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National Fire Protection Association (NFPA) 101 Life Safety Code - 2000 Edition
19.3.2.1 Hazardous Areas.
Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.

This standard is not met as evidenced by:

Based on observation it was determined the hospital failed to maintain all hazardous room doors with operable self-closing devices. Findings include:

On 02/08/11 at approximately 1:00 p.m., the supply storage room (greater than fifty (50) square feet) located near laundry was observed to have the self-closing device disconnected on the corridor door.

Based on observation it was determined the hospital failed to maintain all exits readily accessible. Findings include:

During tour of the hospital on 02/07/11 at approximately 1:15 p.m., a computer on wheels was observed stored (on charge) unattended in the acute care unit corridor egress path.

Based on review of facility documentation and staff interview it was determined the hospital failed to maintain the medical gas system in accordance with National Fire Protection Association (NFPA) 99, Chapter 4. Findings include:

1. On 02/07/11 at approximately 3:00 p.m., a medical gas system inspection report prepared by Northeast Medical Consulting Incorporated and dated 10/24/10 was reviewed. This report indicated the following deficiencies were found during the medical gas inspection:

I) Source Equipment
A) Oxygen
1. A gas specific demand check should be installed on the master pressure switch and main gauge.

B) Vacuum
1. A local audible and visual signal for the lag pump in use should be installed, function, and wired to the master alarm panels.
2. The receiver should have a drain installed.
3. The receiver should have by-pass valves installed.
4. A gas specific demand check should be installed on the master low vacuum switch.
5. The vacuum system should be labeled.
6. The source piping is required to be labeled with color coded directional tape.
7. A gas specific demand check should be installed on the main gauge.

II) Alarms
A) Master Alarms
1. A "lag pump in use" alarm point should be installed for vacuum at both panels.

B) Area Alarms
1. 2 (two) panels have an incorrect or outdated list of rooms controlled and they are required to be updated.

2. On 02/07/11 at approximately 3:15 p.m., an interview with the director of support services revealed that the aforementioned deficiencies cited on the medical system inspection report dated 10/24/10 have not been corrected as of this date 02/07/11.

National Fire Protection Association (NFPA) 101 Life Safety Code - 2000 Edition
19.3.2.1 Hazardous Areas.
Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.

This standard is not met as evidenced by:

Based on observation it was determined the hospital failed to maintain all hazardous room doors with operable self-closing devices. Findings include:

On 02/08/11 at approximately 1:00 p.m., the supply storage room (greater than fifty (50) square feet) located near laundry was observed to have the self-closing device disconnected on the corridor door.

Based on observation it was determined the hospital failed to maintain all exits readily accessible. Findings include:

During tour of the hospital on 02/07/11 at approximately 1:15 p.m., a computer on wheels was observed stored (on charge) unattended in the acute care unit corridor egress path.

Based on review of facility documentation and staff interview it was determined the hospital failed to maintain the medical gas system in accordance with National Fire Protection Association (NFPA) 99, Chapter 4. Findings include:

1. On 02/07/11 at approximately 3:00 p.m., a medical gas system inspection report prepared by Northeast Medical Consulting Incorporated and dated 10/24/10 was reviewed. This report indicated the following deficiencies were found during the medical gas inspection:

I) Source Equipment
A) Oxygen
1. A gas specific demand check should be installed on the master pressure switch and main gauge.

B) Vacuum
1. A local audible and visual signal for the lag pump in use should be installed, function, and wired to the master alarm panels.
2. The receiver should have a drain installed.
3. The receiver should have by-pass valves installed.
4. A gas specific demand check should be installed on the master low vacuum switch.
5. The vacuum system should be labeled.
6. The source piping is required to be labeled with color coded directional tape.
7. A gas specific demand check should be installed on the main gauge.

II) Alarms
A) Master Alarms
1. A "lag pump in use" alarm point should be installed for vacuum at both panels.

B) Area Alarms
1. 2 (two) panels have an incorrect or outdated list of rooms controlled and they are required to be updated.

2. On 02/07/11 at approximately 3:15 p.m., an interview with the director of support services revealed that the aforementioned deficiencies cited on the medical system inspection report dated 10/24/10 have not been corrected as of this date 02/07/11.