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Based on random observation during the survey walk-through, not all doors in exit access corridors are in compliance with 19.3.6.3.

Findings include:

A. At 9:53 AM on March 7, 2012, the door to the Physical Therapy Suite was observed to not be positive latching as required by 19.3.6.3.2. This deficiency could affect any patients, staff, or visitors in the immediate area by permitting smoke or fire to pass to the adjacent corridor.

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Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 39.3.2.1.

Findings include:

A. At 9:44 AM on March 7, 2012, the door to the Central Supply Room (located within the designated existing business occupancy) was observed to not be not self-closing as required by 39.3.2.1. and 8.4.1.1. This deficiency could affect any patients, staff, or visitors in the immediate area by permitting smoke or fire to pass to the adjacent corridor.

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Based on random observation during the survey walk-through, not all designated or required horizontal exits or fire barriers are constructed or maintained as fire resistive assemblies. These deficiencies could affect any staff or visitors in the area by permitting smoke and fire to cross the designated fire barrier between the existing business and existing healthcare occupancies.

Findings include:

A. 10:12 AM March 7, 2012: The following conditions were observed at the 90 minute rated fire door between the existing hospital and the former CT Mobile Unit, all as prohibited by 8.2.3.2.3.1(1): 1. The door was observed to lack positive latching hardware.
2. The door was observed to be held open by an unapproved device (a door wedge).

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Based on random observation during the survey walk-through, not all portions of the building fire alarm system are installed in accordance with 19.3.4. These deficiencies could affect all patients, staff, or visitors in the building because the fire alarm could be inadvertently shut off without their knowledge.

Findings include:

A. At 10:00 AM on March 7, 2012, the Fire Alarm Control Panel, located at the Nurses' Station, was observed to not be labeled as to the Electrical Panel from which it is served, as required by NFPA 72 1999 1-5.2.5.2.

B. 9:44 AM on March 7, 2012: At Electrical Panel EMLS, located in the Basement Mechanical Room, the circuit breaker serving the Fire Alarm Control Panel was observed to not be in compliance with NFPA 72 1999 1-5.2.5.2. because it is not equipped with a mechanical lock-on device, is not labeled, and is not painted red.

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Based on document review, not all portions of the facility's commercial cooking equipment is installed and maintained in accordance with NFPA 96.

Findings include:

A. At 12:04 PM on March 7, 2012, during the document review process, it was discovered that all recent reports from the kitchen hood suppression system service vendor, including one dated June 3, 2011, stated that the activation of the kitchen hood suppression system does not automatically activate the building fire alarm system as required by NFPA 96 1998 7-6.2. This could affect any patients, staff, or visitors in the building because a fire in the Kitchen could occur without their knowledge.

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Based on random observation during the survey walk-through, not all soiled linen or trash receptacles are stored in accordance with 19.7.5.5.

Findings include:

A. At 9:50 AM on March 7, 2012, at the east end of the building's primary east-west Corridor, a recycling bin with a capacity in excess of 32 gallons was observed that is not stored in a room protected as a hazardous area as required by 19.7.5.5. This deficiency could affect any patients, staff, or visitors in the area because they would not be protected from a fire in the bin.

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Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

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Based on document review and staff interview, the emergency generator is not inspected and tested in accordance with NFPA 99. These deficiencies could affect all patients, staff, or visitors in the building because the emergency generator could fail to operate under emergency conditions.

Findings include:

A. During the document review process, it was determined that the emergency generator is not visually inspected on a weekly basis, as required by NFPA 110 1999 6-4.1., because no records of any such inspections were available. This determination was confirmed by the provider's Maintenance Supervisor during an interview held in the Administrative Conference Room at 12:10 PM on March 7, 2012.

B. During the document review process, it was determined that the emergency generator is not tested under load for 30 minutes each month, as required by NFPA 99 1999 3-4.4.1.1. and NFPA 110 1999 6-4.2., because no records of any such inspections were available. This determination was confirmed by the provider's Maintenance Supervisor during an interview held in the Administrative Conference Room at 12:10 PM on March 7, 2012.

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Based on random observation during the survey walk-through and document review, the facility's electrical system is not divided into the critical branch, life safety branch, and the emergency system as required by NFPA 99. These deficiencies could affect any patients, staff, or visitors in the building because the emergency electrical system could become compromised due to its lack of separation from other portions of the building's electrical system.

