HospitalInspections.org

Reference NFPA 101, 2000 Edition

7.2.1.5 Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for the operation from the egress side.

Reference NFPA 101, 2000 Edition
Section 19.2.2.2.4 Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side.

Based on observation and interview, the facility failed to ensure the main exit doors and the emergency department exit doors were not equipped with a latch that may require special knowledge or effort to operate from the exit side. With these latches in the "latched mode" staff and/or patients could likely not be able to exit freely through these doors in an emergency, which presents the risk of potential harm to all ten (10) patients within the facility as identified by the Acute Daily Census provided by the Maintenance Director on 08/25/15. The findings are:

A. On 08/25/15 at 1:00 pm, during observation, the main exit and the emergency department exit are both provided with two sets of double sliding glass doors (these doors form an enclosure [vestibule] at both the main entry and at the emergency department entry). Both sets of these sliding glass doors are break-away doors, which are designed to "break away" from their frames in order to provide required or additional clear exit width in the event of emergency egress. Both sets of these sliding glass break-away doors were equipped with a dead-bolt style latching mechanism that when in the latched position, these doors would not break-away as designed. Also, if these latches were in the latched position and someone was to approach the doors with force to break them away in an emergency situation, the latch and/or the door frame is likely to bend not allowing the latch to release thus not allowing the doors to break-away as designed or may cause great effort to release the latch to break the doors away.

B. On 08/25/15 at 1:15 pm, during interview, the Maintenance Director stated they were concerned about securing the hospital at night and they use the latches after 5:00 pm. He stated without the use of the latches, the doors could be pryed open from the outside. He stated he was unaware the installation could pose a problem with exiting during an emergency.

Reference NFPA 101, 2000 Edition

9.6.2.9 Where a partial smoke detection system is required by another section of this Code, automatic detection of smoke in accordance with NFPA 72, National Fire Alarm Code, shall be provided in all common areas and work spaces, such as corridors, lobbies, storage rooms, equipment rooms, and other tenantless spaces in those environments suitable for proper smoke detector operation. Selective smoke detection unique to other sections of this Code shall be provided as required by those sections.

Reference NFPA 72, 1999 Edition

2-3.4.5 Smooth Ceiling Spacing.
2-3.4.5.1 Spot-Type Detectors.
2-3.4.5.1.1
On smooth ceilings, spacing of 30 ft (9.1 m) shall be permitted to be used as a guide. In all cases, the manufacturer's documented instructions shall be followed. Other spacing shall be permitted to be used depending on ceiling height, different conditions, or response requirements.


Based on observation and interview, the facility failed to ensure the vestibule [enclosure], located at the main entrance to the building was provided with automatic smoke detection as required by NFPA 72 (National Fire Alarm Code). Not providing automatic smoke detection within this vestibule could result in an undetected fire at this location, which would render this required exit as unavailable in the event of fire, which presents the risk of potential harm to ten (10) patients as identified by the Acute Daily Census provided by the Maintenance Director on 08/25/15. The findings are:

A. On 08/25/15 at 1:20 pm, during observation, an automatic smoke detection device was not provided within the vestibule located at the main entrance of the building.

B. On 08/25/15 at 1:25 pm, during interview, the Maintenance Director stated he never noticed the space was not protected by a smoke detector.

Reference NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, 1999 Edition.

3-4.7 Maintenance.
At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.

Note: Hospitals are granted a damper inspection interval not to exceed 6 years.

Based on record review and interview, the facility failed to ensure fire/smoke dampers were maintained by qualified personnel at least every six (6) years as required by NFPA 90A (Standard for Installation of Air Conditioning and Ventilating Systems). Without this preventative maintenance and in the event of fire, the distribution of smoke, hot gases and fire could travel from area to area via the heating and ventilation air duct system, which presents the risk of potential harm to all ten (10) patients within the facility as identified by the Acute Daily Census provided by the Maintenance Director on 08/25/15. The findings are:

A. Record review of the facility's maintenance records revealed no evidence demonstrating the facility's fire/smoke dampers were being inspected every six years as required.

B. On 08/25/15 at 12:15 pm, during interview, the Maintenance Director stated he was not able to find the damper inspection records.

Based on observation and interview, the facility failed to ensure portable space heating devices were not used in the surgical clinic, which is considered a patient care area and/or treatment area. Space heaters can cause fires when they malfunction due to improper use, which presents a risk of potential harm to ten (10) patients as identified by the Acute Daily Census provided by the Maintenance Director 08/25/15. The findings are:

A. On 08/25/15 at 1:17 pm, during observation, office #CL21 located in the surgical clinic had an electric space heater located near the desk.

B. On 08/25/15 at 1:20 pm, during interview, the Maintenance Director
stated he was unaware staff was using space heaters in the facility.

