HospitalInspections.org

Item A:
A walk-through of the facility with the Facilities Maintenance Manager, and others, August 29th, 2012, found through observation the latching function of the following doors to be non-compliant with Section 18.3.6.3.2 of the 2000 edition of NFPA 101, the Life Safety Code.
Doors for rooms 105, 132, and 133, doors to the corridor, failed to positively latch into the frame.

Section 18.3.6.3.2 states: Doors shall be provided with positive latching hardware. Roller latches shall be prohibited.

Exception: Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials.

Item B:
A walk-through of the facility with the Facilities Maintenance Manager, and others, August 29th, 2012, found through observation the closing function of the following door's swing path inhibited and therefore, non-compliant with Section 18.3.6.3.2 of the 2000 edition of NFPA 101, the Life Safety Code.
The door between the nursery and the corridor found wedged open with a rubber wedge (this deficiency corrected during inspection)

According to Section 18.3.6.3.3 of the 2000 edition of NFPA 101, the Life Safety Code: "Hold-open devices that release when the door is pushed or pulled shall be permitted." This is further clarified by the expository language contained in appendix of the 2000 edition of NFPA 101, the Life Safety Code, which reiterates the intent is that doors can be opened or closed with a push or a pull.
This allows simple mechanical hold-open devices, such as spring-clip- or permanent magnet-type, to be utilized as long as the requirements contained in Section 7.2.1.4.5 of the 2000 edition of NFPA 101, the Life Safety Code are met.
These requirements are: The forces required to fully open any door manually in a means of egress shall not exceed 15 lbf (67 N) to release the latch, 30 lbf (133 N) to set the door in motion, and 15 lbf (67 N) to open the door to the minimum required width. Opening forces for interior side-hinged or pivoted-swinging doors without closers shall not exceed 5 lbf (22 N). These forces shall be applied at the latch stile.
Exception No. 1: The opening force for existing doors in existing buildings shall not exceed 50 lbf (222 N) applied to the latch stile.

A review of the records with the Facilities Maintenance Manager, and others, August 29th, 2012, found the facility failed to properly maintain smoke dampers throughout the facility per NFPA 101, the Life Safety Code, and referenced publications.

There are several smoke dampers listed as needing access doors and/or no air actuator, and one damper listed as having wires running through the damper opening, and one damper listed as having a damaged fusible link identified in July 16th, 2012 damper Inspection Inventory report.

Not having access to these dampers precludes proper maintenance; Wires running through a damper precludes its ability to perform smoke control functions; A damaged fusible link precludes a dampers from performing proper fire control functions.

Item A:
A walk-through of the facility with the Facilities Maintenance Manager, and others, August 29th, 2012, found through observation that the facility failed to properly maintain the smoke doors per Sections 18.3.7.6 and 8.3.4 of the 2000 edition of NFPA 101, the Life Safety Code.
The cross-corridor doors located between the OB Nursery and OB Patient Care did not positively close and latch into the frame. This will prevent these doors from acting as a sufficient smoke seal between these two areas.
Item B:
A walk-through of the facility with the Facilities Maintenance Manager, and others, August 29th, 2012, found through observation that the facility failed to properly maintain the smoke barrier status of the corridor per Section 18.3.6 of the 2000 edition of NFPA 101, the Life Safety Code.
There are multiple pipe penetrations through the ceiling tile having gaps about them located in West Med-Surg Hallway Equipment Room, and the interstitial space above the ceiling tile yields atmospheric access to the corridor outside the Equipment Room.

A walk-through of the facility with the Facilities Maintenance Manager, and others, August 29th, 2012, found through observation that the facility failed to properly maintain the proper physical separation of pendent-head sprinklers per Section 5-6.3.4 of the 1999 edition of NFPA 13, Installation of Sprinkler Systems.

Four pendent sprinkler heads located in the Phlebotomy - Draw area were physically too close.

Section 5-6.3.4 states: Sprinklers shall be spaced not less than 6 ft (1.8 m) on center.

This spatial distance is to preclude sprinklers from "wetting" one another, which may lead to a phenomenon call referred to as "cold fusion."

A walk-through of the facility with the Facilities Maintenance Manager, and others, August 29th, 2012, found through observation that the facility failed to install a smoke control system in the operating (OR) suites, thereby not conforming to requirements of the 2000 edition of NFPA 101, Life Safety Code, Sections 19.3.2.3, and the 1999 edition of NFPA 99, Section 5-4.1.3.

The surveyor, the Facilities Maintenance Manager, and others observed there were no smoke detectors in the OR suites, nor did the facility provide documentation that the air handling system for the OR suites works to prevent the recirculation of smoke originating within the surgical suites. OR personnel did confirm the normal use of general anesthesia.

According to the 1999 edition of NFPA 99, Section 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.

A walk-through of the facility with the Facilities Maintenance Manager, and others, August 29th, 2012, found through observation that the facility failed to properly maintain the electrical system in accordance with the 1999 edition of NFPA 72, the National Electrical Code (NEC).

1) Exposed electrical connections and/or splices energized at 120 volts nominal, in junction boxes without proper covers installed, were observed on the east side and above the smoke barrier doors located between the OB Patient corridor and the Main corridor.

2) An appliance without proper disconnecting means, but instead served by a flexible cord spliced directly to energized 120 volt nominal connectors, was observed on the east side and above the smoke barrier doors located between the OB Patient corridor and the Main corridor. This cord and cap appliance (a magnetic door-locking device) was found with its male plug removed and the flexible cord spliced directly into the 120 volt source, thereby precluding a proper disconnecting means.

Article 370-25 of the 1999 NEC states: In completed installations, each box shall have a cover, faceplate, or fixture canopy.

Article 422-30 of the 1999 NEC requires that appliances have a suitable disconnecting means.

