HospitalInspections.org

Based on observations by surveyors 35163 and 16776 on 02/05/2019:

1) The facility had a locksmith install a flush bolt latching device to the bottom of the fire rated door near the pharmacy and stairwell B. No documentation could be provided that the latching device was listed hardware for the fire rated doors.

Per NFPA 80 Standard for Fire Doors and Other Opening Protectives, Section 7.4.3 advised only labeled fire door hardware shall be installed on fire doors.

2) The 45 min rated doors located near exam room # 1186 had penetrations in the door. The facility installed metal plugs to seal the penetrations, but no documentation could be provided that the plug was listed for use in rated doors. Per NFPA 80 Standard for Fire Doors and Other Opening Protectives, Section 5.1.5.2 Field Modifications.

5.1.5.2.1 In cases where a field modification to a fire door assembly is desired, the laboratory whose label is on the assembly shall be contacted and a description of the modifications shall be presented to the laboratory.

5.1.5.2.2 If the laboratory finds that the modifications will not compromise the integrity and fire resistance capabilities of the assembly, the modifications shall be permitted to be authorized by the laboratory without a field visit from the laboratory.

3) Stairwell B & C are marked as exit stairs from the lower level of the building. Both stairs terminate within the interior of the building at level 1. The facilities response to this tag was to remove the exit signs on the lower level and make the stairs a "convenience stair" , however this leaves the lower level with only one exit that meets travel distance.
Life Safety Code Section 19.2.4 Number of Exits.
19.2.4.1 Not less than two exits shall be provided on every story.

The director of Maintenance was present during these observations

Based on observations of surveyors 351163 and 16776 on 02/05/2019

The sliding exit door located in the emergency department has underzizes "push to exit" labels. Per Chapter 19 Life Safety Code Chapter 7 the size has to be a minium of 1/2 inches

The maintainence director was present during this observation

Based on observation by surveyors 35163 and 16776 on 02/05/2019:

The double 45 min rated fire doors located that lead into/out of the anticoagulation unit across from Cancer care were missing the fire labels. The facilities response was to remove the doors, however this wing is labeled as a suite on the plans and would require doors in order to not exceed the maximum sq./ft. of a suite designation.

The maintenance director was present during this observation

Based on observations surveyors 35163 and 16776 on 02/05/2019

1. Housekeeping closet # 1424 has urethane spray foam and no documentation could be provided to indicate it meets requirements for interior finish.

The maintenance director was present during this observation

Based on observation and interview by surveyors 35163 and and 16776 on 02/07/2019:

There is no sprinkler protection above the ceiling in the main corridor. The void space also has exposed beams. No documentation was provided by the facility that they have contracted with a architect/engineer on how to resolve this issue.

NFPA 13 Standard for the Installation of Sprinkler Systems requires all areas to have sprinkler coverage


The maintenance director was present during this observation

Based on observation and record review by surveyors 35163 and 16776 on 02/05/2019

The 2 hr fire rated wall near surgical center does not go to the roof deck. No documentation was provided that they contracted with architect/engineer to resolve this issue.

The maintenance director was present during this observation

Based on observation of surveyors 35163 and 16776 on 02/05/2019

Soiled lined room door located at OB/GYN does not latch.

Life Safety Code Chapter 19 Section 19.3.2 advises all hazardous doors shall self close and positive latch


The maintenance director was present during this observation