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ED FRASER MEMORIAL HOSPITAL
No Description Available
Tag No.: K0023
Based on observations, records reviews, and tour with facility staff on the day of survey, June 9, 2014, it was determined the facility was not in compliance with the requirements of NFPA-101-2000 LSC and the NFPA-99- Healthcare Facility Code. The facility failed to maintain required smoke barriers to resist the spread of fire and the passage of smoke, which could endanger the residents, staff and other building occupants. Every opening in a Fire Barrier, Smoke Wall, or Smoke Partition shall be protected by a system or material to limit the spread of fire and the passage of smoke.
The findings include:
On June 9, 2014 from 2:15 p.m. through 3:30 p.m., a tour of the Medical Surgery Patient Rooms area was conducted with facility staff. Pipe penetrations of the patient rooms' partition walls by the sprinkler system piping were not properly sealed and fire-caulked. The penetrations were observed at Room #s 101; #102; # 104; #105; # 106; # 107; # 108; # 109; # 110; # 111; # 112, and # 113, and at the # 100 Isolation Room, the Nourishment Room, and the Staff Lounge.
NFPA-101-LSC-2000- 19.3.6.2.1, 8.2.4.1, 8.2.2.2, 4.6.12.1 NFPA-99
These findings were confirmed with the Maintenance Supervisor at the exit conference at 4:30 p.m. on June 9, 2014.
LIFE SAFETY CODE STANDARD
Tag No.: K0023
Based on observations, records reviews, and tour with facility staff on the day of survey, June 9, 2014, it was determined the facility was not in compliance with the requirements of NFPA-101-2000 LSC and the NFPA-99- Healthcare Facility Code. The facility failed to maintain required smoke barriers to resist the spread of fire and the passage of smoke, which could endanger the residents, staff and other building occupants. Every opening in a Fire Barrier, Smoke Wall, or Smoke Partition shall be protected by a system or material to limit the spread of fire and the passage of smoke.
The findings include:
On June 9, 2014 from 2:15 p.m. through 3:30 p.m., a tour of the Medical Surgery Patient Rooms area was conducted with facility staff. Pipe penetrations of the patient rooms' partition walls by the sprinkler system piping were not properly sealed and fire-caulked. The penetrations were observed at Room #s 101; #102; # 104; #105; # 106; # 107; # 108; # 109; # 110; # 111; # 112, and # 113, and at the # 100 Isolation Room, the Nourishment Room, and the Staff Lounge.
NFPA-101-LSC-2000- 19.3.6.2.1, 8.2.4.1, 8.2.2.2, 4.6.12.1 NFPA-99
These findings were confirmed with the Maintenance Supervisor at the exit conference at 4:30 p.m. on June 9, 2014.