HospitalInspections.org

The Main Storage Room, Hospital Storage Room, and the Administrative Storage Room were part of the latest remodel to the hospital. New storage rooms over 100 square feet must be separated from the rest of the building by one-hour fire resistive rated construction.

The facility failed to ensure the walls that enclose three (3) of three (3) new storage rooms were at least one-hour fire resistive rated.

Observation determined:

1) The doors to the three storage rooms were equipped with fire rated smoke gaskets but were not equipped with intumescent gaskets.

2) The north wall of the Hospital Storage Room was penetrated by two air ducts that were not sealed with fire rated material.

3) The Main Storage Room door frame was not labeled as having at least a 45 minute fire resistance rating.

4) The control joints above the Main Storage Room double door were not backed with fire rated material.

5) The north wall of the Administrative Storage Room was a composite wall of metal studs, gypsum board, bricks, and clay block. There are no UL fire rated assemblies for this composite wall and for the corner joints where the east and west walls tie into the north wall.

6) The 60 minute fire rated door to the Administrative Storage Room would not self-close to the latched position.

Not more than 50 percent of the required number of exits, and not more than 50 percent of the required egress capacity is permitted to discharge through areas on the level of exit discharge. 7.7.2

The facility failed to ensure that at least two acceptable exits, remote from each other, were provided for each floor or fire section of the building.

Observation determined an exit passageway was not provided from the west basement stair enclosure to the exterior of the building. The west stair enclosure now discharges into the building as a result of the recent additions and remodeling.

Emergency illumination of means of egress must be arranged so that a failure of a single lighting fixture (bulb) will not leave the area in darkness and be arranged to provide not less than an average of 1 ft-candle measured along the path of egress at floor level. 7.9.2.1

The emergency illumination lighting system must be arranged to provide the required illumination automatically. 7.9.2.2

The emergency lighting system must be either continuously in operation or must be capable of repeated automatic operation without manual intervention. 7.9.2.5

The facility failed to provide emergency illumination throughout the facility.

Observation determined:

1) The South Entry Meeting Room had two marked exits but only one light fixture that provided emergency illumination of the entire space.

2) The Clinic Suite had two marked exits but the exit paths throughout the suite were not equipped with emergency illumination.

3) The two stair enclosures from the basement were not equipped with emergency illumination.

4) The windowless basement was not equipped with emergency illumination.

Exits must be marked by approved signage that is readily visible from any direction of exit access and that obviously and clearly identifies the exit. 7.10.1.2

The facility failed to mark exit paths with readily visible signage.

Observation determined the south end of the west north/south corridor was not marked by approved signage to clearly identify the path of exit.

The facility failed to ensure the fire alarm system is in compliance with NFPA 72.

Observation determined the fire alarm panel dialer located in the Main Boiler Room was not protected. CMS requires a photoelectric smoke detector above the fire alarm panel. If conditions do not permit a smoke detector, a rate-of-rise heat detector may be used.

The facility failed to ensure the automatic sprinkler system was continuously maintained in a reliable operating condition as required by NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems.

Observation determined:

1) Side-wall sprinklers installed in areas that have pitched ceilings, must be installed at high-point of the ceiling with the sprinkler deflector aligned parallel to the ceiling. NFPA 13, Standard for the Installation of Sprinkler Systems 5-7.4.2

The sprinklers in the South Entry Meeting Room and Clinic Entry that protected the high-pitched ceiling areas were side-wall sprinklers that were not installed in accordance with the sprinkler's limitations. The sprinklers were not installed at the top of the pitched ceilings and sprinkler deflectors were not installed parallel to the ceiling.

2) A sprinkler in the north/west corner of the Laundry Room was obstructed by a surface mounted light fixture.

3) The recessed sprinkler in the Foundation Office was covered with the shipping cap and was not functional.

Records review indicated the facility failed to maintain fire dampers in a reliable operating condition as required by NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems. The initial testing by the mechanical contractor and the fire alarm company was not available for review during the Life Safety Code survey.

Electrical wiring throughout a health care occupancy must comply with NFPA 70, National Electrical Code.

All electrical panelboard circuits must be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel doors.

The facility failed to ensure all of the electrical circuits were identified on the face or inside of the panel doors.

Observation determined that electrical circuits in one (1) of the three (3) electrical panelboards in the Clinic Electrical Room were not identified on the inside of the panel doors.