HospitalInspections.org

Based on observation and interview, the facility did not provide a proper stairway enclosure system in accordance with NFPA 101 (2012 ed.), 19.2.1 and 7.2.2.5. This deficient practice could affect all of the patients, plus an undetermined number of staff and visitors.

Findings include:

1. On 03/23/22 at 2:00 PM, observation revealed that the main stairway from the hospital had the following deficiencies:
a. The laundry room (an unoccupied room and a hazardous room) opened up onto the stairway and did not have a fire rated door.
b. The elevator opened up to both, the stairway and to other non stairway parts of the building.


This condition was confirmed at the time of discovery by a concurrent interview with staff H.

Based on observation and interview, the facility did not provide corridor width in accordance with NFPA 101 (2012 ed.), 19.2.3.4.(5). This deficient practice could affect all of the patients, plus an undetermined number of staff and visitors.

Findings include:

1. On 03/22/22 at 2:30 PM, observation in the corridor between Pod 3 and 4, revealed 2 chairs that were not fixed to the floor, and blocking the clear width for passage.

This condition was confirmed at the time of discovery by a concurrent interview with staff H.

2. On 03/23/22 at 2:00 PM, observation in the corridor between Pod 2 and the nurses' station, revealed 2 tables that were not fixed to the floor, and blocking the clear width for passage. This was not confirmed with staff at the time, but mentioned 2 hours later at the exit conference.

Based on observation and interview, the facility did not provide a proper location for the fire alarm pull stations in accordance with NFPA 101 (2012 ed.), 19.3.4.2.1, 19.3.4.2.2 and 9.6.2.3. This deficient practice could affect all of the patients, plus an undetermined number of staff and visitors.

Findings include:

1. On 03/23/22 at 9:00 AM, it was noted during observation that the horizontal exit from the hospital into the CBRF did not have a pull station located within 5 feet of the exit. The pull station was located 18 feet from the exit door.

This condition was confirmed at the time of discovery by a concurrent interview with staff H.

Based on record review, observation and interview, the facility did not provide a ventilation system in accordance with NFPA 101 (2012 ed.), 19.5.2.1, 9.2 and NFPA 90A, (2012 ed.) 2-3.11.1 and 4.3.12. This deficient practice could affect all of the patients, plus an undetermined number of staff and visitors.

Findings include:

1.On 03/22/22 at 10:30 am, observation revealed that dampers were missing at the following locations:
a. The penthouse air handling unit, AC #2, which feeds the hospital wing, had main supply and return ducts that did not have fire dampers at the bottom of their respective masonry shafts that extended from the penthouse, through the 4th & 2nd levels to a crawl space located below the 2nd level.
b. Approximately 20 duct penetrations through the level 2 floor did not have fire dampers. The 5 " x12 " ducts in the crawl space passed through the level 2 floor, without dampers, to feed the floor mounted ventilation units on that floor. These ducts exceeded the maximum size permitted by the exception in the section to not have fire dampers.
c. About 6-8 supply and return ducts did not have fire dampers where they penetrated the penthouse and 4th level floors to serve the overhead ventilation grills on the 2nd level in the center core of the hospital space located below the footprint of the penthouse.

2. On 3/23/22 at 8:00 am, during the record review Staff H confirmed that there were no fire dampers in the building when asked.

3. On 03/22/22 at 1:00 PM, observation revealed during a walk-through of the facility that the two offices and the kitchenette were not provided with a supply grille within each room. Only a return air grille was installed within these rooms. The supply air was being taken from the corridor and transferred under the doorway; this required the ventilation system to use the corridor as a plenum for supplying air to these rooms.

These conditions were confirmed at the time of discovery by a concurrent interview with staff H. Staff H also stated that the air handlers shut down upon activation of the fire alarm system and the facility is equipped with a smoke control system.