HospitalInspections.org

Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety.

Findings include:

Refer to A0710 for findings.

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K11. The facility failed to provide a two hour fire barrier separation between the existing conforming bluiding and the new MRI (Magnetic Resonance Imaging) addition nonconforming building per code. Findings include:

During the visit, the following is an example of what was observed:
Per observeation there was no two hour fire barrier separating the following nonconforming construction types:
1. Type II (000) - with no automatic sprinkler system
2. Type V (000) - with no automatic sprinkler system
from the conforming construction Type II (222)
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2000 NFPA (National Fire Protection Association)101, 8.2.1 Buildings or structures occupied or used in accordance with the individual occupancy chapters (Chapters 12 through 42) shall meet the minimum construction requirements of those chapters. NFPA 220, Standard on Types of Building Construction, shall be used to determine the requirements for the construction classification. Where the building or facility includes additions or connected structures of different construction types, the rating and classification of the structure shall be based on either of the following: (1) Separate buildings if a 2-hour or greater vertically-aligned fire barrier wall in accordance with NFPA 221, Standard for Fire Walls and Fire Barrier Walls, exists between the portions of the building Exception: The requirement of 8.2.1(1) shall not apply to previously approved separations between buildings. (2) The least fire-resistive type of construction of the connected portions, if no such separation is provided
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K12. The facility failed to provide a conforming construction type per code. Findings include:

During the visit, the following is an example of what was observed:
The following construction types were observed at the MRI addition:
1. Type II (000) - without an automatic sprinkler system
2. Type V (000) - without an automatic sprinkler system
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2000 NFPA 101, 18.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 18.1.6.2. (See 8.2.1.)


Table 18.1.6.2 Construction Type Limitations

Construction Type Stories
1 2 3 4 or
More

I(443) X X X X
I(332) X X X X
II(222) X X X X
II(111) X X X NP
II(000) X NP NP NP
III(211) X NP NP NP
III(200) NP NP NP NP
IV(2HH) X NP NP NP
V(111) X NP NP NP
V(000) NP NP NP NP

X: Permitted type of construction.
NP: Not permitted.


2000 NFPA 101, 4.6.6 Additions shall conform to the provisions for new construction.
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K18. The facility failed to provide corridor doors per code. Findings include:

During the visit, the following are examples of what was observed:
1. The corridor door to the MRI was not smoke resistive.
2. The corridor door to Radiology did not have positive latching hardware.
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2000 NFPA 101, 19.3.6.3.2 Doors shall be provided with a 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 on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.
2000 NFPA 101, 18.3.6.3.1 Doors protecting corridor openings shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.

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K24. The facility failed to provide smoke compartments per code. Findings include:

During the visit, the following is an example of what was observed:
1) After the construction of the MRI addition the existing two hour fire/smoke barrier did not continue from one outside wall to outside wall or to a fire wall of equal or greater fire rating.
2) The square footage of this smoke compartment appeared, from observation and documentation provided by the facility, to be over 22,500 square feet.
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2000 NFPA 101, 19.3.7.1 Smoke barriers shall be provided to divide every story used for sleeping rooms for more than 30 patients into not less than two smoke compartments. The size of any such smoke compartment shall not exceed 22,500 ft2 (2100 m2), and the travel distance from any point to reach a door in the required smoke barrier shall not exceed 200 ft (60 m).
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K38. The facility failed to provide a level floor surface on both sides of the MRI exterior exit door per code. Findings include:

During the visit, the following is an example of what was observed:
The new exterior exit door for the MRI addition did not have a level floor surface on the exterior side of the building; the stairs start immediately. The door swings out.
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2000 NFPA 101, 7.2.1.3 Floor Level. The elevation of the floor surfaces on both sides of a door shall not vary by more than 1/2 in. (1.3 cm). The elevation shall be maintained on both sides of the doorway for a distance not less than the width of the widest leaf. Thresholds at doorways shall not exceed 1/2 in. (1.3 cm) in height. Raised thresholds and floor level changes in excess of 1/4 in. (0.64 cm) at doorways shall be bevelled with a slope not steeper than 1 in 2.
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K39. The facility failed to provide a corridor per code. Findings include:

During the visit, the following is an example of what was observed:
The new corridor for the MRI addition narrows down to 6'-0" at approximately 7'-0" in front of the exit door.
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2000 NFPA 101, 18.2.3.3 Aisles, corridors, and ramps required for exit access in a hospital or nursing home shall be not less than 8 ft (2.4 m) in clear and unobstructed width. Where ramps are used as exits, see 18.2.2.6.

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K40. The facility failed to provide an exit door per code. Findings include:

During the visit, the following is an example of what was observed:
The MRI addition exit door measured 36".

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2000 NFPA 101, 18.2.3.5 The minimum clear width for doors in the means of egress from sleeping rooms; diagnostic and treatment areas, such as x-ray, surgery, or physical therapy; and nursery rooms shall be as follows:
(1) Hospitals and nursing homes - 41.5 in. (105 cm)
(2) Psychiatric hospitals and limited care facilities - 32 in. (81 cm)

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K46. The facility failed to provide emergency lighting per code. Findings include:

During the visit, the following is an example of what was observed:
Per observation and interview, no emergency lighting was provided in the MRI addiiton.

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2000 NFPA 101, 7.9.2.1 Emergency illumination shall be provided for not less than 11/2 hours in the event of failure of normal lighting. Emergency lighting facilities shall be arranged to provide initial illumination that is not less than an average of 1 ft-candle (10 lux) and, at any point, not less than 0.1 ft-candle (1 lux), measured along the path of egress at floor level. Illumination levels shall be permitted to decline to not less than an average of 0.6 ft-candle (6 lux) and, at any point, not less than 0.06 ft-candle (0.6 lux) at the end of the 11/2 hours. A maximum-to-minimum illumination uniformity ratio of 40 to 1 shall not be exceeded.

2000 NFPA 101, 7.9.2.2 The emergency lighting system shall be arranged to provide the required illumination automatically in the event of any of the following:
(1) Interruption of normal lighting such as any failure of a public utility or other outside electrical power supply
(2) Opening of a circuit breaker or fuse
(3) Manual act(s), including accidental opening of a switch controlling normal lighting facilities

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K51. The facility failed to provide a fire alarm system per code. Findings include:

During the visit, the following are examples of what was observed:
1. There was not a fire alarm pull station in the path of egress in the MRI addition.
2. There was not an audible/visual fire alarm device in the MRI corridor.

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2000 NFPA 101, 9.6.2.3 A manual fire alarm box shall be provided in the natural exit access path near each required exit from an area, unless modified by another section of this Code.

2000 NFPA 101, 9.6.1.3 The provisions of Section 9.6 cover the basic functions of a complete fire alarm system, including fire detection, alarm, and communications. These systems are primarily intended to provide the indication and warning of abnormal conditions, the summoning of appropriate aid, and the control of occupancy facilities to enhance protection of life.

2000 NFPA 101, 9.6.1.9 For the purposes of this Code, a complete fire alarm system shall be used for initiation, notification, and control and shall provide the following. (a) Initiation. The initiation function provides the input signal to the system. (b) Notification. The notification function is the means by which the system advises that human action is required in response to a particular condition. (c) Control. The control function provides outputs to control building equipment to enhance protection of life.

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K56. The facility failed to provide an automatic sprinkler system per code. Findings include:

During the visit, the following is an example of what was observed:
The new MRI addition did not have an automatic sprinkler system.

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2000 NFPA 101, 18.3.5.1 Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.