HospitalInspections.org

Based on observation the facility failed to ensure there were no penetrations to their 2 hour fire wall barrier separating the health occupancy from the business occupancy. Findings:

On 10/28/15 at 11:03 a.m., the fire wall barrier separating the hospital from the medical office building (MOB) was observed to have 3 penetrations.

At 03:49 p.m., 2 penetrations were observed in the fire wall barrier separating the medical records business occupancy area from the hospital health occupancy.

The director of construction acknowledged the penetrations to the fire wall barriers.

Based on observation it was determined the facility failed to ensure the hazardous areas were free from penetrations. Findings:

On 10/28/15 at 04:15 p.m., 4 penetrations were observed in the boiler room hazardous area.

On 10/29/15 at 12:06 p.m., the electrical room in the emergency room was observed to have 2 penetrations.

The director of construction and director of plant operations acknowledged the penetrations.

Based on observation it was determined the facility failed to ensure the means of egress had signs indicating direction of travel to exits. Findings:

On 10/28/15 at 11:13 a.m., it was observed there was no exit sign indicating direction of exit egress near the east end of the hospital's 3rd floor.

On 10/29/15 at 2:23 p.m., the stairway near the mental health department did not have directional signage indicating path of egress to exit discharge.

The director of construction and director of plant operations acknowledged the areas needing additional directional signs.


NFPA 101, 2000 Edition, Chapter 19
19.2.10.1
Means of egress shall have signs in accordance with Section 7.10.

7.10 MARKING OF MEANS OF EGRESS
7.10.1 General.
7.10.1.1 Where Required.
Means of egress shall be marked in accordance with Section 7.10 where required in Chapters 11 through 42.
7.10.1.2* Exits.
Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.
7.10.1.3 Exit Stair Door Tactile Signage.
Tactile signage shall be located at each door into an exit stair enclosure, and such signage shall read as follows: EXIT
Signage shall comply with CABO/ANSI A117.1, American National Standard for Accessible and Usable Buildings and Facilities, and shall be installed adjacent to the latch side of the door 60 in. (152 cm) above the finished floor to the centerline of the sign.
Exception: This requirement shall not apply to existing buildings, provided that the occupancy classification does not change.
7.10.1.4* Exit Access.
Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. Sign placement shall be such that no point in an exit access corridor is in excess of 100 ft (30 m) from the nearest externally illuminated sign and is not in excess of the marked rating for internally illuminated signs.
Exception: Signs in exit access corridors in existing buildings shall not be required to meet the placement distance requirements.
7.10.1.5* Floor Proximity Exit Signs.
Where floor proximity exit signs are required in Chapters 11 through 42, signs shall be placed near the floor level in addition to those signs required for doors or corridors. These signs shall be illuminated in accordance with 7.10.5. Externally illuminated signs shall be sized in accordance with 7.10.6.1. The bottom of the sign shall be not less than 6 in. (15.2 cm) but not more than 8 in. (20.3 cm) above the floor. For exit doors, the sign shall be mounted on the door or adjacent to the door with the nearest edge of the sign within 4 in. (10.2 cm) of the door frame.
7.10.1.6* Floor Proximity Egress Path Marking.
Where floor proximity egress path marking is required in Chapters 11 through 42, a listed and approved floor proximity egress path marking system that is internally illuminated shall be installed within 8 in. (20.3 cm) of the floor. The system shall provide a visible delineation of the path of travel along the designated exit access and shall be essentially continuous, except as interrupted by doorways, hallways, corridors, or other such architectural features. The system shall operate continuously or at any time the building fire alarm system is activated. The activation, duration, and continuity of operation of the system shall be in accordance with 7.9.2.
7.10.1.7* Visibility.
Every sign required in Section 7.10 shall be located and of such size, distinctive color, and design that it is readily visible and shall provide contrast with decorations, interior finish, or other signs. No decorations, furnishings, or equipment that impairs visibility of a sign shall be permitted. No brightly illuminated sign (for other than exit purposes), display, or object in or near the line of vision of the required exit sign that could detract attention from the exit sign shall be permitted.
7.10.2* Directional Signs.
A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent.
7.10.3* Sign Legend.
Signs required by 7.10.1 and 7.10.2 shall have the word EXIT or other appropriate wording in plainly legible letters.
7.10.4* Power Source.
Where emergency lighting facilities are required by the applicable provisions of Chapters 11 through 42 for individual occupancies, the signs, other than approved self-luminous signs, shall be illuminated by the emergency lighting facilities. The level of illumination of the signs shall be in accordance with 7.10.6.3 or 7.10.7 for the required emergency lighting duration as specified in 7.9.2.1. However, the level of illumination shall be permitted to decline to 60 percent at the end of the emergency lighting duration.

