HospitalInspections.org

Based on observation and interview it was determined that the facility failed to maintain the 2-hour fire barrier between this building and the Hospital building.

Findings include:

On 11/30/11 at approximately 2:42 pm it was observed that the door in the 2 hour separation (that crosses in front of the Anesthesia Work Room) does not appear to have the proper rating for this use.

The above were observed and confirmed by the Director of Engineering and the Safety Officer.

Based on observation and interview it was determined that the facility failed to maintain the construction type for this building.

Findings include:

On 11/30/11 at approximately 2:47 pm it was observed that required fireproofing material was missing from structural steel above the ceiling in the Oncology electrical/telephone room.

On 11/30/11 at approximately 2:50 pm it was observed that required fireproofing material was missing from structural steel in the Oncology mechanical room.

On 11/30/11 at approximately 3:09 pm it was observed that combustible firestopping is being used to seal penetrations of rated construction in the Oncology Communications Closet.

On 11/30/11 at approximately 3:55 pm it was observed that required fireproofing material is missing from structural steel in the lobby between the two Oncology departments.

On 12/01/11 at approximately 9:00 am it was observed that required fireproofing material is missing from structural steel in the corridor of Oncology near at the nurses' station.

On 12/01/11 at approximately 9:59 am it was observed that required fireproofing material is missing from structural beams above the ceiling in Elevator 8 Lobby.

On 12/01/11 at approximately 10:14 am it was observed that required fireproofing material is missing from structural beams above the ceiling at the rear exit.

The above were observed and confirmed by the Director of Engineering and the Safety Officer.

Based on observation and interview it was determined that the facility failed to ensure that flame spread ratings are Class A or Class B.

Findings include:

On 12/7/11 at approximately 11:55 am it was observed that there is plywood used on the exterior wall of the Bio-Hazard Room.

On 12/12/11 at approximately 1:23 pm it was observed that wood has been used on the wall outside of EDS on 1W and is over 4' in height from the bottom of the wall.

The above was confirmed by the Director of Engineering and the Safety Officer.

Based on observation and interview it was determined that the interior finish for the gym area does not appear to have the required flame spread rating.

Findings include:

On 11/16/11 at approximately 3:30 pm it was observed that a wood climbing wall was added to the Gym wall. Documentation was not available to show the flame spread rating for this material.

The above was witnessed and confirmed by the Director of Engineering and the Safety Officer.

Based on observation and interview it was determined that the facility failed to maintain smoke tight corridors. Corridors are required to be smoke tight partitions to the deck above because of the use of a plenum above the lay in ceiling.

Findings include:

On 11/16/11 at approximately 1:35 pm it was observed that there are unsealed penetrations to the smoke partition at the Emergency Equipment Room.

On 11/16/11 at approximately 3:05 pm it was observed that there are unsealed penetrations to the smoke partition in the AAU (Adult Unit 1) corridor at Room 204.

On 11/16/11 at approximately 3:07 pm it was observed that there are unsealed penetrations to the smoke partition in the AAU corridor at Room 202.

On 11/16/11 at approximately 3:10 pm it was observed that there are unsealed penetrations to the smoke partition in the AAU corridor at Room 111.

On 11/16/11 at approximately 3:42 pm it was observed that there are unsealed penetrations to the smoke partition in the Cafeteria corridor by wires and conduit.

On 11/16/11 at approximately 3:50 pm it was observed that there are unsealed penetrations to the Health Information Management corridor by conduit, pipes, and wires.

The above were observed and confirmed by the Director of Engineering and the Safety Officer.

Based on observation and interview it was determined that the facility failed to ensure that corridor doors are smoke tight.

Findings include:

On 12/1/11 at approximately 10:33 am it was observed that the door to patient Room 636 is not equipped with a means to keep the door closed.

The above was observed and confirmed by the Director of Engineering and the Safety Officer.

Based on observation and interview it was determined that the facility failed to maintain stairways with a one hour fire resistance rating.

Findings include:

On 11/30/11 at approximately 1:25 pm it was observed that there are unprotected penetrations by sprinkler piping/conduit to the stairwell near the OBGYN entrance.

The above was observed and confirmed by the Director of Engineering and the Safety Officer.

