HospitalInspections.org

Based on observation the facility failed to provide an acceptable 2 hour separation.

The inspector observed while accompanied by the Vice President, Plant Operations Manager, Standards Specialist, and Maintenance Supervisor during the hours of the inspection from 8:00 am to 6:00 pm that there were the following issues at 2 hour separations. They were as follows: 1) there were numerous doors along a required second egress path from the assembly room on the 6th floor that were not rated 90 minute doors or did not close and latch smoothly, and 2) on the 3rd floor the doors in the fire wall were not labeled 90 minute doors.

Based on observation the facility failed to provide acceptable latching at a corridor door.

The inspector observed while accompanied by the Vice President, Plant Operations Manager, Standards Specialist, and Maintenance Supervisor during the hours of the inspection from 8:00 am to 6:00 pm that there was a door on the 2nd floor at the intercom/security room that did not latch properly.

Based on observation the facility failed to provide acceptable smoke barriers at a few locations.

The inspector observed while accompanied by the Vice President, Plant Operations Manager, Standards Specialist, and Maintenance Supervisor during the hours of the inspection from 8:00 am to 6:00 pm that there were penetrations in the smoke barrier above the entry doors to home infusion.

Based on observation the facility failed to provide acceptable smoke barriers at a few locations.

The inspector observed while accompanied by the Vice President, Plant Operations Manager, Standards Specialist, and Maintenance Supervisor during the hours of the inspection from 8:00 am to 6:00 pm that there were the following issues with smoke barriers. They were: 1) 2nd floor there were penetrations above the cross corridor doors in the barrier between surgery room #1 and #3, 2) 2nd floor cross corridor doors at the smoke barrier on the north end of surgery had penetrations, 3) on the 1st floor there was gypsum board missing on the southern smoke barrier on the north side of the cross corridor doors, 4) on the ground level there were penetrations in central supply, and 5) there was a large hole adjacent to a duct penetration between a mechanical space and the kitchen.

Based on observation the facility failed to provide an acceptable closer and/or latching on hazardous area doors.

The inspector observed while accompanied by the Vice President, Plant Operations Manager, Standards Specialist, and Maintenance Supervisor during the hours of the inspection from 8:00 am to 6:00 pm that there were missing door closers on the following doors locations. They are as follows: 1) 6th floor Arnet kitchen supply room, two doors, 2) 5th floor storage room in oncology family room, 3) 5th floor storage room for child birthing, 4) larger second 5th floor storage room for child birthing, 2 doors, 5) 5th floor storage room for education, 6) 5th floor storage room off of photo studio, 7) 4th floor auxiliary storage room, 8) 3rd floor staff support storage room, 9) 3rd floor clean linen storage, 10) 2nd floor large storage for surgery north, 11) 2nd floor linen storage, 12) 2nd floor clean utility, 13) storage room at the nurse station, 14) 1st floor respirator supply, 15) 1st floor traction room/cast room storage, 16) 1st floor storage room at S.W. end of wing, 17) ground level dietary storage, 18) basement level Weldon Gibbs storage room, 19) ground level storage room outside of PBX, 20) ground level storage for gift shop, 21) ground level storage for EVS, 22) ground level biomedical shop and 23) ground level pharmacy storage room.

The following locations had closers on hazardous locations but the closer or the door required adjustment to close properly. They were as follows: 1) 4th floor LDR soiled utility, 2) 2nd floor soiled utility, 3) 1st floor MRI storage room, 4) 1st floor biohazard room, 5) ground level trash room, 6) ground level chemical room, 7) ground level respiratory care/conference storage, and 8) ground level north trash chute room door.

The following locations were lacking latches. They were as follows: 1) 2nd floor clean utility in PICU, and 2) 1st floor door to equipment corridor in the radiology work area.

Based on observation the facility failed to provide an acceptable closer on hazardous area doors.

The inspector observed while accompanied by the Vice President, Plant Operations Manager, Standards Specialist, and Maintenance Supervisor during the hours of the inspection from 8:00 am to 6:00 pm that there were missing door closers on the following doors locations. They are as follows: 1) the storage area at the home infusion rear door, 2) the supply room with two doors, 3) the clean utility in the hyperbaric suite, and 4) the soiled utility in the hyperbaric suite.

Based on observation the facility failed to maintain a closer on a fire stair.

The inspector observed while accompanied by the Vice President, Plant Operations Manager, Standards Specialist, and Maintenance Supervisor during the hours of the inspection from 8:00 am to 6:00 pm that there was a door into a fire stair at the mechanical penthouse that was not closing properly.

