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Based on observation and interview, the facility failed to provide a separation from 1 of 1 nonconforming buildings by a fire barrier having at least a two hour fire resistance rating. This deficient practice affects all occupants of the hospital.

Findings include:

Based on observation during a tour of the facility with the Manager Support Services and the Safety Coordinator on 12/18/13 at 2:40 p.m., the hospital, a two story building of Type II (111) construction was connected to a two story medical office building of Type V (000) construction and lacked a fire barrier separation having a least a two hour fire resistance rating. Based on interview at the time of observation, the Manager Support Services confirmed the lack of a two fire barrier separation and indicated the hospital had a variance when the hospital was constructed and installed additional sprinklers where the two hour fire barrier would be.

Based on observation and interview, the facility failed to ensure 1 of 1 second floor work rooms was separated from the corridor by a partition capable of resisting the passage of smoke as required in a sprinklered building, or met an Exception. LSC 18-3.6.1, Exception # 6, Spaces other than patient sleeping rooms, treatment rooms, and hazardous areas may be open to the corridor and unlimited in area provided: (a) The space and corridors which the space opens onto in the same smoke compartment are protected by an electrically supervised automatic smoke detection system, and (b) Each space is protected by an automatic sprinklers, and (c) The space is arranged not to obstruct access to required exits. This deficient practice could affect 11 patients in the medical/surgery area.

Findings include:

Based on an observation with the Safety Coordinator on 12/19/13 at 10:20 a.m., the second floor work area around the corner from the medical/surgery nurses' station lacked a corridor door. Furthermore, Exception # 6, requirement (a) of the LSC Section 18-3.6.1 was not met in that the second floor work area was not protected by an electrically supervised automatic smoke detection system. This was acknowledged by the Safety Coordinator at the time of observation.

Based on observation and interview, the facility failed to ensure the corridor doors to 4 of 4 CCU rooms and 2 of 2 operating rooms positively latched into the door frame. This deficient practice affects 4 patients in CCU and 2 patients in the operating rooms.

Findings includes:

Based on observation with the Safety Coordinator on 12/19/13 between 9:57 a.m. and 11:57 a.m., the corridor door to the patient rooms in CCU and the two operating room corridor doors were designed with double corridor doors. One door was equipped with a manual latching device that would latch into the door frame and the remaining door was designed to latch into the stationary door. Each door could not latch automatically, and independent of the other door, into the door frame. This was acknowledged by the Safety Coordinator at the time of observations.

Based on observation and interview, the facility failed to maintain the vertical opening protection of 2 of 3 exit stairwells. LSC 8.2.5.2 requires enclosure of vertical openings including stairwells with fire barrier walls with a fire resistance rating of at least one hour. This deficient practice could affect any patient, visitor or staff using the stairwells.

Findings include:

Based on observation on 12/19/13 with the Manager Support Services during the tour from 9:30 a.m. to 11:00 a.m., the following was noted:
1. The center first floor and Terrace level stairwell doors lacked a door label indicating a fire resistance rating.
2. The south second floor stairwell door lacked a door label indicating a fire resistance rating.
Based on interview during the observations, the Manager Support Services acknowledged the stairwell doors were missing fire door labels and indicated documentation showing the stairwell exit doors provided at least a one hour fire resistance rating was not available.

Based on observation and interview; the facility failed ensure 2 of 3 vertical exit egress towers provided a means of egress which discharged to the exterior or the public way in accordance with requirements of NFPA 101, 2000 edition, section 7.7. 7.7.1 requires exits to discharge directly to a public way or exterior exit discharge. 7.7.2 allows no more than 50 percent of the exits or egress capacity to discharge into areas on the level of exit discharge. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on observation and interview with the Manager Support Services on 12/19/13 from 9:30 a.m. to 11:00 a.m., the north and center exit stairs did not discharge directly to the exterior or through an approved exit passageway at the first floor level.

Based on observation and interview the facility failed to maintain the vertical opening protection of 2 of 3 exit stairwells. LSC 8.2.5.2 requires enclosure of vertical openings including stairwells with fire barrier walls with a fire resistance rating of at least one hour. This deficient practice could affect any patient, visitor or staff using the stairwells.

Findings include:

Based on observation on 12/19/13 with the Manager Support Services during the tour from 9:30 a.m. to 11:00 a.m., the following was noted:
1. The center first floor and Terrace level stairwell doors lacked a door label indicating a fire resistance rating.
2. The south second floor stairwell door lacked a door label indicating a fire resistance rating.
Based on interview during the observations, the Manager Support Services acknowledged the stairwell doors were missing fire door labels and indicated documentation showing the stairwell exit doors provided at least a one hour fire resistance rating was not available.

1. Based on observation and interview, the facility failed to ensure a complete automatic sprinkler system was provided for 2 of 2 elevator equipment rooms in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems to provide complete coverage for all portions of the building. NFPA 13, 5-13.6.2 states automatic sprinklers in elevator machine rooms shall be ordinary or intermediate temperature rating. ASME/ANSI A17.1 permits sprinklers in elevator machine rooms when there is a means for disconnecting the main line power supply to the affected elevator automatically upon, or prior to, the application of water from the sprinkler located in the elevator machine room. The elevator equipment rooms were located in the basement and could affect any number of staff.

Findings include:

Based on interview with the Manager Support Services on 12/18/13 at 2:00 p.m., it was acknowledged the basement service elevator and main elevator machine rooms lacked sprinkler coverage. Based on observation during a tour of the facility on 12/18/13 from 2:15 p.m. to 3:45 p.m. with the Manager Support Services and Safety Coordinator, it was confirmed both elevator machine rooms lacked sprinkler coverage.


