HospitalInspections.org

Based on observation and staff interview, the facility failed to ensure room ceilings were smoke resistant in 1 of 5 smoke compartments. The findings were:

Observation of the clinic sample closet on 9/20/11 at 10:07 AM showed there were three unsealed conduit penetrations. The largest gap was 1/2 inch larger than the conduit. At the time of observation, the director of facility services could not explain why the holes had not been noticed and repaired during the annual inspection of the limited access area.

Reference:
NFPA 101, 2000 Edition;
19.1.6.4 Each exterior wall of frame construction and all interior stud partitions shall be firestopped to cut off all concealed draft openings, both horizontal and vertical, between any cellar or basement and the first floor. Such firestopping shall consist of wood not less than 2 in. (5 cm) (nominal) thick or shall be of noncombustible material.

Based on observation and staff interview, the facility failed to ensure hazardous areas were separated from use areas in 2 of 5 smoke compartments. The findings were:

Observation of the telephone room on 9/20/11 at 8:40 AM showed a 1/2 inch gap around an unsealed cable penetration. At the time of observation, the director of facility services could not explain why the hole had not been noticed and repaired during the quarterly inspections.

Based on observation and staff interview, the facility failed to ensure fully sprinkled areas had complete sprinkler coverage in 1 of 5 smoke compartments. The findings were:

1. Observation of the laundry on 9/20/11 at 8:01 AM showed the room behind the dryers had a single sprinkler head. Further observation showed two of the walls terminated at the laundry lay in ceiling tiles and left the room open to the plenum above the rest of the laundry area. The plenum above the laundry did not have sprinkler coverage other than the single sprinkler head above the back of the dryers. At the time of observation, the director of facility services reported he was not aware open plenums required sprinkler coverage.

2. Observation of the radiology office on 9/20/11 at 9:19 AM showed one of three sprinkler heads was installed 2 inches from the wall, less than the allowed 4 inches. At the time of observation, the director of facilities services reported the sprinkler system was inspected annually by an outside contractor and the last inspection report (8/25/11) did not indicate sprinkler spacing issues.

Reference:
NFPA 101, 2000 Edition, 19.3.5.1, 9.7.1.1, NFPA 13, 1999 Edition;
5-1.1 The requirements for spacing, location, and position of sprinklers are based on the following principles:
1) Sprinklers installed throughout the premises
2) Sprinkler located so as not to exceed maximum protection area per sprinkler
3) Sprinklers positioned and located so as to provide satisfactory performance with respect to activation time and distribution
5-6.3.3 Sprinklers shall be located a minimum of 4 in. from the wall.

Based on observation and staff interview the facility failed to ensure sprinkler heads had adequate spacing in 3 of 5 smoke compartments. The findings were:

Observation of the sprinkler system on 9/20/11 between 7:30 AM and 10 AM showed the sprinkler heads in the dietary office, operating room (OR) pre-op/waiting area, OR storeroom, ultrasound bathroom, and #102 bathroom had less than the required 1 inch spacing between the deflector and the ceiling. At the time of observation, the director of facilities services reported the sprinkler system was inspected annually by an outside contractor and the last inspection report (8/25/11) did not indicate sprinkler spacing issues.

Reference:
NFPA 101, 2000 Edition, 19.3.5.1, 9.7.1.1, NFPA 13, 1999 Edition.
5-6.4.1.1 Under unobstructed construction, the distance between the sprinkler deflector and the ceiling shall be a minimum of 1 in. and a maximum of 12 in.

Based on observation and staff interview, the facility failed to ensure damaged electrical equipment was repaired or replaced and failed to ensure junction boxes had covers in 2 of 5 smoke compartments. The findings were:

1. Observation of the operating room (OR) clean room on 9/20/11 at 8:13 AM showed the electrical outlet had char marks on the face plate. At the time of observation the director of facility services could not explain why the outlet had not been noticed and replaced during the quarterly inspections.

2. Observation of the sprinkler riser room on 9/20/11 at 11:17 AM showed the junction box for the sprinkler control valve did not have a cover plate. At the time of observation the director of facility services could not explain why the cover had not been noticed and replaced during the quarterly inspection.

Reference:
NFPA 101, 2000 Edition, 19.5.1, 9.1.2, NFPA 70, 1999 Edition;
90-7 Examination of Equipment for Safety.
...It is the intent of this Code that factory-installed internal wiring or the construction of equipment need not be inspected at the time of installation of the equipment, except to detect alterations of damage ...
370-28. Pull and Junction Boxes.
(3) (c) cover. All pull boxes, junction boxes and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use....

