HospitalInspections.org

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The facility failed to provide smoke barriers that would provide at least a half hour fire resistance rating. Findings include:

During the survey, the following is an example of what was observed:

Unsealed penetrations around a section of conduit in the smoke barrier by Patient Room 103.

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NFPA 101, 19.3.7.3
NFPA 101, 8.3.2
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The facility failed to maintain stairways with at least 1 hour fire resistance
rating. Findings include:

During the survey, the following are examples of what was observed:

1. Unsealed penetrations around a sprinkler line, and flex conduit, in the wall of the stairwell. This is on the first floor exit opens by the designated smoking area.

2. Unsealed penetrations around a sprinkler line in the wall of the stairwell. This is located on the second floor by the roof access.

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NFPA 101, 19.3.1.1, 8.2.3.2.4, and 7.1.3.2.1
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The facility failed to provide protection of openings in fire barriers to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other.

During the survey, the following is an example of what was observed:

Unsealed penetrations around a section of conduit in the fire barrier by CT.

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NFPA 101, 19.2.2.5 and 7.2.4.3 .
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The facility failed to maintain a fire alarm system with approved component devices. Findings include:

During the survey, the following is an example of what was observed:

1. The magnetic locking devices failed to release upon activation of the fire alarm system for the exits by cardiac stress lab, CT, and Lobby waiting area.

2. The magnetic locking devices for the exits by cardiac stress, CT, and Lobby waiting area failed to release upon AC power loss to the fire alarm system.

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NFPA 72 Section 3-9-7 All locks shall release automatically upon activation of the facility fire detection or fire sprinkler system, or upon disablement of the fire alarm system

1999 NFPA 72, 3-9.7.3* All exits with magnetic locking devices shall unlock upon loss of the primary power to the fire alarm system serving the protected premises. The secondary power supply (the fire alarm panel battery) shall not be utilized to maintain these doors in the locked condition.
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Sprinkler coverage was observed during the survey not adequately provided. Findings include:

During the survey, the following is an example of what was observed:

A upright sprinkler located in the partial basement was obstructed, material was built up around the deflector of the sprinkler.

Every required sprinkler system shall be continuously maintained in proper operating condition.

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NFPA 101, 4.6.12.1.

NFPA 101, 9.7.5, and 1999 NFPA 25, 2-2 and Table 2-1.
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Sprinkler coverage was observed during the survey not adequately provided. Findings include:

During the survey, the following is an example of what was observed:

Escutcheon plate missing on a sprinkler in the cooler.

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2000 NFPA 13, 3-2.7.2
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The facility failed to provide a sprinkler system which meets code requirements. Findings include:

During the survey, the following are examples of what was observed:

1. Sprinkler cabinet was not provided with spare sprinkler heads.

2. Wrench was not provided in the cabinet.

3. Documentation was provided for the annual inspection of the antifreeze loop. The tag on the system indicated 3/1/2011, none of the quarterly inspections conducted for 2013, or 2014 indicated any information concerning the annual inspection.

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NFPA 25 1998 Edition 2-4.1.4

NFPA 13 3-2.9.2

NFPA 25 1998 Edition 2-3.4
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The facility failed to provide metal self-closing containers for disposing of cigarette butts and ashes from ashtrays. Findings include:

During the survey, the following is an example of what was observed:

The metal self-closing container in the designated smoking area by the emergency room entrance was inoperable.

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NFPA 101, 19.7.4

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During survey, the provided documentation for the monthly inspection of the hood system was the inspection card attached to the pull station of the hood extinguishing system. This card was observed with space on the reverse side to date and initial each month an inspection was conducted by facility staff. This side of the inspection card was blank.

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NFPA 17, 9-2.1-
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The facility failed to provide proper storage of oxygen cylinders. Findings include:

During the survey, the following is an example of what was observed:

Appropriate signage was not provided for full/empty oxygen cylinders for the outside storage area.

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CGA G-4, 4.1.10, and 1999 NFPA 99, 4-3.5.2.2(b)2 and 4-5.5.2.2(b)2
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The facility failed to provide receptacles for appliances. Findings include:

During the survey, the following is an example of what was observed:

1. Refrigerator was plugged into a circuit breaker protected power strip in the blood bank.

2. All medical equipment used in OR 1 and 2, was plugged into a circuit breaker protected power strip.

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Appliances, such as air conditioners and refrigerators, shall plug directly into a receptacle. 1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99.


