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19.3.6.3.2 Door shall be provided with means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited.

This STANDARD was not met as evidenced by:

Based on observation, the facility failed to ensure that all corridor doors could latch properly, and could resist the passage of smoke. Areas potentially affected by the migration of smoke include the one smoke compartment on Med/Surg 4 East.

Findings include:

Problems were identified at the locations listed below:

On the fourth floor, the double doors to storage room 43006 did not latch properly. The stationary side of the door could not hold in position.

Based on observation, the facility failed to assure that access to exits were readily visible where the way to the exit was not readily apparent. Staff and contract personnel may have difficulty exiting the boiler room in the event of fire or loss of overhead lighting.

Findings include:

Tour of the facility revealed that there was no exit sign leading out of the boiler room. This room was windowless and had four doors visible from the interior. Two of these doors were labeled, "NOT AN EXIT". The facility's emergency power, transfer switch was located in an interior room, within the boiler room.

NFPA 101 (2000 ed.), 19.3.7.6 Door in smoke barriers shall comply with 8.3.4 and be self closing or automatic closing in accordance with 19.2.2.2.6.

8.3.4 Doors in smoke barriers shall close the opening leaving only the minimum clearance necessary for proper operation and shall be without undercuts, louvers, or grilles.

This STANDARD was not met as evidenced by:

Based on observation, the facility failed to assure that smoke barrier doors left only minimum clearance for proper operation of these doors, and for the containment of smoke. The inability of these doors to resist the passage of smoke, could affect staff and patients in two smoke compartments.

Findings include:

Tour of the facility on 1/31/12, in the company of the Safety Officer and Acting Director of Facilities, revealed that a recently installed set of smoke barrier doors had a 5/8" gap between the leading edges of the set of smoke barrier doors. These doors were installed to separated the IMC and 2W smoke compartments.

These findings were shared with the facility's executive staff during the exit interview on 2/3/12.

NFPA 101 (2000 ed.) 7.1.10.2.1 No furnishings, decorations or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof.

This STANDARD was not met as evidenced by:

Based on observation, the facility failed to assure that furnishings did not obstruct access to an exit. Timely evacuation of staff and patients from one smoke compartment could have been affected by the obstruction of one exit.

Findings include:

Tour of the facility on 1/31/12, it was observed that the exit access on the first floor, Orthopedic wing, was blocked by a table and chairs. This exit was adjacent to the "Day Room" (a temporary patient sleeping area used when there was surge in patient load).

These findings were acknowledged by the facility's executive staff during the exit interview on 2/3/12.

NFPA 13 (1996 ed.) Chapter 4 Installation Requirements, 4-1.1 The requirements for spacing, location, and position of sprinklers are based on the following principles: (a) Sprinklers are installed throughout the premises, (b) Sprinklers located so as not to exceed maximum protection area per sprinkler, (c) Sprinklers positioned and located so as to provide satisfactory performance with respect to activation time and distribution.

This STANDARD was not met as evidenced by:

Based on observation and staff interview, the facility failed to assure that sprinklers were installed throughout the premises. Five of six recently constructed closets along the backside of the elevator shafts on the 3rd and 4th floors were not sprinklered. A potential fire in any of the unsprinklered closets could release smoke into the atrium area, affecting all four levels of the hospital.

Findings include:

During a tour of the facility on 1/31/12, in the company of the Safety Officer and the Acting Director of Facilities, three of four closets constructed behind the walls of the elevator shaft on the fourth floor were not sprinklered. On the third floor, two of two closets behind the elevator shaft were not sprinklered. The depth of these closets was two feet and the widths were four feet on the one-door closets and eight feet on the two-door closets.

The Safety Officer stated that this construction was not part of the original building.

