HospitalInspections.org

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Based on the observation of the smoke barriers on 01/06/2015, the facility failed to maintain the smoke barriers to limit the transfer of smoke. Findings include:

The following unsealed penetrations were observed in the smoke barrier on the first floor above the door to Environmental Service:
1. One red wire
2. The end of a sleeve with blue and gray wires

This deficiency impacted 2 of 5 smoke compartments.

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2000 NFPA 101, 8.2.4.4.1
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Based on the observation of hazardous areas on 01/06/2015, the facility failed to maintain the hazardous areas separate from other spaces by smoke-resisting self closing positive latching doors. Findings include:

1. No positive latching hardware on the corridor door for Environmental Services on the Material Management Office Hallway.
2. No self-closing device on the Dietary Pot and Pan Room to Environmental Services.
3. No positive latching hardware on the kitchen door to Environmental Services.
4. No self-closing device on the Dialysis Storage Room.
5. No self-closing device on MDF's Closet.

This deficiency impacted 1 of 1 smoke compartments.

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2000 NFPA 101, 19.3.2.1 Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.

HCFA Transmittal 40-93 It is the intent of the code that (smoke-resisting) separation be provided even in a sprinklered hazardous area. "Where the sprinkler option is used, the (hazardous) areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be equipped with self- or automatic closers and be positive latching."
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Based on the observation of hazardous areas on 01/07/2015, the facility failed to maintain the hazardous areas separate from other spaces by smoke-resisting self closing positive latching doors. Findings include:

1. The Game and Toy Storage Room in the Physical Therapy Center was observed with combustible items without a self closing device on the door.


33999

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2. The Biohazard Waste Room at the Imaging Center was observed without a self closing device.

The deficiency impacted 1 of 1 smoke compartments.

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2000 NFPA 101, 19.3.2.1 Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.
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Based on the observation of hazardous areas on 01/06/2015, the facility failed to maintain hazardous areas separation from other spaces by smoke-resisting self closing positive latching doors. Findings include:

The Soiled Linen Rooms corridor door across from Room 143 was unable to self close and latch into the frame.

The deficiency impacted 1 of 2 smoke compartments.

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Review of 2000 NFPA 101, 19.3.2.1
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Based on the observation of all exit access doors on 01/06/2015, the facility failed to provide readily accessible exits. Findings include:

The exterior Biohazard Storage Room door was observed to be locked with a padlock.

The deficiency impacted 1 of 1 smoke compartments.

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2000 NFPA 101, 7.1.9 Any device or alarm installed to restrict the improper use of a means of egress shall be designed and installed so that it cannot, even in case of failure, impede or prevent emergency use of such means of egress unless otherwise provided in 7.2.1.6 and Chapters 18, 19, 22, and 23.
2000 NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.
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Based on the observation of all required exits means of egress to the public way on 01/06/2015, the facility failed to provide readily accessible exits. Findings include:

The Ground Floor Elevator Lobby exit was observed without an all weather surface to the public way.

The deficiency impacted 1 of 5 smoke compartments.

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2000 NFPA 101, A.7.1.10.1 *A proper means of egress allows unobstructed travel at all times. Any type of barrier including, but not limited to, the accumulations of snow and ice in those climates subject to such accumulations is an impediment to free movement in the means of egress.
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Based on the observation of the automatic sprinkler system on 01/06-07/2015, the facility failed to maintain the automatic sprinkler system. Findings include:

1. The escutcheon plate was observed to be loose and hanging down at the sprinkler head located at the IDF2 Computer Closet on the Ground Floor.
2. A pressure gauge dated 2007 was observed at the sprinklers inspector test area on the Ground Floor.
3. A large amount of foreign material was observed covering the sprinkler located at Room 12 in the ED Department on the Ground Floor.


34000


4. Above ceiling at Environment Service, bottom floor of two story building, there were blue and gray wires as well as silver flex conduit resting on sprinkler main.
5. No sprinkler heads provided in elevator pits.

Deficiencies impacted 3 of 5 smoke compartments.
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2000 NFPA 101, 4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.
1998 NFPA 25, 9-2.8.2: Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced.

