HospitalInspections.org

NFPA 101 (2000) LIFE SAFETY CODE STANDARD - If the building has a common wall with a nonconforming building, the common wall is a fire barrier having at least a two-hour fire resistance rating constructed of materials as required for the addition. Communicating openings occur only in corridors and are protected by approved self-closing fire doors. NFPA 101 (00) Chapter 19, Sections 19.1.1.4.1. and 19.1.1.4.2.

FINDINGS INCLUDE:

On 6/24/10 at 1:10 PM, observation revealed the required 90-minute fire door protecting the opening in the 2-hour fire wall separating the hospital from the Doctor's Clinic, did not self-close. Investigation revealed the automatic door closer was broken.

In a fire emergency, this deficient practice could adversely affect occupants in the hospital and/or clinic, by allowing fire/smoke to migrate between the two occupancies.

This deficient practice was verified with the chief building engineer [RJ].

NFPA 101 (2000) LIFE SAFETY CODE STANDARD - A fire alarm system required for life safety is installed, tested, and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72. National Fire Alarm Code. The system has an approved maintenance and testing program complying with applicable requirements of NFPA 70 and 72, in accordance with NFPA 101 (00) Chapter 9, Section 9.6.1.4.

FINDINGS INCLUDE:

On 6/24/10 between 10:00 AM and 4:00 PM, the following was learned:
A). No documentation could be provided verifying the digital alarm communicator transmitter [DACT] was tested monthly during the previous year;
B). Multiple smoke detectors installed on the Laboratory Corridor, the Director of Nursing Corridor and the 100-Wing Corridor, were located within 3-feet of HVAC supply air diffusers and/or return air openings.

In a fire emergency, this deficient practice could adversely affect 35 of 35 patients, visitors and staff.

This deficient practice was confirmed with the chief building engineer[RJ].

NFPA 101 (2000) LIFE SAFETY CODE STANDARD - Generators must be inspected weekly and exercised under load for 30 minutes per month and shall be in accordance with NFPA 99 (1999 edition) and NFPA 110 (1999 edition).

NFPA 110 (1999 edition) Chapter 3, Section 3-5.5.6 requires the following: All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building.

NFPA 110 (1999 edition) Chapter 3, Section 3-5.6.1 requires the following: A remote, common audible alarm powered by the storage battery shall be provided as specified in 3-5.5.2(d). This remote alarm shall be located outside of the EPS service room at a work site readily observable by personnel.

FINDINGS INCLUDE:

On 6/24/10 between 10:00 AM and 4:00 PM, it was learned that there was no remote manual stop station provided for the emergency generator, which is located outside of the nursing home. The emergency generator was installed in 2005 and is rated at 1,000 Kw.

In a fire or other emergency, this deficient practice could adversely affect the safety of 35 of 35 patients, staff and visitors.

This deficiency was confirmed with the chief building engineer [RJ].

NFPA 101 (2000) LIFE SAFETY CODE STANDARD - If the building has a common wall with a nonconforming building, the common wall is a fire barrier having at least a two-hour fire resistance rating constructed of materials as required for the addition. Communicating openings occur only in corridors and are protected by approved self-closing fire doors. NFPA 101 (00) Chapter 19, Sections 19.1.1.4.1. and 19.1.1.4.2.

FINDINGS INCLUDE:

On 6/24/10 at 1:10 PM, observation revealed the required 90-minute fire door protecting the opening in the 2-hour fire wall separating the hospital from the Doctor's Clinic, did not self-close. Investigation revealed the automatic door closer was broken.

In a fire emergency, this deficient practice could adversely affect occupants in the hospital and/or clinic, by allowing fire/smoke to migrate between the two occupancies.

This deficient practice was verified with the chief building engineer [RJ].

NFPA 101 (2000) LIFE SAFETY CODE STANDARD - A fire alarm system required for life safety is installed, tested, and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72. National Fire Alarm Code. The system has an approved maintenance and testing program complying with applicable requirements of NFPA 70 and 72, in accordance with NFPA 101 (00) Chapter 9, Section 9.6.1.4.

FINDINGS INCLUDE:

On 6/24/10 between 10:00 AM and 4:00 PM, the following was learned:
A). No documentation could be provided verifying the digital alarm communicator transmitter [DACT] was tested monthly during the previous year;
B). Multiple smoke detectors installed on the Laboratory Corridor, the Director of Nursing Corridor and the 100-Wing Corridor, were located within 3-feet of HVAC supply air diffusers and/or return air openings.

In a fire emergency, this deficient practice could adversely affect 35 of 35 patients, visitors and staff.

This deficient practice was confirmed with the chief building engineer[RJ].

NFPA 101 (2000) LIFE SAFETY CODE STANDARD - Generators must be inspected weekly and exercised under load for 30 minutes per month and shall be in accordance with NFPA 99 (1999 edition) and NFPA 110 (1999 edition).

NFPA 110 (1999 edition) Chapter 3, Section 3-5.5.6 requires the following: All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building.

NFPA 110 (1999 edition) Chapter 3, Section 3-5.6.1 requires the following: A remote, common audible alarm powered by the storage battery shall be provided as specified in 3-5.5.2(d). This remote alarm shall be located outside of the EPS service room at a work site readily observable by personnel.

FINDINGS INCLUDE:

On 6/24/10 between 10:00 AM and 4:00 PM, it was learned that there was no remote manual stop station provided for the emergency generator, which is located outside of the nursing home. The emergency generator was installed in 2005 and is rated at 1,000 Kw.

In a fire or other emergency, this deficient practice could adversely affect the safety of 35 of 35 patients, staff and visitors.

This deficiency was confirmed with the chief building engineer [RJ].