HospitalInspections.org

.
The facility failed to provide corridor doors that would close and resist the passage of smoke. Findings include: During the survey, the following is an example of what was observed:

The door to Patient Room 205 failed to positive latch.
-----------------------------------------------

NFPA 101, 19.3.6.3.1 Exception No.2. In the smoke compartments protected throughout by an approved, supervised automatic sprinkler system, doors in corridor walls shall be constructed to resist the passage of smoke and be provided with suitable means of keeping the doors closed.
.

.
The facility failed to provide smoke barriers that would provide at least a half hour fire resistance rating. Findings include: During the survey, the following are examples of what was observed:


1. A hole approximately the size of a golf ball observed in the smoke barrier, by Patient Room 202.

2. Unsealed penetrations around a cable in the smoke barrier, by Old X-Ray Room.

3. Unsealed opening at the top corner of the smoke barrier, by Nuclear Medicine Room.
----------------------------------------------

2000 NFPA 101, 8.2.4.4.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through smoke partitions shall be protected as follows: (1) The space between the penetrating item and the smoke partition shall meet one of the following conditions: a. It shall be filled with a material that is capable of limiting the transfer of smoke. b. It shall be protected by an approved device that is designed for the specific purpose. (2) Where the penetrating item uses a sleeve to penetrate the smoke partition, the sleeve shall be solidly set in the smoke partition, and the space between the item and the sleeve shall meet one of the following conditions: a. It shall be filled with a material that is capable of limiting the transfer of smoke. b. It shall be protected by an approved device that is designed for the specific purpose. (3) Where designs take transmission of vibrations into consideration, any vibration isolation shall meet one of the following conditions: a. It shall be made on either side of the smoke partitions. b. It shall be made by an approved device that is designed for the specific purpose.
2000 NFPA 101, 8.3.2 Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.
.

.
The facility failed to provide protection of openings in fire barriers to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. Findings include: During the survey, the following is an example of what was observed:

Unsealed penetrations at the end of a sleeve, in the fire barrier.
----------------------------------------------------

NFPA 101, 19.2.2.5 and 7.2.4.3 Openings in fire barriers shall be constructed to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other.
.

.
The facility failed to maintain the dietary hood. Findings include: During the survey, the following is an example of what was observed:

A gap of approximately 1/4" observed between filters.
-----------------------------------------------

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 tight fitting and firmly held in place.
.

.
Facility failed to meet the requirements for the operation of the generator. Findings include: During the survey, the following is an example of what was observed:

Documentation was not provided for the monthly 30 minutes under load test for March of 2013.
---------------------------------------------

NFPA 110, 6-3.4 A written record of inspections, tests, exercising, operation, and repairs shall be maintained.
.

.
The facility failed to provide corridor doors that would close and resist the passage of smoke. Findings include: During the survey, the following is an example of what was observed:

The door to Patient Room 205 failed to positive latch.
-----------------------------------------------

NFPA 101, 19.3.6.3.1 Exception No.2. In the smoke compartments protected throughout by an approved, supervised automatic sprinkler system, doors in corridor walls shall be constructed to resist the passage of smoke and be provided with suitable means of keeping the doors closed.
.

.
The facility failed to provide smoke barriers that would provide at least a half hour fire resistance rating. Findings include: During the survey, the following are examples of what was observed:


1. A hole approximately the size of a golf ball observed in the smoke barrier, by Patient Room 202.

2. Unsealed penetrations around a cable in the smoke barrier, by Old X-Ray Room.

3. Unsealed opening at the top corner of the smoke barrier, by Nuclear Medicine Room.
----------------------------------------------

2000 NFPA 101, 8.2.4.4.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through smoke partitions shall be protected as follows: (1) The space between the penetrating item and the smoke partition shall meet one of the following conditions: a. It shall be filled with a material that is capable of limiting the transfer of smoke. b. It shall be protected by an approved device that is designed for the specific purpose. (2) Where the penetrating item uses a sleeve to penetrate the smoke partition, the sleeve shall be solidly set in the smoke partition, and the space between the item and the sleeve shall meet one of the following conditions: a. It shall be filled with a material that is capable of limiting the transfer of smoke. b. It shall be protected by an approved device that is designed for the specific purpose. (3) Where designs take transmission of vibrations into consideration, any vibration isolation shall meet one of the following conditions: a. It shall be made on either side of the smoke partitions. b. It shall be made by an approved device that is designed for the specific purpose.
2000 NFPA 101, 8.3.2 Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.
.

.
The facility failed to provide protection of openings in fire barriers to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. Findings include: During the survey, the following is an example of what was observed:

Unsealed penetrations at the end of a sleeve, in the fire barrier.
----------------------------------------------------

NFPA 101, 19.2.2.5 and 7.2.4.3 Openings in fire barriers shall be constructed to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other.
.

.
The facility failed to maintain the dietary hood. Findings include: During the survey, the following is an example of what was observed:

A gap of approximately 1/4" observed between filters.
-----------------------------------------------

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 tight fitting and firmly held in place.
.

.
Facility failed to meet the requirements for the operation of the generator. Findings include: During the survey, the following is an example of what was observed:

Documentation was not provided for the monthly 30 minutes under load test for March of 2013.
---------------------------------------------

NFPA 110, 6-3.4 A written record of inspections, tests, exercising, operation, and repairs shall be maintained.
.