1998 NFPA 25 2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

1998 NFPA 25, 2-2.2* Pipe and Fittings. Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.
1999 NFPA 13, 5-13.6.1* Sidewall spray sprinklers shall be installed at the bottom of each elevator hoistway not more than 2 ft (0.61 m) above the floor of the pit. Exception: For enclosed, noncombustible elevator shafts that do not contain combustible hydraulic fluids, the sprinklers at the bottom of the shaft are not required.
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Based on the observation of the automatic sprinkler system on 01/06/2015, the facility failed to maintain the automatic sprinkler system. Findings include:

The fire department connection at the hospital main entrance was not provided with an identification sign.

The deficiency impacted 1 of 1 smoke compartments.

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NFPA 25, 1998 Edition, 9-7.1 Fire department connections shall be inspected quarterly. The inspection shall verify the following:
(a) The fire department connections are visible and accessible.
(b) Couplings or swivels are not damaged and rotate smoothly.
(c) Plugs or caps are in place and undamaged.
(d) Gaskets are in place and in good condition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly.
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Based on the observation of the fire extinguishers on 01/06/2015, the facility failed to maintain the fire extinguishers less than 5'-0" above the floor. Findings include:

The following fire extinguishers in the kitchen were observed mounted over 5'-0" above the floor:
1. The regular fire extinguisher
2. The K-extinguisher

This deficiency impacted 1 of 1 smoke compartments.

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1998 NFPA 10, 1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 31/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).
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Based on the observation on 1/06/2015, the facility failed to maintain the fire extinguishers Findings include:
In the Old Boiler Room off of the House Keeping corridor surveyor observed a fire extinguisher sitting next to the door on the floor.

Deficiencies impacted 1 of 2 smoke compartments.
_____________

1998 NFPA 10 1-6.8 Fire extinguishers installed under conditions where they are subject to dislodgement shall be installed in brackets specifically designed to cope with this problem.
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Based on the observation on 1/06/2015, the facility failed to maintain the HVAC system. Findings include:

In the two story portion of the hospital off the ER Lobby inside the Blood Bank there was no access panel provided in the ductwork to allow observation of damper operation. There appeared to be a damper installed but operation of damper during activation of Fire Alarm could not be confirmed.

Deficiencies impacted 2 of 5 smoke compartments.
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1999 NFPA 90A, 2-3.4.1* A service opening shall be provided in air ducts adjacent to each fire damper, smoke damper, and smoke detector. The opening shall be large enough to permit maintenance and resetting of the device.
2-3.4.2 Service openings shall be identified with letters having a minimum height of 1/2 in. (1.27 cm) to indicate the location of the fire protection device(s) within.
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Based on the observation of the kitchen hood filters and the kitchen hood ventilation system on 01/06/2015, the facility failed to maintain the kitchen hood filters tight fitting. Findings include:

1. The kitchen hood filters were observed to have two separate places were the filters had approximate gaps of 2".


34000

2. Seams inside the kitchen hood were not sealed liquidtight.

Deficiencies impacted 1 of 1 smoke compartments.
_____________
1998 NFPA 96, 3-2.3 Grease filters shall be listed and constructed of steel or listed equivalent material and shall be of rigid construction that will not distort or crush under normal operation, handling, and cleaning conditions. Filters shall be tightfitting and firmly held in place.

1998 NFPA 96, 2-1.2 All seams, joints, and penetrations of the hood enclosure that direct and capture grease-laden vapors and exhaust gases shall have a liquidtight continuous external weld to the hood ' s lower outermost perimeter. Internal hood joints, seams, filter support frames, and appendages attached inside the hood need not be welded but shall be sealed or otherwise made greasetight.
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Based on the observation on 1/07/2015, the facility failed to maintain the operation of dampers in ductwork. Findings include:

In the Attic space at room 143 the damper in the square (14 " x 14 " ) duct and the damper in the round (12 " dia.) duct failed to close upon the activation of the fire alarm.

Deficiencies impacted 2 of 2 smoke compartments.
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2000 NFPA 101, 8.3.5.2 Required smoke dampers in ducts penetrating smoke barriers shall close upon detection of smoke by approved smoke detectors in accordance with NFPA 72, National Fire Alarm Code.
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Based on the observation of the battery-powered lights on 01/06/2015, the facility failed to maintain the battery-powered lights. Findings include:

Their was no battery-powered light provided at the generator switch gear room.

The deficiency impacted 1 of 5 smoke compartments.

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1999 NFPA 99, 3-6.1.1 and 3-4.1.1.4, and 1999 NFPA 110, 5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting.
.

