HospitalInspections.org

Based on observation and staff interviews during the course of the survey it was determined the facility failed to maintain the building construction in accordance with NFPA 101. The following evidenced this:

Fire barriers and smoke partitions are cracking and separating throughout the facility. This involves the drywall cracking.

NFPA 101 (2012)
4.6.12.1
Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction.

4.6.12.4
Any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature requiring periodic testing, inspection, or operation to ensure its maintenance shall be tested, inspected, or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction.

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within affected smoke compartments. Deficient items were discussed with the maintenance staff and facility administrator during the exit conference.

Based on observation and staff interview during the survey, it was determined that the facility failed to arrange and maintain the means of egress in accordance with Life Safety Code Section 19.2 and Chapter 7. This was evidenced by the following:

Egress path next to the ED area was blocked from free egress. There was a desk (no wheels) that was being used, that blocked free egress. Fixed during survey.

Life Safety Code Section 19.2.1 requires that means of egress components be in accordance with Chapter 7.
Life Safety Code Section 7.1.10.1 requires that every means of egress be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

The means of egress deficiency has the potential to affect occupants, who might include staff and visitors within the affected smoke compartment; items were discussed during the survey and again during the exit conference.

Based on observation, staff interview and record review during the course of the survey it was determined the facility failed to maintain emergency exit signs in accordance with NFPA 101, section 19.2.10, 7.10. The following evidenced this:

Exit signage needed facing a chevron from ED to stairwell 3.
Zone 2 red exit sign needs both sided directional arrows
The exit sign in the cath lab light is out
Elevator lobby near chaplains office- missing exit signage needed facing
No exit sign above the exit toward main entrance.
Lobby- exit signage from main lobby to conifer lobby needs corrected temporary exit signage


Life Safety Code Section 19.2.10.1 requires Means of Egress signs in accordance with 7.10. Section 7.10.1.5.1, in part, access to exits shall be marked by approved readily visible signs.

The deficiency has the potential to affect occupants, who might include staff, residents and visitors within the smoke compartments; items were discussed during the survey and again during the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and NFPA 221. This was evidenced by:

Fire rated walls throughout need inspected and all penetrations need repaired.

4.9.2 Firestop Systems and Devices Required.

Penetrations for cables, cable trays, conduits, pipes, tubes, combustion vents and exhaust vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, assembly constructed as a fire barrier shall be protected by a firestop system or device.

The deficiency has the potential to affect occupants, who might include staff, residents and visitors within all smoke compartments; items were discussed during the survey and again during the exit conference.

Based on observation and staff interview during the survey, it was determined that the facility failed to maintain the kitchen cooking appliance locations in accordance with National Fire Protection Association (NFPA) Standard 96. This was evidenced by the following:

1) Kitchen cooking appliances were not provided with an approved method to ensure the appliances were returned to the correct design location below the fixed extinguishing system nozzles, as required.


NFPA 96 (2011) Section 12.1.2.3.1: An approved method shall be provided that will ensure that the appliance is returned to an approved design location.

The commercial cooking equipment deficiency has the potential to affect all staff in the kitchen smoke compartments; items were discussed during the survey and again during the exit conference.

Based on observation during the survey it was determined the facility failed to install and maintain the fire alarm system in accordance with NFPA 101, section 19.3.4, 19.3.4.5, and 9.6, including NFPA 72 National Fire Alarm Code. The following evidenced this:

Storage room C smoke detector closer then 3 feet to the diffuser
Across from Colleen ' s office-detector too close to the diffuser.
EEG- staff office smoke detector to close to diffuser.
Fire alarm panel was upgraded without coming in for plan review.

17.7.4.1 *
In spaces served by air-handling systems, detectors shall not be located where airflow prevents operation of the detectors.
A.17.7.4.1
Detectors should not be located in a direct airflow or closer than 36 in. (910 mm) from an air supply diffuser or return air opening. Supply or return sources larger than those commonly found in residential and small commercial establishments can require greater clearance to smoke detectors. Similarly, smoke detectors should be located farther away from high velocity air supplies.

9.6.1.3
A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use.

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within all smoke compartments. Deficient items were discussed with the maintenance staff and facility administrator during the exit conference.

Through observation during documentation review, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, 13 and NFPA 25. This was evidenced by:

1. Cafe/kitchen, vending machines (ICU), RM 4404 loaded/corroded heads.
2. Escutcheons throughout the facility need repaired.
3. Loading mech outside entry-suppression pipe knuckle needs to be replaced.

