HospitalInspections.org

A walk-through of the facility with the Director of Plant Operations, el al, July 29th to August 18th, 2010 found the integrity of a two-hour separation compromised and not conforming to requirements of Section 8.2.3.2.3.1 of the Life Safety Code? at the following location.

The second floor transition point between the Main Hospital and the Pavilion, on the Pavilion side of the bridge, utilizes a one-hour rated door in the two-hour fire rated separation.

This has the effect of reducing the two-hour exterior wall rating on this Type II (222) structure to only one-hour.

A walk-through of the facility with the Director of Plant Operations, el al, July 29th to August 18th, 2010 found the integrity of the smoke barriers compromised and not conforming to requirements of Section 19.3.6.2.2 of the Life Safety Code? at the following locations.

1. The two-hour barriers located at the east & west access/egress points in the Perinatal Unit were breached in such a manner as to allow smoke migration between compartments. (This non-conformance was corrected during inspection)

2. There was a gap about the vacuum tube, which breaches the North Pipe Chase at the 6th floor. This would have allowed smoke migration into the corridor. (This non-conformance was corrected during inspection)

3. There was a gap about the sealed air inlet pipe in the laundry chute room. This would have allowed smoke migration into the corridor. (This non-conformance was corrected during inspection)

4. There was a gap about the sprinkler pipe in the Paint Shop. This would have allowed smoke migration into the corridor. (This non-conformance was corrected during inspection)

5. The separation between the Data Cable Chase and the corridors on several floors was breached at multiple points by cable penetrations. (This non-conformance was corrected during inspection)

A walk-through of the facility with the Director of Plant Operations, el al, July 29th to August 18th, 2010 found a set of doors not conforming to requirements of Section 19.3.6.3.4 of the Life Safety Code? at the following location:

The Gift Shop doors, which are without door-closing mechanisms, were found propped open with Gift Shop displays, thereby exposing the corridor under exigent conditions.

In a fire emergency this will allow smoke migration into the corridor. The Gift Shop, which has an area greater than 500 square feet, is considered a hazardous area under Section 19.3.2.5. Section 19.3.6.3.4 requires hazardous area open to the corridor to have door-closing devices.

A walk-through of the facility with the Director of Plant Operations, el al, July 29th to August 18th, 2010 found a door not conforming to requirements of Sections 8.2.5.2 and 19.2.2.2.6 of the Life Safety Code? at the following location:

The 90-minute door at the top of the stairwell leading from Labor and Delivery to the roof did not positively close and latch into the frame. (This non-conformance was corrected during inspection)

Item A:
A walk-through of the facility with the Director of Plant Operations, el al, July 29th to August 18th, 2010 found a door in a fire-rated enclosure not conforming to requirements of Section 8.2.3.2.1 of the Life Safety Code? at the following location:

The self-closing door between the Lab and the corridor was found held open by a non-automatic releasing means.

Item B:
A walk-through of the facility with the Director of Plant Operations, el al, July 29th to August 18th, 2010 found a door in a fire-rated enclosure not conforming to requirements of Section 8.2.3.2.3.1 of the Life Safety Code? at the following location.

There is a 20-minute rated, self-closing door in a one-hour enclosure for the Soiled Utility Room on the 6th floor.

Item C:
A walk-through of the facility with the Director of Plant Operations, el al, July 29th to August 18th, 2010 found a door in a fire-rated wall not conforming to requirements of Section 8.2.3.2.1 of the Life Safety Code? at the following location:

The self-closing door between the Boiler Plant and the shop area was found held open by a non-automatic releasing means. (This non-conformance was corrected during inspection)

Item D:
A walk-through of the facility with the Director of Plant Operations, el al, July 29th to August 18th, 2010 found a pair of doors in a fire-rated enclosure not conforming to requirements of Section 8.2.3.2.1 of the Life Safety Code? at the following location.

The self-closing doors between the Paint Shop and the shop area corridor were found held open by a non-automatic releasing means. (This non-conformance was corrected during inspection)

A walk-through of the facility with the Director of Plant Operations, el al, July 29th to August 18th, 2010 found the egress markings not conforming to requirements of Section 7.10.1.4 of the Life Safety Code? at the following location.