Based on observation the facility failed to provide acceptable cross referencing between the FACP and the panel providing power to the FACP.

The inspector observed while accompanied by the Vice President, Plant Operations Manager, Standards Specialist, and Maintenance Supervisor during the hours of the inspection from 8:00 am to 6:00 pm that the FACP did not have a label that called out the panel and breaker supplying power to the unit. In addition, the panel and breaker providing the power must have a label adjacent to the breaker indicating " FIRE ALARM CIRCUIT CONTROL " and the breaker shall be colored red.

Based on observation the facility failed to provide an acceptable sprinkler system.

The inspector observed while accompanied by the Vice President, Plant Operations Manager, Standards Specialist, and Maintenance Supervisor during the hours of the inspection from 8:00 am to 6:00 pm that there were the following issues with the sprinkler system. They were: 1) the 1st floor radiology room #2 had an escutcheon plate that was blocking the head, 2) the 1st floor radiology file room had storage above the 18 inch plane below the heads, and 3) on the ground floor there was a missing head in the storage room outside of the PBX room.

The minimum distance from any bulk oxygen system to solid materials that burn rapidly, such as excelsior or paper, shall be 50 ft. - NFPA 50, 2001, 2.2.7.

Based on observation the facility failed to provide an acceptable medical gas system.

The inspector observed while accompanied by the Vice President, Plant Operations Manager, Standards Specialist, and Maintenance Supervisor during the hours of the inspection from 8:00 am to 6:00 pm that there was an issue with the medical gas installation. The bulk oxygen tank had dead leaves gathered around the tank that must be cleaned out.

A. If a public waiting area is open to a corridor, them it shall have either a smoke detection system and direct supervision by a nurse station or a quick response sprinklers and direct supervision by a nurse station or sprinklers and a smoke detection system. (NFPA 101, 2000, 19.3.6.1.)

Based on observation the facility failed to provide a corridor properly protected from a waiting area.

The inspector observed while accompanied by the Vice President, Plant Operations Manager, Standards Specialist, and Maintenance Supervisor during the hours of the inspection from 8:00 am to 6:00 pm that there were locations without direct supervision that did not have smoke detectors. They were: 1) a family waiting room on the 2nd floor that did not have a smoke detector or direct supervision by a nurse station, and 2) a surgical family waiting room also on the 2nd floor.


B. Electrical rooms with transformers larger than 112. kVA shall have a 1 hour fire rating as giving by the following. " Individual dry-type transformers of more than 112.5 kVA rating shall be installed in a transformer room of fire-resistant construction. Unless specified otherwise in this article, the term fire resistant means a construction having a minimum fire rating of 1 hour. " - NFPA 70, 450.21(B).

Based on observation the facility failed to provide an acceptable electrical room enclosure that contained transformers of more than 112.5 kVA.

The inspector observed while accompanied by the Vice President, Plant Operations Manager, Standards Specialist, and Maintenance Supervisor during the hours of the inspection from 8:00 am to 6:00 pm that there were electrical rooms that did not have closures. Closures are required on all fire doors re. NFPA 101, 2000, 8.2.3.2.1 (b). The electrical rooms were as follows: 1) 5th floor electrical room with 150 kVA transformer, 2) 4th floor electrical room with 250 kVA transformer, and 3) 3rd floor electrical room with 225 kVA transformer.


C. Established laboratory practices shall limit working supplies of flammable or combustible liquids. The total volume of Class I, II, and IIIA liquids outside of approved storage cabinets and safety cans shall not exceed 1 gal (3.78 L) per 100 ft2 (9.23 m2). The total volume of Class I, II, and IIIA liquids, including those contained in approved storage cabinets and safety cans, shall not exceed 2 gal (7.57 L) per 100 ft2 (9.23 m2). No flammable or combustible liquid shall be stored or transferred from one vessel to another in any exit corridor or passageway leading to an exit. At least one approved flammable or combustible liquid storage room shall be available within any health care facility regularly maintaining a reserve storage capacity in excess of 300 gal (1135.5 L). Quantities of flammable and combustible liquids for disposal shall be included in the total inventory. (NFPA 99, 1999, 10-7.2.2)

Based on observation the facility failed to limit the quantity of flammable liquids.

The inspector observed while accompanied by the Vice President, Plant Operations Manager, Standards Specialist, and Maintenance Supervisor during the hours of the inspection from 8:00 am to 6:00 pm that there were two locations where the quantity of flammable or combustible liquids may have exceeded the allowable quantities. They were as follows: 1) the histology room on the 1st floor had a 5 gallon container of alcohol and a second 5 gallon container of zylene, and 2) the pharmacy on the ground floor had 20, 16 oz. bottles of alcohol not stored in a approved storage cabinet. The volume in gallons per 100 square feet must be calculated.


