HospitalInspections.org

Occupancy separations are not maintained as 2-hour rated barriers. Failure to maintain occupancy separations can compromise the safety of patients, staff and visitors within the Healthcare occupancy if a fire condition were to develop in the adjacent occupancy and be permitted to spread to the Healthcare occupancy.

Findings include:

On 5/11/21 at 2:45 PM while in the company of the DDFM it was observed at the 2-hour barrier separating the 3rd floor Pharmacy Business occupancy from the Healthcare occupancy that the door assembly did not appear to meet the 90-minute labeling. The narrow light glass window in the door was observed to have wood stops within the thickness of the door and did not secure the glass firmly. The core of the door was exposed at the edge of the veneer at the wood stops and the glass was marked as being "tempered" without an indication of a fire rating. Compliance with NFPA 101-2012, 19.1.3.4.1 and NFPA 80 is not met.

Based on observation, the direction of egress travel within a stair serving 5 or more stories in height is not readily apparent. This deficiency could affect all patients staff and visitors present, by preventing those occupants from readily identifying the level of discharge.

Findings include:

On 05/12/2021 at 11:15 AM while in the company of the FM, the direction of egress travel from a exit stair discharge is not readily apparent in order to comply with 19.2.10 and 7.2.2.5.4 for Stair identification. Example locations:

1. At 9:50 AM First floor Unit B west stair.
2. At 10:10 AM First floor Central Stair
3. At 11:00 AM First floor Stair "L" (number of floor served not determined).

Based upon observation, means of egress are not maintained in accordance with code requirements. Failure to maintain egress paths in accordance with requirements can result in failure of occupants being able to reach exits from the building.

Findings include:

On 5/12/21 at 1:00 PM while in the company of the FM it was observed that the Janitor room corridor door was equipped with a closer which prevents the door from opening in a manner to maintain the required width of the corridor in accordance with NFPA 101-2012, 7.2.1.4.3.1. The fully open door (90 degrees) restricts more than 7" of the required width of the corridor.

Based upon observation, egress doors are locked in a manner not permitted by the Code. Failure to provide locking systems for means of egress doors in accordance with Code requirements can compromise the safety of occupants during a fire/smoke emergency by not providing the safeguards afforded by the Code for exiting from a fire/smoke condition.

Findings include:

A. On 5/12/21 at 9:35 AM while in the company of the DDFM it was observed that a Delayed Egress locking system was installed at the double egress cross corridor door marked as an exit access from the 2nd floor Prep/recovery area to the Endo Procedure room area in non-compliance with 7.2.1.6.1.1(1) which requires the building to be "protected throughout by an approved, supervised automatic fire detection system or an approved supervised automatic sprinkler system". The building was observed to be only partially sprinkler protected and detected. The installed locking system also lacked the signage required by 7.2.1.6.1.1(4).

B. On 5/11/21 at 2:30 PM while in the company of the DDFM it was observed that a magnetic locking system appeared to be installed at the 4th floor Unit B East Stair door in non-compliance with 19.2.2.2.4. Although the system was not actively locked at the time of observation, the system appeared to have electrical power (as indicated by a lit "power" light on the unit) to be a functional locking system. The installed locking system did not appear to meet the requirements of 7.2.1.6.1 or 19.2.2.2.5.

Exit Passageways are not maintained in accordance with Code requirements. Failure to maintain the Exit Passageway can compromise the use of the exit passageway as a protected path of exit from the building during a fire/smoke event requiring evacuation.

Findings include:

A. On 5/12/21 at 10:55 AM while in the company of the DDFM it was observed that the pair of doors from the Unit C large Conference/Classroom which accesses the Exit Passageway serving the Unit B East Stair are not equipped with proper hardware for the doors to function properly in accordance with NFPA 101-2012, 7.2.6.3 and NFPA 80. The doors are equipped with an astragal, coordinator and vertical rod exit devices. The following conditions were observed:

1. The active leaf of the doors did not self-close to a latched condition.

2. Upon operation of the doors, the coordinator did not function to sequence the proper closing of the doors (when the active leaf was unlatched and the inactive leaf was allowed to push the active leaf open far enough to use the inactive leaf for egress).

3. The astragal on the active leaf prevents the use of the exit device on the inactive leaf in non-compliance with 7.2.1.7.3.

4. It was not confirmed that the exit devices were Fire Exit Hardware listed for use on the fire rated door assembly to comply with 7.2.1.7.2.

Based upon observation, exit signs are not provided to identify access to exits from the building. Failure to provide exit signs to correctly identify exit access can prevent occupants from reaching a required exit.

Findings include:

A. On 5/11/21 at 1:45 PM while in the company of the DDFM & FM, it was observed that the north elevator extends to the 7th floor roof (Penthouse level). The elevator lobby and path to an exit at this level lacks exit signage to identify at least one exit from this level to comply with NFPA 101-2012, 7.4.1.6.1. Although key card controlled use of the elevator is provided, access to an exit is not identified in the event the elevator is unavailable due to elevator recall initiation or malfunction of the elevator.


20224

Based on observation, exit signs were not provided, were not fully visible, or incorrectly identified paths of egress. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by preventing those occupants from readily identifying the path to an available exit from the building.

