partition with 45-minute fire rated doors was not provided between the occupied portions of the building and the areas that were currently being remodeled.

Electrical wiring throughout a health care occupancy must comply with NFPA 70, National Electrical Code.

All electrical splices and taps must be within approved electrical boxes. Unused cable or raceway openings in boxes and conduit bodies must be effectively closed to afford protection substantially equivalent to that of the wall of the box or conduit body. NEC 70, 370-16

The facility failed to ensure electrical wiring and electrical equipment comply with NFPA 70.

Observation determined the electrical wiring in several areas throughout the facility was not terminated in covered electrical boxes and electrical receptacles were not equipped with cover plates. These were found in storage rooms, Medical Records, the exit corridor system, and in areas currently being remodeled.

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

Observation determined:

1) The two-hour barrier had pipe, electrical conduit, and low-voltage wire penetrations above the door from the hospital to the Clinic Lobby that were not fire caulked in accordance with the manufacturer's UL listing.

2) The head-of-wall joint on the hospital side of the two-hour wall was not sealed with fire rated material to meet the requirements of a two-hour fire resistive rated wall assembly.

3) The gypsum board on the north side of the 90-minute fire rated door between the hospital and the Clinic Lobby abutted the door frame rather than into the gypsum board stops that are part of the fire rated door frame assembly.

4) The 90-minute fire rated door between Physical Therapy and Pool Room did not self-close to the latched position and was missing the fire rated smoke seal.

5) The gypsum board on the north side of the 90-minute fire rated door between Physical Therapy and Pool Room abutted the door frame rather than into the gypsum board stops that are part of the fire rated door frame assembly.

6) The west door leaf of the 90-minute fire rated double door between the Kitchen Service Corridor and the Clinic was not equipped with a self-closing device and an astragal that would seal the gap between the door leaves.

7) The gypsum board on the north side of the 90-minute fire rated double door between the Kitchen Service Corridor and the Clinic abutted the door frame rather than into the gypsum board stops that are part of the fire rated door frame assembly.

8) The 90-minute fire rated door between the hospital and the assisted living building was missing the fire rated smoke gasket on the hinge side of the door frame.

One story buildings of Type II (000) construction are required to be protected throughout with an automatic sprinkler system.

The facility failed to ensure Type II (111) building construction without an automatic sprinkler system.

Observation determined steel members supporting the roof were not protected throughout the facility. The original construction for the building was altered from Type II (111) to Type II (000) when the monolithic ceiling was removed.

The facility failed to provide interior finish rating documentation for the suspended ceiling tile used throughout the exit corridor system.

Review of documentation determined the facility did not have the interior finish rating of the suspended ceiling tiles that were installed in the exit corridor system.

The facility failed to provide interior finish rating documentation for the suspended ceiling tile used in rooms and spaces not used for corridors throughout the facility.

Review of documentation determined the facility did not have the interior finish rating of the suspended ceiling tiles that were installed in rooms and spaces not used for corridors throughout the facility.

The facility failed to provide corridors separated from use areas by walls with at least 1/2-hour fire resistance rating.

Observation determined the exit corridor walls throughout most of the building were not constructed with 30-minute fire rated material. The exit corridor walls were not fire resistive construction from the floor to the roof deck. The corridor walls were not plastered on both sides of the metal studs. Approximately 12 - 18 inches of the walls (above the suspended ceilings) had exposed metal studs on the corridor side.

Note:

Corridor walls in health care occupancies that are protected with an automatic fire sprinkler system can stop at a suspended ceiling.

The facility failed to ensure the corridor doors were constructed of 1 ?-in. thick, solid-bonded core wood, resisted the passage of smoke, and were provided with hardware to keep the door closed.

Observation determined:

1) The gap between the door to Patient Room 18 and the door frame was more than 1/2 inch and would allow the passage of smoke.

2) The door to Patient Room 21 was removed during remodeling of the area.

3) The doors to Patient Rooms 16 and 24 would not latch into the door frame.

4) The corridor doors to the DON Office and the Lab were propped open with rubber and wooden wedges.

1) In existing health care occupancies protected throughout with a sprinkler system, hazardous areas need to be smoke resistant with self-closing doors. At the time of the Life Safety Code survey, the sprinkler system in the Boiler Room was not operational.

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:

a) The south wall of the Boiler Room had two pipe penetrations that were not sealed with fire rated material.

b) The ceiling of the Boiler Room had numerous holes that have not been sealed with fire rated material.

2) In new health care occupancies (Ambulance Bay Addition) hazardous areas are required to be both sprinklered and separated from the rest of the facility by one-hour fire resistive construction.

The facility failed to provide a minimum of one-hour fire resistive rated partitions and fire rated self-closing fire-rated door assemblies.

Observation determined:

a) An electrical conduit penetration through the west wall of the Ambulance Bay was not sealed with fire rated material.

b) The 90-minute fire rated double doors to the Ambulance Bay would not self-close to the latched position and the gap between the doors were not sealed with an astragal and fire rated smoke gasket.

The width of corridors (clear and unobstructed) serving as exit access in hospitals and nursing homes must be maintained.

The facility failed to maintain clear and unobstructed exit corridors.