D. Critical Care Areas: Patient Bed Location Branch Circuits. Each patient bed location shall be supplied by at least two branch circuits, one or more from the emergency system and one or more circuits from the normal system. At least one branch circuit from the emergency system shall supply an outlet(s) only at that bed location. All branch circuits from the normal system shall be from a single panel board. Emergency System receptacles shall be identified and shall also indicate the panelboard and circuit number supplying them. - NFPA 70, 2002, 517.19(A).

Based on observation the facility failed to provide an acceptable labels on the critical care electrical outlets.

The inspector observed while accompanied by the Vice President, Plant Operations Manager, Standards Specialist, and Maintenance Supervisor during the hours of the inspection from 8:00 am to 6:00 pm that there were the following critical care locations that did not have the critical outlets labeled. They were: 1) 4th floor LDR operating rooms, and 2) 3rd floor LICU rooms.


E. The pressure relationships between spaces are essential for odor and infection control. NFPA 101 references all NFPA publications. Chapter 6 of NFPA 90A, 1999 references ASHRAE documents as a mandatory part of the requirements of the standard. Current ventilation tables are given by ANSI/ASHRAE/ASHE Standard 170.

Based on observation the facility failed to provide an acceptable differential pressure relationship.

The inspector observed while accompanied by the Vice President, Plant Operations Manager, Standards Specialist, and Maintenance Supervisor during the hours of the inspection from 8:00 am to 6:00 pm that there was a protective environment room, 572, that was not positivity pressurized.


F. A generator room shall have a minimum 2-hour fire rating. - NFPA 110, 2002; 7.2.1.1. Closures are required on all fire doors re. NFPA 101, 2000, 8.2.3.2.1 (b).

Based on observation the facility failed to provide an acceptable closing action on a fire door.

The inspector observed while accompanied by the Vice President, Plant Operations Manager, Standards Specialist, and Maintenance Supervisor during the hours of the inspection from 8:00 am to 6:00 pm that generator room #3 did not have a door that closed and latched properly on its own.

Based on observation the facility failed to provide an acceptable 2 hour separation.

The inspector observed while accompanied by the Vice President, Plant Operations Manager, Standards Specialist, and Maintenance Supervisor during the hours of the inspection from 8:00 am to 6:00 pm that there were the following issues at 2 hour separations. They were as follows: 1) there were numerous doors along a required second egress path from the assembly room on the 6th floor that were not rated 90 minute doors or did not close and latch smoothly, and 2) on the 3rd floor the doors in the fire wall were not labeled 90 minute doors.

Based on observation the facility failed to provide acceptable latching at a corridor door.

The inspector observed while accompanied by the Vice President, Plant Operations Manager, Standards Specialist, and Maintenance Supervisor during the hours of the inspection from 8:00 am to 6:00 pm that there was a door on the 2nd floor at the intercom/security room that did not latch properly.

Based on observation the facility failed to provide acceptable smoke barriers at a few locations.

The inspector observed while accompanied by the Vice President, Plant Operations Manager, Standards Specialist, and Maintenance Supervisor during the hours of the inspection from 8:00 am to 6:00 pm that there were penetrations in the smoke barrier above the entry doors to home infusion.

Based on observation the facility failed to provide acceptable smoke barriers at a few locations.

The inspector observed while accompanied by the Vice President, Plant Operations Manager, Standards Specialist, and Maintenance Supervisor during the hours of the inspection from 8:00 am to 6:00 pm that there were the following issues with smoke barriers. They were: 1) 2nd floor there were penetrations above the cross corridor doors in the barrier between surgery room #1 and #3, 2) 2nd floor cross corridor doors at the smoke barrier on the north end of surgery had penetrations, 3) on the 1st floor there was gypsum board missing on the southern smoke barrier on the north side of the cross corridor doors, 4) on the ground level there were penetrations in central supply, and 5) there was a large hole adjacent to a duct penetration between a mechanical space and the kitchen.

Based on observation the facility failed to provide an acceptable closer and/or latching on hazardous area doors.

