HospitalInspections.org

Based on observation and facility staff interview, facility staff failed to provide one and one half hour rated doors in a two-hour fire barrier rated wall separating the hospital emergency department from the rural healthcare clinic. This compromises the fire-resistance rating and would allow the passage of smoke, fumes and products of combustion to the hospital corridors in the event of a fire. This deficient practice as the potential to effect all patients, staff and visitors in the building. This facility had a capacity of 25. The facility census was 22.

1. Observation on 1/31/19, at approximately 11:37 A.M., during the facility tour, showed the following doors did not have a 1 1/2 hour rating in the 2 hours rated wall:

-one door between GI and ED,
-one door between Rural Health clinic and hospital ED

During an interview on 2/05/2019 at approximately 11:01 A.M., the Maintenance Director said a rural health clinic and emergency department expansion construction project was done in 2005 with an architectural firm. Additionally, he/she said hospital staff believed the architectural firm and construction company built the addition per code requirements.

19.1.3.4 Contiguous Non-Health Care Occupancies.

19.1.3.4.1* Ambulatory care facilities, medical clinics, and
similar facilities that are contiguous to health care occupancies,
but are primarily intended to provide outpatient services,
shall be permitted to be classified as business occupancies or
ambulatory health care facilities, provided that the facilities
are separated from the health care occupancy by not less than
2-hour fire resistance-rated construction, and the facility is
not intended to provide services simultaneously for four or
more inpatients who are litterborne.

19.1.3.5 Where separated occupancies provisions are used in
accordance with either 19.1.3.3 or 19.1.3.4, the most stringent
construction type shall be provided throughout the building,
unless a 2-hour separation is provided in accordance with
8.2.1.3, in which case the construction type shall be determined
as follows:
(1) The construction type and supporting construction of the
health care occupancy shall be based on the story on
which it is located in the building in accordance with the
provisions of 19.1.6 and Table 19.1.6.1.
(2) The construction type of the areas of the building enclosing
the other occupancies shall be based on the applicable
occupancy chapters of this Code.

Based on observation and facility staff interview, facility staff failed to provide emergency lighting not controlled by light switches. This deficient practice has the potential to affect all patients, staff and visitors within the facility. Failure to provide emergency lighting could prevent proper illumination of required areas in the event of power loss. The census was 22 with a capacity of 25.

1. Observations on 1/31/19, during the Life Safety Code (LCS) tour, showed the following light fixtures in the facility controlled by light switches:

-Pharmacy,

-Pre-post patient holding,

-Medication -prep room on med surge hall,

-MRI designated exit to the public way,

-Emergency Department medication room,

-Operating room.

During an interview on 2/05/2019 at 10:58 A.M., the Maintenance Director said he/she did not know emergency powered lights could not be controlled by a light switch.

NFPA 99, 2012 edition, section 6.4.2.2.4.2 states:

"6.4.2.2.4.2 The critical branch shall supply power for task illumination,
fixed equipment, select receptacles, and select power
circuits serving the following areas and functions related to patient
care:
(1) Critical care areas that utilize anesthetizing gases, task illumination,
select receptacles, and fixed equipment
(2) Isolated power systems in special environments
(3) Task illumination and select receptacles in the following:
(a) Patient care rooms, including infant nurseries, selected
acute nursing areas, psychiatric bed areas (omit receptacles),
and ward treatment rooms
(b) Medication preparation areas
(c) Pharmacy dispensing areas
(d) Nurses ' stations (unless adequately lighted by corridor
luminaires)
(4) Additional specialized patient care task illumination and
receptacles, where needed
(5) Nurse call systems
(6) Blood, bone, and tissue banks
(7)*Telephone equipment rooms and closets
(8) Task illumination, select receptacles, and select power circuits
for the following areas:
(a) General care beds with at least one duplex receptacle
per patient bedroom, and task illumination as required
by the governing body of the health care facility
(b) Angiographic labs
(c) Cardiac catheterization labs
(d) Coronary care units
(e) Hemodialysis rooms or areas
(f) Emergency room treatment areas (select)
(g) Human physiology labs
(h) Intensive care units
(i) Postoperative recovery rooms (select)
(9) Additional task illumination, receptacles, and select power
circuits needed for effective facility operation, including
single-phase fractional horsepower motors, which are permitted
to be connected to the critical branch"

Based on observation and facility staff interview, the facility staff failed to provide a 1-hour rated separation between hazardous areas (areas that pose a degree of hazard greater than normal to the general occupancy of the building such as areas used for storage or use of combustibles or flammables, toxic, noxious, or corrosive materials, or heat producing appliances) and designated exit corridors in the facility per NFPA (National Fire Protection Association) requirements. Failure to provide compliant hazardous area doors equipped with a self closing devices and latching devices puts all patients, staff and visitors at risk of injury or death from a fire by not containing the fire and smoke within the hazardous area. The facility census was 22 with a capacity of 25.

