HospitalInspections.org

Based on observation and interview, the provider failed to maintain the two hour fire-resistive wall between the hospital and the clinic and the hospital and the tenant spaces in three randomly observed locations (maintenance area, room A170, Lewis Drug pharmacy). Findings include:

1. Observation at 9:30 a.m. on 12/01/15 revealed the 90 minute fire-rated entrance door for the maintenance area (located in the two-hour fire-resistive wall) was being held open with an unapproved device. The door was held open with a piece of railroad steel approximately six inches long.

Interview with the maintenance supervisor at the time of the observation revealed the door was equipped with a card swipe electronic access feature. He stated that door's electronic access was not working for the maintenance staffs' card keys. Those staffs' keys were configured differently from the maintenance supervisor's master card key. He stated parts were ordered to replace the malfunctioning device.

The act of holding the door open with an unapproved device affected one of several required components of fire-resistive separation wall characteristics.

2. Observation at 10:55 a.m. on 12/01/15 revealed room A170 in the tenant space area was being used for clinic medical records storage. There were two large unsealed openings around insulated pipe penetrations of the two-hour fire-resistive wall. Those separated the exit access corridor for the hospital from the tenant spaces.

Interview with the maintenance supervisor at the time of the observation confirmed that finding. It was not determined what areas the piping served.

The unsealed penetrations affected one of several required components of fire-resistive separation wall characteristics.

3. Observation at 11:15 a.m. on 12/01/15 revealed a 90 minute fire-rated entrance door for Lewis Pharmacy located in the two-hour fire-resistive wall between the tenant spaces and the hospital. That door was being held open with an unapproved device, a rubber floor wedge.

Interview with the pharmacist at the time of the observation revealed the door would automatically lock to prevent unauthorized access. Interview with the maintenance supervisor at the time of the observation revealed a magnetic hold-open could be installed on the door.

Holding the 90 minute fire-rated door open with the floor wedge affected one of several required components of fire-resistive separation wall characteristics.

Based on observation and interview, the provider failed to maintain the smoke-tight rating of corridor walls at one location (room A008 [the sub-waiting room]). Findings include:

1. Observation at 10:30 a.m. on 12/01/15 revealed the corridor door for the Sub-waiting room A008 was held open with an unapproved device. The door was held open with a cardboard wedge at the floor.

Interview with the maintenance supervisor at the time of the observation confirmed that finding. He noted the door was equipped with a magnetic hold-open.

The act of holding the door open with an unapproved device affected one of several required components of smoke separation wall characteristics.

Based on observation and interview, the provider failed to maintain proper separation of one randomly observed hazardous area (main electrical room F206). Findings include:

1. Observation at 1:55 p.m. on 12/01/15 revealed several openings around numerous conduit penetrations in the wall of the main electrical room F206. That room was a one-hour fire-rated room with a 3/4 hour fire-rated door. Those openings were not sealed with an appropriate firestop material.

Interview with the maintenance supervisor at the time of the observation confirmed that finding.

The unsealed conduit penetrations affected one of several requirements for providing separation of hazardous areas.

Based on observation, interview, and document review, the provider failed to maintain 90 minute fire-rated horizontal exit doors in operating condition. One randomly observed set of horizontal exit doors (between the tenant spaces and the attached hospital) did not have floor strike plates. Findings include:

1. Observation at 11:05 a.m. on 12/01/15 revealed a set of 90 minute fire-rated cross-corridor horizontal exit doors separated the tenant spaces corridor and the hospital. Those doors were equipped with both top and bottom latching hardware. There were no floor strike plates for the bottom latching hardware.

Interview with the maintenance supervisor at the time of the observation confirmed that finding. Document review of the hospital construction final inspection report dated 9/30/15 revealed that item had been noted as needing completion at that time.

The lack of latching hardware affected one of several required components of two-hour fire-separation wall characteristics.

Based on observation, interview, and document review, the provider failed to install required emergency lighting of at least one hour duration in one randomly observed location (room F205 for the generator transfer switch). Findings include:

1. Observation at 9:35 a.m. on 12/01/15 revealed there was not a battery pack emergency light installed in the electrical room F205 at the emergency power transfer switch for the generator.

Interview with the maintenance supervisor at the time of the observation confirmed that finding.

Document review of the hospital construction final inspection report dated 9/30/15 revealed that item had been noted as needing completion at that time.

The deficiency affected one of several requirements for providing emergency electrical power for the building.

