HospitalInspections.org

Life safety Code Surveyor;
Jim Free

The facility failed to maintain the heating, ventilating, and air conditioning (HVAC) system per code. Findings include:

During the follow-up survey, per interview with the maintenance staff, the dampers are were on order. These dampers will be made to fit the existing HVAC duct.

During the survey, the following was observed:

Fourth Floor
1. The HVAC duct passing through the smoke barrier in the Labor and Delivery Sleep Room did not have a damper or an access panel.
2. The smoke damper at smoke doors (EGB 42) at room #485 did not close under activation of the fire alarm.

Third Floor
3. Two HVAC ducts, passing through the smoke barrier at the smoke doors at Nurses' Station Three West Nutrition Room, did not have access panels.

Second Floor
4. Five HVAC ducts, passing through the smoke/fire barrier at the smoke/fire doors (EGA 23) in the Back Hall by One Day Surgery at Nurses' Station Three West Nutrition Room, did not have dampers or access panels.
5. Two HVAC ducts, passing through the smoke/fire barrier in the Doctors' Lounge did not have dampers or access panels.
6. Two HVAC ducts, passing through the smoke/fire barrier in the Doctors' Locker Room, did not have dampers or access panels.
7. Four HVAC ducts, passing through the smoke/fire barrier at the smoke/fire doors at the Surgery Storage Room, one did not have a damper and all four did not have access panels.
8. The HVAC duct, passing through the smoke/fire barrier in the corridor to Surgery at the stairwell, did not have a damper or an access panel.


First Floor
9. The HVAC duct, passing through the smoke barrier at the smoke doors by the HVAC Shop, did not have an access panel.
10. The HVAC duct, passing through the smoke barrier in the Women's Bathroom in the Radiology Waiting Room, did not have a damper or an access panel.
11. The HVAC duct, passing through the smoke barrier in the Radiology Waiting Room, did not have a damper or an access panel.
12. HVAC ducts, passing through smoke and smoke/fire barriers throughout the facility, were observed not having dampers and/or access panels.



1999 NFPA 90A, 2-3.4.1 A service opening shall be provided in air ducts adjacent to each fire damper, smoke damper, and smoke detector. The opening shall be large enough to permit maintenance and resetting of the device.
1999 NFPA 90A, 3-3.5.1 Smoke dampers shall be installed at or adjacent to the point where air ducts pass through required smoke barriers, but in no case shall a smoke damper be installed more than 2 ft (0.6 m) from the barrier or after the first air duct inlet or outlet, whichever is closest to the smoke barrier.
1999 NFPA 90A, 3-3.1.1*
Approved fire dampers shall be provided where air ducts penetrate or terminate at openings in walls or partitions required to have a fire resistance rating of 2 hours or more.

1999 NFPA 90A, 3-4.5.4 Dampers shall close against the maximum calculated air flow of that portion of the air duct system in which they are installed. Fire dampers shall be tested in accordance with UL 555, Standard for Safety Fire Dampers. Smoke dampers shall be tested in accordance with UL 555S, Standard for Safety Smoke Dampers.
.

27382


Life Safety Code Surveyor:
Jim Free


The facility failed to provide a smoke venting system per code. Findings include:

During the survey, the following was observed:

(1) The sixteen windowless O.R.s on the second floor did not have a smoke venting system, per observation and interview. (Will be corrected during the renovation.)

1999 NFPA 99, 5-4.1.2 Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically vent smoke and products of combustion.
1999 NFPA 99, 5-4.1.3 Ventilating systems for anesthetizing locations shall be provided that automatically (a) prevent recirculation of smoke originating within the surgical suite and (b) prevent the circulation of smoke entering the system intake, without in either case interfering with the exhaust function of the system.
1999 NFPA 99, 5-4.1.4 The electric supply to the ventilating system shall be served by the equipment system of the essential electrical system specified in Chapter 3, "Electrical Systems."
1999 NFPA 99, 5-6.1.1 Ventilating and humidifying equipment for anesthetizing locations shall be kept in operable condition and be continually operating during surgical procedures (see A-5-4.1).
.

27382


Life safety Code Surveyor:
Jim Free


During the survey, based upon observation and interview with Engineering, the three generators the facility have are not provided with Remote Annunciator Panels.



1999 NFPA 99, 3-4.1.1.15 A remote annunciator, storage battery powered, shall be provided to operate outside of the Generating Room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12.) The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load
2. When the battery charger is malfunctioning
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. [110: 3-5.5.2]