HospitalInspections.org

Based on observations made during the follow-up survey for life safety from fire with the facility's Engineer (employee #1), it was determined that the facility failed to ensure that emergency lighting (battery operated lamps) which provides light for a period of 90 minutes, enabling those inside to move about safely in an emergency are provided throughout the hallways of the hospital, waiting area of the emergency room and outside staircases as required by the 2000 edition of the Life Safety Code of the NFPA Section 7.9.

Deficiencies Not Corrected

Findings include:

1. The facility lacks emergency battery operated lamps (EBOL) for a period of 90 minutes as determined by the follow-up observational tour with the facility's Engineer (employee #1) on 11/9/11 from 9:30 am till 12:00 noon in the following areas:
a. Throughout the hallways (means of egress) of the entire facility (floors one through eight).
b. The waiting area of the Emergency Room.
c. The hallway from the hospital to the emergency room.
d. At the outside staircases of the hospital (all landings).
(Emergency lamps are required to ensure adequate lighting until the essential electrical system (generator) turns on or in the event that the essential electrical system fails as required since March 13 of 2006).

Based on observations made during the follow-up survey for life safety from fire with the facility's Engineer (employee #1), it was determined that the facility failed to ensure that smoke detectors are available at all required areas and the fire alarm system lacks annunciation to an approved central station as required by the applicable requirements of NFPA 70 (National Electric Code) and NFPA 72 (National Fire Alarm Code).

Deficiencies Not Corrected

Findings include:

1. Smoke detectors connected to the fire alarm panel are needed in the following areas as determined during the follow-up visit on 11/9/11 from 9:30 am till 12:00 noon:
a. In the triage room of the emergency room.
b. In the treatment room (with a large refrigerator) located next to the triage area of the Emergency Room.
c. In the pantry of the pediatric emergency room (microwave and refrigerator).

2. The fire alarm system lacks annunciation to an approved central station as reviewed during the follow-up survey on 11/9/11 at 3:45 pm with the facility's Engineer (employee #1). The fire alarm system must be arranged to transmit an alarm automatically via a central station to alert the municipal fire department and fire brigade.