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Based on observation and interview, the facility failed to protect hazardous areas as required.

Findings include:

On July 21, 2014 the following storage rooms were found to have doors that were not self-closing.

D401 Clean Equipment Room, OB ward, 6 ft x 16 ft = 96 square feet - no closer
D413 Clean Utility, OB ward, malfunctioning closer

On July 22, 2014 the following storage rooms were found to have doors that were not self-closing.

E256 Supply Room, Acute Care Nursing ward, 8 ft x 16 ft = 128 square feet - no closer
E265 Equipment Room, ER - no closer
A210 Storage (former isolation), ER - no closer
A138 Supply Room (former EKG), 8 ft x 15 ft = 120 square feet, Outpatient ward - no closer

Two Medical Records Storage room roll down doors were not equipped to be self-closing. The doors were equipped with fusible links. Doors to hazardous areas are required to be self-closing or automatic closing. The doors were not self-closing or automatically closing. Automatic closing doors are required to self-close when smoke is detected by an area smoke detection system or smoke detectors installed for door release service and loss of power.

C303, C407, C408 Storage rooms, Laboratory - no closer

Storage rooms that exceed 50 square feet in size and contain combustible materials are considered hazardous areas. Doors to hazardous areas are required to be self-closing or automatic closing.

Ref: 2000 NFPA 101 Section 19.3.2.1, 7.2.1.8.2 (automatic closing); 1999 NFPA 72 Section 2-10.6 (Smoke Detectors for Door Release Service)

On July 22, 2014 the crawlspace in the lower level of the business occupancy was being used for storage. Storage for business occupancy is a hazardous area and is required to be protected with automatic sprinklers or enclosed with a 1 hour fire rated enclosure without windows. The area was not separated as the door was not rated for 45 minutes, nor equipped with fire exit hardware. The area was not protected with automatic fire sprinklers.

The Facility Engineer was present when the deficiency was identified.

Failure to protect hazardous areas as required increases the risk of death or injury due to fire.

The deficiency affected 11 of numerous storage areas in the building.

Based on observation and interview, the facility failed to maintain the means of egress as required.

Findings include:

On July 21, 2014 the following rooms were equipped with dead bolt lock and a lever lock that required two releasing operations.

D415 Delivery Room, OB ward

On July 22, 2014 the following rooms were equipped with dead bolt lock and a lever lock that required two releasing operations.

A115 Audio testing, Out Patient ward

Doors in the means of egress are required to be operable with not more than one releasing operation.

Ref: 2000 NFPA 101 Section 19.2.1, 7.2.1.5.4

On July 21, 2014 the following access controlled egress doors in the means of egress were not equipped with a manual release device and sign that read "Push to Exit" where the device results in direct interruption of power to the lock, and where the door should remain unlocked for at least 30 seconds as required.

D424
D425
D519

Ref: 2000 NFPA 101, Section 19.2.2.2.4, exception 3, 7.2.1.6.2

On July 22, 2014 the following doors in the means of egress was found be equipped with keyed locks in the direction of egress. Doors in the means of egress are not permitted to be equipped with a lock or latch that requires the use of a key in the direction of egress.

E229 Isolation room used for storage, Acute Care ward
G615 dining room, lower level, exit sign above door. This door is required when
movable partitions prevent access to other means of egress.

Ref: 2000 NFPA 101 Section 19.2.2.2.1, 7.2.1.5.1, 19.2.2.2.4

The Facility Engineer was present when the deficiency was identified.

Failure to maintain the means of egress as required increases the risk of death or injury due to fire.

The deficiency affected seven of numerous doors in the means of egress.

Based on observation and interview, the facility failed to install an automatic fire sprinkler system as required.

Findings include:

On July 22, 2014 the following electrical rooms did not meet the exceptions to be without automatic fire sprinkler protection. Electrical rooms are required to be protected with automatic fire sprinklers unless they meet the following requirements:

(a) The room is dedicated to electrical equipment only.
(b) Only dry-type electrical equipment is used.
(c) Equipment is installed in a 2-hour fire-rated enclosure including protection for penetrations.
(d) No combustible storage is permitted to be stored in the room.

