HospitalInspections.org

Based on findings from interview and observations, the hospital corridor double doors to the physician's office building (POB) providing the 2 hour fire rated separation between the hospital corridor and POB occupancy, did not consistently latch to ensure fire separation and corridor protection.

Findings include:

-- Per observations on 12/05/12 at 1:30 pm, the corridor double doors to the POB were open. Once one door leaf was closed and locked, the self-closer was activated on the other door leaf - but it did not consistently close and latch.

-- The Maintenance Technician and Director of Facilities were present during these observations and acknowledged the findings.

Based on findings from document review and observations, an unenclosed vertical opening is present at the hospital's main entrance.

Findings include:

-- Per observations on 12/05/12 at 12:15 pm, the new entrance lobby (reception) area has an unenclosed vertical opening (stairway and light shaft/balcony) between the first and ground floor which opens directly into the hospital corridor on the ground floor.

-- Per review of the corresponding architectural floor plan, there is a 2 hour fire rated enclosure on the first floor separating the vertical opening, and the ground floor has a 2 hour fire rated separation from the POB (Physician Office Building), but the hospital corridor is directly connected to the vertical opening as the fire rated wall does not continue across the corridor and around the waiting room to complete separation.

The unenclosed vertical opening is not compliant with requirements in NFPA 101 addressing healthcare occupancy for a hospital.

Based on findings from observations and interview, four hazardous areas were not enclosed to provide required fire ratings/enclosures.

Findings include:

-- Per observations on 12/04/12 at 12:40 pm, the boiler room has a large eight by eight foot opening in the upper corner of the 2 hour fire rated wall with two pieces of plywood covering it (though about a one foot gap still remained around edges). This opening connects directly into the purchasing storage room upstairs where hospital and patient supplies are located, interrupting the fire rating and creating an avenue for cross contamination to occur between the boiler and storage rooms.

Per interview with the Maintenance Technician and Director of Facilities on 12/04/12 at 12:40 pm, the large opening was made to exchange the previous boiler replacement.

-- Per observations on 12/04/12 at 12:50 pm, unapproved hold-open devices (not electronically connected to the fire and/or sprinkler alarm to release upon activation) were installed at the bottom of both the clean linen and soiled linen storage room doors, opening the hazardous storage rooms to the corridor.

-- Per observations on 12/04/12 at 12:55 pm, the fire rated door to the purchasing office and the inside door to the purchasing storage room were both open, and lacked self closing devices to maintain enclosure of the hazardous area.

Based on findings from observations and interviews, the ground floor landing in stairwell H-SW002 lacks a physical barrier (e.g., gate) or other means to prevent occupants from descending to a non-existent exit versus to a safe exit upstairs.

Findings include:

-- Per observations during survey on 12/04/12 at 1:20 pm, the ground floor landing in stairwell H-SW002 lacked a physical barrier, or other means of separation, to prevent occupants from incorrectly attempting to exit downstairs (leading to a locked boiler room door), instead of using the proper exit upstairs to the first floor main entrance lobby.

-- Per interview of the Maintenance Technician on 12/04/12 at 1:20 pm, in the past, there was a gate located in this stairwell to prevent access downstairs to the boiler room but it was removed at some point in time.

Based on findings from observations and interviews, the Magnetic Resonance Imaging (MRI) room located in the new hospital addition does not have sprinkler or other automatic fire suppression system protection.

Findings include:

-- Per observations on 12/05/12 at 11:00 am, a portable fire extinguisher was located in the MRI waiting room but no sprinkler was located in the MRI room. A sprinkler or other automatic fire suppression system is required for the new building to be fully compliant with NFPA 13.

-- During interview with the Director of Facilities and the Maintenance Technician on 12/05/12 at 11:00 am, they verified the lack of a sprinkler or alternative suppression system in the MRI room.