Reference NFPA 101, 2000 Edition

7.2.1.5 Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for the operation from the egress side.

Reference NFPA 101, 2000 Edition
Section 19.2.2.2.4 Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side.

Based on observation and interview, the facility failed to ensure the main exit doors and the emergency department exit doors were not equipped with a latch that may require special knowledge or effort to operate from the exit side. With these latches in the "latched mode" staff and/or patients could likely not be able to exit freely through these doors in an emergency, which presents the risk of potential harm to all ten (10) patients within the facility as identified by the Acute Daily Census provided by the Maintenance Director on 08/25/15. The findings are:

A. On 08/25/15 at 1:00 pm, during observation, the main exit and the emergency department exit are both provided with two sets of double sliding glass doors (these doors form an enclosure [vestibule] at both the main entry and at the emergency department entry). Both sets of these sliding glass doors are break-away doors, which are designed to "break away" from their frames in order to provide required or additional clear exit width in the event of emergency egress. Both sets of these sliding glass break-away doors were equipped with a dead-bolt style latching mechanism that when in the latched position, these doors would not break-away as designed. Also, if these latches were in the latched position and someone was to approach the doors with force to break them away in an emergency situation, the latch and/or the door frame is likely to bend not allowing the latch to release thus not allowing the doors to break-away as designed or may cause great effort to release the latch to break the doors away.

B. On 08/25/15 at 1:15 pm, during interview, the Maintenance Director stated they were concerned about securing the hospital at night and they use the latches after 5:00 pm. He stated without the use of the latches, the doors could be pryed open from the outside. He stated he was unaware the installation could pose a problem with exiting during an emergency.

Reference NFPA 101, 2000 Edition

9.6.2.9 Where a partial smoke detection system is required by another section of this Code, automatic detection of smoke in accordance with NFPA 72, National Fire Alarm Code, shall be provided in all common areas and work spaces, such as corridors, lobbies, storage rooms, equipment rooms, and other tenantless spaces in those environments suitable for proper smoke detector operation. Selective smoke detection unique to other sections of this Code shall be provided as required by those sections.

Reference NFPA 72, 1999 Edition

2-3.4.5 Smooth Ceiling Spacing.
2-3.4.5.1 Spot-Type Detectors.
2-3.4.5.1.1
On smooth ceilings, spacing of 30 ft (9.1 m) shall be permitted to be used as a guide. In all cases, the manufacturer's documented instructions shall be followed. Other spacing shall be permitted to be used depending on ceiling height, different conditions, or response requirements.


Based on observation and interview, the facility failed to ensure the vestibule [enclosure], located at the main entrance to the building was provided with automatic smoke detection as required by NFPA 72 (National Fire Alarm Code). Not providing automatic smoke detection within this vestibule could result in an undetected fire at this location, which would render this required exit as unavailable in the event of fire, which presents the risk of potential harm to ten (10) patients as identified by the Acute Daily Census provided by the Maintenance Director on 08/25/15. The findings are:

A. On 08/25/15 at 1:20 pm, during observation, an automatic smoke detection device was not provided within the vestibule located at the main entrance of the building.

B. On 08/25/15 at 1:25 pm, during interview, the Maintenance Director stated he never noticed the space was not protected by a smoke detector.

Reference NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, 1999 Edition.

3-4.7 Maintenance.
At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.

Note: Hospitals are granted a damper inspection interval not to exceed 6 years.

Based on record review and interview, the facility failed to ensure fire/smoke dampers were maintained by qualified personnel at least every six (6) years as required by NFPA 90A (Standard for Installation of Air Conditioning and Ventilating Systems). Without this preventative maintenance and in the event of fire, the distribution of smoke, hot gases and fire could travel from area to area via the heating and ventilation air duct system, which presents the risk of potential harm to all ten (10) patients within the facility as identified by the Acute Daily Census provided by the Maintenance Director on 08/25/15. The findings are:

A. Record review of the facility's maintenance records revealed no evidence demonstrating the facility's fire/smoke dampers were being inspected every six years as required.

B. On 08/25/15 at 12:15 pm, during interview, the Maintenance Director stated he was not able to find the damper inspection records.

Based on observation and interview, the facility failed to ensure portable space heating devices were not used in the surgical clinic, which is considered a patient care area and/or treatment area. Space heaters can cause fires when they malfunction due to improper use, which presents a risk of potential harm to ten (10) patients as identified by the Acute Daily Census provided by the Maintenance Director 08/25/15. The findings are:

A. On 08/25/15 at 1:17 pm, during observation, office #CL21 located in the surgical clinic had an electric space heater located near the desk.

B. On 08/25/15 at 1:20 pm, during interview, the Maintenance Director
stated he was unaware staff was using space heaters in the facility.