1. Observation on 1/31/2019, during the facility tour, showed the central sterile room corridor door consisted of a dutch door. Observation showed the door did not have an astragal, did not have a latching mechanism for the upper leaf and had a half inch gap between the upper and lower leaves. Observation showed air flow entering the corridor between the upper and lower door leaves.

2. Observation on 1/31/2019, during the facility tour, of the laundry corridor door showed the following:

-door missing a self closing device,

-the door did not have a fire resistance rating,

-the room measured over 100 square feet containing combustible storage,

-the laundry room shared the open space with soiled linen holding,

-the room did not contain sprinkler coverage (sprinkler coverage reduces door rating requirements),

-the room contained gas fired dryers.

3. Observation on 1/31/2019, during the facility tour, of the soiled laundry holding corridor door showed the following:

-door missing a self closing device,

-the door contained a 12 inch transfer grill covered with a board,

-the door did not have a fire resistance rating,

-the room measured over 100 square feet containing combustible storage,

-the laundry room shared the open space with soiled linen holding,

-the room did not contain sprinkler coverage (sprinkler coverage reduces door rating requirements),

-the room contained gas fired dryers (shared space with laundry).

4. Observation on 1/31/2019, during the facility tour, of the dietary storage corridor door showed the following:

-the door did not have a fire resistance rating,

-the room measured over 100 square feet containing combustible storage,

-the room did not contain sprinkler coverage (sprinkler coverage reduces door rating requirements).


During an interview on 2/05/2019 at 11:06 A.M., the Maintenance Director said the central sterile dutch door and dietary storage door were installed sometime prior to 1998. Additionally, the Maintenance Director said the laundry and soiled holding rooms were constructed during the building construction in 1962.

Please refer to NFPA 101, 2012 edition, Section 19.3.6.3.13 for additional information regarding the use of dutch doors in hazardous areas.

19.3.2.1.1 An automatic extinguishing system, where used in
hazardous areas, shall be permitted to be in accordance with
19.3.5.9.

19.3.2.1.2* Where the sprinkler option of 19.3.2.1 is used, the
areas shall be separated from other spaces by smoke partitions
in accordance with Section 8.4.

19.3.2.1.3 The doors shall be self-closing or automatic-closing.

19.3.2.1.5 Hazardous areas shall include, but shall not be restricted
to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Rooms with soiled linen in volume exceeding 64 gal (242 L)
(6) Rooms with collected trash in volume exceeding 64 gal
(242 L)
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including
repair shops, used for storage of combustible supplies and
equipment in quantities deemed hazardous by the authority
having jurisdiction

Based on observation, record review and facility staff interview, the facility staff did not ensure interior ceiling and wall finishes met Class A or Class B flame spread requirements. The facility census was 22 with a capacity of 25.

Observations on 1/31/2019, during the facility tour, showed a patient room converted to an IT server room. Observation showed the room windows replaced with unrated plywood. Observation showed the plywood surrounded the PTAC casing and measured approximately four feet by eight feet. Observation showed the room did not contain sprinkler coverage. Record review/observation showed the plywood did not have a placard showing the plywood as fire treated wood (FTW).

During an interview on 2/05/2019 at approximately 11:00 A.M., the Maintenance Director said he/she did not know the fire rating requirements.

19.3.3.2* Interior Wall and Ceiling Finish. Existing interior
wall and ceiling finish materials complying with Section 10.2
shall be permitted to be Class A or Class B.

Based on record review and facility staff interview, facility staff did not ensure all devices connected to the fire alarm system were inspected and tested per NFPA 72, National Fire Alarm and Signaling Code, 2010 edition. The census was 22 with a capacity of 25.

