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Unsealed openings/penetrations were observed in the fire walls as follows: During the survey, unsealed penetrations were observed around conduit in the
(2) hour wall, Hall 200 at the Surgery Wing.

8.2.2.2* Fire compartments shall be formed with fire barriers that are continuous from outside wall to outside wall, from one fire barrier to another, or a combination thereof, including continuity through all concealed spaces, such as those found above a ceiling, including interstitial spaces. Walls used as fire barriers shall comply with Chapter 3 of NFPA 221, Standard for Fire Walls and Fire Barrier Walls. The NFPA 221 limitation on percentage width of openings shall not apply.

8.2.3.2.4.2* Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows:
(1) The space between the penetrating item and the fire barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) * Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met:
a. The material shall be capable of maintaining the fire resistance of the fire barrier.
b. The material shall be protected by an approved device that is designed for the specific purpose.
(4) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the fire barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

The facility failed to provide corridor walls that would provide at least a 30 minute fire resistance rating in areas without sprinkler coverage. Findings include: During the survey, unsealed penetrations were observed at the deck in the corridor wall above Patient Room 217.


NFPA 101, 19.3.6.1 Corridors in unsprinklered smoke compartments shall be separated from all other areas by partitions having a fire resistance rating of at least 30 minutes.

The facility failed to provide corridor doors that would close and resist the passage of smoke. Findings include: During the survey, the following was observed:

1. The Storage Room door failed to latch by the X-Ray Waiting Room.

2. Restroom door failed to latch 400 Hall by Physicians' Lounge.

NFPA 101, 19.3.6.3.1 Exception No.2. In the smoke compartments protected throughout by an approved, supervised automatic sprinkler system, doors in corridor walls shall be constructed to resist the passage of smoke and be provided with suitable means of keeping the doors closed.

The facility failed to maintain exit signs. Findings include: During the survey, the following was observed:

1. Exit sign not illuminated above the fire doors at the Kitchen.

2. Exit sign not illuminated by Radiology/Respiratory.

3. Exit sign not illuminated at the Exit Stairwell from the Kitchen ground level.

4. Exit sign not illuminated Emergency Room Exit.

5. Exit sign not illuminated Exit located by the Purchasing Department.

LSC 101 2000 Edition, 7.10.5.2* Continuous Illumination. Every sign required to be illuminated by 7.10.6.3 and 7.10.7 shall be continuously illuminated as required under the provisions of section 7.8

The facility failed to provide smoke barriers that would provide at least a half hour fire resistance rating. Findings include: During the survey, the following was observed:

1. Unsealed penetrations at the end of a sleeve in the Smoke Barrier by Patient Room 110.

2. Unsealed penetrations around a group of wiring in the Smoke Barrier by Patient Room 400.

3. Unsealed penetrations around a group of wiring, and around a sleeve in the Smoke Barrier by the Delivery Room Entrance.

NFPA 101, 19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.

NFPA 101, 8.3.2 Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.

The facility failed to maintain the smoke barrier to restrict the passage of smoke. Findings include: The smoke doors with non-required latching hardware failed to close flush in the door frame with installed hardware when inspected, allowing a path for fire/smoke to transfer from one smoke compartment to another.

1. The door failed to latch by Emergency Room Waiting Room.
2. The doors failed to latch by Patient Room 110.

NFPA 101, 19.3.7.6., 8.3.4 Doors in smoke barriers to be self-closing and comply with 8.3.4. NFPA 101, 8.3.4. Doors in the smoke barrier shall close leaving only a minimum opening for the proper operation of the doors.

The facility failed to provide separation of hazardous areas. Findings include: During the survey, the Dietary Combustible Storage Room, over 50 sq. feet, door was not provided with a self-closing device.


NFPA 101, 19.3.2.1 and 8.4.1 Hazardous areas to be provided with smoke-resisting partitions and doors when protection consists of an automatic extinguishing system. Doors shall be self-closing with positive latching hardware.