Based on observation and interview, the provider failed to maintain the two hour fire-resistive wall between the hospital and the clinic and the hospital and the tenant spaces in three randomly observed locations (maintenance area, room A170, Lewis Drug pharmacy). Findings include:

1. Observation at 9:30 a.m. on 12/01/15 revealed the 90 minute fire-rated entrance door for the maintenance area (located in the two-hour fire-resistive wall) was being held open with an unapproved device. The door was held open with a piece of railroad steel approximately six inches long.

Interview with the maintenance supervisor at the time of the observation revealed the door was equipped with a card swipe electronic access feature. He stated that door's electronic access was not working for the maintenance staffs' card keys. Those staffs' keys were configured differently from the maintenance supervisor's master card key. He stated parts were ordered to replace the malfunctioning device.

The act of holding the door open with an unapproved device affected one of several required components of fire-resistive separation wall characteristics.

2. Observation at 10:55 a.m. on 12/01/15 revealed room A170 in the tenant space area was being used for clinic medical records storage. There were two large unsealed openings around insulated pipe penetrations of the two-hour fire-resistive wall. Those separated the exit access corridor for the hospital from the tenant spaces.

Interview with the maintenance supervisor at the time of the observation confirmed that finding. It was not determined what areas the piping served.

The unsealed penetrations affected one of several required components of fire-resistive separation wall characteristics.

3. Observation at 11:15 a.m. on 12/01/15 revealed a 90 minute fire-rated entrance door for Lewis Pharmacy located in the two-hour fire-resistive wall between the tenant spaces and the hospital. That door was being held open with an unapproved device, a rubber floor wedge.

Interview with the pharmacist at the time of the observation revealed the door would automatically lock to prevent unauthorized access. Interview with the maintenance supervisor at the time of the observation revealed a magnetic hold-open could be installed on the door.

Holding the 90 minute fire-rated door open with the floor wedge affected one of several required components of fire-resistive separation wall characteristics.

Based on observation and interview, the provider failed to maintain the smoke-tight rating of corridor walls at one location (room A008 [the sub-waiting room]). Findings include:

1. Observation at 10:30 a.m. on 12/01/15 revealed the corridor door for the Sub-waiting room A008 was held open with an unapproved device. The door was held open with a cardboard wedge at the floor.

Interview with the maintenance supervisor at the time of the observation confirmed that finding. He noted the door was equipped with a magnetic hold-open.

The act of holding the door open with an unapproved device affected one of several required components of smoke separation wall characteristics.

Based on observation and interview, the provider failed to maintain proper separation of one randomly observed hazardous area (main electrical room F206). Findings include:

1. Observation at 1:55 p.m. on 12/01/15 revealed several openings around numerous conduit penetrations in the wall of the main electrical room F206. That room was a one-hour fire-rated room with a 3/4 hour fire-rated door. Those openings were not sealed with an appropriate firestop material.

Interview with the maintenance supervisor at the time of the observation confirmed that finding.

The unsealed conduit penetrations affected one of several requirements for providing separation of hazardous areas.

Based on observation, interview, and document review, the provider failed to maintain 90 minute fire-rated horizontal exit doors in operating condition. One randomly observed set of horizontal exit doors (between the tenant spaces and the attached hospital) did not have floor strike plates. Findings include:

1. Observation at 11:05 a.m. on 12/01/15 revealed a set of 90 minute fire-rated cross-corridor horizontal exit doors separated the tenant spaces corridor and the hospital. Those doors were equipped with both top and bottom latching hardware. There were no floor strike plates for the bottom latching hardware.

Interview with the maintenance supervisor at the time of the observation confirmed that finding. Document review of the hospital construction final inspection report dated 9/30/15 revealed that item had been noted as needing completion at that time.

The lack of latching hardware affected one of several required components of two-hour fire-separation wall characteristics.

Based on observation, interview, and document review, the provider failed to install required emergency lighting of at least one hour duration in one randomly observed location (room F205 for the generator transfer switch). Findings include:

1. Observation at 9:35 a.m. on 12/01/15 revealed there was not a battery pack emergency light installed in the electrical room F205 at the emergency power transfer switch for the generator.

Interview with the maintenance supervisor at the time of the observation confirmed that finding.

Document review of the hospital construction final inspection report dated 9/30/15 revealed that item had been noted as needing completion at that time.

The deficiency affected one of several requirements for providing emergency electrical power for the building.