Record review of the annual fire alarm inspection dated 8/22/2018 did not show connection function tests for the following devices:

-MRI powered doors;
-ED controlled lock;
-dampers;
-magnetic door hold open devices.

During an interview on 2/05/2019 at 10:50 A.M., the Director of Facilities Management said he/she believed the fire alarm inspection company inspected the fire alarm per code requirements.


Refer to NFPA 72, National Fire Alarm and Signaling Code, 2010 edition, Table 14.3.1, Table 14.4.2.2, Table 14.4.5, sections 14.4.5, 14.4.5.3.1 through section 14.4.5.4 for additional testing information.

Based on record review and facility staff interview, facility staff failed to inspect one of one wet sprinkler system per NFPA 25, Standard for the Inspection, Testing, and maintenance of Water-Based Fire Protection Systems, 2011 edition. Failure to test and maintain the sprinkler system could affect the sprinkler system's performance in the event of a fire. This deficient practice has the potential to affect all patients, staff and visitors. This facility had a census of 22 with a capacity of 25.


1) Record review on 1/30/2019 of the facility's sprinkler system inspection records did not show the following inspections:

- annual sprinkler head visual inspection,

-five year check valve interior inspections,

-annual sprinkler piping visual inspection,

-annual hangars & bracing visual inspection.

During an interview on 2/05/2019 at 10:51 A.M., the Maintenance Director said he/she believed the sprinkler system inspection company inspected the sprinkler systems per code requirements.


Refer to NFPA 25, Standard for the Inspection, Testing, and maintenance of Water-Based Fire Protection Systems, 2011 edition, Chapters 5, 13, and 14 for additional information.

13.4.2 Check Valves.
13.4.2.1 Inspection. Valves shall be inspected internally every
5 years to verify that all components operate correctly, move
freely, and are in good condition.

Based on observation, facility staff failed to ensure two rooms in the facility laundry was adequately vented and kept under a relative negative pressure. This deficient practice has the potential to effect all residents, staff and visitors. Failure to provide adequate ventilation could increase the concentration of smoke, products of combustion and noxious fumes. This facility had a census of 22 with a capacity of 25.

Observation on 1/31/19, during the facility tour, showed the soiled area of the unseparated laundry room did not have functioning exhaust ventilation.

During an interview on 2/05/2019 at 6:42 P.M., the Maintenance Director said the soiled holding and laundry room were built in 1962 and never had powered venting.

Based on facility staff interview and record review, facility staff failed to inspect, test and maintain the fire egress doors in accordance with the 2010 Editions of NFPA 80 (Standard for Fire Doors and Other Opening Protectives) and NFPA 105 (Standard for Fire Doors and Other Opening Protectives). Facility staff failed to conduct an annual inspection of the non rated doors in the building. This facility census was 22 and had a capacity of 25.

1. Review of the facility's inspection, testing and maintenance records did not show documentation of an annual inspection of the non rated doors in the building.

2. Review of the facility's inspection, testing and maintenance records did not show documentation of an annual inspection of the fire doors in the building.


During an interview on 2/05/2019 at 10:53 A.M., the Maintenance Director said he/she did not know the door inspection requirements.


NFPA 101, 2012 Edition states:

19.2.2.2.1 Doors complying with 7.2.1 shall be permitted.

7.2.1.15 Inspection of Door Openings.

7.2.1.15.1* Where required by Chapters 11 through 43, the
following door assemblies shall be inspected and tested not
less than annually in accordance with 7.2.1.15.2 through
7.2.1.15.8:
(1) Door leaves equipped with panic hardware or fire exit
hardware in accordance with 7.2.1.7
(2) Door assemblies in exit enclosures
(3) Electrically controlled egress doors
(4) Door assemblies with special locking arrangements subject
to 7.2.1.6

7.2.1.15.2 Fire-rated door assemblies shall be inspected and
tested in accordance with NFPA 80, Standard for Fire Doors and
Other Opening Protectives. Smoke door assemblies shall be inspected
and tested in accordance with NFPA 105, Standard for
Smoke Door Assemblies and Other Opening Protectives.

7.2.1.15.3 The inspection and testing interval for fire-rated
and nonrated door assemblies shall be permitted to exceed 12
months under a written performance-based program in accordance
with 5.2.2 of NFPA 80, Standard for Fire Doors and Other
Opening Protectives.

