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SAINT JOSEPH MEDICAL CENTER
Exit Signage
Tag No.: K0293
Based upon observation, signage is not placed appropriately to identify available exit paths. Failure to correctly identify exit paths can result in occupants not being able to identify and reach available exit paths during a fire/smoke emergency.
The finding is:
On August 24, 2022, at 10:15 am, while in the company of the AD it was observed that illuminated exit signage is not provided in the basement Main Central Supply Room as required by Section 19.2.10.1 and 7.10. to identify the means of egress.
Cooking Facilities
Tag No.: K0324
Based upon observation, cooking equipment is not in compliance to protect the kitchen from grease fire. This deficiency could harm kitchen staff if the grease fire from hoods spread.
The finding is:
On August 24, 2022, at 11:40am while in the company of the AD the Kitchen Hoods in the Main Kitchen were observed without grease drip trays in accordance with 9.2.3 and NFPA 96-2011, Section 6.2.4.1.
Sprinkler System - Installation
Tag No.: K0351
Based on observation the facility lacks complete sprinkler protection. Failure to properly install a complete suppression system to the minimum standard could result in inadequate coverage by the suppression system during a fire event. This deficient practice could affect patients, staff, and visitors during a fire event.
The finding is:
On August 24, 2022, at 10:35am, while in the company of the DOFM it was observed in Stair 4, located near the Chapel, that the first accessible landing above the bottom of the shaft is not provided with sprinkler protection. This installation does not comply with NFPA 13-2010, 8.15.3.2.1.
Sprinkler System - Maintenance and Testing
Tag No.: K0353
Based upon observation and staff interview, sprinkler systems are not inspected, tested, and maintained in accordance with Code requirements. Failure to inspect, test, and maintain the sprinkler system can result in failure of the system to operate as required when needed to control a fire event.
The finding is:
On August 23, 2022, at 2:45 pm while in the company of the RCD & MEPD it was observed that the documentation for 5 - Year Fire Department Connection (FDC) & Hydrostatic Piping Test in accordance with NFPA 25-2011 Edition, Section 6.3.2.1 and Table 13.8.1, was not available for review.
Gas and Vacuum Piped Systems - Other
Tag No.: K0902
Based upon observation, medical gas system piping is not installed and maintained in accordance with Code requirements. Failure to install piped medical gas systems in accordance with requirements can cause disruption of services or add to the severity and progression of fire throughout the facility.
Findings include:
On August 24, 2022, while in the company of the DOFM it was observed that medical gas system piping is supported by a dissimilar metal not in accordance with 5.1.10.11.4.2. and not otherwise properly insulated to comply with 5.1.10.11.4.4.
Locations include:
A. At 9:50am in the interstitial space above Corridor 12078 ceiling.
B. At 10:10am in the interstitial space above Corridor 12077 ceiling.