HospitalInspections.org

Based on observation and staff interview, the facility failed to assure that the 1 ½ fire rated doors in the 2 hour wall separating the hospital from the medical office building latch properly, failing to provide the proper fire resistance. This deficient practice of allowing 1 ½ hour fire rated doors to remain freely swinging in a 2 hour separation wall affects approximately all occupants in one of six smoke zones. The facility has a capacity of 25 and a census of 10 at the time of survey.

Findings include:

During the survey of the facility on August 12, 2015 at 2:50 PM it is observed that the 1 ½ fire rated doors in the 2 hour fire barrier separating the hospital from the medical office building are not latching when released from the hold open device..

The Maintenance Supervisor was present and acknowledged the findings.

Review of the following NFPA Standard revealed: Additions shall be separated from any existing structure not conforming to the provisions within Chapter 19 by a fire barrier having not less than a 2 hour fire resistance rating and constructed of materials as required for the addition. Communicating openings in the fire barriers shall be permitted only in corridors and protected by approved self-closing fire doors. 2000 NFPA 101, 18/19.1.1.4.1 and 18/19.1.1.4.2

Review of the following NFPA Standard revealed: Occupied buildings shall meet the minimum construction requirements of the occupancy chapters and NFPA 220. Additions or connected structures of different construction types shall have the ratings and classification based on: separate buildings if a 2 hour or greater vertically aligned fire barrier wall in accordance with NFPA 221 exists between the buildings, or the least fire resistive type of construction of the connected portions. 2000 NFPA 101, 8.2.1

Review of the following NFPA Standard revealed: Locks, latches, surface-mounted top and bottom bolts, and fire exit hardware shall be secured to reinforcements in the doors with machine screws or shall be attached with through-bolts. Flush-mounted top and bottom bolts shall be secured to reinforcements in the doors with machine screws.

Exception: Locks and latches shall be attached to wood and plastic-covered composite doors or wood core doors with not less than No. 8, flat, threaded-to-the-head, wood screws or shall be attached with through-bolts. Fire exit hardware and surface-mounted top and bottom bolts shall be attached to wood and plastic-covered composite doors with through-bolts or with steel screws at locations specified in the door manufacturer ' s installation instructions. 1999 NFPA 80, 2-4.4.7

Review of the following NFPA Standard revealed: A fire door assembly shall consist of components that are separate products incorporated into the assembly and allowed to have their own subcomponents. The normal components of a fire door assembly include a door, a door frame, hinges, a lock or latch, and a closing device. They also include, but are not limited to, an astragal, an automatic louver, a coordinator, flush or surface bolts, gasketing, a holder/release device, protection plates, and glazing materials. 1999 NFPA 80, 2-1.1

Review of the following NFPA Standard revealed: All swinging doors shall be closed and latched at the time of fire. 1999 NFPA 80, 2-1.4

Based on observation and staff interview the facility fails to maintain one of four smoke barriers to at least one half hour fire resistance and ensure continuation of the smoke barrier seal. This deficient practice would prevent containment of fire and smoke, affecting 6 occupants in two of six smoke zones. The facility has a capacity of 25 with a census of 10 at the time of survey.

Findings include:

During the survey on August 12, 2015 it is observed at 3:15 PM it is observed that the smoke barrier wall in the maternity corridor is not continuous to the ceiling assembly due to the wall is missing around the sprinkler pipe, around electrical conduit and between the ductwork.

The Maintenance Supervisor was present and acknowledged the findings.

Review of the following NFPA Standard revealed: Requires smoke walls to have a fire resistance rating of at least a half hour and to be continuous from floor to roof deck and from outside wall to outside wall. 2000 NFPA 101, 19.3.7.3

Review of the following NFPA Standard revealed: Smoke barriers shall be continuous from an outside wall to an outside wall. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces per NFPA 101, 8.3.2. When pipes, conduits, cables, wires, air ducts and similar building service equipment pass through smoke barriers, the space between the penetrating item and the smoke barrier shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier or protected by an approved device that is designed for the specific purpose per 2000 NFPA 101, 8.3.6.1

Based on observation and staff interview, the facility failed to provide separation of hazardous areas from other spaces. The area of deficient practice would provide a path for smoke and fire to travel into the adjoining areas, affecting 15 occupants in one of six smoke zones. This facility has a capacity of 25 and a census of 10 at the time of the survey.

