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Tag No.: K0017
Uncorrected Deficiency. Waiver Pending
Prewett, Roger
The facility failed to provide complete corridor walls in areas of the facility which did not have sprinkler coverage.
Examples are as follows: The corridor wall in the compartments without complete sprinkler coverage was observed not extending to the deck above at the following locations:
a) Med Room 5336,
b) In the corridor between Four North West and Four North
NFPA 101, 19.3.6.2.1 Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour.
Exception No. 1: In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.2, a corridor shall be permitted to be separated from all other areas by non-fire-rated partitions and shall be permitted to terminate at the ceiling where the ceiling is constructed to limit the transfer of smoke.
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Tag No.: K0029
The facility failed to provide/maintain smoke-resisting partitions and self-closing/latching doors for hazardous areas.
Examples are as follows:
1) The Trash Room 5338 without sprinkler coverage was observed with flex ducts passing through the walls above the ceiling without fire dampers and the door only twenty minute fire rated, not forty-five minute rated as required.
2) The Soiled Utility Room 4340 without sprinkler coverage was observed with flex ducts passing through the walls above the ceiling.
3) Storage Room 4338 without sprinkler coverage was observed with the walls not extending to the deck above the ceiling.
Prewett, Roger
Easterling, Candy
2000 NFPA 101, 19.3.2.1 Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.
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27382
Tag No.: K0033
The facility failed to maintain stairways with at least one hour fire resistance rating.
Examples are as follows: The following stairwells were observed with air supply ducts passing through the walls supplying air into the corridor and stairwell with only fire dampers which would allow the passage of smoke:
1) Near room 5321,
2) Near room 5311.
NFPA 101, 19.3.1.1 Any vertical opening shall be enclosed or protected in accordance with 8.2.5. Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating.
NFPA 101, 8.2.5.1 Every floor that separates stories in a building shall be constructed as a smoke barrier to provide a basic degree of compartmentation.
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Tag No.: K0051
Facility failed to maintain the Digital Alarm Communicator Transmitter in the fire alarm system.
Findings include: During the survey, the following is an example of what was observed: When the Auto Dialer was tested for Communication Failure, failure was indicated at the protected premise within the proper times but identification of individual lines was not identified.
1999 NFPA 72, Section 1-5.4.6, 5-5.3.2.1.5, and 5-5.3.2.1.6.2. Phone line and communication failure shall be indicated at the facility.
23115
Tag No.: K0052
The facility failed to maintain the fire alarm system in proper working order.
Examples are as follows:
1) Audible/visual appliances were observed not heard or seen upon fire alarm activation at the following locations:
a) Audible/Visual in corridor by OR # 5 Out Patient Surgery.
b) Audible/Visual in corridor by Room 1948 Out Patient Surgery.
c) Audible/Visual by G-628. d) Audible/Visual in the Kitchen located on the wall above the Ice Cream Machine G-6211.
First Floor
2) The following fire alarm audio/visual devices did not strobe:
a) By room 1838
b) At room 1849
c) At room 1807
d) At room 1803
e) At room 16046
Third Floor
3) The following fire alarm audio/visual devices did not strobe:
a) At room 3175
b) At room 3172
NFPA 101, 9.6.1.4 The fire alarm system to be installed, tested, and maintained in accordance with the requirements of NFPA 70 and NFPA 72.
Free, Jim
2000 NFPA 101, 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, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.
1999 NFPA 72, 4-4.2 Light Pulse Characteristics. The flash rate shall not exceed two flashes per second (2 Hz) nor be less than one flash every second (1 Hz) throughout the listed voltage range of the appliance.
1999 NFPA 72, 4-4.2.1 A maximum pulse duration shall be 0.2 seconds with a maximum duty cycle of 40 percent. The pulse duration shall be defined as the time interval between initial and final points of 10 percent of maximum signal.
1999 NFPA 72, 4-4.2.2* The light source color shall be clear or nominal white and shall not exceed 1000 cd (effective intensity).
1999 NFPA 72, 4-4.3.1 Visible notification appliances used in the public mode shall be located and shall be of a type, size, intensity, and number so that the operating effect of the appliance is seen by the intended viewers regardless of the viewer's orientation.
2000 NFPA 101, 9.6.5.2 Where required by another section of this Code, the following functions shall be actuated by the complete fire alarm system: (1) Release of hold-open devices for doors or other opening protectives (2) Stairwell or elevator shaft pressurization (3) Smoke management or smoke control systems (4) Emergency lighting control (5) Unlocking of doors
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23115
27382
Tag No.: K0078
Easterling, Candy
The facility failed to provide smoke venting for the ORs per code. Findings include:
During the survey, the following is an example of what was observed:
The 24 windowless ORs, per observation and interview, did not have a smoke venting system.
1999 NFPA 99, 5-4.1.2 Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically vent smoke and products of combustion.
1999 NFPA 99, 5-4.1.3 Ventilating systems for anesthetizing locations shall be provided that automatically (a) prevent recirculation of smoke originating within the surgical suite and (b) prevent the circulation of smoke entering the system intake, without in either case interfering with the exhaust function of the system.
1999 NFPA 99, 5-4.1.4 The electric supply to the ventilating system shall be served by the equipment system of the essential electrical system specified in Chapter 3, "Electrical Systems."
1999 NFPA 99, 5-6.1.1 Ventilating and humidifying equipment for anesthetizing locations shall be kept in operable condition and be continually operating during surgical procedures (see A-5-4.1).
27382
Tag No.: K0130
Easterling, Candy
The facility failed to the following systems per code. Findings include:
During the survey, the following are examples of what was observed:
1. The six windowless ORs, per observation and interview, did not have a smoke venting system.
2. The following fire alarm audible and visual devices did not strobe when the fire alarm was tested:
a. At OR 3/room 1953
b) In Out Patient Recovery at the Nurses' Station
c) In the corridor outside of Out Patient Recovery at "the picture board"
27382