HospitalInspections.org

Based on observation and staff interview, the facility failed to prevent impediments to the closing of corridor opening doors to resist, in the event of fire, the passage of smoke, as required by NFPA 101, (2000), 19.3.6.3.

Findings include:

1. On 08/20/12, the first day of survey, observation during the interior tour from 9:30 a.m. to 3:00 p.m. accompanied by the Director of Plant Operations revealed numerous patient room doors in which infection control storage devices were hung on patient room doors and were suspended from the top of the patient room corridor door by two metal hangers approximately 1 1/2 inches wide. Further observation revealed some of the metal hangers had been bent and straightened to prevent impediment to door closure.

2. On 08/20/12 observation during the interior tour from 9:30 a.m. to 3:00 p.m. accompanied by the Director of Plant Operations revealed at patient rooms 110 and 111 corridor doors in which the metal hangers for the infection control storage devices were bent and when testing the doors for closure and positive latching the doors would not close, thereby, in the event of fire, permitting the passage of smoke. The Director of Plant Operations confirmed the observation of the two doors not closing.

NFPA 101, (2000), 19.3.6.3
Reference:
19.3.6.3 Corridor Doors.
19.3.6.3.1* Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors. Exception No. 1: Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials. Exception No. 2: In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.2, the door construction requirements of 19.3.6.3.1 shall not be mandatory, but the doors shall be constructed to resist the passage of smoke. 19.3.6.3.2* Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2. Exception No. 1: Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials. Exception No. 2: Existing roller latches demonstrated to keep the door closed against a force of 5 lbf (22 N) shall be permitted to be kept in service. (Roller Latches are not permitted by the Centers for Medicare and Medicaid).

Based on observation and staff interview, the facility failed to install and maintain the required fire alarm system as required by NFPA 101, (2000), 9.6.1.4, 19.3.4.3, 9.6.3.1, NFPA 72, (1999), 4-4.4.3.

Findings include:

1. On 08/20/12 observation during the interior tour from 9:30 a.m. to 3:00 p.m. accompanied by the Director of Plant Operations revealed two physician sleeping quarters (Guest Suite(s)) in which no Occupant Notification fire alarm system was installed. The Director of Plant Operations confirmed there was no enunciator or strobe in the suite.

2. On 08/23/12 exit interview of the Director of Plant Operations during the Exit Conference at approximately 10:00 a.m. revealed in the Emergency Department a single room (Guest Room) physician sleeping room in which no Occupant Notification fire alarm system was installed.

NFPA 101, (2000), 19.3.4.3 Notification. 19.3.4.3.1 Occupant Notification. Occupant notification shall
be accomplished automatically in accordance with 9.6.3.

NFPA 101, (2000), 9.6.3 Occupant Notification.
9.6.3.1 Occupant notification shall provide signal notification to alert occupants of fire or other emergency as required by other sections of this Code. 9.6.3.2 Notification shall be provided by audible and visible
signals in accordance with 9.6.3.3 through 9.6.3.12.

NFPA 101, (2000), 3.3.94 Guest Room. An accommodation combining living, sleeping, sanitary, and storage facilities within a compartment.

NFPA 101, (2000), 3.3.95 Guest Suite. An accommodation with two or more contiguous rooms comprising a compartment, with or without doors between such rooms, that provides

NFPA 72, (1999), 4-4.4.3 Sleeping Areas.
4-4.4.3.1 Combination smoke detectors and visible notification appliances shall be installed in accordance with the applicable requirements of Chapter 2, Chapter 4, and Chapter 8. 4-4.4.3.2* Table 4-4.4.3.2 shall apply to sleeping areas that have no linear dimension greater than 16 ft (4.87 m). For larger rooms, the visible notification appliance shall be located within 16 ft (4.87 m) of the pillow. 4-4.4.4* If visible notification appliances are required, a minimum of one appliance shall be installed in the concentrated viewing path. 4-5 Visible Characteristics, Private Mode. Visible notification appliances used in the private mode shall be of a sufficient quantity and intensity, and located so as to meet the intent of the user and the authority having jurisdiction. 4-6 Supplementary Visible Signaling Method. A supplementary visible notification appliance shall be intended to augment an audible or visible signal.

Based on observation and staff interview the facility failed to provide and maintain a minimum clear distance of "working space", 3 feet, from electrical panels housing 600 volts or less as required by NFPA 101, 9.1.2 and NFPA 70, National Electrical Code, (1999), 110-26, and Table 110-26(a).

Findings include:

1. On 08/20/12 observation during the interior tour from 9:30 a.m. to 3:00 p.m. accompanied by the Director of Plant Operations revealed in the Surgical Electrical Room electrical panels in which sufficient access and working space was not available. The Director of Plant Operations confirmed the observation and had the material removed.

2. On 08/20/12 observation during the interior tour from 9:30 a.m. to 3:00 p.m. accompanied by the Director of Plant Operations revealed in the Special Procedures Electrical Room electrical panels in which sufficient access and working space was not available due to the storage of sterile surgical supplies (combustible material). The Director of Plant Operations confirmed the observation and had the materials removed.

NFPA 101, 9.1.2
NFPA 70, National Electrical Code, 110-26
Reference:
B. 600 Volts, Nominal, or Less. 110-26. Spaces about Electrical Equipment. Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons. (a) Working Space. Working space for equipment operating at 600 volts, nominal, or less to ground and likely to require examination, adjustment, servicing, or maintenance while energized shall comply with the dimensions of (1), (2), and (3) or as required or permitted elsewhere in this code. Table 110-26(a), Nominal Voltage to Ground 0-150, Condition 2, 3 feet.