Findings include:

During the survey on August 12, 2015 at 2:40 PM it is observed the door to the corridor from the med-surge dirty utility room is not latching when self-closing.

The Maintenance Supervisor was present and acknowledged the findings.

Review of the following NFPA Standard revealed: Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1

Review of the following NFPA Standard revealed: Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means:
(1) Enclose the area with a fire barrier without windows that has a 1 hour fire resistance rating in accordance with Section 8.2.
(2) Protect the area with automatic extinguishing systems in accordance with Section 9.7.
(3) Apply both 8.4.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 12 through 42. 2000 NFPA 101, 8.4.1

Based on observation and staff interview the facility failed to provide a remote stop for the emergency generator power supply as required. The deficient practice may prevent the emergency power supply from being stopped at the time of a power loss, affecting all occupants in six of six smoke zones. This facility has a capacity of 25 with a census of 10 at the time of the survey.

Findings include:

During the survey on August 12, 2015 at 3:00 PM it is observed that there is no remote stop for the generator located external to the weatherproof exterior generator enclosure.

Review of the following NFPA Standard revealed: Emergency generators providing power to emergency lighting systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. Stored electrical energy systems, where required in this Code, shall be installed and tested in accordance with NFPA 111, Standard on Stored Electrical Energy Emergency and Standby Power Systems. 2000 NFPA 101, 7.9.2.3

Review of the following NFPA Standard revealed: Emergency generators, where required for compliance with this Code, shall be tested and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. 2000 NFPA 101, 9.1.3

Review of the following NFPA Standard revealed: All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building. 1999 NFPA 110, 3-5.5.6

Based on observation and staff interview, the facility failed to assure that the 1 ½ fire rated doors in the 2 hour wall separating the hospital from the medical office building latch properly, failing to provide the proper fire resistance. This deficient practice of allowing 1 ½ hour fire rated doors to remain freely swinging in a 2 hour separation wall affects approximately all occupants in one of six smoke zones. The facility has a capacity of 25 and a census of 10 at the time of survey.

Findings include:

During the survey of the facility on August 12, 2015 at 2:50 PM it is observed that the 1 ½ fire rated doors in the 2 hour fire barrier separating the hospital from the medical office building are not latching when released from the hold open device..

The Maintenance Supervisor was present and acknowledged the findings.

Review of the following NFPA Standard revealed: Additions shall be separated from any existing structure not conforming to the provisions within Chapter 19 by a fire barrier having not less than a 2 hour fire resistance rating and constructed of materials as required for the addition. Communicating openings in the fire barriers shall be permitted only in corridors and protected by approved self-closing fire doors. 2000 NFPA 101, 18/19.1.1.4.1 and 18/19.1.1.4.2

Review of the following NFPA Standard revealed: Occupied buildings shall meet the minimum construction requirements of the occupancy chapters and NFPA 220. Additions or connected structures of different construction types shall have the ratings and classification based on: separate buildings if a 2 hour or greater vertically aligned fire barrier wall in accordance with NFPA 221 exists between the buildings, or the least fire resistive type of construction of the connected portions. 2000 NFPA 101, 8.2.1

Review of the following NFPA Standard revealed: Locks, latches, surface-mounted top and bottom bolts, and fire exit hardware shall be secured to reinforcements in the doors with machine screws or shall be attached with through-bolts. Flush-mounted top and bottom bolts shall be secured to reinforcements in the doors with machine screws.