The inspector observed while accompanied by the Vice President, Plant Operations Manager, Standards Specialist, and Maintenance Supervisor during the hours of the inspection from 8:00 am to 6:00 pm that there were missing door closers on the following doors locations. They are as follows: 1) 6th floor Arnet kitchen supply room, two doors, 2) 5th floor storage room in oncology family room, 3) 5th floor storage room for child birthing, 4) larger second 5th floor storage room for child birthing, 2 doors, 5) 5th floor storage room for education, 6) 5th floor storage room off of photo studio, 7) 4th floor auxiliary storage room, 8) 3rd floor staff support storage room, 9) 3rd floor clean linen storage, 10) 2nd floor large storage for surgery north, 11) 2nd floor linen storage, 12) 2nd floor clean utility, 13) storage room at the nurse station, 14) 1st floor respirator supply, 15) 1st floor traction room/cast room storage, 16) 1st floor storage room at S.W. end of wing, 17) ground level dietary storage, 18) basement level Weldon Gibbs storage room, 19) ground level storage room outside of PBX, 20) ground level storage for gift shop, 21) ground level storage for EVS, 22) ground level biomedical shop and 23) ground level pharmacy storage room.

The following locations had closers on hazardous locations but the closer or the door required adjustment to close properly. They were as follows: 1) 4th floor LDR soiled utility, 2) 2nd floor soiled utility, 3) 1st floor MRI storage room, 4) 1st floor biohazard room, 5) ground level trash room, 6) ground level chemical room, 7) ground level respiratory care/conference storage, and 8) ground level north trash chute room door.

The following locations were lacking latches. They were as follows: 1) 2nd floor clean utility in PICU, and 2) 1st floor door to equipment corridor in the radiology work area.

Based on observation the facility failed to provide an acceptable closer on hazardous area doors.

The inspector observed while accompanied by the Vice President, Plant Operations Manager, Standards Specialist, and Maintenance Supervisor during the hours of the inspection from 8:00 am to 6:00 pm that there were missing door closers on the following doors locations. They are as follows: 1) the storage area at the home infusion rear door, 2) the supply room with two doors, 3) the clean utility in the hyperbaric suite, and 4) the soiled utility in the hyperbaric suite.

Based on observation the facility failed to maintain a closer on a fire stair.

The inspector observed while accompanied by the Vice President, Plant Operations Manager, Standards Specialist, and Maintenance Supervisor during the hours of the inspection from 8:00 am to 6:00 pm that there was a door into a fire stair at the mechanical penthouse that was not closing properly.

Based on observation the facility failed to provide acceptable cross referencing between the FACP and the panel providing power to the FACP.

The inspector observed while accompanied by the Vice President, Plant Operations Manager, Standards Specialist, and Maintenance Supervisor during the hours of the inspection from 8:00 am to 6:00 pm that the FACP did not have a label that called out the panel and breaker supplying power to the unit. In addition, the panel and breaker providing the power must have a label adjacent to the breaker indicating " FIRE ALARM CIRCUIT CONTROL " and the breaker shall be colored red.

Based on observation the facility failed to provide an acceptable sprinkler system.

The inspector observed while accompanied by the Vice President, Plant Operations Manager, Standards Specialist, and Maintenance Supervisor during the hours of the inspection from 8:00 am to 6:00 pm that there were the following issues with the sprinkler system. They were: 1) the 1st floor radiology room #2 had an escutcheon plate that was blocking the head, 2) the 1st floor radiology file room had storage above the 18 inch plane below the heads, and 3) on the ground floor there was a missing head in the storage room outside of the PBX room.

The minimum distance from any bulk oxygen system to solid materials that burn rapidly, such as excelsior or paper, shall be 50 ft. - NFPA 50, 2001, 2.2.7.

Based on observation the facility failed to provide an acceptable medical gas system.

The inspector observed while accompanied by the Vice President, Plant Operations Manager, Standards Specialist, and Maintenance Supervisor during the hours of the inspection from 8:00 am to 6:00 pm that there was an issue with the medical gas installation. The bulk oxygen tank had dead leaves gathered around the tank that must be cleaned out.

A. If a public waiting area is open to a corridor, them it shall have either a smoke detection system and direct supervision by a nurse station or a quick response sprinklers and direct supervision by a nurse station or sprinklers and a smoke detection system. (NFPA 101, 2000, 19.3.6.1.)

Based on observation the facility failed to provide a corridor properly protected from a waiting area.

The inspector observed while accompanied by the Vice President, Plant Operations Manager, Standards Specialist, and Maintenance Supervisor during the hours of the inspection from 8:00 am to 6:00 pm that there were locations without direct supervision that did not have smoke detectors. They were: 1) a family waiting room on the 2nd floor that did not have a smoke detector or direct supervision by a nurse station, and 2) a surgical family waiting room also on the 2nd floor.