Findings include:

A. The Life Safety Branch of the building's Type I ESS System was observed to include loads other than those permitted by NFPA 99 1999 3-4.2.2.2(b) and NFPA 70 1999 517-32. At 9:29 AM on March 7, 2012, the Panel Directory for Electrical Panel EMLS, located in the Basement Mechanical Room, was observed to indicate that a copy machine was fed from that panel.
B. At 10:30 AM on March 7, 2012, a review of Sheet E-4.0 (dated February 2, 20122) of a set of drawings prepared by the provider's engineering consultant (with respect to the installation of the new emergency generator) was conducted. During that review it was determined that Electrical Panel MEP, located in the basement Mechanical Room, serves both the building's Critical and Equipment Branches of the Type I EES. These branches are thus not separated as required by NFPA 99 1999 3-4.2.2.2. and NFPA 70 1999 517-33.

C. At 9:30 AM on March 7, 2012, Circuit 13 of Electrical Panel MEP, located in the Basement Mechanical Room and designated as serving the Critical and Equipment Branches of the building's Type I EES, was observed to serve exit lights which are required to be served by a Life Safety panel of that system by NFPA 99 1999 3-4.2.2.2(b)(2) and NFPA 70 1999 517-32(b).

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Based on random observation during the survey walk-through, not all portions of the building electrical system are installed in accordance with NFPA 70 1999. These deficiencies could affect any patients in the Emergency Department because there may not be sufficient electrical power at the cited locations to provide care.

Findings include:

A. 10:45 AM March 7, 2012: Emergency Room Bay 2 was observed to lack the following types of electrical receptacles required by the cited sections of NFPA 70 1999:
1. A minimum of 6 electrical receptacles as required by NFPA 70 1999 517-19(b).

2. At least 1 circuit served by the building emergency electrical system as required by NFPA 70 1999 517-18(a).

B. 10:45 AM March 7, 2012: Emergency Room Bays 3 and 4 were observed to lack the following types of electrical receptacles required by the cited sections of NFPA 70 1999:

1. A minimum of 6 electrical receptacles as required by NFPA 70 1999 517-19(b).

2. Electrical receptacles served by a minimum of 2 branch circuits as required by NFPA 70 1999 517-18(a) or 517-19(a). The cited Bays are provided only with one duplex receptacle on emergency power.

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Based on random observation during the survey walk-through, not all doors in exit access corridors are in compliance with 19.3.6.3.

Findings include:

A. At 9:53 AM on March 7, 2012, the door to the Physical Therapy Suite was observed to not be positive latching as required by 19.3.6.3.2. This deficiency could affect any patients, staff, or visitors in the immediate area by permitting smoke or fire to pass to the adjacent corridor.

.

Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 39.3.2.1.

Findings include:

A. At 9:44 AM on March 7, 2012, the door to the Central Supply Room (located within the designated existing business occupancy) was observed to not be not self-closing as required by 39.3.2.1. and 8.4.1.1. This deficiency could affect any patients, staff, or visitors in the immediate area by permitting smoke or fire to pass to the adjacent corridor.

.

Based on random observation during the survey walk-through, not all designated or required horizontal exits or fire barriers are constructed or maintained as fire resistive assemblies. These deficiencies could affect any staff or visitors in the area by permitting smoke and fire to cross the designated fire barrier between the existing business and existing healthcare occupancies.

Findings include:

A. 10:12 AM March 7, 2012: The following conditions were observed at the 90 minute rated fire door between the existing hospital and the former CT Mobile Unit, all as prohibited by 8.2.3.2.3.1(1): 1. The door was observed to lack positive latching hardware.
2. The door was observed to be held open by an unapproved device (a door wedge).

.

Based on random observation during the survey walk-through, not all portions of the building fire alarm system are installed in accordance with 19.3.4. These deficiencies could affect all patients, staff, or visitors in the building because the fire alarm could be inadvertently shut off without their knowledge.

Findings include:

A. At 10:00 AM on March 7, 2012, the Fire Alarm Control Panel, located at the Nurses' Station, was observed to not be labeled as to the Electrical Panel from which it is served, as required by NFPA 72 1999 1-5.2.5.2.

B. 9:44 AM on March 7, 2012: At Electrical Panel EMLS, located in the Basement Mechanical Room, the circuit breaker serving the Fire Alarm Control Panel was observed to not be in compliance with NFPA 72 1999 1-5.2.5.2. because it is not equipped with a mechanical lock-on device, is not labeled, and is not painted red.

.

