HospitalInspections.org

Based upon observation, 2-hour rated fire barriers are not maintained between the Healthcare occupancy and adjacent Business occupancy to comply with requirements for separated occupancies. Failure to maintain fire barriers can result in the spread of fire/smoke to different fire areas of the facility.

Findings include:

On October 12, 2021 at 2:00pm while in the company of the DQ & MS it was observed that the door behind the Nurse station which accesses the corridor of the Business occupancy did not close and latch to comply with NFPA 80 fire rated door assembly requirements.

Based upon observation, corridor doors are not maintained in accordance with Code requirements. Failure to maintain corridor doors can delay closing of the door during a fire/smoke condition.

Findings include:

A. On October 12, 2021 at 1:20pm, while in the company of the DQ & MS, it was observed that the dutch door at the copy room near the lobby reception desk was not in compliance with 19.3.6.3.13 because the upper leaf was not self-latching into the lower leaf (slide bolt only used) and the meeting edges of the upper and lower leaves was not provided with an astragal, rabbit or bevel to resist the passage of smoke.

B. On October 12, 2021 at 1:50pm, while in the company of the DQ & MS, it was observed that the CT Scan room corridor door was equipped with a drop-down door hold-open device which can impede the closing of the door in non-compliance with 19.3.6.3.10.

Trash collection carts are stationed in the corridor and unattended. Failure to station trash collection carts in a protected area can compromise the use of the corridor in an emergency.

Findings include:

On October 12, 2021 it was observed between 1:20pm and 2:00pm while in the company of the DQ & MS that three janitor trash collection carts with a total capacity greater than 32 gal. were stationed in the corridor adjacent the nurse station in non-compliance with 19.7.5.7.1.

Emergency generator systems are not maintained in compliance with Code requirements. Failure to maintain emergency generator system can result in failure of the system to operate when needed.

Findings include:

On October 12, 2021 at 2:10pm while in the compancy of the DQ & MS it was observed that the exterior mounted emergency generator lacked a means of maintaining starting battery temperature to comply with NFPA 110-2010, 5.3.1. Documentation from the generator system manufacturer was not otherwise available to justify that no need for battrery warmers existed.