7.10.5 Illumination of Signs.
7.10.5.1* General.
Every sign required by 7.10.1.2 or 7.10.1.4, other than where operations or processes require low lighting levels, shall be suitably illuminated by a reliable light source. Externally and internally illuminated signs shall be legible in both the normal and emergency lighting mode.
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.
Exception*: Illumination for signs shall be permitted to flash on and off upon activation of the fire alarm system.
7.10.6 Externally Illuminated Signs.
7.10.6.1* Size of Signs.
Externally illuminated signs required by 7.10.1 and 7.10.2, other than approved existing signs, shall have the word EXIT or other appropriate wording in plainly legible letters not less than 6 in. (15.2 cm) high with the principal strokes of letters not less than 3/4 in. (1.9 cm) wide. The word EXIT shall have letters of a width not less than 2 in. (5 cm), except the letter I, and the minimum spacing between letters shall be not less than 3/8 in. (1 cm). Signs larger than the minimum established in this paragraph shall have letter widths, strokes, and spacing in proportion to their height.
Exception No. 1: This requirement shall not apply to existing signs having the required wording in plainly legible letters not less than 4 in. (10.2 cm) high.
Exception No. 2: This requirement shall not apply to marking required by 7.10.1.3 and 7.10.1.5.
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. (1 cm) 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 ft (12.2 m). A directional indicator larger than the minimum established in this paragraph shall be proportionately increased in height, width and stroke. The directional indicator shall be located at the end of the sign for the direction indicated.
Exception: This requirement shall not apply to approved existing signs.
Figure 7.10.6.2 Chevron-type indicator.

7.10.6.3* Level of Illumination.
Externally illuminated signs shall be illuminated by not less than 5 ft-candles (54 lux) at the illuminated surface and shall have a contrast ratio of not less than 0.5.
7.10.7 Internally Illuminated Signs.
7.10.7.1 Listing.
Internally illuminated signs, other than approved existing signs, or existing signs having the required wording in legible letters not less than 4 in. (10.2 cm) high, shall be listed in accordance with UL 924, Standard for Safety Emergency Lighting and Power Equipment.
Exception: This requirement shall not apply to signs that are in accordance with 7.10.1.3 and 7.10.1.5.
7.10.7.2* Photoluminescent Signs.
The face of a photoluminescent sign shall be continually illuminated while the building is occupied. The illumination levels on the face of the photoluminescent sign shall be in accordance with its listing. The charging illumination shall be a reliable light source as determined by the authority having jurisdiction. The charging light source shall be of a type specified in the product markings.

7.10.8 Special Signs.
7.10.8.1* No Exit.
Any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads as follows:
NO
EXIT

Such sign shall have the word NO in letters 2 in. (5 cm) high with a stroke width of 3/8 in. (1 cm) and the word EXIT in letters 1 in. (2.5 cm) high, with the word EXIT below the word NO.
Exception: This requirement shall not apply to approved existing signs.
7.10.8.2 Elevator Signs.
Elevators that are a part of a means of egress (see 7.2.13.1) shall have the following signs, with minimum letter height of 5/8 in. (1.6 cm), in every elevator lobby:
(1) * Signs that indicate that the elevator can be used for egress, including any restrictions on use
(2) * Signs that indicate the operational status of elevators
7.10.9 Testing and Maintenance.
7.10.9.1 Inspection.
Exit signs shall be visually inspected for operation of the illumination sources at intervals not to exceed 30 days.

Based on observation and staff interview it was determined that the facility failed to maintain all egress pathways to be maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. Findings:
On 10/28/15 at 10:47 a.m., approximately 12 steel wire frame multi-level wheeled stock bins were observed to be stored within the semi-restricted surgical corridor egress pathway.
At 10:47 a.m., the director of construction, the director of plant operations acknowledged the steel frame wheeled storage bins stored in the egress pathway of the surgical suite.
NFPA 101, 2000 Edition, Chapter 7
7.1.10.1 requires the 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.

Based on observation and interview with staff the facility failed to ensure: proper airflow and air quality was being monitored and documented, and the facility failed to provide and ensure heating, ventilating, and air-conditioning systems complied with the manufacturer's specifications and recommendations. Findings:

On 10/28/15 at 10:28 a.m., the operating rooms airfilter quality logs were not available when requested. Airflow manometer readings were not being recorded or documented. The airflow quality of the life of the final filters were not being documented or maintained.

