HospitalInspections.org

During the survey tour of 06/10/2015 at 1455, while accompanied by the Facilities Manager, through observation and staff interview, it was discovered that the facility has failed to maintain doors to be held open only by devices arranged to automatically close such doors upon activation of the fire alarm. In the event of a fire, this would allow for the passage of smoke and/or flames into or out of rooms meant to be protected by self-closing doors, placing staff, residents and visitors at risk. This finding was acknowledged by the Facilities Manager.

The findings include but are not limited to:

SDS Soiled Utility Room - Fire-rated door has had a kick-down installed, propping required self-closing door open.

Facilities Manager states that he has an idea of who may have installed this, but was previously unaware of it being on the door.

During the survey tour of 06/10/2015 at 1430, while accompanied by the Facilities Manager, through observation and staff interview, it was discovered that the facility has failed to provide the correct portable fire extinguishers. This could result in a delay in controlling or extinguishing a fire. This finding was acknowledged by the Facilities Manager.

This standard is not being met as evidenced by:

1. On the roof of the existing wing, at the Heliport Lobby, there is one Class 10A 120BC portable fire extinguisher. NFPA 10 (Standard for Portable Fire Extinguishers) references NFPA 418 (Standard for Heliports):

3.6 Fire Protection.

A foam fire-extinguishing system shall be designed and installed to protect the rooftop landing pad.

Exception No. 1: A foam fire-extinguishing system shall not be required for heliports located on parking garages, unoccupied buildings, or other similar unoccupied structures.

Exception No. 2: For H-1 heliports, two portable foam extinguishers, each having a rating of 20-A 160-B, shall be permitted to be used to satisfy this requirement.

The Facilities Manager stated that he was not aware of this requirement as the facility has not previously been cited for this deficiency.

During the survey tour of 06/10/2015 at 1505, while accompanied by the Facilities Manager, through observation and staff interview, it was discovered that the facility has failed to provide the correct portable fire extinguishers. This could result in a delay in controlling or extinguishing a fire. This finding was acknowledged by the Facilities Manager.

This standard is not being met as evidenced by:

1. Mechanical Penthouse on roof of the new wing does not have a portable fire extinguishers available within a 75 ' < travel distance (per NFPA 10, the minimum requirement for this space is a 4A 40BC rated extinguisher).
The Facilities Manager stated that he was not aware that there was no extinguisher in this space and acknowledged it would be most difficult to get an extinguisher up the ladder to this space in a timely fashion.

During the survey tour of 06/10/2015 at 1415, while accompanied by the Facilities Manager, through observation and staff interview, it was confirmed that the facility is out of compliance with NFPA 96 (during record review, at approximately 1115, current hood testing documents could not be produced). This could result in failure of the kitchen hood suppression system to function properly, putting staff at risk. This finding was acknowledged by the Facilities Manager.

The deficiency is as follows:

The most current tag on the UL300 system is punched-out for 07/2014 (by General Fire). There is no evidence of required semi-annual testing since that date.

The Facilities Manager stated that he was unaware that the service had not been performed by the vendor.

During the survey tour of 06/10/2015 at 1455, while accompanied by the Facilities Manager, through observation and staff interview, it was discovered that the facility has failed to maintain doors to be held open only by devices arranged to automatically close such doors upon activation of the fire alarm. In the event of a fire, this would allow for the passage of smoke and/or flames into or out of rooms meant to be protected by self-closing doors, placing staff, residents and visitors at risk. This finding was acknowledged by the Facilities Manager.

The findings include but are not limited to:

SDS Soiled Utility Room - Fire-rated door has had a kick-down installed, propping required self-closing door open.

Facilities Manager states that he has an idea of who may have installed this, but was previously unaware of it being on the door.

During the survey tour of 06/10/2015 at 1430, while accompanied by the Facilities Manager, through observation and staff interview, it was discovered that the facility has failed to provide the correct portable fire extinguishers. This could result in a delay in controlling or extinguishing a fire. This finding was acknowledged by the Facilities Manager.

This standard is not being met as evidenced by:

1. On the roof of the existing wing, at the Heliport Lobby, there is one Class 10A 120BC portable fire extinguisher. NFPA 10 (Standard for Portable Fire Extinguishers) references NFPA 418 (Standard for Heliports):

3.6 Fire Protection.

A foam fire-extinguishing system shall be designed and installed to protect the rooftop landing pad.

Exception No. 1: A foam fire-extinguishing system shall not be required for heliports located on parking garages, unoccupied buildings, or other similar unoccupied structures.

Exception No. 2: For H-1 heliports, two portable foam extinguishers, each having a rating of 20-A 160-B, shall be permitted to be used to satisfy this requirement.

The Facilities Manager stated that he was not aware of this requirement as the facility has not previously been cited for this deficiency.

During the survey tour of 06/10/2015 at 1505, while accompanied by the Facilities Manager, through observation and staff interview, it was discovered that the facility has failed to provide the correct portable fire extinguishers. This could result in a delay in controlling or extinguishing a fire. This finding was acknowledged by the Facilities Manager.

This standard is not being met as evidenced by:

1. Mechanical Penthouse on roof of the new wing does not have a portable fire extinguishers available within a 75 ' < travel distance (per NFPA 10, the minimum requirement for this space is a 4A 40BC rated extinguisher).
The Facilities Manager stated that he was not aware that there was no extinguisher in this space and acknowledged it would be most difficult to get an extinguisher up the ladder to this space in a timely fashion.

During the survey tour of 06/10/2015 at 1415, while accompanied by the Facilities Manager, through observation and staff interview, it was confirmed that the facility is out of compliance with NFPA 96 (during record review, at approximately 1115, current hood testing documents could not be produced). This could result in failure of the kitchen hood suppression system to function properly, putting staff at risk. This finding was acknowledged by the Facilities Manager.

The deficiency is as follows:

The most current tag on the UL300 system is punched-out for 07/2014 (by General Fire). There is no evidence of required semi-annual testing since that date.

The Facilities Manager stated that he was unaware that the service had not been performed by the vendor.