HospitalInspections.org

Based on observations made on 8/18/2010 during a tour of both levels of the hospital, it has been determined that the facility did not ensure all vertical openings containing stairs were properly enclosed with one hour rated doors and other rated construction. This problem also includes vertical openings in floors at locations other than stairways.

Findings include:

In accordance with NFPA 101 Section 8.2.5.7 which states; "A vertical opening serving as other than an exit enclosure, connecting only two adjacent stories, and piercing only one floor shall be permitted to be open to one of the two stories."

1. The surveyor observed a stairwell which connects the east zones of the lower and upper levels and serves as a "communicating stairway" between each level. The stairway is not required to be part of the exiting system of the facility and is not identified for such a purpose. However, the two doors enclosing the stairway (top and bottom) are made of glass and are not rated. There are also partial glass walls that are part of stairway vertical separation. These glass wall sections also were not fire rated of at least 1 hour.

2. At approximately 2:00 p.m. the mechanical penthouse on the roof of the hospital was inspected by the surveyor. In the concrete floor of the penthouse there were two open penetrations which were unsealed. Blue wiring passed through the openings of the penetrations.

Based on observations made by the surveyor during a tour of the interior of the hospital on 8/18/2010, it was determined not all doors intended to be used for exiting are properly identified for such a purpose.

Findings include:

At approximately 8:30 a.m., the surveyor toured the main level of the hospital which included the patient wing located in the southeast section of the hospital. At the end of the corridor at "eye level", there was a hand written sign on the exit door which read "DO NOT USE ! ! Alarm On Door ". This sign was posted next to another sign which identified the door to be used for emergency exiting.

Based on staff interview on 8/18/2010, it was determined that the facility failed to ensure that the battery-powered emergency lights throughout the facility had been properly tested at all times.

Findings include:

In accordance with 3-4.2.2.2(b)5 of NFPA 99 (1999 Edition) and 5-3.1 of NFPA 110 (1999 Edition) the room housing the emergency generator shall be provided with battery-powered emergency lighting. In accordance with 7.9.3 of the Life Safety Code a functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than one and one-half hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Although there is a written record of monthly testing of the battery backup lighting, the surveyor was informed by the maintenance supervisor that there was no testing nor a record for the one and one-half hour testing of the lights annually.

Based on a review of available documentation on 8/18/2010, the facility failed to ensure there was a documented record of fire drills which were conducted quarterly in the past year for each shift.

Findings include:

1. For the "7:00 a.m. to 7:00 p.m. shift", there was no record of a fire drill being held between 8/26/2009 to 2/26/2010 in the past 12 months.

2. For the "7:00 p.m. to 7:00 a.m. shift", there was no record of a fire drill being held from 1/26/2010 to the time of this survey 08/19/2010.

On 8/18/2010, the surveyor reviewed the available sprinkler inspection reports from the past year. It was determined that the facility failed to ensure that the sprinkler system had been inspected and tested as required by NFPA 25.

Findings include:

In accordance with 1-8 and 2-1.3 of NFPA 25 (1998 Edition) records of inspections, tests and maintenance of the sprinkler system and its components shall be made available to the AHJ including but not limited to the quarterly tests required by Table 2-1.

During the final paperwork review in the afternoon of the survey, it was determined that in the past year, only one sprinkler inspection had been done by a licensed contractor on 5/12/2010. Four sprinkler system inspections are required to be done every year.

Based on observations made on 8/18/2010 during a tour of both levels of the hospital, it has been determined that the facility did not ensure all vertical openings containing stairs were properly enclosed with one hour rated doors and other rated construction. This problem also includes vertical openings in floors at locations other than stairways.

Findings include:

In accordance with NFPA 101 Section 8.2.5.7 which states; "A vertical opening serving as other than an exit enclosure, connecting only two adjacent stories, and piercing only one floor shall be permitted to be open to one of the two stories."

1. The surveyor observed a stairwell which connects the east zones of the lower and upper levels and serves as a "communicating stairway" between each level. The stairway is not required to be part of the exiting system of the facility and is not identified for such a purpose. However, the two doors enclosing the stairway (top and bottom) are made of glass and are not rated. There are also partial glass walls that are part of stairway vertical separation. These glass wall sections also were not fire rated of at least 1 hour.

2. At approximately 2:00 p.m. the mechanical penthouse on the roof of the hospital was inspected by the surveyor. In the concrete floor of the penthouse there were two open penetrations which were unsealed. Blue wiring passed through the openings of the penetrations.

Based on observations made by the surveyor during a tour of the interior of the hospital on 8/18/2010, it was determined not all doors intended to be used for exiting are properly identified for such a purpose.

Findings include:

At approximately 8:30 a.m., the surveyor toured the main level of the hospital which included the patient wing located in the southeast section of the hospital. At the end of the corridor at "eye level", there was a hand written sign on the exit door which read "DO NOT USE ! ! Alarm On Door ". This sign was posted next to another sign which identified the door to be used for emergency exiting.

Based on staff interview on 8/18/2010, it was determined that the facility failed to ensure that the battery-powered emergency lights throughout the facility had been properly tested at all times.

Findings include:

In accordance with 3-4.2.2.2(b)5 of NFPA 99 (1999 Edition) and 5-3.1 of NFPA 110 (1999 Edition) the room housing the emergency generator shall be provided with battery-powered emergency lighting. In accordance with 7.9.3 of the Life Safety Code a functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than one and one-half hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Although there is a written record of monthly testing of the battery backup lighting, the surveyor was informed by the maintenance supervisor that there was no testing nor a record for the one and one-half hour testing of the lights annually.

Based on a review of available documentation on 8/18/2010, the facility failed to ensure there was a documented record of fire drills which were conducted quarterly in the past year for each shift.

Findings include:

1. For the "7:00 a.m. to 7:00 p.m. shift", there was no record of a fire drill being held between 8/26/2009 to 2/26/2010 in the past 12 months.

2. For the "7:00 p.m. to 7:00 a.m. shift", there was no record of a fire drill being held from 1/26/2010 to the time of this survey 08/19/2010.

On 8/18/2010, the surveyor reviewed the available sprinkler inspection reports from the past year. It was determined that the facility failed to ensure that the sprinkler system had been inspected and tested as required by NFPA 25.

Findings include:

In accordance with 1-8 and 2-1.3 of NFPA 25 (1998 Edition) records of inspections, tests and maintenance of the sprinkler system and its components shall be made available to the AHJ including but not limited to the quarterly tests required by Table 2-1.

During the final paperwork review in the afternoon of the survey, it was determined that in the past year, only one sprinkler inspection had been done by a licensed contractor on 5/12/2010. Four sprinkler system inspections are required to be done every year.