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FERRELL HOSPITAL COMMUNITY FOUNDATIONS
Fire Alarm System - Installation
Tag No.: K0341
Based upon observation the facility failed to provide the installation of smoke detection in accordance with Code requirements. Failure to properly install smoke detection can affect patients, staff and visitors if the fire alarm detection system failed to notify building occupants in a timely manner.
Finding include:
On January 29, 2020 at 8:30am while in the company of the DF it was observed in multiple rooms of the north wing that smoke detectors were located less than a distance of 3'-0" from an air diffusers, which does not comply with 9.6, NFPA 70 and NFPA 72-2010, 17.7.3.1. A review of all smoke detectors is required as occupied rooms were not reviewed.
Corridor - Doors
Tag No.: K0363
Basec upon observation, dutch doors are not installed in accordance with Code requirements. Failure to install and maintain dutch doors in accordance with requirements can compromise the protection of the corridor should a fire/smoke condition develop in the room where the dutch door is used.
Findings include:
On January 29, 2020 at 8:25am, it was observed while in the company of the DF that a dutch door was installed as a corridor door at the small office in the north wing. The door assembly did not comply with 19.3.6.3.13 because only the bottom leaf was provided with self-latching hardware to permit both doors to self-latch and the meeting edges of the upper and lower leaves lacked an astragal, rabbit or bevel to provide resistance to the passage of smoke and to allow a single operation to open the door for egress to comply with 7.2.1.5.10.2.
Electrical Systems - Essential Electric Syste
Tag No.: K0915
Based upon observation and staff interview during the survey walk-thru, the Essential Electrical System (EES) is not installed and maintained in accordance with Code requirements. Failure to maintain the emergency generator system in accordance with Code requirements may prevent the system from operating to maintain life support and emergency lighting systems which could affect all occupants during an emergency situation.
Findings include:
On January 29, 2020 at 9:00am while in the company of the DF, the generator set enclosure was observed not to be a conditioned building. The starting batteries for the generator were not provided with a means of maintaining battery temperatures (battery warmer) for cold start as determined by generator manufacturer to comply with NFPA 110-2010, 5.3.1.