Exit access on the second floor, in the Pre-Op Waiting Area, was not clearly identified.
1. An Exit sign leading guests to the elevator lobby was needed.
2. An Exit sign leading guests from the elevator lobby to a stairwell was needed.
(These non-conformances were corrected during inspection)

Item A:
A walk-through of the facility with the Director of Plant Operations, el al, July 29th to August 18th, 2010 found the South Wing Electrical Room (East Wing on the facility map) not conforming to requirements of Section 5-13.11 of the 1999 edition of NFPA 13, Standard for the Installation of Sprinkler Systems at the following location:

The electrical room does not have a complete two-hour fire-rated separation, and there was combustible storage in the room. (This non-conformance was corrected during inspection by the installation of four sprinkler heads and the removal of the combustible storage.)

Item B:
A walk-through of the facility with the Director of Plant Operations, el al, July 29th to August 18th, 2010 found the Chiller Plant Electrical Room not conforming to requirements of Section 5-13.11 of the 1999 edition of NFPA 13, Standard for the Installation of Sprinkler Systems at the following location:

Combustible storage was observed in the Chiller Plant Electrical Room. (This non-conformance was corrected during inspection)

Item C:
A walk-through of the facility with the Director of Plant Operations, el al, July 29th to August 18th, 2010 found the Ground-Level Electrical Room in POB 1 not conforming to requirements of Section 5-13.11 of the 1999 edition of NFPA 13, Standard for the Installation of Sprinkler Systems.

The Ground-Level Electrical Room found to not have a complete two-hour separation.

According to Section 5-13.11 of the 1999 edition of NFPA 13:
Sprinkler protection shall be required in electrical equipment rooms...Exception: Sprinklers shall not be required where all of the following conditions are met:
(a) The room is dedicated to electrical equipment only.
(b) Only dry-type electrical equipment is used.
(c) Equipment is installed in a two-hour fire-rated enclosure including protection for penetrations.
(d) No combustible storage is permitted to be stored in the room.

A walk-through of the facility with the Director of Plant Operations, el al, July 29th to August 18th, 2010 found the sprinkler system components in the Kitchen and Dishwashing areas not conforming to requirements of Section 2-2.1.1 of the 1998 edition of NFPA 25, Standard for Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, and Section 3-1.1 of the 1999 edition of NFPA 13 Standard for Installation of Sprinkler Systems, at the following locations, respectively:

1. There were 3 pendent head sprinklers found corroded with copper-oxide in the dishwashing area. (This non-conformance was corrected during inspection)

2. There were several pendent head sprinklers missing escutcheons in the dishwashing and kitchen area. (This non-conformance was corrected during inspection)

A walk-through of the facility with the Director of Plant Operations, el al, July 29th to August 18th, 2010 found the smoke evacuation system in the Ambulatory Surgical Suites (ASC), located in the Wolf building, not in conformance with requirements of Section 5-4.1.3 of the 1999 edition of NFPA 99, the Standard for Health Care Facilities.

The environmental air supply system in the ASC surgical suites maintain continuous supply and exhaust operations when the smoke detectors within the surgical suites are activated.

According to the 1999 edition of NFPA 99, Section 5-4.1.3, "Ventilating systems for anesthetizing locations shall be provided that automatically (a) prevent recirculation of smoke originating within the surgical suite and (b) prevent the circulation of smoke entering the system intake, without in either case interfering with the exhaust function of the system."

A walk-through of the facility with the Director of Plant Operations, el al, July 29th to August 18th, 2010 found the working space access to energized electrical system components did not conform to requirements of Section 110-34 (a), "Working Space," and Table 110-34 (a), "Minimum Depth of Clear Working Space at Electrical Equipment," as mandated in the 1999 edition of NFPA 70, the National Electrical Code at the following location:

There was a temporary building positioned in such a manner as to inhibit the work space access to 13,200 volt, live-front transformer unit components located in equipment identified as EBS-CP-23. (This non-conformance was corrected during inspection by relocating the building)

The required working space pursuant to Section 110-34 (a), and Table 110-34 (a), is six feet from the front of the enclosure.