NFPA 25 (1998 ed.), 2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded or in the improper orientation.
Exception #1: Sprinklers installed in concealed spaces such as above the suspended ceiling shall not require inspection.
Exception #2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

This STANDARD is not met as evidenced by:

Based on observation, the facility failed to assure that sprinklers were free of foreign materials (i.e. grease and dust) which could affect both the thermosensitivity and spray pattern of the sprinkler heads.

Findings include:

Tour of the facility on 1/31/12, revealed that the all of the sprinkler heads in the food preparation and food storage area were coated with grease and dust.

These findings were acknowledged by the facility's executive staff during the exit interview on 2/3/12.

NFPA 10 (2002 ed.) 5.1.2.2 Occupancy hazard protection shall be provided by fire extinguishers suitable for such Class A, B, C, D, or K fire potentials as might be present.
Table 5.2.1 Fire Extinguisher Size and Placement for: Class A Hazards: Maximum floor area per unit of A-3,000 square feet; Maximum travel distance to extinguisher-75 ft.
Table 5.3.1 Fire Extinguisher Size and Placement for: Class B Hazards: Maximum travel distance to extinguisher-30 ft.
5.5 Fire Extinguisher Size and Placement for Class C Hazards. Fire extinguishers with Class C ratings shall be required where energized electrical equipment can be encountered. This requirement includes situations where fire either directly involves or surrounds electrical equipment. Since the fire itself is a Class A or Class B hazard, the fire extinguishers shall be sized and located on the basis of the anticipated Class A or Class B hazard.

This STANDARD was not met as evidenced by:

Based on observation, the facility failed to assure adequate placement of "ABC" fire extinguishers within the food preparation and food storage areas. These extinguishers are effective in putting out small fires involving ordinary materials, flammable liquids, and fires caused by energized equipment.

Findings include:

During a tour of the facility on 1/31/12, it was observed that kitchen area had five, "K" type extinguishers located throughout its department (department size is greater than 6,000 square feet). No "ABC" type extinguishers were seen in this area. Type "K" extinguishers are used to extinguish combustible cooking substances.

These findings were shared with the executive staff during the exit interview on 2/3/12.

NFPA 99, Chapter 9 Gas Equipment
9.7.5.2 If stored within the same enclosure, empty cylinders shall be segregated from full cylinders.

This STANDARD was not met, as evidenced by:

Based on observation, the facility failed to assure that full and empty oxygen cylinders were stored separately within the same room. Grabbing an empty, or near empty, cylinder from a rack could affect patients suffering from respiratory problems.

Findings include:

During a tour of the facility on 1/31/12, oxygen storage racks were observed containing a mix of both full and empty "E" cylinders, in the following locations within the hospital:
1. Third floor Med Room (total 12 tanks)
2. Second floor oxygen storage (total 10 tanks)
3. ICU Med Storage Room (total 5 tanks)
4. Second floor storage (total 10 tanks)

These findings were shared with the executive staff during the exit interview on 2/3/12.

Based on observation, the facility failed to assure that the electrical installations within the building are properly maintained and in good repair, conforming to NFPA 70, National Electrical Code.

Findings include:

During a tour of the facility on 1/31/12, it was observed that a wall-mounted, twelve outlet, power strip was loosely connected to an electrical box, and two of these outlets were cracked, one showed scorch marks, and one outlet was covered with medical tape. This power strip was located across the corridor from the blood bank.

This finding was shared with the facility's executive staff during the exit conference on 2/3/12.

Based on observation, the facility failed to assure that Alcohol Based Hand Rub (ABHR) dispensers were not installed over, or adjacent to, ignition sources. ABHR's are flammable liquids and electrical switches are potential sources for ignition.

Findings include:

During a tour of the facility with the Security Director and the Acting Director of Facilities revealed that ABHR's were installed directly over light switches in patient rooms number 435 and 438. Also, it was observed that an ABHR was installed directly over a computer processing unit on the desk of the discharge manager, near the second floor day room.

These findings were acknowledged by the facility's executive staff during the exit interview on 2/3/12.