HospitalInspections.org

During the Survey conducted on 5 2-3 2017 it was deter4mined that the facility failed to keep the exit corridors clear.

Fixed furniture in exit corridors shall be attached to floor or wall and grouped to not exceed 50 s.f. per NFPA 01 (2012) 19.2.3.4

Not met as evidenced by: Chairs adjacent to Imaging not attached and exceeding groupings of 50 s.f.

NFPA 101 (2012) 8.6.7 (5)
For other than existing previously approved atriums an engineering study has to be performed that demonstrates that the building is designed to keep the smoke layer interface above the highest unprotected opening to adjoining spaces, or 6 feet above the highest floor level of exit access open to the Atrium, for a period equal to 1.5 times the calculated egress time or 20 minutes, whichever is greater.

NFPA 101 (2012) 8.6.7 (6)
In other than existing previously approved Atriums, where an engineered smoke control system is installed to meet the requirements of 8.6.7(5) the system is independently activated by each of the following:
A) Required automatic sprinkler system.
B) Manual controls that are readily available to the fire department.

Not met as evidenced by: At the time of inspection no information was available to support these requirements.

Based on observation during the course of the survey conducted on May 3, 2017, it was determined the facility failed to maintain the hazardous areas in accordance with NFPA 101 Section 19.3.2.1. The following evidenced this:

During the walk through of the facility with the Maintenance Supervisor, the partitions were not properly sealed to prevent the passage of smoke.

1.) 1 hr rated wall in receiving dock not sprayed at the top of wall to prevent the passage of smoke

Based on observation and record review during the survey, it was determined that the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association NFPA 72, National Fire Alarm Code. This was evidenced by the following:

Strobes in first floor lobby and surrounding areas are not synchronized as required.

Smoke detection systems are provided in spaces open to corridors as required by 19.3.6.1

Not met as evidenced by: No smoke detection in area open to corridor, backroom of surgery waiting area, laboratory reception area, Imaging waiting area.

It was determined by observation during the survey on February 15, 2002 that the facility failed to provide a complete coverage automatic fire sprinkler system, installed in accordance with National Fire Protection Association (NFPA) Standard 13, for all portions of the facility.
The findings include:

The following areas are not protected by automatic sprinklers as required:
1. Fith floor family waiting room skylight larger than 32 s.f.
2. ICU waiting room skylight larger than 32 s. f.

Failure to provide automatic sprinkler protection in all areas of the facility creates the potential for harm to residents and staff by not assuring prompt detection and suppression of a fire within the facility.

Sprinkler systems shall be maintained.

Not met as evidenced by:
1) multiple escutcheon plates not secured to ceiling in Pharmacy corridor, Volunteer work area.

2) Loaded heads in SD, Physicians offices Radiology, and other locations.

Based on observation during the course of the survey conducted on February 1-2, 2006, it was determined the facility failed to maintain the doors that protect the corridors in accordance with NFPA 101 Section 19.3.6.3. The following evidenced this:

1.) During the walk through of the facility with the Maintenance Supervisor, Doors to rooms 5002, 2010 would not latch. Corrected during survey.
2) Doors at Pharmacy corridor west don't latch.
3) Basement Storage room

Emergency Department smoke barrier walls have multiple penetrations. Corrected at time of survey.