HospitalInspections.org

Observations, and staff interview revealed that there is 2 of several fire barriers located throughout the facility that did not meet the rated requirements for fire separations and are not in accordance with NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 18.1.1.4.3,. These deficient practices could allow the products of combustion to travel from one building to another, which could negatively impact all the patients, staff and visitors of the facility.

Findings include:

On facility tour between 1:00 PM 02/02/2015 and 3:30 PM on 02/04/2015, observation revealed that the 3rd floor south 2 hour fire door did not latch into the frame and there are penetrations located above the ceiling tiles in the 2 hour fire separation between the hospital and the clinic located on the 1st floor of the hospital

This deficient practices was confirmed by the Environmental Director (JH).

Observations, and staff interview revealed that there is 2 of several fire barriers located throughout the facility that did not meet the rated requirements for fire separations and are not in accordance with NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 19.1.1.4.3,. These deficient practices could allow the products of combustion to travel from one building to another, which could negatively impact all the patients, staff and visitors of the facility.

Findings include:

On facility tour between 1:00 PM 02/02/2015 and 3:30 PM on 02/04/2015, observation revealed that the 3rd floor south 2 hour fire door did not latch into the frame and there are penetrations located above the ceiling tiles in the 2 hour fire separation between the hospital and the clinic located on the 1st floor of the hospital

This deficient practices was confirmed by the Environmental Director (JH).

Based on observation and staff interview, the facility failed to provide means of egress in accordance with the following requirements of 2000 NFPA 101, Section 19.2.1 and 7.2.1.5.4, 7.2.1.6.1(d). The deficient practice could affect patients, staff and visitors.


Findings include:

On facility tour between 1:00 PM 02/02/2015 and 3:30 PM on 02/04/2015, observation revealed that on the 3rd floor in the Labor and Delivery there are magnetic locks installed on exit doors that do not have the following:

1) Remote unlocking from a 24 hour location
2) No manual re-locking when fire alarm system is reset

This deficient practices was confirmed by the Environmental Director (JH).

Based on documentation review and interview with staff, the facility has failed to properly inspect and maintain the automatic sprinkler system in accordance with NFPA 101 Life Safety Code (00), and NFPA 25 Standard for the Inspection, Testing and Maintenance of Water Based Fire Protection Systems, (98). This deficient practice does not ensure that the water based fire protection system is functioning properly and is fully operational in the event of a fire and could negatively affect patients, staff and visitors.

Findings include:

On facility tour between 1:00 PM 02/02/2015 and 3:30 PM on 02/04/2015, a review of documentation and interview with the Director of Maintenance (BN), revealed the facility failed to inspect the foam fire suppression system located at the roof top helistop annual, to include testing of the foam.


This deficient practices was confirmed by the Environmental Director (JH).

Observations, and staff interview revealed that there is 2 of several fire barriers located throughout the facility that did not meet the rated requirements for fire separations and are not in accordance with NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 18.1.1.4.3,. These deficient practices could allow the products of combustion to travel from one building to another, which could negatively impact all the patients, staff and visitors of the facility.

Findings include:

On facility tour between 1:00 PM 02/02/2015 and 3:30 PM on 02/04/2015, observation revealed that the 3rd floor south 2 hour fire door did not latch into the frame and there are penetrations located above the ceiling tiles in the 2 hour fire separation between the hospital and the clinic located on the 1st floor of the hospital

This deficient practices was confirmed by the Environmental Director (JH).

Observations, and staff interview revealed that there is 2 of several fire barriers located throughout the facility that did not meet the rated requirements for fire separations and are not in accordance with NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 19.1.1.4.3,. These deficient practices could allow the products of combustion to travel from one building to another, which could negatively impact all the patients, staff and visitors of the facility.

Findings include:

On facility tour between 1:00 PM 02/02/2015 and 3:30 PM on 02/04/2015, observation revealed that the 3rd floor south 2 hour fire door did not latch into the frame and there are penetrations located above the ceiling tiles in the 2 hour fire separation between the hospital and the clinic located on the 1st floor of the hospital

This deficient practices was confirmed by the Environmental Director (JH).

Based on observation and staff interview, the facility failed to provide means of egress in accordance with the following requirements of 2000 NFPA 101, Section 19.2.1 and 7.2.1.5.4, 7.2.1.6.1(d). The deficient practice could affect patients, staff and visitors.


Findings include:

On facility tour between 1:00 PM 02/02/2015 and 3:30 PM on 02/04/2015, observation revealed that on the 3rd floor in the Labor and Delivery there are magnetic locks installed on exit doors that do not have the following:

1) Remote unlocking from a 24 hour location
2) No manual re-locking when fire alarm system is reset

This deficient practices was confirmed by the Environmental Director (JH).

Based on documentation review and interview with staff, the facility has failed to properly inspect and maintain the automatic sprinkler system in accordance with NFPA 101 Life Safety Code (00), and NFPA 25 Standard for the Inspection, Testing and Maintenance of Water Based Fire Protection Systems, (98). This deficient practice does not ensure that the water based fire protection system is functioning properly and is fully operational in the event of a fire and could negatively affect patients, staff and visitors.

Findings include:

On facility tour between 1:00 PM 02/02/2015 and 3:30 PM on 02/04/2015, a review of documentation and interview with the Director of Maintenance (BN), revealed the facility failed to inspect the foam fire suppression system located at the roof top helistop annual, to include testing of the foam.


This deficient practices was confirmed by the Environmental Director (JH).