HospitalInspections.org

Based on observation and interview, the facility failed to protect their hazardous areas. This was evidenced by one hazardous area door that was not equipped with a self-closer and was obstructed from closing. This was also evidenced by one hazardous area door that failed to latch. This affected one of five floors and the basement of the main hospital. This could result in the faster spread of smoke and fire and the increased risk of injury to patients, visitors, and staff.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.2.1 Hazardous Areas. 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. Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.
Exception: Doors in rated enclosures shall be permitted to have nonrated, factory- or field-applied protective plates extending not more than 48 in. (122 cm) above the bottom of the door.

Findings:

During a facility tour with staff from 5/16/16 to 5/18/16, the hazardous areas were observed.

MAIN HOSPITAL
FIRST FLOOR

1. At 3:47 p.m., on 5/16/16, the self-closing fire-rated door to the soiled utility closet in Radiology failed to latch during four of four attempts. The closet contained multiple receptacles of trash.

MAIN HOSPITAL
BASEMENT

2. At 4:32 p.m., on 5/17/16, the trash room near Pharmacy contained two approximately 125-gallon trash receptacles. The door to the trash room was opened and not equipped with a self-closer. The door dragged on the floor and was obstructed from closing.

During an interview at 4:33 p.m., the Manager of Facilities (MF) stated that the door was not closing because its bottom hinge was broken.

Based on document review and interview, the facility failed to maintain their elevators. This was evidenced by the failure to conduct monthly testing for all elevators equipped with Phase I and Phase II Firefighter service. This affected five of five elevators at the main hospital. This could result in the increased risk of malfunction of the elevator safety features, in the event of a fire, and could result in the increased risk of patients, staff, and visitors.

NFPA 101 Life Safety Code, 2000 Edition
19.5.3 Elevators, Escalators, and Conveyors. Elevators, escalators, and conveyors shall comply with the provisions of Section 9.4.

9.4.6 Elevator Testing. Elevators shall be subject to routine and periodic inspections and test as specified in ASME/ANSI A17.1, Safety Code for Elevators and Escalators. All elevators equipped with fire fighter service in accordance with 9.4.4 and 9.4.5 shall be subject to a monthly operation with a written record of the findings made and kept on the premises as required by ASME/ANSI A17.1, Safety Code for Elevators and Escalators.

Findings:

During record review with staff from 5/16/16 to 5/18/16, the elevator inspection records were requested.

1. At 4:15 p.m., on 5/16/16, a record titled "Elevator Fire Service Phase I and II Monthly Test Log for State # 1, 2, 3, 4" was reviewed. The log showed that the Phase I and Phase II Keyswitch tests were not conducted for more than a year between 10/9/14 to 12/4/15. The log also showed that there were no tests conducted in April 2016. The vendor indicated that, from December 2015 to March 2016, the monthly testing was only conducted for "Cars 2 to 4."

During an interview at 4:16 p.m., the Manager of Facilities (MF) and the Facilities Consultant (FC) stated that the hospital operated five elevators. MF stated that there were no other elevator maintenance records available.