A) The facility failed to provide a reliable means of egress to the public way. Based upon observation during the survey, the following was observed:

1. The Exit Stairwell from ICU was not provided with an all weather surface to the public way.

2. The Exit from the Kitchen was not provided with an all weather surface to the public way.

3. The Exit by the Physicians' Lounge, Emergency Room corridor, was not provided with an all weather surface to the public way.

4. The Exit from Hall 400 by Patient Room 400 was not provided with an all weather surface to the public way.

NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

NFPA 101, A.7.1.10.1 *A proper means of egress allows unobstructed travel at all times. Any type of barrier including, but not limited to, the accumulations of snow and ice in those climates subject to such accumulations is an impediment to free movement in the means of egress.


B) The facility failed to provide readily accessible exits at all times. Findings include:

The Exit Stairwell door failed to open until pressure was applied at the bottom of the door with a foot, and pressure applied to the Panic Hardware, at the same time. This was the ground level egess door.


NFPA 101, 7.2.1.4.5 The forces required to fully open any door manually in a means of egress shall not exceed 15 lbf to release the latch, 30 lbf to set the door in motion, and 15 lbf to open the door to the minimum required width.

The facility failed to provide continuous lighting for means of egress. Findings include: During the survey, a single bulbed light fixture was observed at the Exit Discharge for the Exit Stairwell from ICU.


NFPA 101, 19.2.8 and 7.8.1.2 Illumination of means of egress shall be continuous.

The facility failed to provide continuously illuminated exit signs. Findings include: During the survey, the Exit sign was observed not to have a directional arrow, indicating access to the Exit, by Physicians' Lounge Hall 400.

NFPA 101, 7.10.6.2* Size and Location of Directional Indicator. The directional indicator shall be located outside of the Exit legend, not less than 3/8 in. from any letter. The directional indicator shall be of a chevron type, as shown in figure 7.10.6.2. The directional indicator shall be identifiable as a directional indicator at a distance of 40 feet. The directional indicator shall be located at the end of the sign for the direction indicated.

The facility failed to maintain a fire alarm system with approved component devices or equipment installed to provide effective warning of fire in any part of the building. Findings include:

A) During the survey, while testing the Fire Alarm System, the following was observed:

1. The audible device was not operational in the Purchasing Department.
2. The audible device was not operational in the Basement corridor by the Purchasing Department.

NFPA 101, 9.6.1.7 Components of the fire alarm system were not maintained.

NFPA 101, 9.6.3.2 Notification shall be provided by audible and visible signals in accordance with 9.6.3.3 through 9.6.3.12.


B) Based upon observation, while testing the function of the dailer for audible/visual signal, the dailer was not located in a location where it would be heard.

The automatic dialer function of the fire alarm system failed to send an audible/visual signal to a location within the facility where it is most likely to be heard when line interruption occurred. NFPA 101, 19.3.4.1 and 9.6.7, and 1999 NFPA 72, 1-5.4.6 and 5-5.3.2.1.6.2 Supervisory Signals on Central Fire Alarm Systems.

Documentation provided by the facility, during the survey, did not indicate sensitivity testing of the smoke detectors. Detector sensitivity shall be checked within one year after installation and every alternate year thereafter per NFPA 72, 7-3.2.1. (Up to 5 years permitted under certain circumstances. See 7-3.2.1).

Sprinkler coverage was observed during the survey not adequately provided. Findings include: During the survey, the following was observed:

1. Ceiling tiles missing throughout the Basement/Mechancial Room.

2. Ceiling tiles missing in the Janitor Room in the Kitchen.

3. Ceiling tiles missing in the Riser Room located in the Lab.

NFPA 13 5-6., Sprinklers shall be arranged to be in compliance.


4. In the Dry Storage Room, a sprinkler had a heavy build up of corrosion.

5. All sprinklers throughtout the Kitchen had heavy corrosion build up and grease build up.

6. The deflector on the sprinkler in the Freezer had a heavy build up of ice on approximatley half of the deflector.

1999 NFPA 25, 2-2.1.1 and 2-4.1.2 Sprinklers that are painted, corroded or damaged shall be replaced with new listed sprinklers of the same characteristics, including orifice size, thermal response, and water distribution.