A walk-through of the facility with the Director of Plant Operations, el al, July 29th to August 18th, 2010 found the integrity of a two-hour separation compromised and not conforming to requirements of Section 8.2.3.2.3.1 of the Life Safety Code? at the following location.

The second floor transition point between the Main Hospital and the Pavilion, on the Pavilion side of the bridge, utilizes a one-hour rated door in the two-hour fire rated separation.

This has the effect of reducing the two-hour exterior wall rating on this Type II (222) structure to only one-hour.

A walk-through of the facility with the Director of Plant Operations, el al, July 29th to August 18th, 2010 found the integrity of the smoke barriers compromised and not conforming to requirements of Section 19.3.6.2.2 of the Life Safety Code? at the following locations.

1. The two-hour barriers located at the east & west access/egress points in the Perinatal Unit were breached in such a manner as to allow smoke migration between compartments. (This non-conformance was corrected during inspection)

2. There was a gap about the vacuum tube, which breaches the North Pipe Chase at the 6th floor. This would have allowed smoke migration into the corridor. (This non-conformance was corrected during inspection)

3. There was a gap about the sealed air inlet pipe in the laundry chute room. This would have allowed smoke migration into the corridor. (This non-conformance was corrected during inspection)

4. There was a gap about the sprinkler pipe in the Paint Shop. This would have allowed smoke migration into the corridor. (This non-conformance was corrected during inspection)

5. The separation between the Data Cable Chase and the corridors on several floors was breached at multiple points by cable penetrations. (This non-conformance was corrected during inspection)

A walk-through of the facility with the Director of Plant Operations, el al, July 29th to August 18th, 2010 found a set of doors not conforming to requirements of Section 19.3.6.3.4 of the Life Safety Code? at the following location:

The Gift Shop doors, which are without door-closing mechanisms, were found propped open with Gift Shop displays, thereby exposing the corridor under exigent conditions.

In a fire emergency this will allow smoke migration into the corridor. The Gift Shop, which has an area greater than 500 square feet, is considered a hazardous area under Section 19.3.2.5. Section 19.3.6.3.4 requires hazardous area open to the corridor to have door-closing devices.

A walk-through of the facility with the Director of Plant Operations, el al, July 29th to August 18th, 2010 found a door not conforming to requirements of Sections 8.2.5.2 and 19.2.2.2.6 of the Life Safety Code? at the following location:

The 90-minute door at the top of the stairwell leading from Labor and Delivery to the roof did not positively close and latch into the frame. (This non-conformance was corrected during inspection)

Item A:
A walk-through of the facility with the Director of Plant Operations, el al, July 29th to August 18th, 2010 found a door in a fire-rated enclosure not conforming to requirements of Section 8.2.3.2.1 of the Life Safety Code? at the following location:

The self-closing door between the Lab and the corridor was found held open by a non-automatic releasing means.

Item B:
A walk-through of the facility with the Director of Plant Operations, el al, July 29th to August 18th, 2010 found a door in a fire-rated enclosure not conforming to requirements of Section 8.2.3.2.3.1 of the Life Safety Code? at the following location.

There is a 20-minute rated, self-closing door in a one-hour enclosure for the Soiled Utility Room on the 6th floor.

Item C:
A walk-through of the facility with the Director of Plant Operations, el al, July 29th to August 18th, 2010 found a door in a fire-rated wall not conforming to requirements of Section 8.2.3.2.1 of the Life Safety Code? at the following location:

The self-closing door between the Boiler Plant and the shop area was found held open by a non-automatic releasing means. (This non-conformance was corrected during inspection)

Item D:
A walk-through of the facility with the Director of Plant Operations, el al, July 29th to August 18th, 2010 found a pair of doors in a fire-rated enclosure not conforming to requirements of Section 8.2.3.2.1 of the Life Safety Code? at the following location.

The self-closing doors between the Paint Shop and the shop area corridor were found held open by a non-automatic releasing means. (This non-conformance was corrected during inspection)

A walk-through of the facility with the Director of Plant Operations, el al, July 29th to August 18th, 2010 found the egress markings not conforming to requirements of Section 7.10.1.4 of the Life Safety Code? at the following location.

