HospitalInspections.org

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Based on record review and interview the facility failed to maintain in effect a written copy of the plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building, when necessary, as required by NFPA 101, Life Safety Code, 19.7.1.

This deficient practice could result in failure to safely and efficiently protect or evacuate patients, staff, and visitors in the event of a fire or other emergency.

Record review of the facility's Emergency Preparedness Plan (EPP) revealed it contained an approved page for signatures of Hospital Personnel. Further record review of the EPP cover page revealed 5 of 6 lines remained blank (not signed). The following lines remained blank/unsigned:

Chief of Medical Staff, Chairman of the Board of Directors, Administrators, Director of Employee of Health/Risk Management, and Approval Date.

Further review revealed the last time the Emergency Preparedness Plan was reviewed, updated and approved was on 01/29/2024.

In an exit interview at approximately 2:55 PM on 05/06/2025, this deficiency was discussed with the Plant Operations Director and the Director of Nursing. The Director of Nursing confirmed the signature and date page needed to be completed by some listed parties.

Code Reference(s):
NFPA 101, 2012 edition
19.7.1 Evacuation and Relocation Plan and Fire Drills.
19.7.1.1 The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary.
19.7.1.2 All employees shall be periodically instructed and kept informed with respect to their duties under the plan required by 19.7.1.1.
19.7.1.3 A copy of the plan required by 19.7.1.1 shall be readily available at all times in the telephone operator's location or at the security center.

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Based on observations and interview the facility failed to maintain smoke barrier walls to resist the passage of smoke as required by NFPA 101, Life Safety Code, 19.3.7 and 8.5.

This deficient practice could result in failure to contain toxic products of combustion to all smoke compartments, thus placing the patients, staff, and visitors of multiple smoke compartments in jeopardy in the event of a fire.

The inspector observed, while accompanied by the Plant Operations Director on 05/06/2025 from 1:20 PM to 2:45 PM the following:

The smoke barrier wall outside the Café & Director of Nutritional Services office had unsealed penetrations, penetrations sealed with materials of unknown fire resistivity, and/or sealed in a manner not compliant with a listed firestopping system.

The smoke barrier wall by Storage Room and Linen Closet (around the Café) had unsealed penetrations, penetrations sealed with materials of unknown fire resistivity, and/or sealed in a manner not compliant with a listed firestopping system.

The smoke barrier wall by Room 20 (Lab Office) & Room 27 (Patient Room) had unsealed penetrations, penetrations sealed with materials of unknown fire resistivity, and/or sealed in a manner not compliant with a listed firestopping system.

The smoke barrier wall by Mammography/Bone Density had unsealed penetrations, penetrations sealed with materials of unknown fire resistivity, and/or sealed in a manner not compliant with a listed firestopping system.

The smoke barrier wall by Room 18 (Patient Entrance) & Room 19 (Registration) had unsealed penetrations, penetrations sealed with materials of unknown fire resistivity, and/or sealed in a manner not compliant with a listed firestopping system.

In an interview at the time of each finding, The Plant Operations Director was informed of each deficiency and he was able to observe the deficiencies.

In an exit interview at approximately 2:55 PM on 05/06/2025, these deficiencies were discussed with the Plant Operations Director and the Director of Nursing.

Code Reference(s):
NFPA 101, 2012 edition
19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a minimum 1/2-hour fire resistance rating, unless otherwise permitted by one of the following:
(1) This requirement shall not apply where an atrium is used, and both of the following criteria also shall apply:
(a) Smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with 8.6.7(1)(c).
(b) Not less than two separate smoke compartments shall be provided on each floor.
(2) Smoke dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air-conditioning systems where an approved, supervised automatic sprinkler system in accordance with 19.3.5.8 has been provided for smoke compartments adjacent to the smoke barrier.

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