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Based on observation and staff interview, the facility did not ensure that exit doors have no impediment to the closing of the doors and have positive latch.

Finding:

During a tour of the hospital on the afternoon of 9/16/2015, the Exit Door next to the laundry room was found to not have a positive latching mechanism as required by NFPA 101- 2000 edition.

The above finding was identified in the presence of the Manager of Facility Operation who acknowledged the finding.

Based on observation and staff interview, the facility did not ensure that the required automatic sprinkler systems are continuously maintained in reliable operating condition. 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5

Finding:

During a tour of the hospital on the afternoon of 9/17/2015, the sprinkler head in rooms 2112 and 2110 were found to be dirty and dust laden, which prevent their proper functions in the event of fire.

The above finding was identified in the presence of the Manager of Facility Operation, who acknowledged the finding.

Based on staff interview and document review, it was determined that the hospital's emergency generators are not in compliance with the requirement of NFPA 99. The Hospital's Essential Electrical System is not Type I EES because it is not divided into the critical branch, life safety branch and the equipment branch in accordance with NFPA 99 - 3.4.2.2.2.
The hospital performs general anesthesia and has patients who use Life Support Systems (Ventilators) and is required to comply with the provision of Type 1 EES system (Essential Electrical System).

Findings include:

In an interview with the Director of Facilities on 09/17/15 and review of the directions on the panels of the Essential Electrical System (EES), it was determined that the wiring configuration of the Essential Electrical System in the facility does not conform with Type I EES and therefore, the EES system in the hospital does not comply with 1999 NFPA 99 3-4.2.2.1.
The specific issue involved was the separation of the generator branches into a Life Safety branch, Critical, and Equipment Branches as per the requirement of NFPA 99. The Director of Facilities indicated that the hospital as a whole does not have a code compliant EES Type 1 as per NFPA 99 requirement. The Hospital performs general anesthesia and operates a ventilator dependent unit, and as such, requires a Type I EES.

Review of the directions on the panels and switches also revealed that items required to be served by the Equipment Branch of the EES system were not independent or separate from items required to be served by the Life Safety Branch of EES system, and/or from items required to be served the Critical Branch of the EES system.

1999 NFPA 99 3-4.2.1.4, 3-4.2.2, NFPA 70: Article 517 and Article 70

Based on observation and staff interview, the facility did not ensure that exit doors have no impediment to the closing of the doors and have positive latch.

Finding:

During a tour of the hospital on the afternoon of 9/16/2015, the Exit Door next to the laundry room was found to not have a positive latching mechanism as required by NFPA 101- 2000 edition.

The above finding was identified in the presence of the Manager of Facility Operation who acknowledged the finding.

Based on observation and staff interview, the facility did not ensure that the required automatic sprinkler systems are continuously maintained in reliable operating condition. 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5

Finding:

During a tour of the hospital on the afternoon of 9/17/2015, the sprinkler head in rooms 2112 and 2110 were found to be dirty and dust laden, which prevent their proper functions in the event of fire.

The above finding was identified in the presence of the Manager of Facility Operation, who acknowledged the finding.

Based on staff interview and document review, it was determined that the hospital's emergency generators are not in compliance with the requirement of NFPA 99. The Hospital's Essential Electrical System is not Type I EES because it is not divided into the critical branch, life safety branch and the equipment branch in accordance with NFPA 99 - 3.4.2.2.2.
The hospital performs general anesthesia and has patients who use Life Support Systems (Ventilators) and is required to comply with the provision of Type 1 EES system (Essential Electrical System).

Findings include:

In an interview with the Director of Facilities on 09/17/15 and review of the directions on the panels of the Essential Electrical System (EES), it was determined that the wiring configuration of the Essential Electrical System in the facility does not conform with Type I EES and therefore, the EES system in the hospital does not comply with 1999 NFPA 99 3-4.2.2.1.
The specific issue involved was the separation of the generator branches into a Life Safety branch, Critical, and Equipment Branches as per the requirement of NFPA 99. The Director of Facilities indicated that the hospital as a whole does not have a code compliant EES Type 1 as per NFPA 99 requirement. The Hospital performs general anesthesia and operates a ventilator dependent unit, and as such, requires a Type I EES.

Review of the directions on the panels and switches also revealed that items required to be served by the Equipment Branch of the EES system were not independent or separate from items required to be served by the Life Safety Branch of EES system, and/or from items required to be served the Critical Branch of the EES system.

1999 NFPA 99 3-4.2.1.4, 3-4.2.2, NFPA 70: Article 517 and Article 70