Based on observation and interview it was determined that the facility failed to maintain fire doors that they will close automatically.

Findings include:

On 11/15/11 at approximately 11:08 am it was observed that the door to Stair 1, 1st floor is being held open by unapproved means. Further, this door is not automatically latching in the closed position.

The above were observed and confirmed by the Director of Engineering and the Safety Officer.

Based on observation and interview it was determined that the facility failed to maintain the construction of smoke barrier walls.

Findings include:

On 11/30/11 at approximately 9:10 am it was observed that combustible foam is being used to seal penetrations to the smoke barrier in the lobby of ER Triage.

On 11/30/11 at approximately 9:12 am it was observed that combustible foam is being used to seal penetrations to the smoke barrier in the ER Meditation Room.

On 11/30/11 at approximately 9:20 am it was observed that there are unsealed penetrations in the corridor of ER Triage by conduit/piping.

On 11/30/11 at approximately 9:42 am it was observed that there are unsealed penetrations in the corridor at ER Super Track by conduit/piping.

On 11/30/11 at approximately 10:14 am it was observed that there are unsealed penetrations to ER Super Track room by conduit.

On 11/30/11 at approximately 10:32 am it was observed that there are unsealed penetrations to ER Fast Track by conduit/wiring.

On 11/30/11 at approximately 10:41 am it was observed that combustible foam is being used for sealing the smoke barrier in the ER Ambulatory Lobby entrance.

On 11/30/11 at approximately 10:45 am it was observed that combustible foam is being used for sealing the smoke barrier in the ER-EMS room.

On 11/30/11 at approximately 2:42 pm it was observed that there are unsealed penetrations to the barrier wall above the ceiling at the Anesthesia Work Room.

The above were observed and confirmed by the Director of Engineering and the Safety Officer.

Based on observation and interview it was determined that the facility failed to maintain door openings in smoke barriers.

Findings include:

On 11/30/11 at approximately 2:55 pm it was observed that the dutch fire doors in the barrier wall at Blue Ridge Oncology are not automatically closing when the fire alarm is activated. One door in the reception area had the opposite leaf propped open. An additional door at the reception area was obstructed from closing by shelving.

On 11/30/11 and 12/1/11 at approximately 3:27 pm and 9:30 am it was observed that the two rated doors in the barrier wall across from Exam Room 4 in Blue Ridge Oncology were being held open with a door stop.

The above was observed and confirmed by the Director of Engineering and the Safety Officer.

Based on observation and interview it was determined that the facility failed to maintain identified hazardous areas separated by required construction with properly rated doors that remain self-closing.

Findings include:

On 11/16/11 at approximately 1:34 pm it was observed that the old pharmacy area was changed to a storage room and is not separated in accordance with the construction requirements for hazardous areas. (Section 18-3.2.1)

On 11/16/11 at approximately 1:35 pm it was observed that the old exam room was changed to storage and is not separated in accordance with the construction requirements for hazardous areas. (Section 18-3.2.1)

On 11/16/11 at approximately 3:25 pm it was observed that the office in the Gym was changed to a storage room and is not separated in accordance with the construction requirements for hazardous areas. (Section 18-3.2.1)

On 11/16/11 at approximately 3:27 pm it was observed that an additional office in the Gym was changed to a storage room and is not separated in accordance with the construction requirements for hazardous areas. (Section 18-3.2.1)

On 11/16/11 at approximately 3:30 pm it was observed that the door to Storage Room A in the Gym is not self-closing.

The above were observed and confirmed by the Director of Engineering and the Safety Officer.

Based on observation and interview it was determined that the facility failed to maintain stairways with a fire resistance rating.

Findings include:

On 12/13/11 at approximately 10:47 am it was observed that the door to Stair 5, Floor G is not latching.

The above were observed and confirmed by the Director of Engineering and the Safety Officer.

Based on observation and interview it was determined that the facility failed to maintain exits readily accessible.

Findings include:

On 12/1/11 at approximately 2:50 pm it was observed that egress from Room 438 was partially obstructed by furniture.

The above was observed and confirmed by the Director of Engineering and the Safety Officer.

