HospitalInspections.org

Based on observation the facility did not maintain the fire resistive ratings of the fire wall separating the Business Occupancy from the Hospital.

NFPA 101 Life Safety Code, 2000, Chapter 19, Sections 19.1.1.4.1, 19.1.1.4.2 and , 19.1.2.1 "Section 19.1.1.4.1," "Additions shall be separated from any existing structure not conforming to the provisions within Chapter 19 by a fire barrier having not less than a 2-hour fire resistance rating and constructed of materials as required for the addition." Section 19.1.1.4.2, "Communicating openings in dividing fire barriers required by 19.1.1.4.1 shall be permitted only in corridors and shall be protected by approved self-closing fire doors." Section 19.1.2.1, "Sections of health care facilities shall be permitted to be classified as other occupancies, provided that they meet all of the following conditions:"
(1) They are not intended to serve health care occupants for purposes of housing, treatment, or
customary access by patients incapable of self-preservation."
(2) They are separated from areas of heath care occupancies by construction having a fire resistance rating of not less than 2 hours."

Findings Include:

On June 21, 2011, the surveyor, accompanied by the Maintenance Supervisor and Facility Staff, observed the fire separation wall between the Hospital and the Business Office Building. The separation has penetrations and does not go to the underside of the roof above.

During the exit conference on June 21, 2011, the above findings were again acknowledge by the Maintenance Supervisor and Facility Staff. The Maintenance Supervisor stated that the facility had contacted a contractor for bids to complete the 2 hour wall.

The facility failed to complete and fill holes in a fire resistive wall. Failing to contain smoke or heat from a fire will cause harm to the patients.

Based on observation the facility failed to maintain corridor doors to resist the passage of heat/smoke.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.6.3.1, 19.3.6.3.2, 19.3.6.3.3. Section 19. 19.3.6.3.1 "Doors protecting corridor openings shall be constructed to resist the passage of smoke. Clearance between the bottom of the door and the floor covering not exceeding 1 in. shall be permitted for corridor doors." Section 19.3.6.3.2 "Doors shall be provided with positive latching hardware. Roller latches shall be prohibited." Section 19.3.6.3.3 "Hold -open devices that release when the door is pushed or pulled shall be permitted."

Findings Include:

On June 21, 2010 the surveyor, accompanied by the Director of Maintenance and Facility Staff, observed that the all door handles and latching hardware were removed from the patient sleeping room doors. By removing the hardware a hole approximately 2 inches in diameter has been left uncovered. The Maintenance Supervisor stated that new psychiatric door hardware has been ordered and should be in and installed in a few weeks.

During the exit conference on June 21, 2011, the above findings were again acknowledged by the Maintenance Supervisor and Facility Staff.

In time of a fire failing to protect patients from heat and smoke could cause harm to the patients.


Based on observation the facility failed to have smoke resistant dutch doors.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.6.3.6, "Dutch doors shall be permitted where they conform to 19.3.6.3. In addition, both the upper leaf and lower leaf shall be equipped with a latching device and the meeting edges of the upper and lower leaves shall be equipped with an astragal, a rabbet, or a bevel. Dutch doors protecting openings in enclosures around hazardous areas shall comply with NFPA 80, Standard for Fire Doors and Fire Windows.

Findings Include:

On June 21, 2011, the surveyor, accompanied by the Maintenance Supervisor and Facility Staff, observed a number of dutch doors adjacent to the nursing station. When the upper and lower leaves of all the doors were closed there is a gap which measured approximately 1/4 inch.

During the exit conference on June 21, 2011, the above findings were again acknowledged by the Maintenance Supervisor and Facility Staff.

Failure to provide smoke resistant doors will harm patients in time of a fire.

Based on observation the facility failed to maintain the self closing/automatic-closing doors in the smoke barrier.

NFPA 101 Life Safety Code, 2000, Chapter 19, Sections, 19.3.7.6 "Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 19.2.2.2.6. ( See Chapter 19 for additional requirements) Chapter 8, Section 8.3.4."Doors" Section 8.3.4.3, "Doors in smoke barriers shall be self-closing or automatic-closing in accordance with 7.2.1.8 and shall comply with the provisions of 7.2.1. Section 7.2.1.8.1 (1) "Upon release of the hold-open mechanism, the door becomes self-closing."

Findings include:

On June 21, 2011, the surveyor, accompanied by the Maintenance Supervisor and Facility Staff observed, the smoke barrier door to the patient sleeping wing. The door was wedged open. Other doors throughout the facility were wedged in the open position.

During the exit conference on June 21, 2011, the above findings were again acknowledged by the Maintenance Supervisor and Facility Staff.

Failure to keep smoke doors closed or held open by a fire alarm activated magnet will allow smoke to enter smoke zones not directly effected by the fire, which could cause harm to the patients.

Based on observation the facility did not keep exits readily accessible at all times.

NFPA 101 Life Safety Code, 2000, Chapter 19 Section 19.2.1, and Section 19.2.3.3. "Every aisle, passageway, corridor, exit discharge, exit location and access shall be in accordance with Chapter 7. Section 19.2.3.3 "Aisles, corridors and ramps required for exit access in a limited care facility or hospital for psychiatric care shall be not less than 6 feet (Existing built to 6 feet must be maintained 6 feet clear) in clear and unobstructed width". Chapter 7 Section 7.5.1.1" Exits shall be so located and exit access shall be arranged so that exits are readily accessible at all times." Section 7.5.1.2 "Where exits are not immediately accessible from an open floor area, continuous passageways, aisles, or corridors leading directly to every exit and shall be maintained and shall be arranged to provide access for each occupant to not less than two exits by separate ways of travel."