At 10:30 a.m., the director of plant operations was interviewed. The director of plant operations was asked for the documentation of airflow quality for each of the operating rooms. He said that they just started documenting the changes air filters.

At 10:40 a.m., one sterilizer was observed to not be vented. This sterilizer was located in the semi-restricted corridor.

The director of construction acknowledged the non-vented sterilizer in the surgical suite.

On 10/28/15 at 5:15 p.m., the mechanical vents in two soiled linen rooms located within the surgical suite were observed to not be working.

AIA Health Care Guidelines & ANI/ASHE Standard 170-208 Ventilation of Health Care Facilities requires the manometers to be used to determine the life of the filter. A 1.1 of ANI/ASHE Annex A states that filters shall be replaced on air pressure drop in accordance with the manometer readings.


NFPA 101, 2000 Edition, Chapter 9
9.2 HEATING, VENTILATING, AND AIR CONDITIONING
9.2.1 Air Conditioning, Heating, Ventilating Ductwork, and Related Equipment.
Air conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, as applicable, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.
9.2.2 Ventilating or Heat-Producing Equipment.
Ventilating or heat-producing equipment shall be in accordance with NFPA 91, Standard for Exhaust Systems for Air Conveying of Vapors, Gases, Mists, and Noncombustible Particulate Solids; NFPA 211, Standard for Chimneys, Fireplaces, Vents, and Solid Fuel-Burning Appliances; NFPA 31, Standard for the Installation of Oil-Burning Equipment; NFPA 54, National Fuel Gas Code; or NFPA 70, National Electrical Code, as applicable, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

Based on observation and staff interview it was determined that the facility failed to maintain all egress pathways to be maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. Findings:
On 10/28/15 at 10:47 a.m., approximately 12 steel wire frame multi-level wheeled stock bins were observed to be stored within the semi-restricted surgical corridor egress pathway.
At 10:47 a.m., the director of construction, the director of plant operations acknowledged the steel frame wheeled storage bins stored in the egress pathway of the surgical suite.
At 11:48 a.m., the corridor of the surgical suite was observed to still be filled with steel frame wheeled storage bins filled with assorted sterile surgical supplies within the semi-restricted surgical corridor egress pathway.

NFPA 101, 2000 Edition, Chapter 7
7.1.10.1 requires the 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.

Based on observation, record review and staff interview it was determined the facility failed to ensure two operating rooms were equipped with smoke evacuation as required. Findings:

On 10/28/15 at 11:52 a.m., it was observed that the ventilating systems for the facility's operating rooms numbered #1 & #2 were not equipped with automatic smoke evacuation mechanical venting equipment.

On 10/29/1515 at 10:34 a.m., the building manager was interviewed. He was asked if the facility has smoke evacuation equipment installed serving each of the operating rooms. He said there is no smoke evacuation in operating room #1 and #2.

NFPA 99, 1999 Edition, Chapter 5 Environmental Systems
5-4.1.2
Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically vent smoke and products of combustion.

Based on observation and staff interview it was determined that the facility failed to ensure their remote annunciator for the generator was installed in a supervised area. Findings:

On 10/28/15 at 12:01 p.m., it was observed the generator remote annunciator was installed in the boiler room.

At 12:02 p.m., the director of construction was interviewed. The director of construction was asked where the remote annunciator to their generator was located. He said it is installed in the boiler room and it is not supervised at all times.


NFPA 110, 2000 Edition
Chapter 3 Emergency Power Supply (EPS): Energy Sources, Converters, and Accessories
3-5.6 Remote Controls and Alarms.
3-5.6.1
A remote, common audible alarm powered by the storage battery shall be provided as specified in 3-5.5.2(d). This remote alarm shall be located outside of the EPS service room at a work site readily observable by personnel.

Based on observation it was determined the facility failed to ensure alcohol based hand rub dispensers were not installed over an ignition source. Findings:

On 10/28/15 at 05:10 p.m., two alcohol based hand rub (ABHR) were observed to be installed over two separate light switches in the PACU.

The director of construction and the director of plant operations acknowledged the two ABHR's installed over light switches.