Findings include:

B. On 05/12/2021 while accompanied by the FM, corridors were observed which lack designated access to two remote exits and therefore produce dead end conditions which does not comply with 7.10 and 19.2.10.1.
Example locations observed:

1. At 10:20 AM First floor Corridor #1100 (per the facility provided life safety floor plans) contains one exit sign at the East end of the corridor.

2. At 9:35 AM Corridor First floor Elevator Lobby #100 exiting from Stair # 120 (per the facility provided life safety floor plans) contains one exit sign leading to corridor adjacent to the Gift shop, there is no other designated means of egress.

Based upon observation, hazardous areas are not properly separated from the remainder of the occupancy and the means of egress. Failure to properly separate storage of combustible material (which represents a degree of hazard greater than that normal to the general occupancy due to quantity and density of materials) from required means of egress paths can compromise the safety of occupants if a fire were to originate at the stored material to compromise the use of the adjacent corridor for exiting.

Findings include:

A. It was observed while in the company of the DDFM that sprinklered storage rooms containing combustibles were not provided with self-closing doors to comply with 19.3.2.1.3 and 19.3.6.3.5. Locations observed include:

1. On 5/11/21 at 2:10 PM the Storage room 649 lacked a self-closing door.

2. On 5/11/21 at 2:35 PM the Storage room 449 lacked a self-closing door.

3. On 5/12/21 at 9:20 AM the self-closing door at Soiled Utility room 216 failed to self-close to a latched condition.

4. On 5/12/21 at 10:30 AM the auto-operated corridor door accessing the Loading Dock at the Ground floor level failed to self-close and latch. Loading Dock Staff indicated the push pad switch often sticks to hold the door open. It was not confirmed that the auto-opener ceases to function under fire alarm activation to allow the door to close and latch to comply with NFPA 101-20, 7.2.1.9.2(4).

By observation during the survey walk through the facility failed to document inspection of the kitchen / cafeteria hood fire suppression system. This deficient practice could affect patients, staff and visitors during a fire event.

The finding is:

On 5/12/21 at 9:45 AM acompamied by the Maintenance Mechanic it was observed that the record of the date and initials of the person completing the monthly inspection is not provide on the fire suppression system tags for the kitchen and cafeteria grease hoods. NFPA, 17, 2009, 11.2.4 / NFPA 17A, 2009, 7.2.5.

Based on observation manually operated pull stations are not properly located. This could affect patients, staff and visitors in areas served if the fire alarm components are not readily available to provide for a complete system operation during a fire emergency.

The finding is:

On 05/12/2012 at 9:45am while in the company of the FM, manual pull stations are not located within 5 feet of the designated exit door to comply with 9.6.2.3 for the first floor exit passageway serving stair #17BC (per the facility provided life safety floor plans).
Locations observed:

1. East end of Elevator Lobby #1608

2. West end of Corridor #1100.

By observation during the survey walk through the facility failed to maintain fire sprinkler installation. This deficient practice could result in the delayed response and suppression during a fire event, which may affect patients, staff and visitors.

The finding is:

On 5/12/21 at 10:35 AM in the company of the Maintenance Mechanic the surveyor observed that multiple ceiling tile in the Ambulance Garage were either missing or falling out of the ceiling grid allowing the installed pendant sprinkler heads to be more than 12 inches from the interstitial ceiling above. NFPA 13, 2010, 8.6.4.1

Based upon observation, portable fire extinguishers are not documented to be inspected and maintained in accordance with Code requirements. Failure to document inspection and maintenance of portable fire extinguishers can result in failure of equipment to perform as intended when needed during a fire event.

Findings include:

A. On 5/12/21 at 12:50 PM while in the company of the FM was observed that portable fire extinguishers are not documented to be inspected on a monthly basis because inspection tags are not initialed & dated to comply with NFPA 10-2010, 7.2.1.2 and 7.2.4.

1. The extinguisher at the north exit door had a 2021 tag punch as March 2021 but no monthly inspection dates.

2. The extinguisher located in the Infusion room was last dated 3/7/21.

Based upon observation, Trash chutes are not maintained in accordance with Code requirements. Failure to maintain Trash chutes can permit fire/smoke conditions to spread to other floors of the building.

Findings include:

On 5/12/21 at 9:50 AM while in the company of the DDFM it was observed that the Trash chute access door, opening to the 2nd floor corridor of the Surgery Dept. near Anesthesia room 282, was not self-closing to a latched condition to comply with 19.5.4.1 and fire rating requirements.

Based upon observation, ground fault circuit interruption (GFCI) is not provided in accordance with code requirements. If GFCI protection is not provided, the circuit remains an electrical shock hazard to occupants. This deficient practice could affect the safety of patients, staff, and visitors.

The finding is:

A. On 5/12/21 at 12:58 PM while in the company of the FM, it was observed that numerous electrical receptacles within 6'-0" of sink fixtures are not confirmed to be provided with GFCI protection to comply with NFPA 70 2011, 210.8(B)(5).

1. At the Infusion room.
2. At the Staff Break room adjacent the Infusion room
3. At multiple Exam rooms