HospitalInspections.org

Facility failed to provide protection of hazardous combustibel storage in one room in accordance with the 2000 edition of the Life Safety Code, NFPA 101. Findings included:

Surveyor observed between 1pm and 2pm on 7/14/11 that unsprinklered paper storage room greater than 50 sq ft did not have 3/4 hour rated door with self-closing function in accordance with 19.3.2.1.

Facility failed to provided fire alarm system in accordance with 2000 edition of the Life Safety Code, NFPA 101. Findings included:

Surveyor observed between 1pm and 2pm on 7/14/11, that fire alarm was not audible during test of system as required by NFPA 101, 2000: 9.6.3.

Facility failed to maintain venitlation system in accordance with Standard for Installation of Air-Conditioning and Ventilating Systems, NFPA 90A. Findings included the following.

Surveyor between 1pm and 2pm on 7/14/11in meeting with representatives of design and construction of Buidling 502 that ventilation including exhaust functions of facility shut-down on initiation of fire alarm. This does not meet NFPA 90A: 2.3.1. ASHRAE Publications. 2003 ASHRAE Handbook, Chapter 7, Table 3. Ventilation Requirements for Areas Affecting Patient Care in Hospitals and Outpatient Faclities. All air shall be exhausted directly to outside for Airborne infection rooms.

Facility failed to maintain electrical system in accordance with NFPA 70, National Electrical Code. Findings included:

Surveyor observed between 1pm and 2pm on 7/14/11 that essential emergency electric panels were not readily identifiable. In addition, directories for the panels will be required. This is in accordance to the requirements of NFPA 70, 1996: 110-22, 700-9(a) and NEC, 1996: 110-22 and 700-9(a). The panels for the essential electrical distribution from the alternate power source need to be clearly labeled to indicate the branches that these panels serve. These branch panels labels are required to read; "LIFE SAFETY", "CRITICAL" and "EQUIPMENT". In all electric panel boxes, the circuit directories need to be labeled in accordance to which circuit breakers serve what electrical devices by room name and room number or any equipment with proper name as required by NFPA 70, 1999: 384-13 and NEC, 1999: 384-13.