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Based on observation and interview, the facility did not maintain the fire rated barrier around a hazard area in accordance with NFPA 101 2012, 19.3.2.1

Findings include:

During a tour of the hospital on 3/20/2017 at approximately 10:50 AM, it was observed that the 45- minute rated door to storage room R 103, located near the ambulance entrance of the Emergency Department, failed to positively latch when allowed to self-close. Upon closing, the door latch did not allow the door to close completely, leaving a gap between the door and the frame.

Failure to maintain the fire rated barrier around a hazard area may pose a safety risk to patients and staff, by accelerating the spread of smoke and flames should any stored combustible items ignite.

At the time of the observation, Staff R, Director of Physical Plant, verified that the door latch was not functioning properly.

Based on observation and interview, the facility did not maintain the automatic sprinkler system in accordance with NFPA 101 2012 - 19.3.5 and NFPA 13 2010 - 6.2.7 and 6.2.6.2.

Findings include:

During tour of the hospital on 3/20/2017 between 11:00 AM and 11:30 AM, the following was observed:

A sprinkler head inside storage room R104 was coated with fire proofing material which could impede its functioning.

A sprinkler head next to the ambulance entrance was observed to be lacking its escutcheon and was coated with dust.

Numerous sprinkler heads in the corridor leading from the ambulance entrance to the Emergency Department were not flush with the ceiling, leaving a gap between the escutcheon and the ceiling. This could allow smoke and heat to rise into the gap, and cause the sprinkler head to discharge prematurely.
Failure to maintain the sprinkler head components of the automatic sprinkler system may pose a safety risk to patients and staff in the event of a fire emergency.

These findings were verified by Staff R, Director of Physical Plant, at the time of observation.

Based on observation and interview, the facility failed to maintain the required smoke barriers in such a way to resist the passage of smoke in accordance with NFPA 101 19.3.7.3 and 8.6.7 (1), and NFPA 90A 3-4.6.

Findings include:

During a tour of the hospital on 3/20/2017 between 10:30 AM and 1:00 PM, and 3/22/2017 at approximately 10:00 AM, numerous Heating, Ventilation and Air Conditioning (HVAC) ducts equipped with smoke dampers were observed to be penetrating the smoke barrier. The annular space around the ducts was sealed with fired stopping caulk.
Per NFPA 90.3.6.4, smoke dampers shall be installed in accordance with the conditions of their listings and the manufacturers installation instructions.

Underwriter's Laboratory (UL) 555S, the test standard for smoke dampers, requires that ducts with smoke dampers be equipped with metal retaining angles, and states that the space between the retaining angle and the wall does not allow significant movement of smoke through the duct penetration. While certain manufacturers of smoke dampers may allow a sealant to be used around the retaining angles, it is never permissible to use any type of fire stopping material as a sealant.

Examples of smoke dampered duct penetrations sealed with fire stopping caulk include, but are not limited to, the following locations:

1) The smoke barrier between the Emergency Department and the adjacent family medical practice on the 1st floor.
2) The smoke barrier above the door to the OR suite on the second floor.
3) The smoke barrier above door 8-4 on the 8th floor.

Failure to properly install ducts in the smoke barrier walls will pose a risk to the safety of patients and staff by impeding the operation of the smoke dampers, and allowing the movement of smoke throughout the hospital in the event of a fire.

During interview with Staff S, Director of Physical Plant on 3/22/17 at 10:00 AM, the staff acknowledged findings.

Based on observation and interview, the facility did not maintain the required clearance around electrical equipment and controls in accordance with NFPA 99 2012 15.5.1.2 and NFPA 70 2011 110.26.

Findings include:

On a tour of the hospital on 3/20/2017 at approximately 10:30 AM, three electrical panels in Storage Room R 104, located in the Emergency Department, were observed to lack the required 36" of clearance around the panels. Numerous objects including tool boxes, equipment and cardboard boxes were stored within several inches of the front of the panels and extended out approximately three feet in front of the panels.

Failure to provide the necessary 36" clearance around electrical panels will prevent hospital staff and emergency personnel from disconnecting the electrical power quickly and with minimal effort in the event of fire or other emergencies. In addition, storage near electrical equipment may provide an ignition source and pose a fire risk.

During interview with Staff S, Director of Physical Plant on 3/20/17 at 10:35 AM, staff acknowledged findings.

Based on observation and interview, the facility did not maintain bulk oxygen storage equipment in accordance with NFPA 55, 7.1.2.5.6 &8.3.4 and NFPA 99, 5.1.3.3.3.

Findings include:

During tour of the hospital's bulk oxygen storage on 3/23/17 at approximately 1:15 PM, a substantial amount of frozen condensation was observed around the pressure relief valves of the larger of the two liquid oxygen storage tanks.
A build-up of frozen condensation was also observed on the liquid oxygen vaporizer, which converts liquid oxygen to its gaseous form.

Failure to maintain the bulk oxygen storage devices may interfere with their proper operation, and impact the facility's ability to provide medical oxygen in critical patient care areas.

During interview with Staff S, Director of Physical Plant at the time of the tour on 3/23/17 at approximately 1:20 PM, staff acknowledged findings.