HospitalInspections.org

Observations revealed that the 2 and 3-hour fire barriers between 2000 hospital building (01) and the old hospital building (03) and the clinic building (02) are not in accordance with NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 19.1.1.4.1. This deficient practice could allow the products of combustion to travel from one building to another, which could negatively impact all the patients, staff and visitors of the facility.

Findings include:
During the facility tour on June 17, 2010, between 10:00 AM and 12:15 PM, observations revealed that:

1) The gap between the meeting edges of the 3-hour fire rated cross corridor doors into the old hospital was more than the 1/8 th of an inch allowed by NFPA 80 for labeled fire rated doors, The gap was over 1/4 of an inch and the doors did not have an astragal.

2) The 2-hour fire barrier between the clinic building (02) and the hospital building (01), above the ceiling near the south east exit door from the clinic, had unsealed pipe and wire penetrations and a 1 inch square hole through the barrier wall.

The Director of Maintenance verified these findings during the facility tour and during the exit conference.

Observations revealed that the 2 hour fire barrier between 2000 hospital building (01) and the clinic building (02) is not in accordance with NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 19.1.1.4.1. This deficient practice could allow the products of combustion to travel from one building to another, which could negatively impact all the patients, staff and visitors of the facility.

Findings include:
During the facility tour on June 17, 2010, between 10:00 AM and 12:15 PM, observations revealed that the 2-hour fire barrier between the clinic building (02) and the hospital building (01), above the ceiling near the south east exit door from the clinic, had unsealed pipe and wire penetrations and a 1 inch square hole through the barrier wall.

The Director of Maintenance verified this finding during the facility tour and during the exit conference.

Observations revealed that the 3-hour fire barriers between 2000 hospital building (01) and the old hospital building (03) is not in accordance with NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 19.1.1.4.1. This deficient practice could allow the products of combustion to travel from one building to another, which could negatively impact all the patients, staff and visitors of the facility.

Findings include:
During the facility tour on June 17, 2010, between 10:00 AM and 12:15 PM, observations revealed that the gap between the meeting edges of the 3-hour fire rated cross corridor doors into the old hospital was more than the 1/8 th of an inch allowed by NFPA 80 for labeled fire rated doors, The gap was over 1/4 of an inch and the doors did not have an astragal.

The Director of Maintenance verified this finding during the facility tour and during the exit conference.

Observations revealed that structural support beams are not protected from fire in accordance with NFPA 220 Standard on Types of Building Construction 1999 edition and NFPA 101 "The Life Safety Code" 2000 edition section 19.1.6.2. A building that does not meet the hourly fire rating required could allow the building to collapse early in a fire, preventing all patients, guests and staff from exiting the building and could also trap fire fighters.

Findings include:
During the facility tour on June 17, 2010, between 10:00 AM and 12:15 PM, observations revealed that a 10 foot section of the connecting link to the new hospital building 01 before the 3-hour fire barrier has steel I beams and steel roof decking that is not protected from fire which would cause the building to be a Type II (000) building that is not sprinkler protected which is not allowed by the table in LSC section 19.1.6.2

The Director of Maintenance verified this finding during the facility tour and during the exit conference.

Observations revealed that the main entrance/ exit door from the clinic building is not in accordance with NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 39.2.2.2.2. This deficient practice could prevent the occupants from exiting through this door in an emergency effected all patients in the clinic.

Findings include:
During the facility tour on June 17, 2010, between 10:00 AM and 12:15 PM, observations revealed that the main entrance/ exit door from the clinic waiting room has a dead bolt lock on it, but is not signed in accordance with LSC section 7.2.1.5.1 "THIS DOOR TO REMAIN UNLOCKED WHEN THE BUILDING IS OCCUPIED".

The Director of Maintenance verified this finding during the facility tour and during the exit conference.

Observations revealed that the exit signage is not in accordance with "The Life Safety Code" NFPA 101 (2000 edition) sections 7.10.1.1. This deficient practice could create confusion in an emergency situation with a need to evacuate the building.

Findings include:
During the facility tour on June 17, 2010, between 10:00 AM and 12:15 PM, observations revealed that the exit back through the main waiting room from the clinic treatment rooms is not clearly marked with an illuminated exit sign.

The Director of Maintenance verified this finding during the facility tour and during the exit conference.

Observations revealed that the oxygen is not stored in accordance with NFPA 99 Health Care Facilities 1999 edition section 4-3.5.2.1. Not properly securing compressed gas cylinders can allow them to tip, damaging the cylinder or valve, which could cause the cylinder release the oxygen into the room it ids in elevating the oxygen level within the room and for the cylinder to become a projectile, which can injure all the residents, staff and visitors within the area of the oxygen storage room.

Findings include:
During the facility tour on June 17, 2010, between 10:00 AM and 12:15 PM, observations revealed that 5 E size compressed oxygen cylinders were not properly secured within the oxygen storage room.

The Director of Maintenance verified this finding during the facility tour and during the exit conference.

