HospitalInspections.org

* 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.

.


.

27382


* 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.

.

27382



* 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


* 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.