Based on observation and interview it was determined that the facility failed to maintain corridors free and clear of obstructions.

On 12/12/11 at approximately 1:10 pm it was observed that there was combustible storage in the EVS hallway outside of the Clean Linen and Cart Room.

On 12/7/11 at approximately 2:47 pm it was observed that there is a significant amount of housekeeping storage in the EVS corridor outside of the rear of Endoscopy.

The above was observed and confirmed by the Director of Engineering and the Safety Director.

Based on observation and interview it was determined that the facility failed to maintain horizontal exits.

Findings include:

On 12/5/11 at approximately 10:53 am it was observed that the closer for the rated door at the CCU Waiting Room on 3E was removed. This corridor is part of a horizontal exit.

On 12/13/11 at approximately 10:15 am it was observed that the door in the horizontal exit from Radiology to OR (2 hour barrier) was "dogged down" and not self-latching on the ground floor.

The above were observed and confirmed by the Director of Engineering and the Safety Officer.

Based on observation and interview the facility failed to install the fire alarm system in accordance with NFPA 72.

On 12/13/11 at approximately 10:15 am it was observed that there are no fire alarm pull stations on either side of the 2 hour barrier (Horizontal Exit from Radiology to OR) on the ground floor.

The above was observed and confirmed by the Director of Engineering and the Safety Officer.

Based on observation and interview the facility failed to maintain smoke detectors as required.

On 12/12/11 at approximately 1:30 pm it was observed that a smoke detector in an ante-room off the office in the Business office on 1W appears to be too close to the air diffuser. (NFPA 72, 2-3.5.1)

The above was observed and confirmed by the Director of Engineering and the Safety Officer.

Based on observation and interview it was determined that the facility failed to install a complete automatic sprinkler system in accordance with NFPA 13.

Findings include:

On 11/15/11 at approximately 11:48 am it was observed that sprinklers appear to be installed improperly (too close together). (NFPA 13, Section 5-6.3.4)

The above was observed and confirmed by the Director of Engineering and the Safety Officer.

Based on observation and interview it was determined that the facility failed to continuously maintain the sprinkler system in a reliable operating condition..

Findings include:

On 11/30/11 at approximately 10:40 am it was observed that sprinkler covers are painted(recessed sprinklers) in ER Fast Track. (NFPA 13, Section 3-2.6.3)

On 11/30/11 at approximately 1:37 pm it was observed that there is an escutcheon missing from a sprinkler in the Janitor's Closet on the OR floor. (NFPA 13, Section 3-2.7.2)

The above were observed and confirmed by the Director of Engineering and the Safety Officer.

Based on observation and interview it was determined that the facility failed to maintain the HVAC system.

Findings include:

On 12/5/11 at approximately 3:45 pm it was observed that no damper was provided for the flex duct that runs into the lounge in Central Sterile on the 2nd floor. (two hour barrier)

The above was observed and confirmed by the Director of Engineering and the Safety Officer.

Based on observation and interview it was determined that the facility failed to maintain kitchen hoods systems.

Findings include:

On 12/12/11 at approximately 2:12 pm it was observed that the kitchen range hood system in Dietary is not provided with a grease drip pan.

On 12/12/11 at approximately 2:12 pm it was observed that the filters for the kitchen range hood system in Dietary are not properly installed.

On 12/12/11 at approximately 2:41 pm it was observed that the kitchen range hood system in the kitchen work area has a damaged filter. There are also gaps between the filters.

The above were observed and confirmed by the Director of Engineering and the Safety Officer.

Based on observation and interview it was determined that the facility failed to maintain the fire resistance rating for the walls of the linen and trash chutes.

Findings include:

On 12/12/11 at approximately 9:30 am it was observed that there are unprotected penetrations to the rated walls of the Trash Chute Room on 1E.

On 12/12/11 at approximately 9:35 am it was observed that there are unprotected penetrations of the front and rear wall of the Linen Chute Room on 1E.

On 12/12/11 at approximately 11:28 am it was observed that there is an unprotected penetration at the corner of Trash Chute Room on 1W.

The above were observed and confirmed by the Director of Engineering and the Safety Officer.

Based on observation and interview it was determined that the facility failed to maintain exits free of all obstructions.