Based on observation and staff interview, the facility failed to ensure room ceilings were smoke resistant in 1 of 5 smoke compartments. The findings were:

Observation of the clinic sample closet on 9/20/11 at 10:07 AM showed there were three unsealed conduit penetrations. The largest gap was 1/2 inch larger than the conduit. At the time of observation, the director of facility services could not explain why the holes had not been noticed and repaired during the annual inspection of the limited access area.

Reference:
NFPA 101, 2000 Edition;
19.1.6.4 Each exterior wall of frame construction and all interior stud partitions shall be firestopped to cut off all concealed draft openings, both horizontal and vertical, between any cellar or basement and the first floor. Such firestopping shall consist of wood not less than 2 in. (5 cm) (nominal) thick or shall be of noncombustible material.

Based on observation and staff interview, the facility failed to ensure hazardous areas were separated from use areas in 2 of 5 smoke compartments. The findings were:

Observation of the telephone room on 9/20/11 at 8:40 AM showed a 1/2 inch gap around an unsealed cable penetration. At the time of observation, the director of facility services could not explain why the hole had not been noticed and repaired during the quarterly inspections.

Based on observation and staff interview, the facility failed to ensure fully sprinkled areas had complete sprinkler coverage in 1 of 5 smoke compartments. The findings were:

1. Observation of the laundry on 9/20/11 at 8:01 AM showed the room behind the dryers had a single sprinkler head. Further observation showed two of the walls terminated at the laundry lay in ceiling tiles and left the room open to the plenum above the rest of the laundry area. The plenum above the laundry did not have sprinkler coverage other than the single sprinkler head above the back of the dryers. At the time of observation, the director of facility services reported he was not aware open plenums required sprinkler coverage.

2. Observation of the radiology office on 9/20/11 at 9:19 AM showed one of three sprinkler heads was installed 2 inches from the wall, less than the allowed 4 inches. At the time of observation, the director of facilities services reported the sprinkler system was inspected annually by an outside contractor and the last inspection report (8/25/11) did not indicate sprinkler spacing issues.

Reference:
NFPA 101, 2000 Edition, 19.3.5.1, 9.7.1.1, NFPA 13, 1999 Edition;
5-1.1 The requirements for spacing, location, and position of sprinklers are based on the following principles:
1) Sprinklers installed throughout the premises
2) Sprinkler located so as not to exceed maximum protection area per sprinkler
3) Sprinklers positioned and located so as to provide satisfactory performance with respect to activation time and distribution
5-6.3.3 Sprinklers shall be located a minimum of 4 in. from the wall.

Based on observation and staff interview the facility failed to ensure sprinkler heads had adequate spacing in 3 of 5 smoke compartments. The findings were:

Observation of the sprinkler system on 9/20/11 between 7:30 AM and 10 AM showed the sprinkler heads in the dietary office, operating room (OR) pre-op/waiting area, OR storeroom, ultrasound bathroom, and #102 bathroom had less than the required 1 inch spacing between the deflector and the ceiling. At the time of observation, the director of facilities services reported the sprinkler system was inspected annually by an outside contractor and the last inspection report (8/25/11) did not indicate sprinkler spacing issues.

Reference:
NFPA 101, 2000 Edition, 19.3.5.1, 9.7.1.1, NFPA 13, 1999 Edition.
5-6.4.1.1 Under unobstructed construction, the distance between the sprinkler deflector and the ceiling shall be a minimum of 1 in. and a maximum of 12 in.

Based on observation and staff interview, the facility failed to ensure damaged electrical equipment was repaired or replaced and failed to ensure junction boxes had covers in 2 of 5 smoke compartments. The findings were:

1. Observation of the operating room (OR) clean room on 9/20/11 at 8:13 AM showed the electrical outlet had char marks on the face plate. At the time of observation the director of facility services could not explain why the outlet had not been noticed and replaced during the quarterly inspections.

2. Observation of the sprinkler riser room on 9/20/11 at 11:17 AM showed the junction box for the sprinkler control valve did not have a cover plate. At the time of observation the director of facility services could not explain why the cover had not been noticed and replaced during the quarterly inspection.

Reference:
NFPA 101, 2000 Edition, 19.5.1, 9.1.2, NFPA 70, 1999 Edition;
90-7 Examination of Equipment for Safety.
...It is the intent of this Code that factory-installed internal wiring or the construction of equipment need not be inspected at the time of installation of the equipment, except to detect alterations of damage ...
370-28. Pull and Junction Boxes.
(3) (c) cover. All pull boxes, junction boxes and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use....