HospitalInspections.org

New Deficiency:

Based on observation, document review, and staff interview, it was determined that the facility failed to ensure occupant loads within sleeping rooms are maintained in accordance with the 2000 edition of the National Fire Protection Association's (NFPA) Life Safety Code 101.

Findings include:

Reference #1: NFPA 101:19.1.7, Occupant Load. The occupant load, in number of persons for whom means of egress and other provisions are required, shall be determined on the basis of the occupant load factors of table 7.3.1.2 that are characteristic of the use of the space or shall be determined as the maximum probable population of the space under consideration, whichever is greater.

Reference #2: NFPA 101, Table 7.3.1.2, Occupant Load Factor: Health Care Use, Sleeping departments, 120 square feet per person.

Reference #3: 2001 Guidelines For Design and Construction of Hospital And Health Care Facilities, 11.2.A2, Patient room areas, exclusive of toilet rooms, closets, lockers, wardrobes, alcoves, or vestibules, shall be at least 100 square feet for single-bed rooms and 80 square feet per bed for multiple-bed rooms.

Reference 4: October, 1983 Facility Floor Plan and Data Sheets, detailing Room Size, Square footage and Bed Capacity.

1. During an interview on 4/15/15, Staff #17 confirmed the facility determines the occupant load for sleeping departments by multiplying the length and width of the entire smoke compartment and dividing the total square footage by 120.

a. Staff #17 confirmed that the square footage of non-sleeping rooms were not subtracted from the total square footage prior to calculating the occupant load.

b. Staff #17 added, 80 square feet is used within individual sleeping rooms to calculate occupancy based on reference #3.

2. On 4/16/15 at approximately 10:00 AM in the presence of Staff #9, a tour of the Main Building Ward M118 provided evidence of the following:

a. Four (4) of eight (8) rooms were not used for sleeping.

b. The smoke compartment is approximately 2,606 square feet. 1,043 square feet are used for sleeping purposes. Based on the Life Safety Code, eight (8) Patients can be housed within the smoke compartment.

i. A total of fourteen (14) beds are available within the M118 Ward.

3. On 4/16/15 at approximately 10:15 AM, a tour of the Main Building Ward M118 Ward the following rooms exceeded occupancy:

a. Room M111:

i. Sleeping Room M111 measures 278 square feet based on facility supplied measurements and contained four (4) beds.

ii. 278 square feet divided by 80 allows for three(3) patients prior to subtracting the square footage of toilet rooms, closets, wardrobes, dressers, alcoves as required by code.

iii. Four (4) beds are located in Room M111.

iv. Facility data sheets state the bed capacity of this room is two (2).

b. Room M116:

i. Sleeping Room M116 measures 270 square feet based on facility supplied measurements.

ii. 270 square feet divided by 80 allows three (3) patients prior to subtracting the square footage of toilet rooms, closets, wardrobes, dressers, alcoves as required by code.

iii. Four (4) beds are located in Room M116.

iv. Facility data sheets state the bed capacity of this room is three (3).

c. Room M115:

i. Sleeping Room M115 measures 225 square feet based on facility supplied measurements.

ii. 225 divided by 80 allows for two (2) patients prior to subtracting the square footage of toilet rooms, closets, wardrobes, dressers, alcoves as required by code.

iii. Three (3) beds are located in this room.

iv. The Facility data sheets indicate the room space is use as an office.

4. On 4/16/15 at approximately 10:30 AM in the presence of Staff #9, a tour of the Birch Hall Ward B111 provided evidence of the following:

a. Three (3) of nine (9) rooms were not used for sleeping.

b. The smoke compartment is approximately 2,247 square feet. 1,262 square feet are used for sleeping purposes. Based on the Life Safety Code, ten (10) patients can be housed within the smoke compartment.

i. A total of fourteen (14) beds are available within the B111 Ward

c. On 4/16/15 at approximately 10:30 AM, a tour of Birch Hall Ward B111, the following rooms exceeded occupancy:

a. Room 111B:

i. Sleeping Room 111B measures 192 square feet based on facility supplied measurements

ii. 192 divided by 80 allows for two (2) patients prior to subtracting the square footage of toilet rooms, closets, wardrobes, dressers, alcoves as required by code.

iii. Three (3) beds are located in this room.

iv. Facility data sheets state the bed capacity for this room is two (2).

b. Room 111C:

i. Sleeping Room 111C measures 192 square feet based on facility supplied measurements.

ii. 192 divided by 80 allows for two (2) patients prior to subtracting the square footage of toilet rooms, closets, wardrobes, dressers, alcoves as required by code.

iii. Three (3) beds are located in this room.

iv. Facility data sheets state the bed capacity for this room is two (2).

5. On 4/16/15 at approximately 11:00 AM in the presence of Staff #9, a tour of Larch Hall Ward L116 provided evidence of the following:

a. Three (3) of nine (9) rooms were not used for sleeping.

b. The smoke compartment is approximately 2,772 square feet. 1,660 square feet are used for sleeping purposes. Based on the Life Safety Code, thirteen (13) patients can be housed within the smoke compartment.

i. A total of 19 beds are available within the L116 Ward.

