HospitalInspections.org

Based on observations and confirmed by staff, the facility failed to ensure compliance with chapter 19. Section 19.3.6.2.1 states 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.
Exception No. 2: Existing corridor partitions shall be permitted to terminate at ceilings that are not an integral part of a floor construction if 5 ft (1.5 m) or more of space exists between the top of the ceiling subsystem and the bottom of the floor or roof above, provided that the following criteria are met:
(a) The ceiling shall be part of a fire-rated assembly tested to have a fire resistance rating of not less than 1 hour in compliance with the provisions of 8.2.3.1.
(b) The corridor partitions form smoketight joints with the ceilings (joint filler, if used, shall be noncombustible).
(c) Each compartment of interstitial space that constitutes a separate smoke area is vented, in a smoke emergency, to the outside by mechanical means having sufficient capacity to provide not less than two air changes per hour but, in no case, a capacity less than 5000 ft3/min (2.36 m3/s).
(d) The interstitial space shall not be used for storage.
(e) The space shall not be used as a plenum for supply, exhaust, or return air, except as noted in 19.3.6.2.1(3).
Exception No. 3*: Existing corridor partitions shall be permitted to terminate at monolithic ceilings that resist the passage of smoke where there is a smoketight joint between the top of the partition and the bottom of the ceiling.


THE FINDINGS INCLUDE:

On the morning of 6/9/14, during a building tour of the psychiatric unit in the Fowler building, the following was observed:

- The Psychiatric Unit is not sprinklered.
- The corridor walls above the ceiling tiles have unsealed penetrations and the space above the ceiling tile is used as a plenum.
-The construction type of the building in which the psychiatric unit is located is a Type I(332), and is not required to be sprinklered.
- The Heating, Ventilation and Air Conditioning (HVAC) system in the unit uses the area above the ceiling tile as a plenum and needs to have opening between the rooms and the corridor to allow the return air to flow back to the HVAC unit.

The following deficiencies were noted:

1) Since the unit is not sprinklered the openings between the rooms and the corridor above the ceiling titles can not be used as stated in 19.3.6.2.1, because the corridor walls are not continuous.

2) Since the unit uses the area above the ceiling tile as a plenum the facility does not meet the exception no. 2 as stated in 19.3.6.2.1.

This was confirmed by the Director of Engineering and reviewed with facility Administration during a summary of survey findings.

Based on observations and confirmed by staff, the facility failed to assure that hazardous areas are enclosed as required. Section 19.3.2.1 requires the doors to rooms or spaces larger than 50 sq. ft. including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction, to be self-closing.

THE FINDINGS INCLUDE:

Throughout the LSC survey, conducted 6/09/14 through 6/11/14, it was observed that the corridor doors to the facility's hazardous areas, identified as Room # 2041, # 2127, # 2344, # 2324, and # 3059 were not self-closing as required by Section 19.3.2.1.

This was confirmed by the Director of Engineering and the facility Administration staff during a summary of survey findings.

Based on observations and a review of documentation, the facility failed to assure that discharge from exits is in accordance with the following sections of Chapter 7 of the 2000 Edition of the NFPA 101 Life Safety Code.

1) Section 7.1.6.3 states walking surfaces shall be nominally level. The slope of a walking surface in the direction of travel shall not exceed 1 in 20 unless the ramp requirements of 7.2.5 are met. The slope perpendicular to the direction of travel shall not exceed 1 in 48.

2) Section 7.1.7.1 states changes in level in means of egress shall be achieved either by a ramp or a stair where the elevation difference exceeds 21 in. (53.3 cm).

3) Section 7.1.10.1 requires every exit, exit access and exit discharge to be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. In areas where there are climatic conditions such as rain or snow which could render a yard or unpaved area unusable, a permanent sidewalk must be provided.

THE FINDINGS INCLUDE:

A. Observations made while touring the facility on the afternoon of 6/10/14 at approximately 2:30 P.M. and on the morning of 6/11/14 at approximately 9:30 A.M. revealed the following:

a) There are a total of four (4) ground floor exits, identified as such by the use of illuminated exit signs, which discharge into the facility's courtyard.

b) There are evacuation signs on the walls of the courtyard's perimeter which direct travel to an approximately twenty-eight (28) foot long, unpaved, 1 in 5 sloped hill located between the Fowler and Surgical buildings. The hill which is covered with packed stone dust is a component of the exit discharge which leads away from the facility to a public way.

c) Observations made on the morning of 6/11/14 revealed that as a result of an
overnight rainfall some of the packed stone dust had been washed away from the hill creating several deep ruts. The unstable nature of the hill's surface and the severity of it's slope creates an impediment to emergency travel.

B. A review of the facility's "Policy and Procedure Manual" on the morning of 6/11/14 indicated that the subject labeled "Evacuation of Patients and Staff" directs staff and patients to exit the courtyard by means of the unpaved, 1 in 5 sloped hill located between the Fowler and Surgical buildings.

As a result of the observations made and the documentation reviewed the hill component of the exit discharge from the courtyard is found to be non-compliant with the above listed sections of Chapter 7 of the 2000 edition of the NFPA 101 Life Safety Code.

The findings were confirmed by the Director of Plant Services during the exit conference.

