HospitalInspections.org

Based on observation and interview, the facility failed to maintain fire/smoke dampers that penetrated the fire/smoke barrier walls in the attic area. This deficient practice affected ten of ten smoke compartments, staff, and all the residents. The facility has the capacity for 25 beds with a census of 20 on the day of the survey.

The findings include:

During the Life Safety Code survey on 03/20/13, at 10:55 PM, with the Director of Maintenance (DOM), a fire/smoke barrier wall above the fire doors on the third floor was observed to have ductwork that contained a fire/smoke damper. A fire/smoke damper closes to prevent fire and hot gases from penetrating the fire/smoke barrier wall and is required to be inspected and maintained every six years. An interview with the DOM on 03/20/13, at 10:55 PM revealed the dampers were located throughout the facility. The DOM was aware the dampers were required to be inspected but did not know when they were last inspected. The DOM stated there was no work order to have the dampers inspected.

This deficient practice was revealed to the Administrator upon exit.

Reference: NFPA 90a (1999 Edition).

3-4.7 Maintenance.
At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.

Based on observation and interview, the facility failed to ensure that a fire/smoke barrier door was maintained according to NFPA standards. This deficient practice would affect two of ten smoke compartments, staff, and visitors.

The findings include:

During the Life Safety Code tour on 03/20/13 at 12:00 PM, with the Director of Maintenance (DOM), a fire/smoke barrier door located on the ground level was observed to be wedged open. This type of door must remain closed or be connected to the fire alarm system so it would close automatically in case of fire conditions. An interview with the DOM on 03/20/13 at 12:00 PM revealed he had planned on connecting this door to the fire alarm system, however, there was no work order to do so.

This deficient practice was revealed to the Administrator upon exit.

Reference: NFPA 101 (2000 Edition).

7.2.1.8.1*
A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2.
7.2.1.8.2
In any building of low or ordinary hazard contents, as defined in 6.2.2.2 and 6.2.2.3, or where approved by the authority having jurisdiction, doors shall be permitted to be automatic-closing, provided that the following criteria are met:
(1) Upon release of the hold-open mechanism, the door becomes self-closing.
(2) The release device is designed so that the door instantly releases manually and upon release becomes self-closing, or the door can be readily closed.
(3) The automatic releasing mechanism or medium is activated by the operation of approved smoke detectors installed in accordance with the requirements for smoke detectors for door release service in NFPA 72, National Fire Alarm Code?.
(4) Upon loss of power to the hold-open device, the hold-open mechanism is released and the door becomes self-closing.
(5) The release by means of smoke detection of one door in a stair enclosure results in closing all doors serving that stair.

Based on observation and interview, the facility failed to maintain fire alarm requirements for fire/smoke barrier doors. This deficient practice affected ten of ten smoke compartments, staff, and all the residents. The facility has the capacity for 25 beds with a census of 20 on the day of the survey.

The findings include:

During the Life Safety Code tour on 03/20/13 at 10:40 AM, with the Director of Maintenance (DOM), observation revealed one smoke detector on one side of a fire/smoke barrier door on the fourth floor. Smoke detection is required on both sides of the door. An interview with the DOM on 03/20/13 at 10:40 AM revealed he was not aware of this requirement. Smoke detection was observed on one side of fire/smoke barrier doors throughout the facility during the survey.

This deficient practice was revealed to the Administrator upon exit.

Reference: NFPA 101 (2000 Edition).

7.2.1.8.2
In any building of low or ordinary hazard contents, as defined in 6.2.2.2 and 6.2.2.3, or where approved by the authority having jurisdiction, doors shall be permitted to be automatic-closing, provided that the following criteria are met:

(3) The automatic releasing mechanism or medium is activated by the operation of approved smoke detectors installed in accordance with the requirements for smoke detectors for door release service in NFPA 72, National Fire Alarm Code?.


Reference: NFPA 72 (1999 Edition).

2-10.6.5.1.2*
If the depth of wall section above the door is greater than 24 in. (610 mm), two ceiling-mounted detectors shall be required, one on each side of the doorway. Figure 2-10.6.5.1.1, part F, shall apply.

Based on observation and interview, the facility failed to maintain the smoking area according to NFPA standards. This deficient practice would affect one of ten smoke compartments, staff, and visitors.

The findings include:

During the Life Safety Code tour on 03/20/13 at 11:40 AM, with the Director of Maintenance (DOM), a smoking area at the back of the hospital was observed not to have a metal self-closing container to empty cigarette ashtrays in as required. An interview with the DOM on 03/20/13 at 11:40 AM revealed he was not aware of this requirement.

This deficient practice was revealed to the Administrator upon exit.