Item A:
A walk-through of the facility with the Facilities Maintenance Manager, and others, August 29th, 2012, found through observation the latching function of the following doors to be non-compliant with Section 18.3.6.3.2 of the 2000 edition of NFPA 101, the Life Safety Code.
Doors for rooms 105, 132, and 133, doors to the corridor, failed to positively latch into the frame.

Section 18.3.6.3.2 states: Doors shall be provided with positive latching hardware. Roller latches shall be prohibited.

Exception: Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials.

Item B:
A walk-through of the facility with the Facilities Maintenance Manager, and others, August 29th, 2012, found through observation the closing function of the following door's swing path inhibited and therefore, non-compliant with Section 18.3.6.3.2 of the 2000 edition of NFPA 101, the Life Safety Code.
The door between the nursery and the corridor found wedged open with a rubber wedge (this deficiency corrected during inspection)

According to Section 18.3.6.3.3 of the 2000 edition of NFPA 101, the Life Safety Code: "Hold-open devices that release when the door is pushed or pulled shall be permitted." This is further clarified by the expository language contained in appendix of the 2000 edition of NFPA 101, the Life Safety Code, which reiterates the intent is that doors can be opened or closed with a push or a pull.
This allows simple mechanical hold-open devices, such as spring-clip- or permanent magnet-type, to be utilized as long as the requirements contained in Section 7.2.1.4.5 of the 2000 edition of NFPA 101, the Life Safety Code are met.
These requirements are: The forces required to fully open any door manually in a means of egress shall not exceed 15 lbf (67 N) to release the latch, 30 lbf (133 N) to set the door in motion, and 15 lbf (67 N) to open the door to the minimum required width. Opening forces for interior side-hinged or pivoted-swinging doors without closers shall not exceed 5 lbf (22 N). These forces shall be applied at the latch stile.
Exception No. 1: The opening force for existing doors in existing buildings shall not exceed 50 lbf (222 N) applied to the latch stile.

A review of the records with the Facilities Maintenance Manager, and others, August 29th, 2012, found the facility failed to properly maintain smoke dampers throughout the facility per NFPA 101, the Life Safety Code, and referenced publications.

There are several smoke dampers listed as needing access doors and/or no air actuator, and one damper listed as having wires running through the damper opening, and one damper listed as having a damaged fusible link identified in July 16th, 2012 damper Inspection Inventory report.

Not having access to these dampers precludes proper maintenance; Wires running through a damper precludes its ability to perform smoke control functions; A damaged fusible link precludes a dampers from performing proper fire control functions.

Item A:
A walk-through of the facility with the Facilities Maintenance Manager, and others, August 29th, 2012, found through observation that the facility failed to properly maintain the smoke doors per Sections 18.3.7.6 and 8.3.4 of the 2000 edition of NFPA 101, the Life Safety Code.
The cross-corridor doors located between the OB Nursery and OB Patient Care did not positively close and latch into the frame. This will prevent these doors from acting as a sufficient smoke seal between these two areas.
Item B:
A walk-through of the facility with the Facilities Maintenance Manager, and others, August 29th, 2012, found through observation that the facility failed to properly maintain the smoke barrier status of the corridor per Section 18.3.6 of the 2000 edition of NFPA 101, the Life Safety Code.
There are multiple pipe penetrations through the ceiling tile having gaps about them located in West Med-Surg Hallway Equipment Room, and the interstitial space above the ceiling tile yields atmospheric access to the corridor outside the Equipment Room.

A walk-through of the facility with the Facilities Maintenance Manager, and others, August 29th, 2012, found through observation that the facility failed to properly maintain the proper physical separation of pendent-head sprinklers per Section 5-6.3.4 of the 1999 edition of NFPA 13, Installation of Sprinkler Systems.

Four pendent sprinkler heads located in the Phlebotomy - Draw area were physically too close.

Section 5-6.3.4 states: Sprinklers shall be spaced not less than 6 ft (1.8 m) on center.

This spatial distance is to preclude sprinklers from "wetting" one another, which may lead to a phenomenon call referred to as "cold fusion."

A walk-through of the facility with the Facilities Maintenance Manager, and others, August 29th, 2012, found through observation that the facility failed to install a smoke control system in the operating (OR) suites, thereby not conforming to requirements of the 2000 edition of NFPA 101, Life Safety Code, Sections 19.3.2.3, and the 1999 edition of NFPA 99, Section 5-4.1.3.

The surveyor, the Facilities Maintenance Manager, and others observed there were no smoke detectors in the OR suites, nor did the facility provide documentation that the air handling system for the OR suites works to prevent the recirculation of smoke originating within the surgical suites. OR personnel did confirm the normal use of general anesthesia.

According to the 1999 edition of NFPA 99, Section 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.

A walk-through of the facility with the Facilities Maintenance Manager, and others, August 29th, 2012, found through observation that the facility failed to properly maintain the electrical system in accordance with the 1999 edition of NFPA 72, the National Electrical Code (NEC).

1) Exposed electrical connections and/or splices energized at 120 volts nominal, in junction boxes without proper covers installed, were observed on the east side and above the smoke barrier doors located between the OB Patient corridor and the Main corridor.

2) An appliance without proper disconnecting means, but instead served by a flexible cord spliced directly to energized 120 volt nominal connectors, was observed on the east side and above the smoke barrier doors located between the OB Patient corridor and the Main corridor. This cord and cap appliance (a magnetic door-locking device) was found with its male plug removed and the flexible cord spliced directly into the 120 volt source, thereby precluding a proper disconnecting means.

Article 370-25 of the 1999 NEC states: In completed installations, each box shall have a cover, faceplate, or fixture canopy.

Article 422-30 of the 1999 NEC requires that appliances have a suitable disconnecting means.