Based on observations, the facility failed to ensure that automatic sprinklers are installed throughout the premises and in accordance with regulations. NFPA 13-1999 Edition, Section 5.1.1(1) requires sprinklers to be installed throughout the premises. Section 5.13.11 states: "Sprinkler protection shall be required in electrical equipment rooms. Hoods or shields installed to protect important electrical equipment from sprinkler discharge shall be noncombustible. Exception: Sprinklers shall not be required where all of the following conditions are met:
(a) The room is dedicated to electrical equipment only.
(b) Only dry-type electrical equipment is used.
(c) Equipment is installed in a 2-hour fire-rated enclosure including protection for penetrations.
(d) No combustible storage is permitted to be stored in the room."

THE FINDINGS INCLUDE:

Observations while touring the facility on the afternoon of 6/10/14 at approximately 11:00 A.M. revealed that automatic sprinkler protection is not provided in the main electrical room in the Fowler building. The door is non fire rated open metal wire type with a plywood panel attached to it which does not meet NFPA 13, Section 5.13.11.


This was confirmed by the Director of Engineering and reviewed with facility Administration during a summary of survey findings.

Based on observations, the facility failed to properly maintain the automatic sprinkler system. NFPA #25 1998 Edition Section 2-3.1.1 states where sprinklers have been in service for 50 years, they shall be replaced or representative samples from one or more sample areas shall be submitted to a recognized testing laboratory acceptable to the authority having jurisdiction for field service testing. Test procedures shall be repeated at 10-year intervals.

FINDINGS INCLUDE:

1) Observations made while touring the facility on the afternoon of 6/10/14, at approximately 1:30 P.M., revealed that sprinkler heads located in the ground floor landings of stairways #9 and #8 of the Fowler building have engraved manufacture dates of 1963. Further observations revealed the existence of 1963 dated sprinkler heads in some storage and mechanical rooms located off of the corridor which connects stairway #9 to stairway #8. The findings include but are not limited to these locations.

2) There was no documentation made available to indicate that any of the facility's sprinkler heads which are in excess of fifty (50) years old have been tested for reliability.

The findings were confirmed by the Director of Plant Services during the exit conference.

Based on observations and confirmed by staff the facility failed to assure that an accurate and adequate municipal water supply pressure could be monitored. NFPA #13, Section 4.7.7 requires a listed pressure gage to be installed immediately below the control valve of each system.

FINDINGS INCLUDE:

Observations made while touring the facility's #3 mechanical room on the afternoon of 6/10/14, at approximately 2:15 P.M., revealed the existence of a four (4) inch sprinkler riser supplying system water to the facility's Fowler Wing and Intensive Care Unit. The riser incorporates a backflow valve which checks the municipal water supply against the backflow of the sprinkler systems water. At the time of observation the backflow valve was found to be without a required pressure gage. Pressure gages are required to be installed immediately below the control valves of each (wet & dry) system, however they are required to be installed on the supply side of the backflow preventer. Backflow preventers allow water to pass through them in one direction locking the water pressure on the system (house) side of the device. This prevents the water pressure on the system side from going down when the pressure on the supply side goes down, such as during peak use periods during the day. A pressure gage must be installed on the supply side of the backflow preventers.

Due to the lack of an installed pressure gage on the supply side of the backflow valve the facility is found to be non-compliant with NFPA #13, Section 4.7.7.

The finding was confirmed by the Director of Plant Services during the exit conference.

Based on record review and staff interview the facility failed to certify the installation of a new kitchen range hood fire suppression system. NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 1998 Edition Chapter 7 Fire Extinguishing Equipment Section 7-2.2.1 states automatic fire-extinguishing systems shall be installed in accordance with the terms of their listing, the manufacturer's instructions, and the following standards where applicable.
(a) NFPA 12, Standard on Carbon Dioxide Extinguishing Systems
(b) NFPA 13, Standard for the Installation of Sprinkler Systems
(c) NFPA 17, Standard for Dry Chemical Extinguishing Systems
(d) NFPA 17A, Standard for Wet Chemical Extinguishing Systems

NFPA 17A, 1998 Edition Chapter 4 Plans and Acceptance Tests, Section 4-3 Approval of Installations states the completed system shall be tested by trained personnel as required by the manufacturer's listed installation and maintenance manual. The tests shall determine that the system has been properly installed and will function as intended. Section 4-3.1 states the installer shall certify that the system has been installed in accordance with the approved plans and the manufacturer's listed installation and maintenance manual.

FINDINGS INCLUDE:

A review of kitchen range hood documentation conducted on the morning of 6/09/14, at approximately 9:30 A.M., indicated that a certification test of the facility's new kitchen hood fire suppression system installed in 04/14 had not been conducted. When questioned the Director of Plant Services stated that all the proper testing had been completed but he was unable to locate the documentation. As a result of not having documentation available to substantiate the certification testing of the newly installed kitchen hood fire suppression system the facility was found to be non-compliant with NFPA 17A, Section 4-3.

The finding was confirmed by the Director of Plant Services during the exit conference.

Note: Several attempts were made by the Director of Plant Services to contact the installation contractor in an effort to secure documentation. Unable to provide the required documentation the Director of Plant Services scheduled a certification test with the installation vendor. The test was completed prior to the conclusion of the survey.

Based on observations, the facility failed to ensure the bulk oxygen tank is maintained in accordance with NFPA 50. Sections 2.2.1 and 2.2.1.12 require the minimum distance between any bulk oxygen storage container and any sidewalk or parked vehicle to be at least 10 feet.

THE FINDINGS INCLUDE:

Observations while touring the facility on the morning of 6/11/14 at 9:00 A.M. revealed that a car was parked on a "Do Not Park" area within eight feet of the bulk oxygen tank which is not in accordance with NFPA 50, Section 2.2.1.12.

This was confirmed by the Director of Engineering and the facility Administration staff during a summary of survey findings.