NFPA 101, 18.3.2.7 & Code of Federal Regulations (CFR)- 403.744, 418.100, 460.72, 482.41, 483.70, 483.623, 485.623:
Where Alcohol Based Hand Rub (ABHR) dispensers are installed in a corridor:
* The corridor is at least 6 feet wide
* The maximum individual fluid dispenser capacity shall be 1.2 liters (2 liters in suites of rooms)
* The dispensers have a minimum spacing of 4 ft from each other
* Not more than 10 gallons are used in a single smoke compartment outside a storage cabinet.
* Dispensers are not installed over or adjacent to an ignition source.
* If the floor is carpeted, the building is fully sprinklered.

Based on observation the facility failed to ensure there were no penetrations to their 2 hour fire wall barrier separating the health occupancy from the business occupancy. Findings:

On 10/28/15 at 11:03 a.m., the fire wall barrier separating the hospital from the medical office building (MOB) was observed to have 3 penetrations.

At 03:49 p.m., 2 penetrations were observed in the fire wall barrier separating the medical records business occupancy area from the hospital health occupancy.

The director of construction acknowledged the penetrations to the fire wall barriers.

Based on observation it was determined the facility failed to ensure the hazardous areas were free from penetrations. Findings:

On 10/28/15 at 04:15 p.m., 4 penetrations were observed in the boiler room hazardous area.

On 10/29/15 at 12:06 p.m., the electrical room in the emergency room was observed to have 2 penetrations.

The director of construction and director of plant operations acknowledged the penetrations.

Based on observation it was determined the facility failed to ensure the means of egress had signs indicating direction of travel to exits. Findings:

On 10/28/15 at 11:13 a.m., it was observed there was no exit sign indicating direction of exit egress near the east end of the hospital's 3rd floor.

On 10/29/15 at 2:23 p.m., the stairway near the mental health department did not have directional signage indicating path of egress to exit discharge.

The director of construction and director of plant operations acknowledged the areas needing additional directional signs.


NFPA 101, 2000 Edition, Chapter 19
19.2.10.1
Means of egress shall have signs in accordance with Section 7.10.

7.10 MARKING OF MEANS OF EGRESS
7.10.1 General.
7.10.1.1 Where Required.
Means of egress shall be marked in accordance with Section 7.10 where required in Chapters 11 through 42.
7.10.1.2* Exits.
Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.
7.10.1.3 Exit Stair Door Tactile Signage.
Tactile signage shall be located at each door into an exit stair enclosure, and such signage shall read as follows: EXIT
Signage shall comply with CABO/ANSI A117.1, American National Standard for Accessible and Usable Buildings and Facilities, and shall be installed adjacent to the latch side of the door 60 in. (152 cm) above the finished floor to the centerline of the sign.
Exception: This requirement shall not apply to existing buildings, provided that the occupancy classification does not change.
7.10.1.4* Exit Access.
Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. Sign placement shall be such that no point in an exit access corridor is in excess of 100 ft (30 m) from the nearest externally illuminated sign and is not in excess of the marked rating for internally illuminated signs.
Exception: Signs in exit access corridors in existing buildings shall not be required to meet the placement distance requirements.
7.10.1.5* Floor Proximity Exit Signs.
Where floor proximity exit signs are required in Chapters 11 through 42, signs shall be placed near the floor level in addition to those signs required for doors or corridors. These signs shall be illuminated in accordance with 7.10.5. Externally illuminated signs shall be sized in accordance with 7.10.6.1. The bottom of the sign shall be not less than 6 in. (15.2 cm) but not more than 8 in. (20.3 cm) above the floor. For exit doors, the sign shall be mounted on the door or adjacent to the door with the nearest edge of the sign within 4 in. (10.2 cm) of the door frame.
7.10.1.6* Floor Proximity Egress Path Marking.
Where floor proximity egress path marking is required in Chapters 11 through 42, a listed and approved floor proximity egress path marking system that is internally illuminated shall be installed within 8 in. (20.3 cm) of the floor. The system shall provide a visible delineation of the path of travel along the designated exit access and shall be essentially continuous, except as interrupted by doorways, hallways, corridors, or other such architectural features. The system shall operate continuously or at any time the building fire alarm system is activated. The activation, duration, and continuity of operation of the system shall be in accordance with 7.9.2.
7.10.1.7* Visibility.
Every sign required in Section 7.10 shall be located and of such size, distinctive color, and design that it is readily visible and shall provide contrast with decorations, interior finish, or other signs. No decorations, furnishings, or equipment that impairs visibility of a sign shall be permitted. No brightly illuminated sign (for other than exit purposes), display, or object in or near the line of vision of the required exit sign that could detract attention from the exit sign shall be permitted.
7.10.2* Directional Signs.
A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent.
7.10.3* Sign Legend.
Signs required by 7.10.1 and 7.10.2 shall have the word EXIT or other appropriate wording in plainly legible letters.
7.10.4* Power Source.
Where emergency lighting facilities are required by the applicable provisions of Chapters 11 through 42 for individual occupancies, the signs, other than approved self-luminous signs, shall be illuminated by the emergency lighting facilities. The level of illumination of the signs shall be in accordance with 7.10.6.3 or 7.10.7 for the required emergency lighting duration as specified in 7.9.2.1. However, the level of illumination shall be permitted to decline to 60 percent at the end of the emergency lighting duration.

