HospitalInspections.org

1) The facility failed to ensure doors in a two hour fire resistance rated occupancy separation wall provided a 90-minute fire resistance rating.

Observation determined the cross corridor door in the two-hour fire resistance occupancy separation wall on third floor at the north end of the west corridor did not have a rating plate on the door. The fire resistance rating of the door could not be verified.

Failure to ensure the fire resistance rating of fire doors increases the risk of injury or death due to fire.

This deficiency affected one (1) of three (3) two-hour fire resistance rated walls on the third floor.

2) The facility failed to ensure communicating openings in a two-hour fire resistance rated wall occur only in corridors.

Observation determined the two-hour fire resistance rated occupancy separation wall on the first floor separating the hospital from the clinic had seven (7) doors through the wall leading into a room on the hospital side of the wall.

Failure to ensure communicating openings through a two-hour fire resistance rated wall occur only in corridors increases the risk of injury or death due to fire.

This deficiency affected seven (7) of fifteen (15) communicating openings through the two-hour fire resistance rated occupancy separation wall on the first floor.

During its swing, any door in a means of egress shall leave not less than one-half of the required width of an aisle, corridor, passageway, or landing unobstructed and shall not project more than 7 inches into the required width of an aisle, corridor, passageway, or landing, when fully open. 7.2.1.4.4.

The facility failed to ensure exit access was readily available at all times.

Observation determined the double set of corridor doors to the I.T. Room on the third floor opened outward into the exit corridor and extended more than 7 inches from the wall when fully opened.

Failure to ensure exit access is readily available at all times increases the risk of death or injury due to fire.

This deficiency affected two (2) of numerous corridor doors in the means of egress throughout the facility.

Smoke detectors must not be located in a direct airflow nor closer than 3 ft. (1 m) from an air supply diffuser or return air opening. 19.3.4.5.1, 9.6.2.10.1, NFPA 72 2-3.5.1

The facility failed to ensure the smoke detection system was in compliance with NFPA 72, National Fire Alarm Code.

Observation determined smoke detectors located throughout the facility were installed within 3 ft. of an air supply diffuser.

Failure to install the smoke detection system as required increases the risk of death or injury due to fire.

This deficiency affected smoke detectors throughout the facility. The smoke detection system serves the entire facility.

The facility failed to install the automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems to provide adequate coverage for all portions of the building.

Observation determined:

1) Two (2) of four (4) sprinklers located in the E.R. X-Ray Room were obstructed by ceiling mounted equipment. The track for the X-Ray equipment was mounted on the ceiling next to two sprinklers obstructing the flow and affecting coverage of the sprinklers in the room.

The deficiency affected one (1) of numerous areas in the facility. The automatic sprinkler system serves the entire building.

2) Automatic sprinkler systems must be installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.

Ordinary-temperature-rated sprinklers shall be used throughout buildings. NFPA 13, Section 5-3.1.5

The facility failed to provide ordinary-temperature-rated sprinklers throughout the building.

Observation determined four (4) of four (4) intermediate-temperature-rated sprinklers were installed in place of ordinary-temperature-rated sprinklers in the Pharmaceutical Storage Room in the Penthouse.

The deficiency affected one (1) of numerous rooms protected by the automatic sprinkler system, which serves the entire facility.

Failure to install the automatic sprinkler system in accordance with NFPA 13 increases the risk of injury and death due to fire.

Automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. 19.7.6, 4.6.12, NFPA 25, 1-11

The facility failed to ensure the automatic sprinkler system was continuously maintained in a reliable operating condition as required by NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems.

Observation determined corrosion on the sprinkler located in the North Entryway of the facility, affecting the activation and flow of water from the sprinkler.

Failure to test and maintain the automatic sprinkler system in accordance with NFPA 25 increases the risk of death or injury due to fire.

This deficiency affected one (1) of numerous sprinklers in the facility. The automatic sprinkler system which serves the entire facility.

The facility failed to maintain the means of egress free of obstructions or impediments to full instant access in case of fire.

Observation determined:
1) Numerous pieces of equipment and other various items were being stored in the exit corridors throughout the Operating Room area.
2) A wall mounted water fountain extended nine (9) inches from the wall into the exit corridor in the 5-West Wing.

Failure to maintain exit access free of obstructions increases the risk of injury or death due to fire.

This deficiency affected exit access in two (2) of eighteen (18) smoke compartments in the facility.

1) A functional test must be conducted on every required battery powered emergency lighting system at 30-day intervals for a minimum of 30 seconds. An annual test must be conducted for 90-minute duration. Written records of testing must be kept by the owner for inspection by the authority having jurisdiction.

The facility failed to ensure emergency lighting of at least 90-minute duration.

Review of documentation determined the battery powered emergency lights throughout the facility were not tested for 90 minutes duration in the past year.Failure to test the emergency lighting system at 30-day intervals for not less than 30 seconds and test every battery-powered emergency lighting system annually for not less than 90 minutes increases the risk of injury or death.
The deficiency affected emergency lighting in the entire facility.

2) The facility failed to test and maintain the fire alarm system as required by NFPA 72, National Fire Alarm Code.

Review of documentation and interview with staff determined the annual test of the fire alarm system was not performed as required. No record was available of testing of the fire alarm system.

Failure to test and maintain the fire alarm system in accordance with NFPA 72 increases the risk of death or injury due to fire.

This deficiency affected one (1) of one (1) fire alarm system. The fire alarm system serves the entire facility.

3) Visual inspection frequencies and specific testing and maintenance frequencies for smoke detection systems are dictated by the prescriptive requirements of NFPA 72, National Fire Alarm Code (Chapter 10-Inspection, Testing and Maintenance Tables 10.3.1, 10.4.2.2 and 10.4.3). This code identifies specific inspection, testing and maintenance frequencies and methods.

Sensitivity testing of smoke detectors is to be completed for all smoke detectors during the first year in service, and the alternate year following. After the second required calibration test, if the detector has remained within its listed and marked sensitivity range, the length of time between calibration tests may be extended, not to exceed five years.

The facility failed to ensure smoke detectors were maintained, inspected and tested in accordance with the manufacturer's specifications.

Review of documentation and interview with staff determined the smoke detection system did not have sensitivity testing at frequencies in compliance with the minimum requirements of NFPA 72.

No records were available to indicate the smoke detectors were sensitivity tested as required by NFPA 72.

Failure to test the smoke detection system in accordance with NFPA 72 increases the risk of death or injury due to fire.

This deficiency affected the entire building.

The facility failed to ensure the emergency generator was in compliance with NFPA 110, Standard for Emergency and Standby Power Systems. 6-3.6.

Storage batteries, including electrolyte levels, used in connection with Level 1 and Level 2 systems shall be inspected at intervals of not more than 7 days and shall be maintained in full compliance with manufacturer's specifications. Defective batteries shall be repaired or replaced immediately upon discovery of defects.

Record review determined the specific gravity of the emergency generator batteries was not checked at seven (7) day intervals during the past twelve (12) months.

Failure to inspect and maintain the emergency generator in accordance with NFPA 110 increases the risk of death or injury due to fire.

The deficiency affected one (1) emergency generator which provides all emergency power to the facility.