Findings include:

On 12/5/11 at approximately 10:20 am it was observed that beds were being stored in the elevator lobby for elevators 6 and 7 on 3E.

The above were observed and confirmed by the Director of Engineering and the Safety Officer.

Based on observation and interview it was determined that the facility failed to ensure that all decorative material is flame retardant.

Findings include:

On 12/1/11 at approximately 1:50 pm it was observed that in the area of Room 539 and continuing down the corridor, a significant amount of flammable material is affixed to the walls.

On 12/1/11 at approximately 1:59 pm it was observed that documentation was not available to show that the large poster affixed to the wall is flame retardant at Room 543.

On 12/5/11 at approximately 10:05 am it was observed that documentation was not available to show that the plastic shoe holders are flame retardant (on 3 middle) in the area open to the corridor.

On 12/5/11 at approximately 3:41 pm it was observed that black plastic was hung over the windows to the PAT call nurse office.

The above were observed and confirmed by the Director of Engineering and the Safety Officer.

Based on observation and interview it was determined that the facility failed to maintain flame retardant drapes and curtains.

Findings include:

On 12/1/11 at approximately 3:02 pm it was observed that documentation was not available to verify that the drapes in the Conference Room on 4E are flame retardant.

The above was observed and confirmed by the Director of Engineering and the Safety Officer.

Based on observation and interview it was determined that the facility failed to properly store trash and soiled linen containers that exceed 32 gallons.

Findings include:

On 12/7/11 at approximately 2:03 pm it was observed that four 44 gallon containers are being stored in the corridor at the Morgue.

On 12/12/11 at approximately 9:39 am it was observed that a trash container over 32 gallons capacity was being used in the Private Office across from Pharmacy Storage.

The above were observed and confirmed by the Director of Engineering and the Safety Officer.

Based on observation and interview it was determined that the facility failed to label oxygen shut-off valves.

Findings include:

On 11/30/11 at approximately 11:43 am it was observed that there is no labeled oxygen shut-off for Suites A & B in ER. [NFPA 99, Section 4.3.1.2.3(n)]

The above were observed and confirmed by the Director of Engineering and the Safety Officer.

Based on observation and interview it was determined that the facility failed to maintain horizontal sliding doors.

Findings include:

On 12/5/11 at approximately 2:37 pm it was observed that the horizontal sliding doors leading into Cardiac Holding on the 2nd floor are not functioning properly with respect to the breakaway function. (Section 7-2.1.4)


Based on observation and interview it was determined that the facility failed to construct ramps in accordance with the regulations.

Findings include:

On 12/7/11 at approximately 2:20 pm it was observed that the ramp leading from the exit near the Morgue does not appear to meet the requirements of the code.
(Sections 19.2.2.6, 7.2.5, and Table 7.2.5.2(b) for Existing Ramps)

The above were observed and confirmed by the Director of Engineering and the Safety Officer.

Based on observation and interview it was determined that the facility failed to comply with the electrical requirements of NFPA 70.

Findings include:

On 11/30/11 at approximately 11:45 am it was observed that an approved cover is not provided for an electrical junction box in the Electrical Room of ER. [NFPA 70, Section 370-28(b)]

On 11/30/11 at approximately 1:35 pm it was observed that an approved cover is not provided for a junction box above the ceiling at the fire barrier on the OR floor. [NFPA 70, Section 370-28(b)]

On 11/30/11 at approximately 2:09 pm it was observed that an approved cover is not provided for an electrical junction box at OR 2. [NFPA 70, Section 370-28(b)]

On 11/30/11 at approximately 2:35 pm it was observed that an approved cover is not provided for an electrical junction box above the ceiling in the storage room beside OR 11.
[NFPA 70, Section 370-28(b)]

The above were observed and confirmed by the Director of Engineering and the Safety Officer.

Based on observation and interview it was determined that the facility failed to install ABHR's in accordance with all requirements.

Findings include:

On 12/1/11 at approximately 11:27 am it was observed that an alcohol based hand rub dispenser is positioned over a light switch in the Soiled Utility Room on 6E.

The above was observed and confirmed by the Director of Engineering and the Safety Officer.