Observations revealed that the 2 and 3-hour fire barriers between 2000 hospital building (01) and the old hospital building (03) and the clinic building (02) are not in accordance with NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 19.1.1.4.1. This deficient practice could allow the products of combustion to travel from one building to another, which could negatively impact all the patients, staff and visitors of the facility.

Findings include:
During the facility tour on June 17, 2010, between 10:00 AM and 12:15 PM, observations revealed that:

1) The gap between the meeting edges of the 3-hour fire rated cross corridor doors into the old hospital was more than the 1/8 th of an inch allowed by NFPA 80 for labeled fire rated doors, The gap was over 1/4 of an inch and the doors did not have an astragal.

2) The 2-hour fire barrier between the clinic building (02) and the hospital building (01), above the ceiling near the south east exit door from the clinic, had unsealed pipe and wire penetrations and a 1 inch square hole through the barrier wall.

The Director of Maintenance verified these findings during the facility tour and during the exit conference.

Observations revealed that the 2 hour fire barrier between 2000 hospital building (01) and the clinic building (02) is not in accordance with NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 19.1.1.4.1. This deficient practice could allow the products of combustion to travel from one building to another, which could negatively impact all the patients, staff and visitors of the facility.

Findings include:
During the facility tour on June 17, 2010, between 10:00 AM and 12:15 PM, observations revealed that the 2-hour fire barrier between the clinic building (02) and the hospital building (01), above the ceiling near the south east exit door from the clinic, had unsealed pipe and wire penetrations and a 1 inch square hole through the barrier wall.

The Director of Maintenance verified this finding during the facility tour and during the exit conference.

Observations revealed that the 3-hour fire barriers between 2000 hospital building (01) and the old hospital building (03) is not in accordance with NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 19.1.1.4.1. This deficient practice could allow the products of combustion to travel from one building to another, which could negatively impact all the patients, staff and visitors of the facility.

Findings include:
During the facility tour on June 17, 2010, between 10:00 AM and 12:15 PM, observations revealed that the gap between the meeting edges of the 3-hour fire rated cross corridor doors into the old hospital was more than the 1/8 th of an inch allowed by NFPA 80 for labeled fire rated doors, The gap was over 1/4 of an inch and the doors did not have an astragal.

The Director of Maintenance verified this finding during the facility tour and during the exit conference.

Observations revealed that structural support beams are not protected from fire in accordance with NFPA 220 Standard on Types of Building Construction 1999 edition and NFPA 101 "The Life Safety Code" 2000 edition section 19.1.6.2. A building that does not meet the hourly fire rating required could allow the building to collapse early in a fire, preventing all patients, guests and staff from exiting the building and could also trap fire fighters.

Findings include:
During the facility tour on June 17, 2010, between 10:00 AM and 12:15 PM, observations revealed that a 10 foot section of the connecting link to the new hospital building 01 before the 3-hour fire barrier has steel I beams and steel roof decking that is not protected from fire which would cause the building to be a Type II (000) building that is not sprinkler protected which is not allowed by the table in LSC section 19.1.6.2

The Director of Maintenance verified this finding during the facility tour and during the exit conference.

Observations revealed that the main entrance/ exit door from the clinic building is not in accordance with NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 39.2.2.2.2. This deficient practice could prevent the occupants from exiting through this door in an emergency effected all patients in the clinic.

Findings include:
During the facility tour on June 17, 2010, between 10:00 AM and 12:15 PM, observations revealed that the main entrance/ exit door from the clinic waiting room has a dead bolt lock on it, but is not signed in accordance with LSC section 7.2.1.5.1 "THIS DOOR TO REMAIN UNLOCKED WHEN THE BUILDING IS OCCUPIED".

The Director of Maintenance verified this finding during the facility tour and during the exit conference.

Observations revealed that the exit signage is not in accordance with "The Life Safety Code" NFPA 101 (2000 edition) sections 7.10.1.1. This deficient practice could create confusion in an emergency situation with a need to evacuate the building.

Findings include:
During the facility tour on June 17, 2010, between 10:00 AM and 12:15 PM, observations revealed that the exit back through the main waiting room from the clinic treatment rooms is not clearly marked with an illuminated exit sign.

The Director of Maintenance verified this finding during the facility tour and during the exit conference.

Observations revealed that the oxygen is not stored in accordance with NFPA 99 Health Care Facilities 1999 edition section 4-3.5.2.1. Not properly securing compressed gas cylinders can allow them to tip, damaging the cylinder or valve, which could cause the cylinder release the oxygen into the room it ids in elevating the oxygen level within the room and for the cylinder to become a projectile, which can injure all the residents, staff and visitors within the area of the oxygen storage room.

Findings include:
During the facility tour on June 17, 2010, between 10:00 AM and 12:15 PM, observations revealed that 5 E size compressed oxygen cylinders were not properly secured within the oxygen storage room.

The Director of Maintenance verified this finding during the facility tour and during the exit conference.