New Deficiency:

Based on observation, document review, and staff interview, it was determined that the facility failed to ensure occupant loads within sleeping rooms are maintained in accordance with the 2000 edition of the National Fire Protection Association's (NFPA) Life Safety Code 101.

Findings include:

Reference #1: NFPA 101:19.1.7, Occupant Load. The occupant load, in number of persons for whom means of egress and other provisions are required, shall be determined on the basis of the occupant load factors of table 7.3.1.2 that are characteristic of the use of the space or shall be determined as the maximum probable population of the space under consideration, whichever is greater.

Reference #2: NFPA 101, Table 7.3.1.2, Occupant Load Factor: Health Care Use, Sleeping departments, 120 square feet per person.

Reference #3: 2001 Guidelines For Design and Construction of Hospital And Health Care Facilities, 11.2.A2, Patient room areas, exclusive of toilet rooms, closets, lockers, wardrobes, alcoves, or vestibules, shall be at least 100 square feet for single-bed rooms and 80 square feet per bed for multiple-bed rooms.

Reference 4: October, 1983 Facility Floor Plan and Data Sheets, detailing Room Size, Square footage and Bed Capacity.

1. During an interview on 4/15/15, Staff #17 confirmed the facility determines the occupant load for sleeping departments by multiplying the length and width of the entire smoke compartment and dividing the total square footage by 120.

a. Staff #17 confirmed that the square footage of non-sleeping rooms were not subtracted from the total square footage prior to calculating the occupant load.

b. Staff #17 added, 80 square feet is used within individual sleeping rooms to calculate occupancy based on reference #3.

2. On 4/16/15 at approximately 10:00 AM in the presence of Staff #9, a tour of the Main Building Ward M118 provided evidence of the following:

a. Four (4) of eight (8) rooms were not used for sleeping.

b. The smoke compartment is approximately 2,606 square feet. 1,043 square feet are used for sleeping purposes. Based on the Life Safety Code, eight (8) Patients can be housed within the smoke compartment.

i. A total of fourteen (14) beds are available within the M118 Ward.

3. On 4/16/15 at approximately 10:15 AM, a tour of the Main Building Ward M118 Ward the following rooms exceeded occupancy:

a. Room M111:

i. Sleeping Room M111 measures 278 square feet based on facility supplied measurements and contained four (4) beds.

ii. 278 square feet divided by 80 allows for three(3) patients prior to subtracting the square footage of toilet rooms, closets, wardrobes, dressers, alcoves as required by code.

iii. Four (4) beds are located in Room M111.

iv. Facility data sheets state the bed capacity of this room is two (2).

b. Room M116:

i. Sleeping Room M116 measures 270 square feet based on facility supplied measurements.

ii. 270 square feet divided by 80 allows three (3) patients prior to subtracting the square footage of toilet rooms, closets, wardrobes, dressers, alcoves as required by code.

iii. Four (4) beds are located in Room M116.

iv. Facility data sheets state the bed capacity of this room is three (3).

c. Room M115:

i. Sleeping Room M115 measures 225 square feet based on facility supplied measurements.

ii. 225 divided by 80 allows for two (2) patients prior to subtracting the square footage of toilet rooms, closets, wardrobes, dressers, alcoves as required by code.

iii. Three (3) beds are located in this room.

iv. The Facility data sheets indicate the room space is use as an office.

4. On 4/16/15 at approximately 10:30 AM in the presence of Staff #9, a tour of the Birch Hall Ward B111 provided evidence of the following:

a. Three (3) of nine (9) rooms were not used for sleeping.

b. The smoke compartment is approximately 2,247 square feet. 1,262 square feet are used for sleeping purposes. Based on the Life Safety Code, ten (10) patients can be housed within the smoke compartment.

i. A total of fourteen (14) beds are available within the B111 Ward

c. On 4/16/15 at approximately 10:30 AM, a tour of Birch Hall Ward B111, the following rooms exceeded occupancy:

a. Room 111B:

i. Sleeping Room 111B measures 192 square feet based on facility supplied measurements

ii. 192 divided by 80 allows for two (2) patients prior to subtracting the square footage of toilet rooms, closets, wardrobes, dressers, alcoves as required by code.

iii. Three (3) beds are located in this room.

iv. Facility data sheets state the bed capacity for this room is two (2).

b. Room 111C:

i. Sleeping Room 111C measures 192 square feet based on facility supplied measurements.

ii. 192 divided by 80 allows for two (2) patients prior to subtracting the square footage of toilet rooms, closets, wardrobes, dressers, alcoves as required by code.

iii. Three (3) beds are located in this room.

iv. Facility data sheets state the bed capacity for this room is two (2).

5. On 4/16/15 at approximately 11:00 AM in the presence of Staff #9, a tour of Larch Hall Ward L116 provided evidence of the following:

a. Three (3) of nine (9) rooms were not used for sleeping.

b. The smoke compartment is approximately 2,772 square feet. 1,660 square feet are used for sleeping purposes. Based on the Life Safety Code, thirteen (13) patients can be housed within the smoke compartment.

i. A total of 19 beds are available within the L116 Ward.