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NFPA 101, LIFE SAFETY CODE (2012 edition)
4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire resistive construction, or any other feature is required for compliance with the provisions of this code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements.

Based on observations and interview the facility failed to ensure that fire resistive coatings on structural steel are maintained.

Findings include:

Observations during tour on 12/06/16 between 2:00 p.m. and 3:00 p.m. with Staff A (Vice President, Clinical & Support Services), Staff B (Director of Facilities Maintenance), and Staff C (Safety/Security/Environmental Services) revealed that inside of the mechanical room, located off of stairwell "C", approximately 5 feet of fire resistive coating has fallen off the bottom of a steel beam. The beam is located above the communicating opening between the original building and a newer mechanical room addition.

Interview with Staff A, Staff B, and Staff C confirmed the above findings and location of the steel I-beam.

NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations
(2011 edition)
4.1.2 All such equipment and it's performance shall be maintained in accordance with the requirements of this standard during all periods of operations of the cooking equipment.
4.1.3 The following equipment shall be kept in working condition:
(1) Cooking equipment
(2) Hoods
(3) Ducts
(4) Fans
(5) Fire-extinguishing equipment
(6) Special effluent or energy control equipment

Based on observations and interviews the facility failed to ensure that the commercial cooking equipment has proper coverage by the automatic fire extinguishing equipment.

Findings include:

Observations during tour on 12/07/16 between 10:00 a.m. and 10:30 a.m. with Staff A (Vice President, Clinical & Support Services), Staff B (Director of Facilities Maintenance) and Staff C (Safety/Security/Environmental Services) revealed that the main cooking line equipment is located directly under a commercial exhaust system. The Ansul system (fire-extinguishing system) nozzles were not orientated to directly cover the appliances. The nozzles were instead pointed in a straight line in front of the cooking equipment towards the floor, lacking any complete coverage of the equipment in use.

Interview with Staff A, Staff B, and Staff C confirmed the location and above findings.

Based on observations and interview the facility failed to ensure that 1 visible fire alarm/strobe notification device was not obstructed from view.

Findings include:

Observations during tour on 12/07/16 between 8:30 a.m. and 9:00 a.m. with Staff A (Vice President, Clinical & Support Services), Staff B (Director of Facilities Maintenance), and Staff C (Director Safety/Security/Environmental Services) revealed that inside the hospital's Laboratory Department there is 1 Fire Alarm Strobe notification device that is blocked from view. The Fire Alarm strobe notification device is located between 2 refrigerators with an approximate space of 6-8 inches of space in between. This device is not visible to the Lab departments occupants.

Interview with Staff A, Staff B, and Staff C confirmed the above findings and location.

NFPA 13 Standard for the Installation of Sprinkler Systems (2010 edition)
8.8.5.1.1 Sprinklers shall be located so as to minimize obstructions to discharge as defined in 8.8.5.2 and 8.8.5.3 or additional sprinklers shall be provided to ensure adequate coverage of the hazard.

NFPA 25 Water-Based Fire Protection Systems
Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

Based on observations and interview the facility failed to ensure that 1 sprinkler head is located as to provide adequate coverage for spray patterns, and the facility failed to ensure that several sprinkler heads are not "loaded" with lint, grease, dust or debris.


Findings include:

Observations during tour on 12/07/16 between 11:00 a.m. and 12:00 p.m. with Staff A (Vice President, Clinical & Support Services), Staff B (Director of Facilities's Maintenance and Laundry) and Staff C (Safety/Security/Environmental Services) revealed that the main Laundry room (commercial dryer section) has a section of HVAC (Heating, Ventilation & Air Conditioning) ductwork mounted in the center of the room and has 1sprinkler head located approximately 2" away and 10" above the bottom of the ductwork. The spray pattern from this sprinkler head is 60% blocked in the direction of the ductwork.

Observations during tour on 12/07/16 between 9:00 a.m. and 2:00 p.m. with Staff A (Vice President, Clinical & Support Services) , Staff B (Director of Facilities Maintenance/Laundry) , and Staff C (Safety/Security/Environmental Services) revealed that at least 6 sprinkler heads in the Laundry room (commercial dryer section) are loaded with a large amount of lint or debris.

Observations in the main Kitchen revealed at least 5 sprinkler heads loaded with a large amount of grease, lint or debris.

Observations in the food service cafeteria revealed at least 3 sprinkler heads loaded with a large amount of lint or debris.

Observations in the main hospital Lab has at least 2 sprinkler heads loaded with a large amount of lint or debris.

Interview with Staff A, Staff B, and Staff C during the observations, confirmed the above findings and locations of sprinkler heads with lint or debris.

Based on observations, interview and life safety code plan review the facility failed to ensure that 1 fire barrier is maintained to prevent the passage of smoke or the effects of fire.

Findings include:

Record review of the life safety code plans for smoke and fire barriers during tour on 12/06/16 and 12/07/16 revealed the location of smoke barriers, fire barriers and occupancy separation barriers throughout the facility.

Observations during tour on 12/07/16 between 12:00 p.m. and 2:30 p.m. with Staff A, Staff B, and Staff C revealed that above the suspended ceiling, on the 1st floor, across from the cafeteria, there is a 4 inch pneumatic tube/pipe passing through the wall without being protected. This section of the 2 hour occupancy separation will not resist the passage of smoke or the effects from fire.

Above the suspended ceiling, on the 1st floor, there is a 4 inch piece of conduit running through the wall of pathology department that will not resist the passage of smoke or the effects of fire.

Interview with Staff A, Staff B, and Staff C confirmed the above findings, locations of the separation barriers and locations of the unprotected penetrations.

Based on record review and interview the facility failed to ensure that fire drills are held at unexpected and varying times for the 3rd shift (11-00 p.m.--7:00 a.m.).

Record review during tour on 12/06/16 between 8:00 a.m. and 10:30 a.m. with Staff A (Vice Pesident, Clinical & Support Services) revealed that 6 out of the last 7 fire drills have been held within 18 minutes of each other.

The fire drill times are as follows:
09/29/16 1:46 a.m.
06/21/16 6:07 a.m.
03/29/16 6:18 a.m.
12/23/15 6:14 a.m.
09/29/15 6:13 a.m.
06/24/15 6:03 a.m.
03/25/15 6:21 a.m.

Interview with Staff A confirmed the above findings.