7. The escutcheon plates were missing on seven sprinklers in the Kitchen.

2000 NFPA 13, 3-2.7.2 Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.


8. A Storage Room located in the Recovery Room ICU Unit was not provided with sprinkler coverage.

NFPA 19.3.5.1 Where required by 19. 1. 6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.

The facility failed to provide supervision of all sprinkler control valves. During the survey, the following was observed:

The tamper switch for Hall 100 was not electronically supervised.

Sprinkler control valves shall be electrically supervised so that at least a local alarm will sound at a constantly attended location when the valve is turned. NFPA 101, 19.3.5.1 and 9.7.2.1, 1999 NFPA 13, 5-14.1.1.3, and
1999 NFPA 72, 2-9.1.

The facility failed to comply with the required maintenance of the facility sprinkler system. During the survey, the following was observed:

A) There was not an access provided for the inspector test for Hall 100 flow switch. Inspectors test sign located on wall by Patient Room 112, flow switch is located inside Patient Room 112, only access would be to remove the light fixture each time the quarterly inspection is conducted by the sprinkler company, and this flow switch is not being inspected because access is not provided.

NFPA 25, 9-2.3 All system valves shall be protected from physical damage and shall be accessible.


B) Documentation provided, during the survey, indicated quarterly sprinkler system inspections were conducted as follows:

12/11/2009, 3/15/2010, quarterly inspection was due in June 2010.

NFPA 101, 4.6.12, and NFPA 25, 2-2 and Table 2-1 Requires an inspection every quarter (three months).


C) The Cat Scan Room was observed to have three central recall sprinklers.

Every required sprinkler system shall be continuously maintained in proper operating condition. NFPA 101, 4.6.12.1.

The facility failed to provide metal self-closing containers for disposing of cigarette butts and ashes from ashtrays. Findings include: During the survey, the designated smoking area for the Psych. Unit was not provided with a metal container for smoking material.

NFPA 101, 19.7.4 Ashtrays of noncombustible material and safe design, and metal self-closing containers for disposing of cigarette butts and ashes from ashtrays shall be provided.

The facility failed to maintain the dietary hood. Findings include: During the survey, the filters in the dietary hood were observed not to be tight fitting or firmly held in place. One of the filters was observed bent and damaged.

NFPA 96, 3-2.3 Grease filters shall be listed and constructed of steel or listed equivalent material and shall be of rigid construction that will not distort or crush under normal operation, handling, and cleaning conditions. Filters shall be tight fitting and firmly held in place.

During the survey, documentation was not provided for the draperies/cubicle curtains to indicate if the standards for NFPA 701 flame resistant were met.

LSC 101,2000 10.3.1 Where required by the applicable provisions of this code, draperies, curtains, and other similar loosely hanging furnishings, and decorations shall be flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.

Documentation was not provided, during the survey, for the annual inspection of the medical gas system.

NFPA 99, 4.2.1 Each bulk oxygen system installed on consumer premises shall be inspected annually and maintained by a qualified representative of the equipment owner.

During the survey, Maintenance advised this surveyor that the smoke vent for the OR was not operational and that plans had been approved by staff at TSU for correction.

1976 and 1999, NFPA 99, 5-4.1 Supply and exhaust systems for windowless
anesthetizing locations shall be arranged to automatically vent smoke and products of combustion, and prevent recirculation of smoke originating within the surgical suite, and also prevent circulation of smoke entering the system intake, without interfering with the system exhaust function.

Documentation was not provided for annual service of the fire hydrants.
NFPA 25, 4-4.3 Hydrants, the facility has four.

4-4.3.1 Hydrants shall be lubricated annually to ensure that all stems, caps, plugs, and threads are in proper operating condition.

The facility failed to provide approved electrical utilities. Findings include : During the survey, exposed wiring was observed at the junction box for the wall fan unit in the Ice Machine Room Hall 200.

NFPA 101, 19.5.1 States utilities shall comply with NFPA 101, 9.1. Electrical shall comply with the NFPA 70, National Electrical Code. The NFPA 70, Article 110-12(c) states there shall be no damaged parts that may adversely affect the safe operation or mechanical strength of the equipment such as parts that are broken.