HospitalInspections.org

*The facility failed to provide a two hour fire barrier separation between the existing conforming building and the new MRI addition nonconforming building per code. Findings include:

During the visit, the following is an example of what was observed:
Per observation and interview 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)

___________________________

2000 NFPA 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
.

*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

_____________________

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.
.

*The facility failed to provide a two hour fire barrier separation between the existing conforming building and the new MRI addition nonconforming building per code. Findings include:

During the visit, the following is an example of what was observed:
Per observation and interview 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)

___________________________

2000 NFPA 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
.

*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".

________________

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)

.

The facility failed to maintain the Digital Alarm Communicator Transmitter (DACT) per code. Findings include:
During the survey, the following is an example of what was observed:
The Digital Alarm Communicator Transmitter (DACT) did not have a remote annunciator at a manned location. The fire alarm system sounds in the building and sends a signal offsite.
_________________
2000 NFPA 101, 9.6.7.5 A system trouble signal shall be annunciated at the control center by means of audible and visible indicators.
1999 NFPA 72, 1-5.4.6 Trouble signals and their restoration to normal shall be indicated within 200 seconds at the locations identified in 1-5.4.6.1 or 1-5.4.6.2. Trouble signals required to indicate at the protected premises shall be indicated by distinctive audible signals. These audible trouble signals shall be distinctive from alarm signals. If an intermittent signal is used, it shall sound at least once every 10 seconds, with a minimum duration of 1/2 second. An audible trouble signal shall be permitted to be common to several supervised circuits. The trouble signal(s) shall be located in an area where it is likely to be heard.
.

*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.

__________________

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.

.

The facility failed to maintain the electrical system per code. Findings include:
During the survey, the following are examples of what was observed:
1. The following rooms had microwave(s) and/or refrigerator(s) plugged into surge protector(s):
Basement
a. Home Health had a microwave and a refrigerator
b. Dietary Break Room had a refrigerator
First Floor
c. Nurses ' Lounge in the O.R. had two refrigerators
d. ICU Break Room had a microwave and a refrigerator
e. Doctors ' Dictation Room in ICU had a refrigerator
f. Pharmacy Break Room had a microwave
2. Infection Control Office had an extension cord feeding a surge protector, feeding another surge protector
_________________
1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip.

1999 NFPA 70, 400-7 (b) Attachment Plugs. Where used as permitted in subsections (a)(3), (a)(6), and (a)(8), each flexible cord shall be equipped with an attachment plug and shall be energized from a receptacle outlet.

The facility failed to maintain the Digital Alarm Communicator Transmitter (DACT) per code. Findings include:
During the survey, the following is an example of what was observed:
The Digital Alarm Communicator Transmitter (DACT) did not have a remote annunciator at a manned location. The fire alarm system sounds in the building and sends a signal offsite.
_________________
2000 NFPA 101, 9.6.7.5 A system trouble signal shall be annunciated at the control center by means of audible and visible indicators.
1999 NFPA 72, 1-5.4.6 Trouble signals and their restoration to normal shall be indicated within 200 seconds at the locations identified in 1-5.4.6.1 or 1-5.4.6.2. Trouble signals required to indicate at the protected premises shall be indicated by distinctive audible signals. These audible trouble signals shall be distinctive from alarm signals. If an intermittent signal is used, it shall sound at least once every 10 seconds, with a minimum duration of 1/2 second. An audible trouble signal shall be permitted to be common to several supervised circuits. The trouble signal(s) shall be located in an area where it is likely to be heard.
.

*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.

__________________

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.

.

The facility failed to maintain the electrical system per code. Findings include:
During the survey, the following are examples of what was observed:
1. The following rooms had microwave(s) and/or refrigerator(s) plugged into surge protector(s):
Basement
a. Home Health had a microwave and a refrigerator
b. Dietary Break Room had a refrigerator
First Floor
c. Nurses ' Lounge in the O.R. had two refrigerators
d. ICU Break Room had a microwave and a refrigerator
e. Doctors ' Dictation Room in ICU had a refrigerator
f. Pharmacy Break Room had a microwave
2. Infection Control Office had an extension cord feeding a surge protector, feeding another surge protector
_________________
1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip.

1999 NFPA 70, 400-7 (b) Attachment Plugs. Where used as permitted in subsections (a)(3), (a)(6), and (a)(8), each flexible cord shall be equipped with an attachment plug and shall be energized from a receptacle outlet.