NFPA 101, 19.5.1 Utilities shall comply with NFPA 101, 9.1. Electrical utilities shall comply with 1999 NFPA 70, National Electrical Code.
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The facility failed to provide smoke barriers that would provide at least a half hour fire resistance rating. Findings include:

During the survey, the following is an example of what was observed:

Unsealed penetrations around a section of conduit in the smoke barrier by Patient Room 103.

------------------


NFPA 101, 19.3.7.3
NFPA 101, 8.3.2
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The facility failed to maintain stairways with at least 1 hour fire resistance
rating. Findings include:

During the survey, the following are examples of what was observed:

1. Unsealed penetrations around a sprinkler line, and flex conduit, in the wall of the stairwell. This is on the first floor exit opens by the designated smoking area.

2. Unsealed penetrations around a sprinkler line in the wall of the stairwell. This is located on the second floor by the roof access.

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NFPA 101, 19.3.1.1, 8.2.3.2.4, and 7.1.3.2.1
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The facility failed to provide protection of openings in fire barriers to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other.

During the survey, the following is an example of what was observed:

Unsealed penetrations around a section of conduit in the fire barrier by CT.

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NFPA 101, 19.2.2.5 and 7.2.4.3 .
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The facility failed to maintain a fire alarm system with approved component devices. Findings include:

During the survey, the following is an example of what was observed:

1. The magnetic locking devices failed to release upon activation of the fire alarm system for the exits by cardiac stress lab, CT, and Lobby waiting area.

2. The magnetic locking devices for the exits by cardiac stress, CT, and Lobby waiting area failed to release upon AC power loss to the fire alarm system.

_____________


NFPA 72 Section 3-9-7 All locks shall release automatically upon activation of the facility fire detection or fire sprinkler system, or upon disablement of the fire alarm system

1999 NFPA 72, 3-9.7.3* All exits with magnetic locking devices shall unlock upon loss of the primary power to the fire alarm system serving the protected premises. The secondary power supply (the fire alarm panel battery) shall not be utilized to maintain these doors in the locked condition.
.

.
Sprinkler coverage was observed during the survey not adequately provided. Findings include:

During the survey, the following is an example of what was observed:

A upright sprinkler located in the partial basement was obstructed, material was built up around the deflector of the sprinkler.

Every required sprinkler system shall be continuously maintained in proper operating condition.

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NFPA 101, 4.6.12.1.

NFPA 101, 9.7.5, and 1999 NFPA 25, 2-2 and Table 2-1.
.

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Sprinkler coverage was observed during the survey not adequately provided. Findings include:

During the survey, the following is an example of what was observed:

Escutcheon plate missing on a sprinkler in the cooler.

____________


2000 NFPA 13, 3-2.7.2
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The facility failed to provide a sprinkler system which meets code requirements. Findings include:

During the survey, the following are examples of what was observed:

1. Sprinkler cabinet was not provided with spare sprinkler heads.

2. Wrench was not provided in the cabinet.

3. Documentation was provided for the annual inspection of the antifreeze loop. The tag on the system indicated 3/1/2011, none of the quarterly inspections conducted for 2013, or 2014 indicated any information concerning the annual inspection.

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NFPA 25 1998 Edition 2-4.1.4

NFPA 13 3-2.9.2

NFPA 25 1998 Edition 2-3.4
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The facility failed to provide metal self-closing containers for disposing of cigarette butts and ashes from ashtrays. Findings include:

During the survey, the following is an example of what was observed:

The metal self-closing container in the designated smoking area by the emergency room entrance was inoperable.

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NFPA 101, 19.7.4

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During survey, the provided documentation for the monthly inspection of the hood system was the inspection card attached to the pull station of the hood extinguishing system. This card was observed with space on the reverse side to date and initial each month an inspection was conducted by facility staff. This side of the inspection card was blank.

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NFPA 17, 9-2.1-
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The facility failed to provide proper storage of oxygen cylinders. Findings include:

During the survey, the following is an example of what was observed:

Appropriate signage was not provided for full/empty oxygen cylinders for the outside storage area.

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CGA G-4, 4.1.10, and 1999 NFPA 99, 4-3.5.2.2(b)2 and 4-5.5.2.2(b)2
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The facility failed to provide receptacles for appliances. Findings include:

During the survey, the following is an example of what was observed:

1. Refrigerator was plugged into a circuit breaker protected power strip in the blood bank.

2. All medical equipment used in OR 1 and 2, was plugged into a circuit breaker protected power strip.

---------------------

Appliances, such as air conditioners and refrigerators, shall plug directly into a receptacle. 1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99.


NFPA 101, 19.5.1 Utilities shall comply with NFPA 101, 9.1. Electrical utilities shall comply with 1999 NFPA 70, National Electrical Code.
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