HospitalInspections.org

Based upon staff interview and observations made in the presence of the plant manager on 8/13/14, it was determined that the facility did not maintain smoke barriers to be fire and smoke separated from other sections of the facility in 1 of 4 smoke compartments in accordance with NFPA 101: 18.3.7.3., 8.3 and 18.3.7.5.

Findings include:

The Operating suite smoke barrier separation wall that had a 4 ' x 8 ' that would not resist the passage of smoke and fire.

Based upon staff interview and observations made in the presence of the plant manager on 8/13/14, it was determined that the facility did not maintain hazardous areas to be fire and smoke separated from other sections of the facility in 1 of 4 smoke compartments in accordance with NFPA 101: 18.3.2.1., 8.4 and 7.2.1.8.

Findings include:

1. The soiled utility door by the laundry did not have fire rating listed.
2. The laundry door frame did not have fire rating listed on the frame.
3. The door frame and door from the dryers to laundry did not have fire rating listed.

Based upon staff interview and observations made in the presence of the plant manager on 8/13/14, it was determined that the facility did not maintain the fire sprinkler tamper switches in accordance with NFPA 101: 18.3.5., 18.3.5.1 and 9.7.2.1.

Findings include:

The fire sprinkler post indicating valves had locks with the water supply in the open position and the vales were not being monitored by the fire alarms system. Control valves need to be monitored by the fire alarm panel.

Based upon staff interview and observations made in the presence of the plant manager on 8/13/14, it was determined that the facility did not maintain oxygen storage areas in accordance with NFPA 101: 18.3.2.4 and NFPA 99: 4.3.1.1.2.

Findings include:

The lab area had two C-tanks unsecured on the countertop.

Based upon staff interview and observations made in the presence of the plant manager on 8/13/14, it was determined that the facility did not maintain smoke barriers to be fire and smoke separated from other sections of the facility in 1 of 4 smoke compartments in accordance with NFPA 101: 18.3.7.3., 8.3 and 18.3.7.5.

Findings include:

The Operating suite smoke barrier separation wall that had a 4 ' x 8 ' that would not resist the passage of smoke and fire.

Based upon staff interview and observations made in the presence of the plant manager on 8/13/14, it was determined that the facility did not maintain hazardous areas to be fire and smoke separated from other sections of the facility in 1 of 4 smoke compartments in accordance with NFPA 101: 18.3.2.1., 8.4 and 7.2.1.8.

Findings include:

1. The soiled utility door by the laundry did not have fire rating listed.
2. The laundry door frame did not have fire rating listed on the frame.
3. The door frame and door from the dryers to laundry did not have fire rating listed.

Based upon staff interview and observations made in the presence of the plant manager on 8/13/14, it was determined that the facility did not maintain the fire sprinkler tamper switches in accordance with NFPA 101: 18.3.5., 18.3.5.1 and 9.7.2.1.

Findings include:

The fire sprinkler post indicating valves had locks with the water supply in the open position and the vales were not being monitored by the fire alarms system. Control valves need to be monitored by the fire alarm panel.

Based upon staff interview and observations made in the presence of the plant manager on 8/13/14, it was determined that the facility did not maintain oxygen storage areas in accordance with NFPA 101: 18.3.2.4 and NFPA 99: 4.3.1.1.2.

Findings include:

The lab area had two C-tanks unsecured on the countertop.