HospitalInspections.org

This Standard is not met as evidenced by:

Based on observation, the facility failed to provide stairways, elevator shafts, light and ventilation shafts, chutes,and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least one hour in accordance NFPA 19.3.1.1, 8.2.5, 8.2.5.6.
These deficient practices have the potential of effecting the entire facility.

Findings include:

While inspecting vertical openings on November 17, 2015 at 1:30 p.m., observation revealed open and unsealed penetrations of vertical piping chase connecting to 2nd to 6th floors.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview on 11/18/15.

This Standard is not met as evidenced by:

Based on observations the facility failed to provide the required 30 minute fire resistance rating for smoke barrier walls in accordance with 19.3.7.3, 19.1.6.3, 19.1.6.4. These deficient practices have the potential of affecting 8 of 18 smoke compartments.

Finding include:

While inspecting smoke barrier walls on November 17, 2015 at 2:30 p.m., observation revealed the following unsealed penetrations above the ceiling in the North and South smoke barrier walls on 3rd, 4th, 5th, and 6th floors of the facility.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview on 11/18/15.

This Standard is not met as evidenced by:

Based on observation and testing, the facility failed to properly protect hazardous areas in accordance NFPA 101 19.3.2.1. These deficient practices have the potential of affecting 8 of 18 smoke compartments.

Findings include:

On November 17, 2015 at 3:00 p.m., observation revealed the "Patient Belonging" Rooms on the 3rd, 4th, 5th & 6th floors were incapable of resisting the passage of smoke due to a large cutout opening in hard ceilings.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview on 11/18/15.

This standard is not met as evidenced by:

Based on observations, the facility failed to have a properly installed fire alarm system as required by NFPA 72. This condition affected 5 of 18 smoke compartments at the time of survey.

Findings Include:

On November 17, 2015 at 2:30 p.m., observation revealed the manual pull station for the Main Entrance was approximately 18 feet from exit door. The manual pull station was located outside the foyer and receptionist room.

On November 18, 2015 at 9:00 am, observation revealed no emergency strobes lights and horn systems installed in the following areas of the facility:

1. Recreation Room on 1st Floor.

2. 4th Floor Zone near main elevators across from Patient Room 4-131.

3. 1st floor Corridor near Room 1-165.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview on 11/18/15.

NFPA 72 2-8.2.2
Manual fire alarm boxes shall be located within 5 ft (1.5 m) of the exit doorway opening at each exit on each floor.

This standard is not met as evidenced by:

Based on observations, the facility failed to provide a supervised automatic sprinkler system with complete coverage for all portions of the building as directed in NFPA 13 section 5-13.3.2. This condition affected 7 of 18 smoke compartments at the time of survey.

Findings include:

On November 17, 2015 at 11:20 a.m., observation revealed that West Stairwell and Stairwell #2 were not protect by sprinkler coverage.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview on 11/18/15.

NFPA 13 section 5-13.3.2

In noncombustible stair shafts with noncombustible stairs, sprinklers shall be installed at the top of the shaft and under the first landing above the bottom of the shaft. Exception: Sprinklers shall be installed beneath landings or stairways where the area beneath is used for storage.

This Standard is not met as evidenced by:

Based on observation, the facility failed to provide stairways, elevator shafts, light and ventilation shafts, chutes,and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least one hour in accordance NFPA 19.3.1.1, 8.2.5, 8.2.5.6.
These deficient practices have the potential of effecting the entire facility.

Findings include:

While inspecting vertical openings on November 17, 2015 at 1:30 p.m., observation revealed open and unsealed penetrations of vertical piping chase connecting to 2nd to 6th floors.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview on 11/18/15.

This Standard is not met as evidenced by:

Based on observations the facility failed to provide the required 30 minute fire resistance rating for smoke barrier walls in accordance with 19.3.7.3, 19.1.6.3, 19.1.6.4. These deficient practices have the potential of affecting 8 of 18 smoke compartments.

Finding include:

While inspecting smoke barrier walls on November 17, 2015 at 2:30 p.m., observation revealed the following unsealed penetrations above the ceiling in the North and South smoke barrier walls on 3rd, 4th, 5th, and 6th floors of the facility.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview on 11/18/15.

This Standard is not met as evidenced by:

Based on observation and testing, the facility failed to properly protect hazardous areas in accordance NFPA 101 19.3.2.1. These deficient practices have the potential of affecting 8 of 18 smoke compartments.

Findings include:

On November 17, 2015 at 3:00 p.m., observation revealed the "Patient Belonging" Rooms on the 3rd, 4th, 5th & 6th floors were incapable of resisting the passage of smoke due to a large cutout opening in hard ceilings.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview on 11/18/15.

This standard is not met as evidenced by:

Based on observations, the facility failed to have a properly installed fire alarm system as required by NFPA 72. This condition affected 5 of 18 smoke compartments at the time of survey.

Findings Include:

On November 17, 2015 at 2:30 p.m., observation revealed the manual pull station for the Main Entrance was approximately 18 feet from exit door. The manual pull station was located outside the foyer and receptionist room.

On November 18, 2015 at 9:00 am, observation revealed no emergency strobes lights and horn systems installed in the following areas of the facility:

1. Recreation Room on 1st Floor.

2. 4th Floor Zone near main elevators across from Patient Room 4-131.

3. 1st floor Corridor near Room 1-165.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview on 11/18/15.

NFPA 72 2-8.2.2
Manual fire alarm boxes shall be located within 5 ft (1.5 m) of the exit doorway opening at each exit on each floor.

This standard is not met as evidenced by:

Based on observations, the facility failed to provide a supervised automatic sprinkler system with complete coverage for all portions of the building as directed in NFPA 13 section 5-13.3.2. This condition affected 7 of 18 smoke compartments at the time of survey.

Findings include:

On November 17, 2015 at 11:20 a.m., observation revealed that West Stairwell and Stairwell #2 were not protect by sprinkler coverage.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview on 11/18/15.

NFPA 13 section 5-13.3.2

In noncombustible stair shafts with noncombustible stairs, sprinklers shall be installed at the top of the shaft and under the first landing above the bottom of the shaft. Exception: Sprinklers shall be installed beneath landings or stairways where the area beneath is used for storage.