Based on document review, not all portions of the facility's commercial cooking equipment is installed and maintained in accordance with NFPA 96.

Findings include:

A. At 12:04 PM on March 7, 2012, during the document review process, it was discovered that all recent reports from the kitchen hood suppression system service vendor, including one dated June 3, 2011, stated that the activation of the kitchen hood suppression system does not automatically activate the building fire alarm system as required by NFPA 96 1998 7-6.2. This could affect any patients, staff, or visitors in the building because a fire in the Kitchen could occur without their knowledge.

.

Based on random observation during the survey walk-through, not all soiled linen or trash receptacles are stored in accordance with 19.7.5.5.

Findings include:

A. At 9:50 AM on March 7, 2012, at the east end of the building's primary east-west Corridor, a recycling bin with a capacity in excess of 32 gallons was observed that is not stored in a room protected as a hazardous area as required by 19.7.5.5. This deficiency could affect any patients, staff, or visitors in the area because they would not be protected from a fire in the bin.

.

Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

.

Based on document review and staff interview, the emergency generator is not inspected and tested in accordance with NFPA 99. These deficiencies could affect all patients, staff, or visitors in the building because the emergency generator could fail to operate under emergency conditions.

Findings include:

A. During the document review process, it was determined that the emergency generator is not visually inspected on a weekly basis, as required by NFPA 110 1999 6-4.1., because no records of any such inspections were available. This determination was confirmed by the provider's Maintenance Supervisor during an interview held in the Administrative Conference Room at 12:10 PM on March 7, 2012.

B. During the document review process, it was determined that the emergency generator is not tested under load for 30 minutes each month, as required by NFPA 99 1999 3-4.4.1.1. and NFPA 110 1999 6-4.2., because no records of any such inspections were available. This determination was confirmed by the provider's Maintenance Supervisor during an interview held in the Administrative Conference Room at 12:10 PM on March 7, 2012.

.

Based on random observation during the survey walk-through and document review, the facility's electrical system is not divided into the critical branch, life safety branch, and the emergency system as required by NFPA 99. These deficiencies could affect any patients, staff, or visitors in the building because the emergency electrical system could become compromised due to its lack of separation from other portions of the building's electrical system.

Findings include:

A. The Life Safety Branch of the building's Type I ESS System was observed to include loads other than those permitted by NFPA 99 1999 3-4.2.2.2(b) and NFPA 70 1999 517-32. At 9:29 AM on March 7, 2012, the Panel Directory for Electrical Panel EMLS, located in the Basement Mechanical Room, was observed to indicate that a copy machine was fed from that panel.
B. At 10:30 AM on March 7, 2012, a review of Sheet E-4.0 (dated February 2, 20122) of a set of drawings prepared by the provider's engineering consultant (with respect to the installation of the new emergency generator) was conducted. During that review it was determined that Electrical Panel MEP, located in the basement Mechanical Room, serves both the building's Critical and Equipment Branches of the Type I EES. These branches are thus not separated as required by NFPA 99 1999 3-4.2.2.2. and NFPA 70 1999 517-33.

C. At 9:30 AM on March 7, 2012, Circuit 13 of Electrical Panel MEP, located in the Basement Mechanical Room and designated as serving the Critical and Equipment Branches of the building's Type I EES, was observed to serve exit lights which are required to be served by a Life Safety panel of that system by NFPA 99 1999 3-4.2.2.2(b)(2) and NFPA 70 1999 517-32(b).

.

Based on random observation during the survey walk-through, not all portions of the building electrical system are installed in accordance with NFPA 70 1999. These deficiencies could affect any patients in the Emergency Department because there may not be sufficient electrical power at the cited locations to provide care.

Findings include:

A. 10:45 AM March 7, 2012: Emergency Room Bay 2 was observed to lack the following types of electrical receptacles required by the cited sections of NFPA 70 1999:
1. A minimum of 6 electrical receptacles as required by NFPA 70 1999 517-19(b).

2. At least 1 circuit served by the building emergency electrical system as required by NFPA 70 1999 517-18(a).

B. 10:45 AM March 7, 2012: Emergency Room Bays 3 and 4 were observed to lack the following types of electrical receptacles required by the cited sections of NFPA 70 1999:

1. A minimum of 6 electrical receptacles as required by NFPA 70 1999 517-19(b).

2. Electrical receptacles served by a minimum of 2 branch circuits as required by NFPA 70 1999 517-18(a) or 517-19(a). The cited Bays are provided only with one duplex receptacle on emergency power.

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