HospitalInspections.org

Based on observation and interview, the facility has failed to maintain the fire protection rating of ceiling / floor penetrations in various Data/Telecon rooms.

Based on observation and interview with Staff 1, material for the protection of sleeves for the passage of communication wires through fire rated barriers had not been maintained in various IT rooms. The rooms are 1313; 2410; and 3418. The IT rooms are sprinkler protected and properly separated from corridors.

Based on observation and interview, the facility has failed to maintain cross corridor fire/smoke doors so they properly close and latch automatically.

Based on observation and interview with Staff 1, persons responsible for inspecting and ensuring these doors are properly maintaining these doors has not been doing the job properly. The problems involve one leaf on each set of doors not closing and latching without assistance. The doors are at the following locations:
(A) Doors near room 1305
(B) Doors near room 2301
(C) Doors near room 2408
(D) Doors near room 3322

(A) Based on observation, on the first floor, the door near Stair B, to the FMC storage area, would automatically close, but not latch without assistance.

(B) Based on observation, on the second floor, the door to Stair B would automatically close, but would not latch without assistance.

Based on observation and interview with Staff I, the doors in (A) and (B) had not been properly maintained. These fire doors do not latch as required by applicable codes.

Based on observation, there was no portable fire extinguisher located in the first floor corridor compartment housing rooms 1303 and 1314.

Based on observation and interview, no extinguisher had been located in this area so that one would be visible and readily available. There is a portable extinguisher through doors at each end of the compartment in other corridor compartments. There are extinguishers in some rooms off the corridor in the compartment. This appears to have been an oversight during the construction phase.

(A) Based on observation and interview, Relocatable Power Taps (RPT's) at various locations were not being used in compliance with the International Fire Code and National Electrical Code.

Based on observation and interview with Staff 1, RPT's were found not mounted off the floor so as to protect them from physical damage, as required by the codes noted above. The locations of improperly installed RPT's follow.
(1) Second floor nurse's stations.
(2) Administrative offices on the second floor.
(3) Education room 2405 (Cord taped to the floor in a walking pated.
(4) Third floor nurse's stations.

(B) Based on observation, in the FMC storage area on the first floor, an unapproved black extension cord was being used to provide four outlets for the training area.

Based on observation and interview with Staff 1, the noted cord violates the National Electrical Code and International Fire Code.

(C ) Based on observation, there was a Junction box above the training area missing the protective cover.

Based on observation and interview with Staff 1, the protective cover was missing in violation of the International Fire Code and the National Electrical Code.

(D) Based on observation, it appeared that wiring to a sprinkler control valve tamper switch over the training area in the first floor FMC storage area was not connected to the fire alarm system.

Based on observation and interview with Staff 1, it appeared that the wiring to the noted tamper switch was not connected to the fire alarm system as required by NFPA 101 and NFPA 72.