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OSF HOLY FAMILY MEDICAL CENTER
Hazardous Areas - Enclosure
Tag No.: K0321
Based on observation, not all enclosures for hazardous areas are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building, smoke and fire could pass from the hazardous areas to the remainder of the building in the event of a fire emergency.
Findings include:
On 05/04/2023 at 11:01am while in the company of the SFIS, the pair of doors to large storage room (greater than 100 sf) does not comply with 8.7.1.3, 7.2.1.8, and 19.3.2.1.3 due to the following:
1. Both of the doors do not self close.
2. Both of the doors do not self latch.
Maintenance, Inspection and Testing - Doors
Tag No.: K0761
Based upon review of record documentation of door inspections, doors are not being maintained in fully functional condition to afford the protection they are intended to provide. Failure to maintain doors can compromise adjacent spaces during a fire condition.
Findings include:
On 05/04/2023 at 1:15 pm accompanied by the SFIS during document review the following information was observed:
1. There is no indication that all doors requiring repair or modification have received them to comply with 7.2.1.15.8, NFPA 80 2010, 5.1.5.1 for an immediate resolution. There are currently 9 doors remaining to correct without an indication of being completed.
2. There is no indication that any door has been inspected from both sides of the door to comply with 7.2.1.15.6.
Gas and Vacuum Piped Systems - Other
Tag No.: K0902
Based on observation and staff interview during the building tour the facility lacks complete protection of the medical gas piping system. Failure to install and maintain this installation could result in the piping system to become electrically energized. This deficient practice could affect patients staff and visitors.
The finding is:
On 05/04/2023 at 11:45 am while accompanied by the SFIS, it could not be confirmed that electrical bonding of the building's medical gas piping system has been completed. This does not comply with NFPA 70, 2011, 250.104 (B).
Gas and Vacuum Piped Systems - Categories
Tag No.: K0903
Based on observation the facility failed to install a compliant category 1 medical gas system. This deficient practice could result in the failure/response during a fire event, which may affect patients, staff and visitors.
The finding is
On 05/04/2023 at 11:15 am while accompanied by the SFIS it was observed that zone valves do not readily indicate the type of gases it serves. Location observed Surgery suite. This does not comply with NFPA 99 2012 5.1.11.2.1.