HospitalInspections.org

NFPA 101 (2000) LIFE SAFETY CODE SURVEY STANDARD - If the building has a common wall with a nonconforming building, the common wall is a fire barrier having at least a two-hour fire resistance rating constructed of materials as required for the addition. Communicating openings occur only in corridors and are protected by approved self-closing fire doors, in accordance with NFPA 101 (00) Chapter 19, Section 19.1.1.4.1 and 19.1.1.4.2

FINDINGS INCLUDE:

On 6/16/10 between 9:30 AM and 1:30 PM, it was observed that the hospital was connected to both a nursing home and an outpatient medical clinic, and the following observations were made:
A). The hospital was not separated from the nursing home with fire barriers having not less than 2-hour fire resistance ratings, and;
B). The hospital was not separated from the outpatient medical clinic with fire barriers having not less than 2-hour fire resistance ratings.

These findings were confirmed with the chief building engineer [DS] at the times of discovery.

NFPA 101 (2000) LIFE SAFETY CODE SURVEY STANDARD - Illumination of means of egress, including exit discharge, is arranged so that a failure of any single lighting fixture or bulb will not leave the area in darkness.

Based on observation, the facility had an exit discharge location(s) which was not illuminated in accordance with NFPA 101 (2000), Chapter 19, Section 19.2.8. and Chapter 7, Section 7.9.1. In an emergency evacuation situation, this deficient practice could adversely affect 20 of 20 patients, visitors and staff.

FINDINGS INCLUDE:

On 6/16/10 at 12:05 PM, observation revealed that illumination of the means of egress from the exit discharge door on the South Solarium corridor was by a single light fixture, of the single-bulb type.

This finding was verified with the chief building engineer (DS) at the time of discovery.

Emergency lighting of at least 1 1/2-hour duration shall be provided in accordance with NFPA 101 (2000), Chapter 19, Section 19.2.9.1 and Chapter 7, Section 7.9. Based on an interview with the chief building engineer (DS), it could not be verified that the exterior emergency lighting fixtures were served by the emergency generator, pursuant to NFPA 101 (00), Chapter 7, Section 7.9.2.3. If an emergency evacuation of the building occupants were required during a period of power outage, this deficient practice could adversely affect 20 of 20 patients, staff and visitors.

FINDINGS INCLUDE:

On 6/16/10 at 12:10 PM, observation revealed a light fixture mounted on the exterior wall of the building, located at the exit discharge door from the South Solarium corridor. This light fixture provided emergency illumination of the means of egress, and it could not be confirmed that the light fixture was connected to the emergency generator. As such, the requirement to provide emergency lighting of at least 90-minute duration could not be confirmed.

Based on observation, the facility's method of storing nonflammable gases was not in conformance with NFPA 101 (2000) Chapter 19, Section 19.3.2.4 and NFPA 99 (1999) Chapter 4. This deficient practice could adversely affect 20 of 20 patients staff and visitors.

FINDINGS INCLUDE:

On 6/16/10 at 11:40 AM, while inspecting the facility's Oxygen Storage Room, the following deficiencies were observed:
A). The required 1-hour fire resistive enclosure had not been maintained, in accordance with NFPA 99 (99) Chapter 4, Section 4-3.1.1.2 (b) 3, and;
B). It could not be confirmed that the existing mechanical ventilation system for the Oxygen Storage Room was in conformance with NFPA 99 (1999) Chapter 4, Section 4-3.1.1.2 (b) 4.

These findings were confirmed with the chief building engineer [DS] at the time of discovery.

NFPA 101 (2000) LIFE SAFETY CODE SURVEY STANDARD - Anesthetizing locations shall be protected in accordance with NFPA 99 (1999 edition) Standard for Health Care Facilities, pursuant to NFPA 101 (2000) Chapter 19, Section 19.3.2.3.

FINDINGS INCLUDE:

On 6/16/10 at 12:40 PM while inspecting the surgical area, observation revealed an electrical panel with GFI circuitry located directly outside of the sole operating room, and it could not be confirmed that a circuit interruption could be tolerated [NFPA 70 (99) article 517-20(a)]. If an interruption can be tolerated, GFI protection is permitted. If an interruption cannot be tolerated, an isolated power system is required [NFPA 70 (99), article 517-20(a). Based upon observation, it could not be determined whether this existing arrangement complies with the requirements at NFPA 99 (1999).

The chief building engineer [DS] was in agreement with this finding.

