HospitalInspections.org

Based on observation and interview the facility failed to ensure that 1 stairwell door would automatically close to a latched position.

Findings include:

Observations during tour on 05/11/16 between 10:00 a.m. and 10:30 a.m. with Staff A (Director of Facilities) and Staff B (Facilities Supervisor) revealed that the "Maroon Stairwell" door, on the 3rd floor, failed to automatically close to a latched position without additional force being applied.

Observations of the "Maroon Stairwell" on the 3rd floor landing also revealed an "Infant crib" placed inside the stairwell, on the landing next to the fire door.

Interview with Staff A and Staff B at the time of the observations confirmed the findings and locations.

Based on observations and interview the facility failed to ensure that 1 door located in a smoke barrier is equipped with an automatic door closing device.

Findings include:

Observations during tour on 05/11/16 between 9:00 a.m. and 9:30 a.m. with Staff A (Director of Facilities) and Staff B (Facilities Supervisor) revealed that the "Rehab gym", located on the 4th floor, next to the "Elevator Lobby" is part of the 4th floor, 1 hour smoke barrier. The Rehab entrance door is a rated fire door, however this door is not equipped with an automatic door closing device.

Interview with Staff A and Staff B at the time of observation confirmed the "Smoke Barrier" location and the findings.

Based on observations and interview the facility failed to ensure that 2 storage rooms (over 50 sq, ft,) with combustible materials have an automatic door closing device installed.

Findings include:

Observations during tour on 05/11/16 between 9:00 a.m. and 11:00 a.m. with Staff A (Director of Facilities) and Staff B (Facilities Supervisor) revealed the following 2 storage rooms with combustible contents and exceed 50 square feet in size.

(1) The "Clean Linen Storage" room door on the 3rd floor failed to have an automatic door closing device installed.
(2) The main "Dietary Storage" room on the 1st floor has 2 doors, the door leading to the service corridor failed to have an automatic closing device installed.

Interview with Staff A and Staff B at the time of observations confirmed the location and the findings.

NFPA 13 Standard for the Installation of Sprinkler Systems
8.5.5.3 Obstructions That Prevent Sprinkler Discharge from Reaching The Hazard. Continuous or noncontiguous obstructions that interrupt the water discharge in a horizontal plane more than 18" below the sprinkler deflector in a manner to limit the distribution from the protected hazard shall comply with 8.5.5.3
8.5.5.3.1 Sprinklers shall be installed under fixed obstructions over 4 feet wide such as ducts, decks, open grate flooring, cutting tables, and overhead doors.
8.5.5.3.2 Sprinklers shall not be required under obstructions that are not fixed in place such as conference tables.

Based on observations and interview the facility failed to ensure that sprinkler coverage was not partially blocked by HVAC (Heating, Ventilation, and Air Conditioning) ductwork in excess of 4 feet wide.

Findings include:

Observations during tour on 5/11/16 between 11:00 a.m. and 2:30 p.m. with Staff A (Director of Facilities) and Staff B (Facilities Supervisor) revealed the following locations where the existing ductwork (over 4 feet wide) could affect adequate sprinkler coverage for protection:

(1) The Maintenance Shop/Mechanical Room has an area of ductwork approximately 8' feet wide by 14' long above the main walkway through the room with no additional sprinkler coverage under the ductwork.
(2) The Maintenance Shop/Mechanical Room has a large area of ductwork approximately 5' feet wide by 10' feet long above the "Control Air Compressor" with no additional sprinkler coverage under the ductwork.
(3) The "Purchasing Department" has a large area of ductwork, approximately 6' feet wide by 10' feet long above a row of supply shelve's with no additional sprinkler coverage under the ductwork.

Interview with Staff A and Staff B at the time of observations confirmed the findings and locations.

Based on observation and interview the facility failed to ensure that 1 stairwell door would automatically close to a latched position.

Findings include:

Observations during tour on 05/11/16 between 10:00 a.m. and 10:30 a.m. with Staff A (Director of Facilities) and Staff B (Facilities Supervisor) revealed that the "Maroon Stairwell" door, on the 3rd floor, failed to automatically close to a latched position without additional force being applied.

Observations of the "Maroon Stairwell" on the 3rd floor landing also revealed an "Infant crib" placed inside the stairwell, on the landing next to the fire door.

Interview with Staff A and Staff B at the time of the observations confirmed the findings and locations.

Based on observations and interview the facility failed to ensure that 1 door located in a smoke barrier is equipped with an automatic door closing device.

Findings include:

Observations during tour on 05/11/16 between 9:00 a.m. and 9:30 a.m. with Staff A (Director of Facilities) and Staff B (Facilities Supervisor) revealed that the "Rehab gym", located on the 4th floor, next to the "Elevator Lobby" is part of the 4th floor, 1 hour smoke barrier. The Rehab entrance door is a rated fire door, however this door is not equipped with an automatic door closing device.

Interview with Staff A and Staff B at the time of observation confirmed the "Smoke Barrier" location and the findings.

Based on observations and interview the facility failed to ensure that 2 storage rooms (over 50 sq, ft,) with combustible materials have an automatic door closing device installed.

Findings include:

Observations during tour on 05/11/16 between 9:00 a.m. and 11:00 a.m. with Staff A (Director of Facilities) and Staff B (Facilities Supervisor) revealed the following 2 storage rooms with combustible contents and exceed 50 square feet in size.

(1) The "Clean Linen Storage" room door on the 3rd floor failed to have an automatic door closing device installed.
(2) The main "Dietary Storage" room on the 1st floor has 2 doors, the door leading to the service corridor failed to have an automatic closing device installed.

Interview with Staff A and Staff B at the time of observations confirmed the location and the findings.

NFPA 13 Standard for the Installation of Sprinkler Systems
8.5.5.3 Obstructions That Prevent Sprinkler Discharge from Reaching The Hazard. Continuous or noncontiguous obstructions that interrupt the water discharge in a horizontal plane more than 18" below the sprinkler deflector in a manner to limit the distribution from the protected hazard shall comply with 8.5.5.3
8.5.5.3.1 Sprinklers shall be installed under fixed obstructions over 4 feet wide such as ducts, decks, open grate flooring, cutting tables, and overhead doors.
8.5.5.3.2 Sprinklers shall not be required under obstructions that are not fixed in place such as conference tables.

Based on observations and interview the facility failed to ensure that sprinkler coverage was not partially blocked by HVAC (Heating, Ventilation, and Air Conditioning) ductwork in excess of 4 feet wide.

Findings include:

Observations during tour on 5/11/16 between 11:00 a.m. and 2:30 p.m. with Staff A (Director of Facilities) and Staff B (Facilities Supervisor) revealed the following locations where the existing ductwork (over 4 feet wide) could affect adequate sprinkler coverage for protection:

(1) The Maintenance Shop/Mechanical Room has an area of ductwork approximately 8' feet wide by 14' long above the main walkway through the room with no additional sprinkler coverage under the ductwork.
(2) The Maintenance Shop/Mechanical Room has a large area of ductwork approximately 5' feet wide by 10' feet long above the "Control Air Compressor" with no additional sprinkler coverage under the ductwork.
(3) The "Purchasing Department" has a large area of ductwork, approximately 6' feet wide by 10' feet long above a row of supply shelve's with no additional sprinkler coverage under the ductwork.

Interview with Staff A and Staff B at the time of observations confirmed the findings and locations.