Life Safety Code Section 9.7.5 maintenance and testing of automatic sprinkler systems to comply with NFPA 25.
NFPA 25 section 5.2.1.1.2, Any sprinkler that shows signs of any of the following shall be replaced:
(1) Leakage
(2) Corrosion
(3) Physical damage
(4) Loss of fluid in the glass bulb heat responsive element
(5) Loading
(6) Painting unless painted by the sprinkler manufacturer

6.2.7.1
Plates, escutcheons, or other devices used to cover the annular space around a sprinkler shall be metallic or shall be listed for use around a sprinkler.

5.2.2.1
Pipe and fittings shall be in good condition and free of mechanical damage, leakage, and corrosion.

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within all smoke compartments. Deficient items were discussed with the facility administrator and maintenance director during the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and NFPA 80. This was evidenced by:

Fire/Smoke doors throughout the facility do not close or are damaged.
Missing smoke seal on pt room door 5201
Doors don ' t latch when tested: 5302, 5206, 5208, 5300 wing staff elevator lobby doors, 5403, 5410.
Main door into robotics waiting room: did not latch when tested. SC 1-A
Room 4108: door seals poorly but latches


7.2.1.15.8

Door openings not in proper operating condition shall be repaired or replaced without delay.

5.2.15.2

Any breaks in the face covering of doors shall be repaired immediately.

5.2.15.3

Where a fire door, frame, or any part of its appurtenances is damaged to the extent that it could impair the door ' s proper emergency function, the following actions shall be performed:
(1)
The fire door, frame, door assembly, or any part of its appurtenances shall be repaired with labeled parts or parts obtained from the original manufacturer.

(2)
The door shall be tested to ensure emergency operation and closing upon completion of the repairs.

These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the affected smoke compartments. Deficient items were discussed with the facility administrator during the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101. This was evidenced by:

Throughout the building, all smoke barriers need insepcted and all penetrations through the barriers need fixed.

Life Safety Code section 19.3.7.3 to comply with section 8.5. Section 8.5.2.2, "Smoke barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces."

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within affected smoke compartments. Deficient items were discussed with the maintenance staff and facility administrator during the exit conference.

Through observation during documentation review, it was determined that the facility failed to meet the building services requirements in accordance with NFPA 101 and NFPA 90A. This was evidenced by:

Fire damper testing report shows there were failures in numerous dampers.

Life Safety Code section 19.5.2.1 to comply with section 9.2. Section 9.2 to comply with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems. NFPA 90A section 5.4.8.1 to comply with NFPA 80, Standard for Fire Doors and Other Opening Protectives. NFPA 80 section

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within all smoke compartments. Deficient items were discussed with the maintenance staff and facility administrator during the exit conference.

Through observation during documentation review, it was determined that the facility failed to meet the operating features requirements in accordance with NFPA 101. This was evidenced by:

1. Fire drills were not conducted under varied conditions and or not completed:
Two missing fire drills in the first quarter on 2nd and 3rd shift.
Varied conditions were not met on the 2nd shift between 2nd and 3rd quarter.

Life Safety Code, section 19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within all smoke compartments. Deficient items were discussed with the maintenance staff and facility administrator during the exit conference.

Based on observation and staff interview during the course of the survey, it was determined the facility failed to maintain electrical wiring and equipment in accordance with NFPA 101 and NFPA 70, National Electric Code. The following evidenced this:

Ground floor intake west- open j box with exposed wires
Ground mech- open j box
Main electric- open j boxes
Healing Garden Mech room-open junction box.
Main OR electrical room: Green j-box in SE corner behind the transformer needs to be reattached.
Spine/Joint OR: Leica microscope damaged electrical power cord
Leica microscope Incorrect electrical power cord
MRI computer room-Extension cord with box fan plugged into it.


9.1.2 Electrical Systems.
Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service.

406.6 Receptacle Faceplates (Cover Plates).
Receptacle faceplates shall be installed so as to completely cover the opening and seat against the mounting surface.
Receptacle faceplates mounted inside a box having a recess-mounted receptacle shall effectively close the opening and seat against the mounting surface.

The electrical deficiency has the potential to affect all room occupants, who might include staff and visitors; items were discussed during the survey and again during the exit conference.