.
Based on the observation of the smoke barriers on 01/06/2015, the facility failed to maintain the smoke barriers to limit the transfer of smoke. Findings include:

The following unsealed penetrations were observed in the smoke barrier on the first floor above the door to Environmental Service:
1. One red wire
2. The end of a sleeve with blue and gray wires

This deficiency impacted 2 of 5 smoke compartments.

------------------------------

2000 NFPA 101, 8.2.4.4.1
.

.
Based on the observation of hazardous areas on 01/06/2015, the facility failed to maintain the hazardous areas separate from other spaces by smoke-resisting self closing positive latching doors. Findings include:

1. No positive latching hardware on the corridor door for Environmental Services on the Material Management Office Hallway.
2. No self-closing device on the Dietary Pot and Pan Room to Environmental Services.
3. No positive latching hardware on the kitchen door to Environmental Services.
4. No self-closing device on the Dialysis Storage Room.
5. No self-closing device on MDF's Closet.

This deficiency impacted 1 of 1 smoke compartments.

------------------------------

2000 NFPA 101, 19.3.2.1 Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.

HCFA Transmittal 40-93 It is the intent of the code that (smoke-resisting) separation be provided even in a sprinklered hazardous area. "Where the sprinkler option is used, the (hazardous) areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be equipped with self- or automatic closers and be positive latching."
.

.
Based on the observation of hazardous areas on 01/07/2015, the facility failed to maintain the hazardous areas separate from other spaces by smoke-resisting self closing positive latching doors. Findings include:

1. The Game and Toy Storage Room in the Physical Therapy Center was observed with combustible items without a self closing device on the door.


33999

.
2. The Biohazard Waste Room at the Imaging Center was observed without a self closing device.

The deficiency impacted 1 of 1 smoke compartments.

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2000 NFPA 101, 19.3.2.1 Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.
.

.
Based on the observation of hazardous areas on 01/06/2015, the facility failed to maintain hazardous areas separation from other spaces by smoke-resisting self closing positive latching doors. Findings include:

The Soiled Linen Rooms corridor door across from Room 143 was unable to self close and latch into the frame.

The deficiency impacted 1 of 2 smoke compartments.

------------------------------

Review of 2000 NFPA 101, 19.3.2.1
.

.
Based on the observation of all exit access doors on 01/06/2015, the facility failed to provide readily accessible exits. Findings include:

The exterior Biohazard Storage Room door was observed to be locked with a padlock.

The deficiency impacted 1 of 1 smoke compartments.

------------------------------

2000 NFPA 101, 7.1.9 Any device or alarm installed to restrict the improper use of a means of egress shall be designed and installed so that it cannot, even in case of failure, impede or prevent emergency use of such means of egress unless otherwise provided in 7.2.1.6 and Chapters 18, 19, 22, and 23.
2000 NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.
.

.
Based on the observation of all required exits means of egress to the public way on 01/06/2015, the facility failed to provide readily accessible exits. Findings include:

The Ground Floor Elevator Lobby exit was observed without an all weather surface to the public way.

The deficiency impacted 1 of 5 smoke compartments.

------------------------------

2000 NFPA 101, A.7.1.10.1 *A proper means of egress allows unobstructed travel at all times. Any type of barrier including, but not limited to, the accumulations of snow and ice in those climates subject to such accumulations is an impediment to free movement in the means of egress.
.

.
Based on the observation of the automatic sprinkler system on 01/06-07/2015, the facility failed to maintain the automatic sprinkler system. Findings include:

1. The escutcheon plate was observed to be loose and hanging down at the sprinkler head located at the IDF2 Computer Closet on the Ground Floor.
2. A pressure gauge dated 2007 was observed at the sprinklers inspector test area on the Ground Floor.
3. A large amount of foreign material was observed covering the sprinkler located at Room 12 in the ED Department on the Ground Floor.


34000


4. Above ceiling at Environment Service, bottom floor of two story building, there were blue and gray wires as well as silver flex conduit resting on sprinkler main.
5. No sprinkler heads provided in elevator pits.

Deficiencies impacted 3 of 5 smoke compartments.
_____________

2000 NFPA 101, 4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.
1998 NFPA 25, 9-2.8.2: Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced.

1998 NFPA 25 2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

1998 NFPA 25, 2-2.2* Pipe and Fittings. Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.
1999 NFPA 13, 5-13.6.1* Sidewall spray sprinklers shall be installed at the bottom of each elevator hoistway not more than 2 ft (0.61 m) above the floor of the pit. Exception: For enclosed, noncombustible elevator shafts that do not contain combustible hydraulic fluids, the sprinklers at the bottom of the shaft are not required.
.

