HospitalInspections.org

RSA 151, He-P 802.07(a)
"Sixty days prior to initiating construction, the hospital shall provide to the department notice and written plans drawn to scale for construction, renovation or structural alterations for the following:
(1) A new building
(2) Structural alterations to any patient area;
(3) Alterations that require approval from local or state authorities: and
(4) Alterations that might affect compliance with the health and safety, fire or building codes, including but not limited to, fire suppression, detection systems and means of egress."

RSA 153:10-b
"All designs of fire protection and warning devices for health care facilities shall be reviewed by the state fire marshal to determine compliance with the requirements of RSA 153:10-b, and no device shall be installed until it has been approved by the state fire marshal."

Based on observations, interview and record review the facility failed to submit construction plans for review by the appropriate authorities.

Findings include:

Observations during tour on 01/23/19 between 9:00 a.m. and 9:30 a.m. with Staff A (Director of Plant Operations), and Staff B (Facilities Manager) revealed that the facility failed to submit new construction plans for review of renovations, new construction, additional sprinkler and fire alarm systems to the Department of Health and Human Services, Health Facilities Administration-State Licensing, the Department of Safety and the NH State Fire Marshal's Office.

Interview with Staff A and Staff B confirmed that construction plans were not submitted to the appropriate authorities.

NFPA 101 LIFE SAFETY CODE (2012 edition)
7.2.9.4 Emergency generators providing power to emergency lighting systems shall be installed, tested and maintained in accordance with NFPA 110 STANDARD for EMERGENCY and STANDBY POWER SYSTEMS (2010 edition).
7.9.3.1.1 Testing of the emergency lighting systems shall be permitted to be conducted as follows:
(1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds.
(2) The test interval shall be permitted to be extended beyond 30 days with the approval of the AHJ (Authority Having Jurisdiction).
(3) Functional testing shall be conducted annually for a minimum of 1 1/2 hours if the emergency lighting system is battery powered.
(4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1 (1) and (3).

NFPA 110 STANDARD for EMERGENCY and STANDBY POWER SYSTEMS (2010 edition)
7.3 Lighting
7.3.1 The level 1 or level 2 EPS (Emergency Power Supply) equipment locations shall be provided with battery powered emergency lighting. This requirement shall not apply to units located outdoors in enclosures that do not include walk in access.

Based on observations and interview the facility failed to ensure that the emergency power ATS (Automatic Transfer Switch) panel locations are equipped with battery powered emergency lighting.

Findings include:

Observations during tour on 01/23/19 between 10:30 a.m. and 10:45 a.m. with Staff A (Director of Plant Operations) and Staff B (Facilities Manager) revealed that the #1, #2, and #3 ATS panels, located in the electrical room attached to the lower level main boiler plant, failed to be equipped with 90 minute battery powered emergency lighting.

Interview with Staff A and Staff B confirmed the above findings and locations.

NFPA 101 Life Safety Code (2012 edition)
8.3.3 Fire Doors and Windows.
8.3.3.1 Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage, and sills in accordance with the requirements of NFPA 80 Standard for Fire Doors and Other Opening Protective (2010 edition).

NFPA 80 Standard for Fire Doors and Other Opening Protective (2010 edition).

5.2.15.3 Where a fire door, frame, or any part of it's appurtenances is damaged to the extent that it could impair the door's proper emergency function, the following actions shall be performed:
(1) The fire door, frame, door assembly, or any part of it's appurtenances shall be repaired with labeled parts or parts obtained from the original manufacturer.
(2) The door shall be tested to ensure emergency operation and closing upon the completion of the repair.

5.2.15.3.1 If repairs cannot be made with labeled components or parts obtained from the original manufacturer, the fire door frame, fire door assembly, or appurtenances shall be replaced.

Based on observations and interview the facility failed to ensure that 1 fire door assembly was not modified in the field without manufacturers approval.

Findings include:

Observations during tour on 01/23/19 between 9:20 a.m. and 9:35 a.m. with Staff A (Director of Plant Operations) and Staff B (Facilities Manager) revealed that the (facility identified) # 4 fire door assembly has had a modification to the right hand door leaf. An extension of approximately 1 1/4" was added to the full length of the 90 minute fire door slab, on the meeting edge of the double door assembly that was not obtained from the manufacturer.

Interview with Staff A and Staff B confirmed the above finding and location.

Based on observations and interview the facility failed to ensure that the elevator shaft was fully enclosed and could resist the passage of smoke or the effects from fire.

Findings include:

Observations during tour on 01/23/19 between 8:30 a.m. and 8:35 a.m. with Staff A (Director of Plant Operations) and Staff B (Facilities Manager) revealed that the Elevator Machine room (hazardous area), located next to the lower level patient registration desk, has an approximately 8" x 8" piece of cinder block removed from the connecting wall to the elevator shaft, which would allow for the passage of smoke and the effects from fire.

