HospitalInspections.org

Reference NFPA 101, 2000 Edition

9.6.2.9 Where a partial smoke detection system is required by another section of this Code, automatic detection of smoke in accordance with NFPA 72, National Fire Alarm Code, shall be provided in all common areas and work spaces, such as corridors, lobbies, storage rooms, equipment rooms, and other tenantless spaces in those environments suitable for proper smoke detector operation. Selective smoke detection unique to other sections of this Code shall be provided as required by those sections.


Based on observation and interview, the facility failed to ensure the enclosed foyers, located at the Emergency Room entrance and the Main Entrance, were provided with automatic smoke detection as required by NFPA 72 (National Fire Alarm Code). Not providing automatic smoke detection within the foyer could result in an undetected fire at this location, which would render this required exit as unavailable in the event of fire. Not providing smoke detection in common work spaces could result in undetected fire in areas where large numbers of staff could be affected and may render them not able to respond to their duties as required by the facility's emergency preparedness plan. In the event of fire, this failed practice presents a risk of potential harm to all forty-two (42) patients as identified by the Census List provided by the Director of Plant Operations/Safety Officer on 05/19/15. The findings are:


A. On 05/20/15 at 10:20 am, during observation, an automatic smoke detection device was not provided within the foyer located at the main exit/entrance of the facility.

B. On 05/20/15 at 10:30 am, during observation, an automatic smoke detection device was not provided within the foyer located at the Emergency Room exit/entrance of the facility.

C. On 05/21/15, during interview, the Administrator and Director of Plant Operations/Safety Officer confirmed the requirement of smoke detection installation at above locations.

NFPA 13 9-7 Fire Department Connections

9-7.1 Fire department connections shall be inspected quarterly. The inspection shall verify the following:

(a) The fire department connections are visible and accessible.
(b) Couplings or swivels are not damaged and rotate smoothly.
(c) Plugs or caps are in place and undamaged.
(d) Gaskets are in place and in good condition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly.

9-7.2 If fire department connection plugs or caps are not in place, the interior of the connection shall be inspected for obstructions, and it shall be verified that the valve clapper is operational over its full range.

9-7.3 Components shall be repaired or replaced as necessary in accordance with the manufacture's instructions. Any obstructions that are present shall be removed.




Based on observation, the facility failed to ensure proper raised signage was posted indicating the location of FDCs (fire department connections), located adjacent to loading dock and emergency room entrance. This failed practice may delay the Fire Department from providing supplemental water to the Automatic Sprinkler System in the event of a fire, which may lead to harm by fire/smoke to all forty-two (42) patient's of the facility as identified by the census list provided by the Director of Plant Operations/Safety Officer on 05/19/15. The findings are:

A. On 05/20/15 at 9:40 am, during observation, no raised signage is located near the FDC adjacent to Loading Dock.

B. On 05/20/15 at 10:50 am, during observation, no raised signage is located near the FDC adjacent to Emergency Room exit/entrance.

C. On 05/21/15 during interview, the Administrator and Director of Plant Operations/Safety Officer confirmed the need for raised signage at above locations.

Reference NFPA 101, 2000 Edition

9.6.2.9 Where a partial smoke detection system is required by another section of this Code, automatic detection of smoke in accordance with NFPA 72, National Fire Alarm Code, shall be provided in all common areas and work spaces, such as corridors, lobbies, storage rooms, equipment rooms, and other tenantless spaces in those environments suitable for proper smoke detector operation. Selective smoke detection unique to other sections of this Code shall be provided as required by those sections.


Based on observation and interview, the facility failed to ensure the enclosed foyers, located at the Emergency Room entrance and the Main Entrance, were provided with automatic smoke detection as required by NFPA 72 (National Fire Alarm Code). Not providing automatic smoke detection within the foyer could result in an undetected fire at this location, which would render this required exit as unavailable in the event of fire. Not providing smoke detection in common work spaces could result in undetected fire in areas where large numbers of staff could be affected and may render them not able to respond to their duties as required by the facility's emergency preparedness plan. In the event of fire, this failed practice presents a risk of potential harm to all forty-two (42) patients as identified by the Census List provided by the Director of Plant Operations/Safety Officer on 05/19/15. The findings are:


A. On 05/20/15 at 10:20 am, during observation, an automatic smoke detection device was not provided within the foyer located at the main exit/entrance of the facility.

B. On 05/20/15 at 10:30 am, during observation, an automatic smoke detection device was not provided within the foyer located at the Emergency Room exit/entrance of the facility.

C. On 05/21/15, during interview, the Administrator and Director of Plant Operations/Safety Officer confirmed the requirement of smoke detection installation at above locations.

NFPA 13 9-7 Fire Department Connections

9-7.1 Fire department connections shall be inspected quarterly. The inspection shall verify the following:

(a) The fire department connections are visible and accessible.
(b) Couplings or swivels are not damaged and rotate smoothly.
(c) Plugs or caps are in place and undamaged.
(d) Gaskets are in place and in good condition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly.

9-7.2 If fire department connection plugs or caps are not in place, the interior of the connection shall be inspected for obstructions, and it shall be verified that the valve clapper is operational over its full range.

9-7.3 Components shall be repaired or replaced as necessary in accordance with the manufacture's instructions. Any obstructions that are present shall be removed.




Based on observation, the facility failed to ensure proper raised signage was posted indicating the location of FDCs (fire department connections), located adjacent to loading dock and emergency room entrance. This failed practice may delay the Fire Department from providing supplemental water to the Automatic Sprinkler System in the event of a fire, which may lead to harm by fire/smoke to all forty-two (42) patient's of the facility as identified by the census list provided by the Director of Plant Operations/Safety Officer on 05/19/15. The findings are:

A. On 05/20/15 at 9:40 am, during observation, no raised signage is located near the FDC adjacent to Loading Dock.

B. On 05/20/15 at 10:50 am, during observation, no raised signage is located near the FDC adjacent to Emergency Room exit/entrance.

C. On 05/21/15 during interview, the Administrator and Director of Plant Operations/Safety Officer confirmed the need for raised signage at above locations.