Findings Include:

On June 21, 2011, the surveyor, accompanied by the Maintenance Supervisor and Facility Staff, observed the storage of, chairs, linen cart, and lockers, within the 6 foot exit corridor, in the substance abuse wing.

During the exit conference on June 21, 2011, the above findings were again acknowledged by the Maintenance Supervisor and Facility Staff.

Failure to keep the exit corridors and exit access clear could hinder the evacuation during an emergency and will cause harm to patients.

Based on observation the facility failed to assure that exits from the building were each illuminated by more than a single light source.

NFPA 101 Life Safety Code 2000, Chapter 19, Section 91.2.1 "Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7, Section 7.8.1.4 "Required illumination shall be arranged so that the failure of any single lighting unit does not result in an illumination level of less than 0.2 ft-candle (2 Lux) in any designated area."

Findings Include:

On June 21, 2011, the surveyor, accompanied by the Maintenance Supervisor and Facility Staff, observed the exit discharge lighting from the inpatient exit corridor. The exit discharge was illuminated by a single-bulb light fixture. All designated exits shall have two bulb fixtures.

During the exit conference on June 21, 2011, the above findings were again acknowledged by the Maintenance Supervisor and Facility Staff.

In an emergency the failure of the one bulb will result in harm to the patients.

Based on observation the facility failed to maintain the battery operated emergency lighting.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.2.9.1 " Emergency lighting shall be provided in accordance with Section 7.9."Section 7.9.2.4 "Battery-operated emergency lights shall use only reliable types of rechargeable batteries provided with suitable facilities for maintaining them in properly charged condition."

Findings Include:

On June 21, 2011, the surveyor, accompanied by the Maintenance Director and Facility Staff , tested the emergency lighting unit located in the De Tox corridor. The lighting unit would not light during the test.

During the exit conference on June 21, 2011, the above findings were again acknowledged by the Maintenance Supervisor and Facility Staff.

Failure to maintain emergency lighting units in proper operating condition will cause harm to the patients during a power outage.

Based on fire alarm record review the facility failed to complete sensitivity testing on the facilities smoke detectors.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.1.1.1.1, "The requirements of this chapter apply to existing buildings or portions thereof currently occupied as health care. Existing health care facilities shall comply with the provisions of this chapter" Chapter 19, Section 19.3.4.1 "General" "Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.", Chapter 9, Section 9.6.1.4. A fire alarm system required for life safety shall be installed, tested and maintained in accordance with the applicable requirements of NFPA 70. National Electrical code, and NFPA 72, National fire Alarm Code. NFPA 101, Chapter 4, Section 4.6.12.3, " Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction." NFPA 72 National Fire Alarm Code, Chapter 7 Inspection Testing, and Maintenance/Paragraph 7-3.2 "Testing shall be performed in accordance with the schedules in this chapter or more frequently where required by authority having jurisdiction. Section 7-3.2.1 "Detectors sensitivity shall be checked within 1 year after installation and every alternate year thereafter. Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced."

Findings Include:

On June 21, 2011, the surveyor accompanied by the Safety Director, Maintenance Supervisor and Facility Staff reviewed the fire alarm inspection report. The report did not indicate the U.L. sensitivity of the smoke detectors or if the smoke detectors passed the required sensitivity range.

During the exit conference on June 21, 2011, the above findings were again acknowledged by the Maintenance Supervisor and Facility Staff.

Failure to test and maintain the fire alarm systems smoke detectors could result in harm to the patients.

Based on observation the facility failed to wall mount a fire extinguisher.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.5.6 "Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1" Section 9.7.4.1 "Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for portable Fire Extinguishers." NFPA 10, Chapter 1, Section 1-6.7 "Portable fire extinguishers other than wheeled types shall be securely installed on the hanger or in the bracket supplied or placed in cabinets or wall recesses. The hanger or bracket shall be securely and properly anchored to the mounting surface in accordance with the manufacturer's instructions.....

Findings Include:

On June 21, 2011, the surveyor accompanied by the Maintenance Supervisor and Facility Staff, observed the fire extinguisher located at the Nursing Station. The fire extinguisher was on the floor next to a cabinet. The wall mounting bracket was in need of repair.

During the exit conference on June 21, 2011, the above findings were again acknowledged by the Maintenance Supervisor and Facility Staff.

Failing to properly secure a charged fire extinguisher could result in harm to the patients and staff.

Based on Policy review the facility failed to provide a written policy, for staff members to follow, when an automatic sprinkler system is out of service.

NFPA 101 Life Safety Code 2000, Chapter 19, Section 19.3.5.1 "Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7." Chapter 9, Section 9.7.6.1 "Where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service."

Findings Include:

On June 21, 2011, the surveyor, accompanied by the Safety Director and Facility Staff , reviewed the fire disaster plan for the facility. The surveyor and Safety Director were unable to find a written policy for an out of service sprinkler system.

During the exit conference on June 21, 2011, the above findings were again acknowledged by the Maintenance Supervisor and Facility Staff.

Failing to provide a written policy for an out of service sprinkler system, will cause staff members to delay protection of the patients and the repair of the sprinkler system.

Based on Policy review the facility failed to provide a written policy, for staff members to follow, when a fire alarm system is out of service.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.4.1. "Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6." Chapter 9, Section 9.6.1.8, "Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service."

Findings Include:

On June 21, 2011, the surveyor, accompanied by the Safety Director and Facility Staff, reviewed the fire disaster plan for the facility. The surveyor and the Safety Director were unable to find a written policy for an out of service fire alarm system.

During the exit conference on June 21, 2011, the above findings were again acknowledged by the Safety Director and Facility Staff.

Failing to provide a written policy for an out of service fire alarm system, will cause staff members to delay protection of the patients and the repair of the fire alarm system.