7.10.5 Illumination of Signs.
7.10.5.1* General.
Every sign required by 7.10.1.2 or 7.10.1.4, other than where operations or processes require low lighting levels, shall be suitably illuminated by a reliable light source. Externally and internally illuminated signs shall be legible in both the normal and emergency lighting mode.
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.
Exception*: Illumination for signs shall be permitted to flash on and off upon activation of the fire alarm system.
7.10.6 Externally Illuminated Signs.
7.10.6.1* Size of Signs.
Externally illuminated signs required by 7.10.1 and 7.10.2, other than approved existing signs, shall have the word EXIT or other appropriate wording in plainly legible letters not less than 6 in. (15.2 cm) high with the principal strokes of letters not less than 3/4 in. (1.9 cm) wide. The word EXIT shall have letters of a width not less than 2 in. (5 cm), except the letter I, and the minimum spacing between letters shall be not less than 3/8 in. (1 cm). Signs larger than the minimum established in this paragraph shall have letter widths, strokes, and spacing in proportion to their height.
Exception No. 1: This requirement shall not apply to existing signs having the required wording in plainly legible letters not less than 4 in. (10.2 cm) high.
Exception No. 2: This requirement shall not apply to marking required by 7.10.1.3 and 7.10.1.5.
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. (1 cm) 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 ft (12.2 m). A directional indicator larger than the minimum established in this paragraph shall be proportionately increased in height, width and stroke. The directional indicator shall be located at the end of the sign for the direction indicated.
Exception: This requirement shall not apply to approved existing signs.
Figure 7.10.6.2 Chevron-type indicator.

7.10.6.3* Level of Illumination.
Externally illuminated signs shall be illuminated by not less than 5 ft-candles (54 lux) at the illuminated surface and shall have a contrast ratio of not less than 0.5.
7.10.7 Internally Illuminated Signs.
7.10.7.1 Listing.
Internally illuminated signs, other than approved existing signs, or existing signs having the required wording in legible letters not less than 4 in. (10.2 cm) high, shall be listed in accordance with UL 924, Standard for Safety Emergency Lighting and Power Equipment.
Exception: This requirement shall not apply to signs that are in accordance with 7.10.1.3 and 7.10.1.5.
7.10.7.2* Photoluminescent Signs.
The face of a photoluminescent sign shall be continually illuminated while the building is occupied. The illumination levels on the face of the photoluminescent sign shall be in accordance with its listing. The charging illumination shall be a reliable light source as determined by the authority having jurisdiction. The charging light source shall be of a type specified in the product markings.

7.10.8 Special Signs.
7.10.8.1* No Exit.
Any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads as follows:
NO
EXIT

Such sign shall have the word NO in letters 2 in. (5 cm) high with a stroke width of 3/8 in. (1 cm) and the word EXIT in letters 1 in. (2.5 cm) high, with the word EXIT below the word NO.
Exception: This requirement shall not apply to approved existing signs.
7.10.8.2 Elevator Signs.
Elevators that are a part of a means of egress (see 7.2.13.1) shall have the following signs, with minimum letter height of 5/8 in. (1.6 cm), in every elevator lobby:
(1) * Signs that indicate that the elevator can be used for egress, including any restrictions on use
(2) * Signs that indicate the operational status of elevators
7.10.9 Testing and Maintenance.
7.10.9.1 Inspection.
Exit signs shall be visually inspected for operation of the illumination sources at intervals not to exceed 30 days.