7.2.1.15.4 A written record of the inspections and testing
shall be signed and kept for inspection by the authority having
jurisdiction.

7.2.1.15.5 Functional testing of door assemblies shall be performed
by individuals who can demonstrate knowledge and
understanding of the operating components of the type of
door being subjected to testing.

7.2.1.15.6 Door assemblies shall be visually inspected from
both sides of the opening to assess the overall condition of the
assembly.

7.2.1.15.7 As a minimum, the following items shall be verified:
(1) Floor space on both sides of the openings is clear of obstructions,
and door leaves open fully and close freely.
(2) Forces required to set door leaves in motion and move to
the fully open position do not exceed the requirements
in 7.2.1.4.5.
(3) Latching and locking devices comply with 7.2.1.5.
(4) Releasing hardware devices are installed in accordance
with 7.2.1.5.10.1.
(5) Door leaves of paired openings are installed in accordance
with 7.2.1.5.11.
(6) Door closers are adjusted properly to control the closing
speed of door leaves in accordance with accessibility requirements.
(7) Projection of door leaves into the path of egress does not
exceed the encroachment permitted by 7.2.1.4.3.
(8) Powered door openings operate in accordance with
7.2.1.9.
(9) Signage required by 7.2.1.4.1(3), 7.2.1.5.5, 7.2.1.6, and
7.2.1.9 is intact and legible.
(10) Door openings with special locking arrangements function
in accordance with 7.2.1.6
(11) Security devices that impede egress are not installed on
openings, as required by 7.2.1.5.12.

19.3.6.3.13 Dutch doors shall be permitted where they conform
to 19.3.6.3 and meet all of the following criteria:
(1) Both the upper leaf and lower leaf are equipped with a
latching device.
(2) The meeting edges of the upper and lower leaves are
equipped with an astragal, a rabbet, or a bevel.
(3) Where protecting openings in enclosures around hazardous
areas, the doors comply with NFPA80, Standard for Fire
Doors and Other Opening Protectives.

Based on record review and facility staff interview, the facility staff failed to provide completed fundamental risk assessments and formally documented risk assessment procedures for all building systems categories are determined by a performed by qualified personnel. Failure to have the building systems risk assessments completed puts patients at risk for a potential negative outcome if category one systems (Category 1 system in which a failure of such equipment or system is likely to cause major injury or death of patients or caregivers) fail with no plan on how to respond if the system fails. This facility had a capacity of 25 with a census of 22.


1. Review of the facility documents for fire safety, building system tests, and policies did not show how the categorical risk assessment scores for the building systems were determined.

2. During an interview on 2/05/2019, the Maintenance Director said he/she became the Maintenance Director December 2018 and has not had a chance to review the risk assessments since taking the position.


The National Fire Protection Association 99 Health Care Facilities Code, 2012 edition, Chapter 4 states:

"Chapter 4 Fundamentals

4.1* Building System Categories. Building systems in health
care facilities shall be designed to meet system Category 1
through Category 4 requirements as detailed in this code.

4.1.1* Category 1. Facility systems in which failure of such equipment
or system is likely to cause major injury or death of patients
or caregivers shall be designed to meet system Category 1 requirements
as defined in this code.

4.1.2* Category 2. Facility systems in which failure of such equipment
is likely to cause minor injury to patients or caregivers shall
be designed to meet system Category 2 requirements as defined
in this code.

4.1.3 Category 3. Facility systems in which failure of such equipment
is not likely to cause injury to patients or caregivers, but can
cause patient discomfort, shall be designed to meet system Category
3 requirements as defined in this code.

4.1.4 Category 4. Facility systems in which failure of such equipment
would have no impact on patient care shall be designed to
meet system Category 4 requirements as defined in this code.

4.2* Risk Assessment. Categories shall be determined by following
and documenting a defined risk assessment procedure.

4.3 Application. The Category definitions in Chapter 4 shall
apply to Chapters 5 through 11."

A.4.2 Risk assessment should follow procedures such as those
outlined in ISO/IEC 31010, Risk Management-Risk Assessment
Techniques, NFPA 551, Guide for the Evaluation of Fire Risk Assessments,
Guide for the Evaluation of Fire Risk Assessments, SEMI S10-
0307E, Safety Guideline for Risk Assessment and Risk Evaluation
Process, or other formal process. The results of the assessment
procedure should be documented and records retained.