.
Based on the observation of the automatic sprinkler system on 01/06/2015, the facility failed to maintain the automatic sprinkler system. Findings include:

The fire department connection at the hospital main entrance was not provided with an identification sign.

The deficiency impacted 1 of 1 smoke compartments.

------------------------------

NFPA 25, 1998 Edition, 9-7.1 Fire department connections shall be inspected quarterly. The inspection shall verify the following:
(a) The fire department connections are visible and accessible.
(b) Couplings or swivels are not damaged and rotate smoothly.
(c) Plugs or caps are in place and undamaged.
(d) Gaskets are in place and in good condition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly.
.

.
Based on the observation of the fire extinguishers on 01/06/2015, the facility failed to maintain the fire extinguishers less than 5'-0" above the floor. Findings include:

The following fire extinguishers in the kitchen were observed mounted over 5'-0" above the floor:
1. The regular fire extinguisher
2. The K-extinguisher

This deficiency impacted 1 of 1 smoke compartments.

------------------------------

1998 NFPA 10, 1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 31/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).
.

.
Based on the observation on 1/06/2015, the facility failed to maintain the fire extinguishers Findings include:
In the Old Boiler Room off of the House Keeping corridor surveyor observed a fire extinguisher sitting next to the door on the floor.

Deficiencies impacted 1 of 2 smoke compartments.
_____________

1998 NFPA 10 1-6.8 Fire extinguishers installed under conditions where they are subject to dislodgement shall be installed in brackets specifically designed to cope with this problem.
.

.
Based on the observation on 1/06/2015, the facility failed to maintain the HVAC system. Findings include:

In the two story portion of the hospital off the ER Lobby inside the Blood Bank there was no access panel provided in the ductwork to allow observation of damper operation. There appeared to be a damper installed but operation of damper during activation of Fire Alarm could not be confirmed.

Deficiencies impacted 2 of 5 smoke compartments.
_____________

1999 NFPA 90A, 2-3.4.1* A service opening shall be provided in air ducts adjacent to each fire damper, smoke damper, and smoke detector. The opening shall be large enough to permit maintenance and resetting of the device.
2-3.4.2 Service openings shall be identified with letters having a minimum height of 1/2 in. (1.27 cm) to indicate the location of the fire protection device(s) within.
.

.
Based on the observation of the kitchen hood filters and the kitchen hood ventilation system on 01/06/2015, the facility failed to maintain the kitchen hood filters tight fitting. Findings include:

1. The kitchen hood filters were observed to have two separate places were the filters had approximate gaps of 2".


34000

2. Seams inside the kitchen hood were not sealed liquidtight.

Deficiencies impacted 1 of 1 smoke compartments.
_____________
1998 NFPA 96, 3-2.3 Grease filters shall be listed and constructed of steel or listed equivalent material and shall be of rigid construction that will not distort or crush under normal operation, handling, and cleaning conditions. Filters shall be tightfitting and firmly held in place.

1998 NFPA 96, 2-1.2 All seams, joints, and penetrations of the hood enclosure that direct and capture grease-laden vapors and exhaust gases shall have a liquidtight continuous external weld to the hood ' s lower outermost perimeter. Internal hood joints, seams, filter support frames, and appendages attached inside the hood need not be welded but shall be sealed or otherwise made greasetight.
.

.
Based on the observation on 1/07/2015, the facility failed to maintain the operation of dampers in ductwork. Findings include:

In the Attic space at room 143 the damper in the square (14 " x 14 " ) duct and the damper in the round (12 " dia.) duct failed to close upon the activation of the fire alarm.

Deficiencies impacted 2 of 2 smoke compartments.
_____________

2000 NFPA 101, 8.3.5.2 Required smoke dampers in ducts penetrating smoke barriers shall close upon detection of smoke by approved smoke detectors in accordance with NFPA 72, National Fire Alarm Code.
.

.
Based on the observation of the battery-powered lights on 01/06/2015, the facility failed to maintain the battery-powered lights. Findings include:

Their was no battery-powered light provided at the generator switch gear room.

The deficiency impacted 1 of 5 smoke compartments.

------------------------------

1999 NFPA 99, 3-6.1.1 and 3-4.1.1.4, and 1999 NFPA 110, 5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting.
.