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Based on observation and staff interview the facility fails to maintain the integrity of the building construction by allowing gaps around sprinkler and other piping to remain open barrier walls. This deficient practice would allow fire products to spread between areas.

On 3/17/17 between 10:30 AM and 4:30 PM the following is observed:

Findings Include:

Based on observation on 3/27/17 between 10:30 AM and 4:30 PM:

1. At 3:22 PM: There are (2) .5" unsealed penetrations around sprinkler piping and conduit through the 1 hour wall between the ambulance bay and the emergency department.

The Maintenance Manager was present and acknowledged the findings.

NFPA Standard: 19.1.3.3* Sections of health care facilities shall be permitted to
be classified as other occupancies, provided that they meet all
of the following conditions:
(1) They are not intended to provide services simultaneously
for four or more inpatients for purposes of housing, treatment,
or customary access by inpatients incapable of self-preservation.
(2) They are separated from areas of health care occupancies
by construction having a minimum 2-hour fire resistance
rating in accordance with Chapter 8.
(3) For other than previously approved occupancy separation
arrangements, the entire building is protected throughout
by an approved, supervised automatic sprinkler system
in accordance with Section 9.7.

Based on observation the facility fails to ensure that the required construction type is maintained in accordance with NFPA 101, including allwoing holes through fire barrier walls. This deficient practice of not maintaing rated fire walls would allow fire and smoke products to spread into other areas of the hospital.

On 3/17/17 between 10:30 AM and 4:30 PM the following is observed:

Findings Include:

Based on observation on 3/27/17 between 10:30 AM and 4:30 PM:

1. At 3:31 PM: There is a 2"X2" hole around a single data cable through the 1 hour wall above the nurses station.

2. At 3:40 PM: There are (3) unsealed penetrations around conduit through the 1 hour fire wall in the Doctor's sleep room.

3. At 3:45 PM: There are (3) unsealed penetrations around conduit and cabling and a 3"X3" hole through the 1 hour fire barrier wall in the corridor of the North exit by surgery and obstetrics.

The Maintenance Manager was present and acknowledged the findings.

Based on observation and staff interview the facility failed to ensure proper separation of hazardous areas from other spaces. This deficient practice would allow for the spread of smoke and fire to travel into the adjacent area.

Findings Include:

On 3/17/17 between 10:30 AM and 4:30 PM the following is observed:

1. At 2:00 PM: Patient room 114 is being utilized as a storage room. The door is without a self-closing device.

2. At 3:01 PM: There are (2) unsealed penetrations around conduit in through the wall of the medical gas storage room.

3. At 3:12 PM: The door to the record storage room in radiology failed to latch due to tape over the jamb.

The Maintenance Manager was present and acknowledged the findings.

NFPA Standard: NFPA 101 2012 ed. 9.3.2.1 Hazardous Areas. Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.7.1. 19.3.2.1.1 An automatic extinguishing system, where used in hazardous areas, shall be permitted to be in accordance with 19.3.5.9. 19.3.2.1.2* Where the sprinkler option of 19.3.2.1 is used, the areas shall be separated from other spaces by smoke partitions in accordance with Section 8.4. 19.3.2.1.3 The doors shall be self-closing or automatic-closing. 19.3.2.1.4 Doors in rated enclosures shall be permitted to have nonrated, factory- or field-applied protective plates extending not more than 48 in. (1220 mm) above the bottom of the door. 19.3.2.1.5 Hazardous areas shall include, but shall not be restricted to, the following: (1) Boiler and fuel-fired heater rooms (2) Central/bulk laundries larger than 100 ft2 (9.3 m2) (3) Paint shops (4) Repair shops (5) Rooms with soiled linen in volume exceeding 64 gal (242 L) (6) Rooms with collected trash in volume exceeding 64 gal (242 L) (7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction (8) Laboratories employing flammable or combustible materials in quantities less.

The facility fails to ensure that the required fire alarm notification devices are installed in all staff sleeping rooms in accordance with NFPA 72.

On 3/17/17 between 10:30 AM and 4:30 PM the following is observed:

1. At 2:29 PM: The staff break room in the imaging department has a side room without notification and a bed that is used for staff.