Exit access on the second floor, in the Pre-Op Waiting Area, was not clearly identified.
1. An Exit sign leading guests to the elevator lobby was needed.
2. An Exit sign leading guests from the elevator lobby to a stairwell was needed.
(These non-conformances were corrected during inspection)

Item A:
A walk-through of the facility with the Director of Plant Operations, el al, July 29th to August 18th, 2010 found the South Wing Electrical Room (East Wing on the facility map) not conforming to requirements of Section 5-13.11 of the 1999 edition of NFPA 13, Standard for the Installation of Sprinkler Systems at the following location:

The electrical room does not have a complete two-hour fire-rated separation, and there was combustible storage in the room. (This non-conformance was corrected during inspection by the installation of four sprinkler heads and the removal of the combustible storage.)

Item B:
A walk-through of the facility with the Director of Plant Operations, el al, July 29th to August 18th, 2010 found the Chiller Plant Electrical Room not conforming to requirements of Section 5-13.11 of the 1999 edition of NFPA 13, Standard for the Installation of Sprinkler Systems at the following location:

Combustible storage was observed in the Chiller Plant Electrical Room. (This non-conformance was corrected during inspection)

Item C:
A walk-through of the facility with the Director of Plant Operations, el al, July 29th to August 18th, 2010 found the Ground-Level Electrical Room in POB 1 not conforming to requirements of Section 5-13.11 of the 1999 edition of NFPA 13, Standard for the Installation of Sprinkler Systems.

The Ground-Level Electrical Room found to not have a complete two-hour separation.

According to Section 5-13.11 of the 1999 edition of NFPA 13:
Sprinkler protection shall be required in electrical equipment rooms...Exception: Sprinklers shall not be required where all of the following conditions are met:
(a) The room is dedicated to electrical equipment only.
(b) Only dry-type electrical equipment is used.
(c) Equipment is installed in a two-hour fire-rated enclosure including protection for penetrations.
(d) No combustible storage is permitted to be stored in the room.

A walk-through of the facility with the Director of Plant Operations, el al, July 29th to August 18th, 2010 found the sprinkler system components in the Kitchen and Dishwashing areas not conforming to requirements of Section 2-2.1.1 of the 1998 edition of NFPA 25, Standard for Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, and Section 3-1.1 of the 1999 edition of NFPA 13 Standard for Installation of Sprinkler Systems, at the following locations, respectively:

1. There were 3 pendent head sprinklers found corroded with copper-oxide in the dishwashing area. (This non-conformance was corrected during inspection)

2. There were several pendent head sprinklers missing escutcheons in the dishwashing and kitchen area. (This non-conformance was corrected during inspection)

A walk-through of the facility with the Director of Plant Operations, el al, July 29th to August 18th, 2010 found the smoke evacuation system in the Ambulatory Surgical Suites (ASC), located in the Wolf building, not in conformance with requirements of Section 5-4.1.3 of the 1999 edition of NFPA 99, the Standard for Health Care Facilities.

The environmental air supply system in the ASC surgical suites maintain continuous supply and exhaust operations when the smoke detectors within the surgical suites are activated.

According to the 1999 edition of NFPA 99, Section 5-4.1.3, "Ventilating systems for anesthetizing locations shall be provided that automatically (a) prevent recirculation of smoke originating within the surgical suite and (b) prevent the circulation of smoke entering the system intake, without in either case interfering with the exhaust function of the system."

A walk-through of the facility with the Director of Plant Operations, el al, July 29th to August 18th, 2010 found the working space access to energized electrical system components did not conform to requirements of Section 110-34 (a), "Working Space," and Table 110-34 (a), "Minimum Depth of Clear Working Space at Electrical Equipment," as mandated in the 1999 edition of NFPA 70, the National Electrical Code at the following location:

There was a temporary building positioned in such a manner as to inhibit the work space access to 13,200 volt, live-front transformer unit components located in equipment identified as EBS-CP-23. (This non-conformance was corrected during inspection by relocating the building)

The required working space pursuant to Section 110-34 (a), and Table 110-34 (a), is six feet from the front of the enclosure.