HospitalInspections.org

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Based on observation and staff interview, the facility failed to maintain fire-resistive construction in accordance with the 2012 NFPA 101, Life Safety Code. Failure to maintain fire-resistive construction could result in injury or death in the event of an emergency. The deficiency affected one (1) of multiple mechanical rooms.

The findings were:

Observation on 02/08/2022 at 9:40 AM revealed that the 1-hour fire rated roof assembly had not been properly maintained. Observation of the mechanical room which contains the mechanical chiller and fire sprinkler system riser revealed multiple large holes in the gypsum board ceiling used to protected the roof assembly. Observation and interview with the facility manager revealed that new chiller lines had been installed, which resulted in the unprotected penetrations of the fire-rated roof/ceiling assembly. Fire-resistive construction must be continuously maintained.

Interview with the facility manager at the time of the observation acknowledged the deficiency, and indicated that they were aware of the requirement.

Interview with the CEO at the time of exit acknowledged the deficiency.

Ref: 2012 NFPA 101 19.1.1.1.3, 4.6.12.1
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Based on observation and staff interview, the facility failed to protect hazardous areas in accordance with the 2012 NFPA 101, Life Safety Code. Failure to protect hazardous areas could result in injury or death in the event of a fire. The deficiency affected one (1) of multiple hazardous storage rooms.

The findings were:

Observation on 02/08/2022 at 10:34 AM in the restricted corridor of the OR suite revealed a storage room greater than 50 s.f., and containing combustible materials, that was not provided with a self-or automatic-closing device. Hazardous storage rooms greater than 50 s.f. shall be equipped with doors that are self-closing or automatic-closing.

Interview with the facility manager at the time of the observation acknowledged the deficiency, and indicated that they were aware of the requirement.

Interview with the CEO at the time of exit acknowledged the deficiency.

Ref: 2012 NFPA 101 19.3.2.1.3, 19.3.2.1.5(7)
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Based on observation and staff interview, the facility failed to protect cooking facilities in accordance with the 2012 NFPA 101, Life Safety Code. Failure to protect cooking facilities could result in injury or death in the event of a fire. The deficiency affected one (1) of one (1) kitchen.

The findings were:

Observation on 02/08/2022 at 10:08 AM revealed a gas cook-top under a commercial range hood located in the facility's kitchen. Observation of the cook-top revealed that no means was provided to ensure it is returned to the approved location after being moved. Cooking appliances requiring fire-extinguishing protection shall be provided with a means of returning to the approved location after being moved for cleaning or maintenance purposes.

Interview with the facility manager at the time of the observation acknowledged the deficiency, and indicated that they were unaware of the requirement.

Interview with the CEO at the time of exit acknowledged the deficiency.

Ref: 2012 NFPA 101 19.3.2.5.5, 9.2.3; 2011 NFPA 96 12.1.2.3
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Based on observation and staff interview, the facility failed to maintain the fire sprinkler system in accordance with the 2010 NFPA 13, Standard for the Installation of Sprinkler Systems. Failure to maintain fire sprinkler systems could result in injury or death in the event of a fire. The deficiency affected one (1) of multiple hazardous storage rooms.

The findings were:

Observation on 02/08/2022 at 11:40 AM of the storage room located in the IT office revealed storage located on shelves that were positioned as close as 6 inches to the sprinkler head. The clearance between the sprinkler head and the top of the storage shall be at least 18 inches.

Interview with the facility manager at the time of the observation acknowledged the deficiency, and indicated that they were aware of the requirement.

Interview with the CEO at the time of exit acknowledged the deficiency.

Ref: 2010 NFPA 13 8.6.6.1
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Based on observation and staff interview, the facility failed to utilize power strips in accordance with the 2012 NFPA 99, Health Care Facilities Code. Failure to properly utilize power strips could result in injury or death. The deficiency affected one (1) of one (1) operating rooms.

The findings were:

Observation on 02/08/2022 at 10:00 AM revealed a power strip located in the operating room. Observation of the power strip revealed that it was positioned on the ground and not part of an equipment assembly. Power strips are permitted when part of a movable equipment assembly and when permanently attached to that assembly.

Interview with the facility manager at the time of the observation acknowledged the deficiency, and indicated that they were unaware of the requirement.

Interview with the CEO at the time of exit acknowledged the deficiency.

Ref: 2012 NFPA 99 10.2.3.6,
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Based on observation and staff interview, the facility failed to protect medical gas storage in accordance with the 2012 NFPA 99, Health Care Facilities Code. Failure to properly protect medical gas storage could result in injury or death in the event of a fire. The deficiency affected one (1) of one (1) medical gas rooms.

The findings were:

Observation on 02/08/2022 at 10:00 AM revealed that the interior medical gas storage room, located near the laundry room, contained approximately 94 full E tanks (25 cu. ft.), 3 full M tanks (125 cu. ft.), and 2 full H tanks (250 cu. ft.), as well as 4 full H tanks of nitrous oxide. The room was provided with an exhaust duct at the ceiling, but it could not be established that the ventilation rate was adequate, nor could it be determined if the exhaust ductwork was noncombustible. Additionally, it could not be established that the exhaust system was provided with power from the emergency electrical system. Interior medical gas storage rooms containing greater than 3,000 cu. ft. of oxidizing gases shall be supplied with continuous mechanical exhaust with a ventilation rate of 500 cfm, an inlet located within 1 foot of the floor, and the exhaust fan shall be supplied with electrical power from the emergency electrical system.

Interview with the facility manager at the time of the observation acknowledged the deficiency, and indicated that they were unaware of the requirement.

Interview with the CEO at the time of exit acknowledged the deficiency.

Ref: 2012 NFPA 99 11.3.1, 9.3.7.5, 9.3.7.5.3