Interview with Staff A and Staff B confirmed the above finding and location.

Based on observations and interview the facility failed to ensure that 1 large storage room was equipped with an automatic door closing device.

Findings include:

Observations during tour on 01/23/19 between 10:50 a.m. and 11:00 a.m. with Staff A (Director of Plant Operations) and Staff B (Facilities Manager) revealed that the door to the Surgical Supply storage room, with more than 200 square feet of space, failed to be equipped with an automatic door closing device. The storage room (containing combustible storage) is located directly next to the (facility identified) # 6 fire door assembly.

Interview with Staff A and Staff B confirmed the above findings and location.

Based on observations and interview the facility failed to ensure that 1 ABHR (Alcohol Based Hand Rub) dispenser is not installed directly over an electrical outlet.

Findings include:

Observations during tour on 01/23/19 between 10:35 a.m. and 10 :40 a.m. with Staff A (Director of Plant Operations) and Staff B (Facilities Manager) revealed that 1 ABHR dispenser is mounted directly over an electrical outlet, in the corridor across from the (facility identified) # 9 fire door assembly.

Interview with Staff A and Staff B confirmed the above finding and location.

NFPA 13 Standard for the Installation of Sprinkler Systems (2010 edition)
8.5.5.3 Obstructions that Prevent Sprinkler Discharge from Reaching the Hazard. Continuous or non-continuous obstructions that interrupt the water discharge in a horizontal plane more than 18 inches below the sprinkler deflector in a manner to limit the distribution from reaching the protected hazard shall comply with 8.5.5.3.

8.5.5.3.1 Sprinklers shall be installed under fixed obstructions over 4 feet wide such as ducts, decks, open grate flooring, cutting tables, and overhead doors.

8.5.5.3.2 Sprinklers shall not be required under obstructions that are not fixed in place such as conference tables.

Based on observations and interview the facility failed to ensure that 1 sprinkler heads' coverage is not blocked or obstructed.

Findings include:

Observations during tour on 01/23/19 between 8:00 a.m. and 8:15 a.m. with Staff A (Director of Plant Operations) and Staff B (Facilities Manager) revealed that 1 sprinkler head, located in the lower level electrical room (near the chiller room), has a sheet metal drip pan, approximately 4' x 5', installed below the sprinkler head to divert potential leaks from a water source on the floor above. The installed sheet metal drip pan would block or obstruct the sprinkler discharge pattern.

Interview with Staff A and Staff B confirmed the above finding and location.

Based on observations and interview the facility failed to maintain the continuity of at least 5 smoke barrier walls to resist the passage of smoke.

Findings include:

Observations during tour on 01/23/19 between 1:00 p.m. and 2:45 p.m. with Staff A (Director of Plant Operations) and Staff B (Facilities Manager) revealed at least 5 locations that had unprotected penetrations through the 1 hour smoke barrier walls.
These 5 locations and conditions are as follows:
1. The lower level electrical room has 4 electrical conduits with unsealed penetrations through the ceiling into the 2nd floor.
2. Above the suspended ceiling, over the (facility identified) # 3 fire door assembly has an approximately 2 1/2" unsealed penetration through the smoke barrier wall.
3. Above the suspended ceiling, between the lobby and the private waiting room, has 1 sprinkler pipe and 1 electrical conduit creating an unsealed penetration through the smoke barrier wall.
4. Above the suspended ceiling, over the (facility identified) # 6 fire door assembly has a 2 1/2" galvanized pipe penetrating through the smoke barrier wall. Both ends of the pipe are open on each side of the barrier.
5. Above the suspended ceiling, over the (facility identified) # 7 fire door assembly has a 1" penetration through the smoke barrier wall for Internet technology computer wires.

Interview with Staff A and Staff B confirmed the above findings and locations.

NFPA 99 Health Care Facilities Code (2012 edition)
5.1.3.1.9 Locations containing central supply systems or cylinders containing only oxygen or medical air shall have their door(s) or gates labeled as follows:
Medical Gases
NO Smoking or Open Flame

Based on observations and interview the facility failed to ensure that the "bulk oxygen enclosure" has no-smoking signs installed on the chain link fencing enclosure.

Findings include:

Observations during tour on 01/23/19 between 10:35 a.m. and 10:45 a.m. with Staff A (Director of Plant Operations) and Staff B (Facilities Manager) revealed that the Bulk Oxygen Enclosure, located behind the hospital, failed to have "No Smoking" signs posted on the 2 gates or enclosure fencing.

Interview with Staff A confirmed the above findings and locations.