B. Electrical rooms with transformers larger than 112. kVA shall have a 1 hour fire rating as giving by the following. " Individual dry-type transformers of more than 112.5 kVA rating shall be installed in a transformer room of fire-resistant construction. Unless specified otherwise in this article, the term fire resistant means a construction having a minimum fire rating of 1 hour. " - NFPA 70, 450.21(B).

Based on observation the facility failed to provide an acceptable electrical room enclosure that contained transformers of more than 112.5 kVA.

The inspector observed while accompanied by the Vice President, Plant Operations Manager, Standards Specialist, and Maintenance Supervisor during the hours of the inspection from 8:00 am to 6:00 pm that there were electrical rooms that did not have closures. Closures are required on all fire doors re. NFPA 101, 2000, 8.2.3.2.1 (b). The electrical rooms were as follows: 1) 5th floor electrical room with 150 kVA transformer, 2) 4th floor electrical room with 250 kVA transformer, and 3) 3rd floor electrical room with 225 kVA transformer.


C. Established laboratory practices shall limit working supplies of flammable or combustible liquids. The total volume of Class I, II, and IIIA liquids outside of approved storage cabinets and safety cans shall not exceed 1 gal (3.78 L) per 100 ft2 (9.23 m2). The total volume of Class I, II, and IIIA liquids, including those contained in approved storage cabinets and safety cans, shall not exceed 2 gal (7.57 L) per 100 ft2 (9.23 m2). No flammable or combustible liquid shall be stored or transferred from one vessel to another in any exit corridor or passageway leading to an exit. At least one approved flammable or combustible liquid storage room shall be available within any health care facility regularly maintaining a reserve storage capacity in excess of 300 gal (1135.5 L). Quantities of flammable and combustible liquids for disposal shall be included in the total inventory. (NFPA 99, 1999, 10-7.2.2)

Based on observation the facility failed to limit the quantity of flammable liquids.

The inspector observed while accompanied by the Vice President, Plant Operations Manager, Standards Specialist, and Maintenance Supervisor during the hours of the inspection from 8:00 am to 6:00 pm that there were two locations where the quantity of flammable or combustible liquids may have exceeded the allowable quantities. They were as follows: 1) the histology room on the 1st floor had a 5 gallon container of alcohol and a second 5 gallon container of zylene, and 2) the pharmacy on the ground floor had 20, 16 oz. bottles of alcohol not stored in a approved storage cabinet. The volume in gallons per 100 square feet must be calculated.


D. Critical Care Areas: Patient Bed Location Branch Circuits. Each patient bed location shall be supplied by at least two branch circuits, one or more from the emergency system and one or more circuits from the normal system. At least one branch circuit from the emergency system shall supply an outlet(s) only at that bed location. All branch circuits from the normal system shall be from a single panel board. Emergency System receptacles shall be identified and shall also indicate the panelboard and circuit number supplying them. - NFPA 70, 2002, 517.19(A).

Based on observation the facility failed to provide an acceptable labels on the critical care electrical outlets.

The inspector observed while accompanied by the Vice President, Plant Operations Manager, Standards Specialist, and Maintenance Supervisor during the hours of the inspection from 8:00 am to 6:00 pm that there were the following critical care locations that did not have the critical outlets labeled. They were: 1) 4th floor LDR operating rooms, and 2) 3rd floor LICU rooms.


E. The pressure relationships between spaces are essential for odor and infection control. NFPA 101 references all NFPA publications. Chapter 6 of NFPA 90A, 1999 references ASHRAE documents as a mandatory part of the requirements of the standard. Current ventilation tables are given by ANSI/ASHRAE/ASHE Standard 170.

Based on observation the facility failed to provide an acceptable differential pressure relationship.

The inspector observed while accompanied by the Vice President, Plant Operations Manager, Standards Specialist, and Maintenance Supervisor during the hours of the inspection from 8:00 am to 6:00 pm that there was a protective environment room, 572, that was not positivity pressurized.


F. A generator room shall have a minimum 2-hour fire rating. - NFPA 110, 2002; 7.2.1.1. Closures are required on all fire doors re. NFPA 101, 2000, 8.2.3.2.1 (b).

Based on observation the facility failed to provide an acceptable closing action on a fire door.

The inspector observed while accompanied by the Vice President, Plant Operations Manager, Standards Specialist, and Maintenance Supervisor during the hours of the inspection from 8:00 am to 6:00 pm that generator room #3 did not have a door that closed and latched properly on its own.