NFPA 101 (2000) LIFE SAFETY CODE SURVEY STANDARD - If the building has a common wall with a nonconforming building, the common wall is a fire barrier having at least a two-hour fire resistance rating constructed of materials as required for the addition. Communicating openings occur only in corridors and are protected by approved self-closing fire doors, in accordance with NFPA 101 (00) Chapter 19, Section 19.1.1.4.1 and 19.1.1.4.2

FINDINGS INCLUDE:

On 6/16/10 between 9:30 AM and 1:30 PM, it was observed that the hospital was connected to both a nursing home and an outpatient medical clinic, and the following observations were made:
A). The hospital was not separated from the nursing home with fire barriers having not less than 2-hour fire resistance ratings, and;
B). The hospital was not separated from the outpatient medical clinic with fire barriers having not less than 2-hour fire resistance ratings.

These findings were confirmed with the chief building engineer [DS] at the times of discovery.

NFPA 101 (2000) LIFE SAFETY CODE SURVEY STANDARD - Illumination of means of egress, including exit discharge, is arranged so that a failure of any single lighting fixture or bulb will not leave the area in darkness.

Based on observation, the facility had an exit discharge location(s) which was not illuminated in accordance with NFPA 101 (2000), Chapter 19, Section 19.2.8. and Chapter 7, Section 7.9.1. In an emergency evacuation situation, this deficient practice could adversely affect 20 of 20 patients, visitors and staff.

FINDINGS INCLUDE:

On 6/16/10 at 12:05 PM, observation revealed that illumination of the means of egress from the exit discharge door on the South Solarium corridor was by a single light fixture, of the single-bulb type.

This finding was verified with the chief building engineer (DS) at the time of discovery.

Emergency lighting of at least 1 1/2-hour duration shall be provided in accordance with NFPA 101 (2000), Chapter 19, Section 19.2.9.1 and Chapter 7, Section 7.9. Based on an interview with the chief building engineer (DS), it could not be verified that the exterior emergency lighting fixtures were served by the emergency generator, pursuant to NFPA 101 (00), Chapter 7, Section 7.9.2.3. If an emergency evacuation of the building occupants were required during a period of power outage, this deficient practice could adversely affect 20 of 20 patients, staff and visitors.

FINDINGS INCLUDE:

On 6/16/10 at 12:10 PM, observation revealed a light fixture mounted on the exterior wall of the building, located at the exit discharge door from the South Solarium corridor. This light fixture provided emergency illumination of the means of egress, and it could not be confirmed that the light fixture was connected to the emergency generator. As such, the requirement to provide emergency lighting of at least 90-minute duration could not be confirmed.

Based on observation, the facility's method of storing nonflammable gases was not in conformance with NFPA 101 (2000) Chapter 19, Section 19.3.2.4 and NFPA 99 (1999) Chapter 4. This deficient practice could adversely affect 20 of 20 patients staff and visitors.

FINDINGS INCLUDE:

On 6/16/10 at 11:40 AM, while inspecting the facility's Oxygen Storage Room, the following deficiencies were observed:
A). The required 1-hour fire resistive enclosure had not been maintained, in accordance with NFPA 99 (99) Chapter 4, Section 4-3.1.1.2 (b) 3, and;
B). It could not be confirmed that the existing mechanical ventilation system for the Oxygen Storage Room was in conformance with NFPA 99 (1999) Chapter 4, Section 4-3.1.1.2 (b) 4.

These findings were confirmed with the chief building engineer [DS] at the time of discovery.

NFPA 101 (2000) LIFE SAFETY CODE SURVEY STANDARD - Anesthetizing locations shall be protected in accordance with NFPA 99 (1999 edition) Standard for Health Care Facilities, pursuant to NFPA 101 (2000) Chapter 19, Section 19.3.2.3.

FINDINGS INCLUDE:

On 6/16/10 at 12:40 PM while inspecting the surgical area, observation revealed an electrical panel with GFI circuitry located directly outside of the sole operating room, and it could not be confirmed that a circuit interruption could be tolerated [NFPA 70 (99) article 517-20(a)]. If an interruption can be tolerated, GFI protection is permitted. If an interruption cannot be tolerated, an isolated power system is required [NFPA 70 (99), article 517-20(a). Based upon observation, it could not be determined whether this existing arrangement complies with the requirements at NFPA 99 (1999).

The chief building engineer [DS] was in agreement with this finding.