HospitalInspections.org

This is a recite.

Based on observation and staff interview, the facility failed to protect an opening into one hazardous area with a fire-rated door, or protect the hazardous room with an automatic extinguishing system and a self-closing door in accordance with the requirement of NFPA 101 38.3.2.1, 8.4.1. This could affect all patients and staff of the facility.

Findings include

During a tour of the Suring Primary Care facility with Staff N (environmental services director), and Staff J (clinic director) on 7/13/2011, Surveyor 12316 observed at 9:40 am that the Medical Records Storage behind the reception area had a solid bonded wood core door, but the door was not 3/4 hr fire-rated and self-closing; nor was the storage room protected with a automatic extinguishing system in lieu of the fire-rated enclosure and a door with a self-closing device.
The above deficiency was acknowledged by the environmental services director, and clinic director at the time of discovery, and confirmed with Staff Z (administrator/CEO), Staff A (chief nursing officer), and Staff B (director of quality) at the exit conference on 7/13/2011 at 4:30 pm.


NFPA 101 38.3.2.1
" Hazardous areas including, but not limited to, areas used for general storage, boiler or furnace rooms, and maintenance shops that include woodworking and painting areas shall be protected in accordance with Section 8.4. "

NFPA 101 8.4.1.1
" Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means:
(1) Enclose the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.2.
(2) Protect the area with automatic extinguishing systems in accordance with Section 9.7.
(3) Apply both 8.4.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 12 through 42. "

NFPA 101 8.4.1.2
" In new construction, where protection is provided with automatic extinguishing systems without fire-resistive separation, the space protected shall be enclosed with smoke partitions in accordance with 8.2.4. "


During the verification visit on 8/31/2011, Surveyor 12316 determined that the facility has made a satisfactory progress toward correcting the deficiency. When interviewed on 8/31/2011 at 3:30 pm, Staff N (environmental services director) stated that the facility will install new 1 hr-fire rated enclosure, if existing walls are verified to be not a 1-hr fire-rated construction, and also install a 1-hr rated ceiling, as necessary by the completion date of September 23, 2011.