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Based upon observation and interview the facility failed to ensure smoke barrier doors resist the passage of smoke. This practice would allow smoke to move freely across the barrier and endanger patients.

Findings include:

During the facility tour on July 6, 2011 observation revealed smoke barrier doors on the second floor had damaged astragals not capable of resisting the passage of smoke. This observation was confirmed by the maintenance engineer who acknowledged other doors in the facility also needed work.

Actual NFPA standard:

NFPA 101- 2000 Edition

18.3.7.8
Rabbets, bevels, or astragals shall be required at the meeting edges, and stops shall be required at the head and sides of door frames in smoke barriers. Positive latching hardware shall not be required. Center mullions shall be prohibited.

NFPA 80 Standard for Fire Doors and Fire Windows -1999 Edition (informational only)

2-3.1.7
The clearance between the edge of the door on the pull side and the frame, and the meeting edges of doors swinging in pairs on the pull side shall be 1/8 in. ? 1/16 in. (3.18 mm ? 1.59 mm) for steel doors and shall not exceed 1/8 in. (3.18 mm) for wood doors.

Based upon observation and interview the facility failed to ensure electrical panels were readily accessible at all times, blocked panels can delay control of electrical equipment during an emergency.

Findings include:

During the facility tour on July 5& 6, 2011 observation revealed electrical panels in the Administrative area, and two panels in the laboratory were blocked by furnishings. Clear access of three feet (36 inches) is required. This was acknowledged by the maintenance engineer as an ongoing issue, and he noted that the panels were labeled to maintain the clear space.

Actual NFPA standard:

NFPA 70 NAtional Electrical Code, 1999

110.26 Spaces About Electrical Equipment.
Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons.
(A) Working Space. Working space for equipment operating at 600 volts, nominal, or less to ground and likely to require examination, adjustment, servicing, or maintenance while energized shall comply with the dimensions of 110.26(A)(1), (2), and (3) or as required or permitted elsewhere in this Code.
(1) Depth of Working Space. The depth of the working space in the direction of live parts shall not be less than that specified in Table 110.26(A)(1) unless the requirements of 110.26(A)(1)(a), (b), or (c) are met. Distances shall be measured from the exposed live parts or from the enclosure or opening if the live parts are enclosed.
Table 110.26(A)(1) Working Spaces
Nominal Voltage to Ground - Minimum Clear Distance Condition 1 - Condition 2 - Condition 3
0-150 900 mm (3 ft) 900 mm (3 ft) 900 mm (3 ft)
151-600 900 mm (3 ft) 1 m (3? ft) 1.2 m (4 ft)

Based upon observation and interview the facility failed to ensure alcohol based hand rub (ABHR) dispensers were not located above or adjacent to an ignition source. Failure to separate the location of flammable liquids and ignition sources could create a fire.

Findings include:

During the facility tour on July 5 & 6, 2011 observation revealed ABHR dispensers installed directly over night lights in patient rooms 201 through 209 and adjacent to light switches in the rest room next to the Emergency Department and the Physical Therapy Department hydro room. This observation was acknowledged by the maintenance engineer.

Actual NFPA Standard:

NFPA 101, TIA 00-1

1. Add new text to Chapter 18 for new health care occupancies as follows:
18.3.2.7* Alcohol-based Hand-rub Solutions. Alcohol-based hand-rub dispensers shall be protected in accordance with 8.4.3 unless all of the following conditions are met:
(1) Where dispensers are installed in a corridor, the corridor shall have a minimum width of 6 ft (1.8 m).
(2) The maximum individual dispenser fluid capacity shall be:
(a) 0.3 gallons (1.2 liters) for dispensers in rooms, corridors, and areas open to corridors
(b) 0.5 gallons (2.0 liters) for dispensers in suites of rooms
(3) The dispensers shall have a minimum horizontal spacing of 4 ft (1.2 m) from each other.
(4) Not more than an aggregate 10 gallons (37.8 liters) of alcohol-based hand rub solution shall be in use in a single smoke compartment outside of a storage cabinet.
(5) Storage of quantities greater than 5 gallons (18.9 liters) in a single smoke compartment shall meet the requirements of NFPA 30, Flammable and Combustible Liquids Code.
(6) The dispensers shall not be installed over or directly adjacent to an ignition source.
(7) In locations with carpeted floor coverings, dispensers installed directly over carpeted surfaces shall be permitted only in sprinklered smoke compartments.