Observation determined:

1) The corridor width by the Nurses Station was obstructed by a card table and a temporary roller stand that was being used for the storage of electronic equipment.

2) Construction supplies were being stored in the Acute Wing corridor.

3) An extension cord was run across the Acute Wing corridor.

4) A sheet of poly was draped across the Acute Wing corridor.

The emergency illumination lighting system must be arranged to provide the required illumination automatically. 7.9.2.2

Note: CMS allows a light fixture equipped with a single long-life bulb with a quick strike feature to illuminate exit discharge.

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 the exterior of two (2) of four (4) exits was illuminated with a single-bulb light fixture. The light fixtures that illuminated the two signed exit discharge areas from the Ambulance Bay were single-bulb light fixtures without the quick strike feature.

Exits must be marked by approved signage that is readily visible from any direction of exit access and that obviously and clearly identifies the exit. 7.10.1.2

The facility failed to mark the exit paths with readily visible signage. If permanent exit signs are removed during the remodeling of an occupied building, temporary exit signs must be installed so occupants of the building can identify the exit path.

Observation determined the exit signage that was attached to the suspended ceiling at the Main Nurses Station was removed with the suspended ceiling.

The administration of health care facilities is to develop and distribute to all supervisory personnel written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. All employees are to be periodically instructed and kept informed with respect to their duties under the plan. 19.7.2.

Review of policies/procedures indicated the facility failed to provide a written evacuation plan that indicates safe exiting in the event of a fire. The facility's Evacuation Plan was not changed or altered to accommodate changes to the exit system throughout the remodeling project.

The fire alarm system must be in compliance with NFPA 72. Whenever devices are added to or alterations are made to a fire alarm system, all initiating devices and signaling devices must be tested to ensure the fire alarm panel recognizes and addresses each device.

The facility failed to ensure the fire alarm system was maintained, inspected and tested in accordance with the manufacturer's specifications.

1) Review of the fire alarm test records indicated the facility failed to ensure the fire alarm system was operating properly. The June 2011 fire alarm test report indicated that three devices failed the test but were not replaced.

2) Observation indicated that smoke detectors have been removed and/or covered during the remodeling project.

3) Observation indicated that several new signaling devices were added and others appear to be attached to temporary wiring.

4) Heat and smoke rises to the ceiling and stratifies at that elevation. When the suspended ceiling is partially removed, it delays the activation of smoke detectors and the fire alarm system. Ceiling assemblies need to be maintained intact as much as possible and all suspended ceiling tile that can be reinstalled at the end of the construction day should be installed.

Newly introduced upholstered furniture in non-sprinklered portions of the facility must be tested in accordance with NFPA 261, Standard Method of Test for Determining Resistance to Mock-up Upholstered Furniture Material Assemblies to Ignition by Smoldering Cigarettes and ASTM E 1537, Standard Method for Fire Testing of Real Scale Upholstered Furniture Items.

The facility failed to provide documentation to ensure all upholstered furniture meets these standards.

Records review determined documentation was not available for the upholstered furniture located in the Day Room (three chairs and a couch) to verify the fire resistance rating or the date the furniture was purchased.

Enclosures shall be provided for supply systems cylinder storage or manifold locations for oxidizing agents such as oxygen and nitrous oxide. Such enclosures shall be constructed of an assembly of building materials with a fire-resistive rating of at least 1 hour and shall not communicate directly with anesthetizing locations. Other nonflammable (inert) medical gases may be stored in the enclosure. Flammable gases shall not be stored with oxidizing agents. Storage of full or empty cylinders is permitted. Such enclosures shall serve no other purpose. NFPA 99, Standard for Health Care Facilities 4-3.1.1.2

The facility failed to maintain a 1-hour fire-resistance rated enclosure for the oxygen manifold location within the building.

Observation determined the 60-minute door to the Oxygen Room was missing the center hinge. All components of the rated door assembly must be present and functioning to maintain the door rating.

NFPA 241 Section 8.6.2 Temporary Separation Walls.

a) Protection shall be provided to separate an occupied portion of the structure from a portion of the structure undergoing alteration, construction, or demolition operations when such operations are considered as having a higher level of hazard than the occupied portion of the building.

b) Walls shall have at least a 1-hour fire resistance rating.

c) Opening protection shall have at least a 45-minute fire protection rating.

The facility failed to provide fire rated partitions between the occupied spaces and the construction areas.

Observation determined that a one-hour fire rated partition with 45-minute fire rated doors was not provided between the occupied portions of the building and the areas that were currently being remodeled.

Electrical wiring throughout a health care occupancy must comply with NFPA 70, National Electrical Code.

All electrical splices and taps must be within approved electrical boxes. Unused cable or raceway openings in boxes and conduit bodies must be effectively closed to afford protection substantially equivalent to that of the wall of the box or conduit body. NEC 70, 370-16

The facility failed to ensure electrical wiring and electrical equipment comply with NFPA 70.

Observation determined the electrical wiring in several areas throughout the facility was not terminated in covered electrical boxes and electrical receptacles were not equipped with cover plates. These were found in storage rooms, Medical Records, the exit corridor system, and in areas currently being remodeled.