Exception: Locks and latches shall be attached to wood and plastic-covered composite doors or wood core doors with not less than No. 8, flat, threaded-to-the-head, wood screws or shall be attached with through-bolts. Fire exit hardware and surface-mounted top and bottom bolts shall be attached to wood and plastic-covered composite doors with through-bolts or with steel screws at locations specified in the door manufacturer ' s installation instructions. 1999 NFPA 80, 2-4.4.7

Review of the following NFPA Standard revealed: A fire door assembly shall consist of components that are separate products incorporated into the assembly and allowed to have their own subcomponents. The normal components of a fire door assembly include a door, a door frame, hinges, a lock or latch, and a closing device. They also include, but are not limited to, an astragal, an automatic louver, a coordinator, flush or surface bolts, gasketing, a holder/release device, protection plates, and glazing materials. 1999 NFPA 80, 2-1.1

Review of the following NFPA Standard revealed: All swinging doors shall be closed and latched at the time of fire. 1999 NFPA 80, 2-1.4

Based on observation and staff interview the facility fails to maintain one of four smoke barriers to at least one half hour fire resistance and ensure continuation of the smoke barrier seal. This deficient practice would prevent containment of fire and smoke, affecting 6 occupants in two of six smoke zones. The facility has a capacity of 25 with a census of 10 at the time of survey.

Findings include:

During the survey on August 12, 2015 it is observed at 3:15 PM it is observed that the smoke barrier wall in the maternity corridor is not continuous to the ceiling assembly due to the wall is missing around the sprinkler pipe, around electrical conduit and between the ductwork.

The Maintenance Supervisor was present and acknowledged the findings.

Review of the following NFPA Standard revealed: Requires smoke walls to have a fire resistance rating of at least a half hour and to be continuous from floor to roof deck and from outside wall to outside wall. 2000 NFPA 101, 19.3.7.3

Review of the following NFPA Standard revealed: Smoke barriers shall be continuous from an outside wall to an outside wall. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces per NFPA 101, 8.3.2. When pipes, conduits, cables, wires, air ducts and similar building service equipment pass through smoke barriers, the space between the penetrating item and the smoke barrier shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier or protected by an approved device that is designed for the specific purpose per 2000 NFPA 101, 8.3.6.1

Based on observation and staff interview, the facility failed to provide separation of hazardous areas from other spaces. The area of deficient practice would provide a path for smoke and fire to travel into the adjoining areas, affecting 15 occupants in one of six smoke zones. This facility has a capacity of 25 and a census of 10 at the time of the survey.

Findings include:

During the survey on August 12, 2015 at 2:40 PM it is observed the door to the corridor from the med-surge dirty utility room is not latching when self-closing.

The Maintenance Supervisor was present and acknowledged the findings.

Review of the following NFPA Standard revealed: Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1

Review of the following NFPA Standard revealed: Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means:
(1) Enclose the area with a fire barrier without windows that has a 1 hour fire resistance rating in accordance with Section 8.2.
(2) Protect the area with automatic extinguishing systems in accordance with Section 9.7.
(3) Apply both 8.4.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 12 through 42. 2000 NFPA 101, 8.4.1

Based on observation and staff interview the facility failed to provide a remote stop for the emergency generator power supply as required. The deficient practice may prevent the emergency power supply from being stopped at the time of a power loss, affecting all occupants in six of six smoke zones. This facility has a capacity of 25 with a census of 10 at the time of the survey.

Findings include:

During the survey on August 12, 2015 at 3:00 PM it is observed that there is no remote stop for the generator located external to the weatherproof exterior generator enclosure.

Review of the following NFPA Standard revealed: Emergency generators providing power to emergency lighting systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. Stored electrical energy systems, where required in this Code, shall be installed and tested in accordance with NFPA 111, Standard on Stored Electrical Energy Emergency and Standby Power Systems. 2000 NFPA 101, 7.9.2.3

Review of the following NFPA Standard revealed: Emergency generators, where required for compliance with this Code, shall be tested and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. 2000 NFPA 101, 9.1.3

Review of the following NFPA Standard revealed: All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building. 1999 NFPA 110, 3-5.5.6