HospitalInspections.org

Based on observation on 01/07/2010, the licensed hospital area of the building is separated from the clinic area of the building by a wall with cross-corridor doors in the corridor doorway. The cross-corridor doors are not a miminum 1-1/2 hour fire-rated assembly as required by NFPA 101.

Based on observation on 01/07/2010, the construction of the building did not comply with the Life Safety Code requirements for Type II (111) construction type required for a one-story, non-sprinklered hospital. The suspended ceiling was removed at patient room 18, patient room 16, and a closet near the x-ray room, which exposed the steel roof joists above. The roof structure of the pantry at the rear of the kitchen is exposed. Therefore, the building is not classified Type II (111) construction because the ceiling/roof assembly does not provide a minimum 1-hour fire resistance rating.

Based on observation on 01/07/2010, the corridors were not properly separated from the adjacent rooms because the corridor walls did not extend above the suspended ceilings. The corridor walls are required to extend to the underside of the roof deck above.

Based on observation on 01/07/2010, the corridor doors to the following rooms did not have postive latching hardware as required: kitchen door; two dining room doors; patient sleeping rooms 31,32,33,34,35,36,37,38,39,40. (These patient rooms have roller latches that are not approved.) Each corridor door must have hardware that automatically latches with a positive latch when the door is closed.
Base on observation on 01/07/2010, the corridor door to the gift shop was a glass door which did not provide a minimum 20-minute fire rating as required by NFPA 101.

Based on observation on 01/07/2010, the cross-corridor smoke doors did not comply with NFPA 101 because an astragal was not installed to seal the opening between the meeting edges of the doors when they are closed.

Based on observation on 01/07/2010, the following rooms were used for storage of large amounts of combustible items and are classified as hazardous areas: X-ray file storage room; patient rooms 16, 18, 24, end patient room at the north wing. These rooms must be protected by an automatic fire sprinkler system, or they must be enclosed with construction having a minum 1-hour fire resistance rating.

Based on observation on 01/07/2010, the corridor doors to the following patient rooms had locking hardware on the corridor side which could not be opened from inside the room when locked: 19; 21; 2. NFPA 101 requires that each patient room have a door to an egress corridor that can be opened from inside the room without the use of a key.

Based on observation on 01/07/2010, the building is not protected by an automatic fire sprinkler system. The Hospital building was reclassified Type II (000) construction because the ceiling/roof assembly did not have a minimum 1-hour fire resistance rating as described in K012. NFPA 101 requires hospitals of Type II (000) constuction to be protected by a fire sprinkler system installed in compliance with NFPA 13.

Based on observation on 01/07/2010, the heating, ventilating, and air conditioning system did not comply with NFPA 90A because the following egress corridors were used for return-air movement from rooms: North Corridor (cenral supply, pharmacy, waiting room, X-ray room, offices) South Corridor (patient rooms 31, 32, 33, 34, 35, 36 ,37, 38, 39, 40.) NFPA 90A requires that egress corridors in health care occupancies must not be used as a portion of a supply, return, or exhaust air system serving adjoining areas.

Based on observation on 01/07/2010, the kitchen range hood extinguishing system did not comply with NFPA 96 because the manual means of activating the system was located adjacent to the stove. NFPA 96 requires the manual pull be located remote from the stove so it is accessible in the event of a fire and in the path of egress from the kitchen.

Based on observation on 01/07/2010, the piped medical gas system did not comply with NFPA 99, because the following zone shut off valves were not labeled properly: two in the emergency suite (labled OR 1 and OR2); near the emergency entry (not lableled); near dining room (labeled East-West Wings.) NFPA 99 requires the shut off valves be labled to indicate the name of the room or area served. There are not any "ORs" in the hospital, and "East and West Wings" does not adequately identify the areas served.

Based on observation on 01/07/2010, the following electrical installations did not comply with NFPA No. 70:
(a) An electrical junction box above the shelves in the kitchen pantry did not have a cover plate installed on it.
(b) The electrical junction box, near the wall mounted air-conditioning unit in the counseling office, was not secured in place.
(c) There were two missing ciruit breakers in the electrical panelboard on the corridor wall near the kitchen. The missing breakers must be replaced with spare breakers or blanks.
(d) Electrical wiring in patient rooms 18 and 24 had abandoned wiring that must be removed, electical connections not in junctions boxes, junction boxes without cover plates, junction boxes not secured in place.