Based on observation and staff interview it was determined that the facility failed to maintain all egress pathways to be maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. Findings:
On 10/28/15 at 10:47 a.m., approximately 12 steel wire frame multi-level wheeled stock bins were observed to be stored within the semi-restricted surgical corridor egress pathway.
At 10:47 a.m., the director of construction, the director of plant operations acknowledged the steel frame wheeled storage bins stored in the egress pathway of the surgical suite.
NFPA 101, 2000 Edition, Chapter 7
7.1.10.1 requires the 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.

Based on observation and interview with staff the facility failed to ensure: proper airflow and air quality was being monitored and documented, and the facility failed to provide and ensure heating, ventilating, and air-conditioning systems complied with the manufacturer's specifications and recommendations. Findings:

On 10/28/15 at 10:28 a.m., the operating rooms airfilter quality logs were not available when requested. Airflow manometer readings were not being recorded or documented. The airflow quality of the life of the final filters were not being documented or maintained.

At 10:30 a.m., the director of plant operations was interviewed. The director of plant operations was asked for the documentation of airflow quality for each of the operating rooms. He said that they just started documenting the changes air filters.

At 10:40 a.m., one sterilizer was observed to not be vented. This sterilizer was located in the semi-restricted corridor.

The director of construction acknowledged the non-vented sterilizer in the surgical suite.

On 10/28/15 at 5:15 p.m., the mechanical vents in two soiled linen rooms located within the surgical suite were observed to not be working.

AIA Health Care Guidelines & ANI/ASHE Standard 170-208 Ventilation of Health Care Facilities requires the manometers to be used to determine the life of the filter. A 1.1 of ANI/ASHE Annex A states that filters shall be replaced on air pressure drop in accordance with the manometer readings.


NFPA 101, 2000 Edition, Chapter 9
9.2 HEATING, VENTILATING, AND AIR CONDITIONING
9.2.1 Air Conditioning, Heating, Ventilating Ductwork, and Related Equipment.
Air conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, as applicable, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.
9.2.2 Ventilating or Heat-Producing Equipment.
Ventilating or heat-producing equipment shall be in accordance with NFPA 91, Standard for Exhaust Systems for Air Conveying of Vapors, Gases, Mists, and Noncombustible Particulate Solids; NFPA 211, Standard for Chimneys, Fireplaces, Vents, and Solid Fuel-Burning Appliances; NFPA 31, Standard for the Installation of Oil-Burning Equipment; NFPA 54, National Fuel Gas Code; or NFPA 70, National Electrical Code, as applicable, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

Based on observation and staff interview it was determined that the facility failed to maintain all egress pathways to be maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. Findings:
On 10/28/15 at 10:47 a.m., approximately 12 steel wire frame multi-level wheeled stock bins were observed to be stored within the semi-restricted surgical corridor egress pathway.
At 10:47 a.m., the director of construction, the director of plant operations acknowledged the steel frame wheeled storage bins stored in the egress pathway of the surgical suite.
At 11:48 a.m., the corridor of the surgical suite was observed to still be filled with steel frame wheeled storage bins filled with assorted sterile surgical supplies within the semi-restricted surgical corridor egress pathway.

NFPA 101, 2000 Edition, Chapter 7
7.1.10.1 requires the 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.

Based on observation, record review and staff interview it was determined the facility failed to ensure two operating rooms were equipped with smoke evacuation as required. Findings:

On 10/28/15 at 11:52 a.m., it was observed that the ventilating systems for the facility's operating rooms numbered #1 & #2 were not equipped with automatic smoke evacuation mechanical venting equipment.

On 10/29/1515 at 10:34 a.m., the building manager was interviewed. He was asked if the facility has smoke evacuation equipment installed serving each of the operating rooms. He said there is no smoke evacuation in operating room #1 and #2.

NFPA 99, 1999 Edition, Chapter 5 Environmental Systems
5-4.1.2
Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically vent smoke and products of combustion.

Based on observation and staff interview it was determined that the facility failed to ensure their remote annunciator for the generator was installed in a supervised area. Findings:

On 10/28/15 at 12:01 p.m., it was observed the generator remote annunciator was installed in the boiler room.

At 12:02 p.m., the director of construction was interviewed. The director of construction was asked where the remote annunciator to their generator was located. He said it is installed in the boiler room and it is not supervised at all times.


NFPA 110, 2000 Edition
Chapter 3 Emergency Power Supply (EPS): Energy Sources, Converters, and Accessories
3-5.6 Remote Controls and Alarms.
3-5.6.1
A remote, common audible alarm powered by the storage battery shall be provided as specified in 3-5.5.2(d). This remote alarm shall be located outside of the EPS service room at a work site readily observable by personnel.