Ref: 2000 NFPA 101 Section 19.3.5.3, 9.7.1.1, 1999 NFPA 13 Section 5-13.11

Dental electrical room - the fire resistance rating of the door could not be verified. There was no label on the door. The door had a blond colored wood plug on the hinge edge. The plugs meaning was undetermined. Ninety (90) minute FRR doors are required at openings to 2 hour FRR enclosures.

Ref: 2000 NFPA 101 Section 8.2.3.2.3.1

F208 plant areas - door to electrical room did not self-close to latch. Door stuck on latch. Fire door closing mechanisms are required to be adjusted to overcome the resistance of the latch mechanism so that positive latching is achieved on each door operation.
Ref: 2000 NFPA 101 Section 19.1.2.1(2), 8.2.3.2.1, 1999 NFPA 80 Section 2-4.1.4
F109 Switch gear room - storage of tool boxes, ladder and chair (combustible storage)

F109 Switch gear room - door does not latch, upside down strike plate

Ref: Section 8.2.3.2.1, 1999 NFPA 80 Section 2-1.4.1

H409 Electrical room - hatch open. All doors to openings in FRR enclosures are required to be closed.

The Facility Engineer was present when the deficiency was identified.

Failure to protect buildings required to be equipped with automatic fire sprinklers as required increases the risk of death or injury due to fire.

The deficiency affected five of numerous rooms requiring automatic fire sprinklers.

Based on observation and interview, the facility failed to maintain the sprinkler system as required.

Findings include:

On July 22, 2014 ceiling tiles in the following rooms were missing or incomplete. The tiles are a feature of the fire protection system that prevents smoke and heat from escaping to the space above the tiles and delaying the sprinkler response. As such, they are required to be maintained.
Room J806, room is sprinkler protected - 2 tiles missing, one with 12 inch diameter hole

The Facility Engineer was present when the deficiency was identified.

Failure to maintain the sprinkler system as required increases the risk of death or injury due to fire.

The deficiency affected one room in the lower level of business occupancy.

Ref: 2000 NFPA 101 Section 4.6.12.1

Based on observation and interview, the facility failed to protect piped medical gas systems as required.

Findings include:

On July 21, 2014 the nitrous oxide storage room was not equipped to be self-closing. Nitrous oxide storage is required to be stored in an enclosure with a 1 hour fire resistance rating (FRR). Openings to 1 hour FRR enclosures are required to be self-closing.

Ref: 2000 NFPA 101 Section 19.3.2.4; 1999 NFPA 99 Section 12-4.2.1.7, 4-3.1.1.2(a)2; 2000 NFPA 101 Section 8.2.3.2.3.1, 8.2.3.2.1; 1999 NFPA 80 Section 2-1.4.1

On July 22, 2014 the medical gas testing report dated September 17, 2013 indicated that there were deficiencies with the medical gas system. The facility engineer indicated that there was a medical gas project that corrected these deficiencies. The deficiencies were the same as in the report of 2012. The medical gas project was done in November of 2012. Medical gas documentation is required to be accurate.

Ref: 2000 NFPA 101 Section 19.3.2.4; 1999 NFPA 99 Section 12-3.4.1, 4-3.4.1.1

The Facility Engineer was present when the deficiency was identified.

Failure to maintain medical gas systems as required increases the risk of death or injury due to fire.

The deficiency affected one location and one of two reports reviewed.

Based on observation and interview, the facility failed to protect penetrations to smoke barriers by ducts as required.

Findings include:

On July 22, 2014 the smoke barrier locations listed below were unsealed where the penetration would not resist the passage of smoke. Penetrations in smoke barriers by conduits are required to be filled with material that will resist the passage of smoke or be protected by an approved device that is designed for the specific purpose.
Smoke barrier near door D129, OB ward - 2" dia conduits, 2" dia hole with com wires, ½ " electrical conduit.
Smoke barrier near door D123 - 1" diameter IT wires unsealed above corridor door, 2 each.
The Facility Engineer was present when the deficiency was identified.

Failure to maintain smoke barriers as required increases the risk of death or injury due to fire.

The deficiency affected two of eight smoke compartments.

Ref: 2000 NFPA 101 Section 19.3.7.3, 8.3.6.1