HospitalInspections.org

Based on observation and interview it was determined the facility failed to ensure that hazardous areas maintained a smoke resistant rating and doors were equipped with door closures as required.

The findings include:

During the Life Safety Code survey on July 15, 2010, at 11:00 AM, with the Director of Maintenance, the first floor mechanical room was observed to have holes in the ceiling and gaps around piping. The door closure was also observed to be disengaged. These holes and gaps must be filled with a suitable material to help prevent smoke and fire from spreading to other parts of the facility. Doors to hazardous areas are required to be equipped with a door closing device. An interview with the Director of Maintenance revealed most of the damage throughout the facility was caused by contractors. The Director of Maintenance stated that it was hard to keep up with the contractors because the Director of Maintenance did not know when or where the contractors would be working at in the hospital.

During the survey, observation revealed numerous penetrations, missing ceiling tiles and door closing devices throughout the facility, to include but not limited to the first floor housekeeping and medical records rooms; the second floor dirty utility; central storage; the third floor storage and medical records rooms; and, the fourth floor storage room.

The facility was cited on July 28, 2005 for the same deficient practice. It is recommended this facility receive a follow up survey for continued non compliance issues cited on July 28, 2005, under K25 and July 8, 2010 under K29.



Reference: NFPA 101 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. Exception: Doors in rated enclosures shall be permitted to have nonrated, factory- or field-applied protective plates extending not more than 48 in. (122 cm) above the bottom of the door.

Based on observation and interview it was determined the facility failed to ensure that exits had a durable surface to the public way.

The findings include:

During the Life Safety Code tour on July 15, 2010, at 10:45 AM, with the Director of Maintenance, an exit located near the X-ray room was noted to exit to a grassy area. Exits must have a durable surface to the public way to support foot traffic, wheelchairs, beds, equipment etc., in case of an emergency situation. An interview with the Director of Maintenance revealed he was not aware exterior exits should have a durable surface to the public way. The emergency room exit was also observed during the survey to exit to a grassy area.

Based on observation and interview it was determined the facility failed to ensure that hazardous areas maintained a smoke resistant rating and doors were equipped with door closures as required.

The findings include:

During the Life Safety Code survey on July 15, 2010, at 11:00 AM, with the Director of Maintenance, the first floor mechanical room was observed to have holes in the ceiling and gaps around piping. The door closure was also observed to be disengaged. These holes and gaps must be filled with a suitable material to help prevent smoke and fire from spreading to other parts of the facility. Doors to hazardous areas are required to be equipped with a door closing device. An interview with the Director of Maintenance revealed most of the damage throughout the facility was caused by contractors. The Director of Maintenance stated that it was hard to keep up with the contractors because the Director of Maintenance did not know when or where the contractors would be working at in the hospital.

During the survey, observation revealed numerous penetrations, missing ceiling tiles and door closing devices throughout the facility, to include but not limited to the first floor housekeeping and medical records rooms; the second floor dirty utility; central storage; the third floor storage and medical records rooms; and, the fourth floor storage room.

The facility was cited on July 28, 2005 for the same deficient practice. It is recommended this facility receive a follow up survey for continued non compliance issues cited on July 28, 2005, under K25 and July 8, 2010 under K29.



Reference: NFPA 101 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. Exception: Doors in rated enclosures shall be permitted to have nonrated, factory- or field-applied protective plates extending not more than 48 in. (122 cm) above the bottom of the door.

Based on observation and interview it was determined the facility failed to ensure that exits had a durable surface to the public way.

The findings include:

During the Life Safety Code tour on July 15, 2010, at 10:45 AM, with the Director of Maintenance, an exit located near the X-ray room was noted to exit to a grassy area. Exits must have a durable surface to the public way to support foot traffic, wheelchairs, beds, equipment etc., in case of an emergency situation. An interview with the Director of Maintenance revealed he was not aware exterior exits should have a durable surface to the public way. The emergency room exit was also observed during the survey to exit to a grassy area.