HospitalInspections.org

Based on observation the facility failed to provide positive latching at room 123.

"Doors shall be self-latching and provided with positive latching hardware." - NFPA 101: 2012: 18.3.6.3.5



Based on observation the facility failed to provide positive latching at rooms adjacent to corridors. facility to veryfy all openings to corridors are supplied with closers.
"Doors (Corridor Doors) shall be self-latching and provided with positive latching hardware." - NFPA 101, 2012: 18-3.6.3.5




Based on observation the facility failed to provide adequate documentation of inspections of fire rated doors assemblies and other certain doors in the means of egress.

Based on observation the facility failed to provide adequate documentation regarding maintanace of HVAC system..

Based on observation the facility failed to provide adequate documentation regarding evacuation and relocation plan.

Based on observation the facility failed to provide adequate documentation of fire drills.

Based on observation the facility failed to provide adequate documentation regarding risk assesment of the building systems.

Based on observation the facility failed to provide adequate protection to outdoor med gas tanks.

Special Precautions - Storage of Cylinders and Containers. Cylinders stored in the open shall be protected as follows: (1) Against extremes of weather and from the ground beneath to prevent rusting, (2) During winter, against accumulation of ice or snow, and (3) In summer, screened against continuous exposure to direct rays of the sun in those localities where extreme temperatures prevail." - NFPA 99, 2002: 5.1.13.5.

Based on observation the facility failed to provide adequate identification for existing essential panels.

"Identification. All boxes and enclosures (including transfer switches, generators, and power panels) for emergency circuits shall be permanently marked so they will be readily identified as a component of an emergency circuit or system." - NFPA 70, 2011, 700.10. They shall be labeled "LIFE SAFETY", "CRITICAL", or "EQUIPMENT" as applicable.




Based on observation the facility failed to provide adequate identification for existing critical plugs.

"Critical care Areas, Patient Bed Location Branch Circuits. Each patient bed location shall be supplied by at least two branch circuits, one or more form the emergency system and one or more circuits from the normal system. At least on Branch circuit from the emergency system shall supply an outlet(s) only at that bed location. All branch circuits from the normal system shall be from a single panelboard. Emergency system receptacles shall be identified and shall also indicate the panelboard and circuit number supply them." NFPA 70, 2011, 517.19(A)

Based on observation the facility failed to provide adequate documentation of testing of hospital grade receptacles.

Based on observation the facility failed to provide adequate identification for existing sprinkler heads at red box.

"A list of the sprinklers installed in the property shall be posted in the sprinkler cabinet." - NFPA 13, 2010, 6.2.9.7
"The list shall include the following:
1. Sprinkler Identification Number (SIN) if equipped; or the manufacturer, model, orifice, deflector type, thermal sensitivity, and pressure rating
2. General description (upright, pendent, residential, etc.)
3. Quantity of each type to be contained in the cabinet (min. of 2 of each type)
4. Issue or revision date of the list." - NFPA 13, 2010, 6.2.9.7.1