The Maintenance Manager was present and acknowledged the findings.

NFPA Standard: NFPA 72 2010 ed. 18.5.4.6.1 Combination smoke detectors and visible notification
appliances or combination smoke alarms and visible notification
appliances shall be installed in accordance with the
applicable requirements of Chapters 17, 18, and 29.
18.5.4.6.2* Table 18.5.4.6.2 shall apply to sleeping areas.

Based on observation, record review and interview the facility does not assure a complete fire watch procedure and policy is written for when the fire alarm system is out of service for more than 4 hours in a 24 hour period. This deficient practice would allow facility exposure to undetected smoke and/or fire without an automatic detection compensatory provision when it occurred, and without appropriately prepared staff response.

Findings Include:

On 3/17/17 between 10:30 AM and 4:30 PM the following is observed:

1. At 12:38 PM: The facility fire watch plan fails to address notification of the AHJ and the insurance company.

The Maintenance Manager was present and acknowledged the findings.

NFPA Standard:

NFPA 101 2012 ed. 9.6.1.6 Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated, or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.

Based on observation, record review and interview the facility does not assure a complete fire watch procedure and policy is written and available for implementation when the fire sprinkler system is out of service for more than 10 hours in a 24 hour period. This deficient practice would allow facility exposure to undetected smoke and/or fire without an automatic sprinkler compensatory provision when it occurred, and without appropriately prepared staff response.

Findings Include:

On 3/17/17 between 10:30 AM and 4:30 PM the following is observed:

Findings include:

At 12:39 PM: The facility fire watch plan fails to address notification of the AHJ and the insurance company.

The Maintenance Manager was present and acknowledged the findings.

NFPA Standard: 101, 2012 ed.19.3.5.1, 9.7.5, 15.5.2 (NFPA 25) Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.
9.7.6 Sprinkler 15.5.1 All preplanned impairments shall be authorized by
the impairment coordinator.
NFPA 25 2011 ed. 15.5.2 Before authorization is given, the impairment coordinator shall be responsible for verifying that the following procedures have been implemented: (1) The extent and expected duration of the impairment have been determined. (2) The areas or buildings involved have been inspected and the increased risks determined. (3) Recommendations have been submitted to management or the property owner or designated representative. (4) Where a required fire protection system is out of service for more than 10 hours in a 24-hour period, the impairment coordinator shall arrange for one of the following: (a) Evacuation of the building or portion of the building affected by the system out of service (b)*An approved fire watch (c)*Establishment of a temporary water supply (d)*Establishment and implementation of an approved program to eliminate potential ignition sources and limit the amount of fuel available to the fire (5) The fire department has been notified. (6) The insurance carrier, the alarm company, property owner or designated representative, and other authorities having jurisdiction have been notified. (7) The supervisors in the areas to be affected have been notified. (8) A tag impairment system has been implemented. (See Section 15.3.) (9) All necessary tools and materials have been assembled on the impairment site.

Based on observation, record review and staff interview the facility failed to provide a written fire safety plan that addresses the evacuation of the smoke compartment, triangle evacuation, transmission of alarm, emergency phone call to 911 and bariatric evacuation. The deficient practice may prevent the staff in identifying the need to evacuate occupants beyond the compartment of origin to another smoke compartment.

Findings Include:

On 3/17/17 between 10:30 AM and 4:30 PM the following is observed:

1. At 1:02 PM: The facility fire plan fails to address triangle evacuation from the fire site, smoke compartment evacuation, transmission of alarms, emergency phone call to 911, and bariatric patient evacuation.

The Maintenance Manager was present and acknowledged the findings.


NFPA Standard: NFPA 101 2012 ed. 19.7.2.2 Fire Safety Plan. A written health care occupancy fire
safety plan shall provide for all of the following:
(1) Use of alarms
(2) Transmission of alarms to fire department
(3) Emergency phone call to fire department
(4) Response to alarms
(5) Isolation of fire
(6) Evacuation of immediate area
(7) Evacuation of smoke compartment
(8) Preparation of floors and building for evacuation
(9) Extinguishment of fire