22524

2. Based on observation and interview, the facility failed to ensure complete coverage was provided for 3 of 3 second floor housekeeping closets in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, to provide complete coverage for all portions of the building. This deficient practice was not in a patient area but could affect facility staff.

Findings include:

Based on an observation with the Safety Coordinator on 12/19/13 from 9:45 a.m. to 10:22 a.m., all three second floor housekeeping closets lack sprinkler coverage. This was acknowledged by the Safety Coordinator at the time of observations.

Based on record review and interview, the facility failed to ensure 1 of 1 kitchen range hood's fire extinguishing equipment was inspected and approved every 6 months by properly trained and qualified persons. LSC 9.2.3 refers to NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. NFPA 96, in 8-2 requires the inspection and servicing of the fire extinguishing system and listed exhaust hoods containing a constant or fire actuated water system shall be made at least every 6 months by properly trained and qualified persons. NFPA 96, 8-2.1 requires all actuation components, including remote manual pull stations, mechanical or electrical devices, detectors, actuators, and fire actuated dampers shall be checked for proper operation during the inspection in accordance with the manufacturer's listed procedures. This deficient practice affects occupants of the kitchen.

Findings include:

Based on review of the kitchen range hood suppression system testing documentation with the Manager Support Services and the Safety Coordinator during record review from 11:45 a.m. to 2:15 p.m. on 12/18/13, a range hood fire suppression equipment inspection was last performed by the facility's vendor on 05/06/13. Based on interview at the time of record review, the Manager Support Services acknowledged the 05/06/13 inspection was the most recent kitchen range hood fire suppression equipment inspection.

1. Based on record review and interview, the facility failed to provide the complete documentation for testing 1 of 1 emergency generators providing power to the emergency power system. LSC 7.9.2.3 and NFPA 99, Health Care Facilities, 3-4.1.1.8 requires the generator set(s) shall have sufficient capacity to pick up the load and meet the minimum frequency and voltage stability requirements of the emergency system within 10 seconds after loss of normal power. This deficient practice affects all occupants

Findings include:

Based on review of the "Generator Weekly Load Test" log with the Manager Support Services on 12/18/13 at 1:30 p.m., the weekly load test log indicated the transfer of power from the main source to the emergency generator but lacked documentation of the length of time for generator to start and transfer power. Based on interview at the time of record review, the Manager Support Services acknowledged the length of time for the generator to start and transfer power was generally 10 seconds or less but it was not documented.

2. Based on observation and interview, the facility failed to ensure 1 of 1 emergency generators was provided with an alarm annunciator in a location readily observed by operating personnel at a regular work station such as a nurses' station. NFPA 99, Health Care Facilities, 3-4.1.1.15 requires a remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station. The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate:
1. When the emergency or auxiliary power source is operating to supply power to load.
2. When the battery charger is malfunctioning.
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate:
1. Low lubricating oil pressure.
2. Low water temperature.
3. Excessive water temperature.
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply.
5. Overcrank (failed to start).
6. Overspeed.
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur but need not display these conditions individually. This deficient practice could affect all the patients as well as visitors and staff.

Findings include:

Based on observation on 12/19/13 during the tour from 9:30 a.m. to 11:00 a.m. with the Manager Support Services, a remote alarm annunciator for the generator was provided in the maintenance shop, however, based on interview at the time of observation, the Manager Support Services stated the maintenance shop is not staffed from 11:30 p.m. to 4:00 a.m. but has a security office checking the area on an hourly basis.

Based on observation and interview, the facility failed to ensure 1 of 1 flexible cords was not used as a substitute for fixed wiring to provide power for medical equipment or equipment with a high current draw. NFPA 70, National Electrical Code, 1999 Edition, Article 400-8 requires, unless specifically permitted, flexible cords and cables shall not be used as a substitute for fixed wiring of a structure. This deficient practice was not in a patient care area but could affect therapy staff.

Findings include:

Based on observation and interview with the Safety Coordinator on 12/19/13 at 10:35 a.m., the Safety Coordinator acknowledged a refrigerator was supplied electricity by an extension cord power strip in the therapy department storage room.

Based on observation and interview, the facility failed to provide a separation from 1 of 1 nonconforming buildings by a fire barrier having at least a two hour fire resistance rating. This deficient practice affects all occupants of the hospital.

Findings include:

Based on observation during a tour of the facility with the Manager Support Services and the Safety Coordinator on 12/18/13 at 2:40 p.m., the hospital, a two story building of Type II (111) construction was connected to a two story medical office building of Type V (000) construction and lacked a fire barrier separation having a least a two hour fire resistance rating. Based on interview at the time of observation, the Manager Support Services confirmed the lack of a two fire barrier separation and indicated the hospital had a variance when the hospital was constructed and installed additional sprinklers where the two hour fire barrier would be.

Based on observation and interview, the facility failed to ensure 1 of 1 second floor work rooms was separated from the corridor by a partition capable of resisting the passage of smoke as required in a sprinklered building, or met an Exception. LSC 18-3.6.1, Exception # 6, Spaces other than patient sleeping rooms, treatment rooms, and hazardous areas may be open to the corridor and unlimited in area provided: (a) The space and corridors which the space opens onto in the same smoke compartment are protected by an electrically supervised automatic smoke detection system, and (b) Each space is protected by an automatic sprinklers, and (c) The space is arranged not to obstruct access to required exits. This deficient practice could affect 11 patients in the medical/surgery area.

Findings include:

Based on an observation with the Safety Coordinator on 12/19/13 at 10:20 a.m., the second floor work area around the corner from the medical/surgery nurses' station lacked a corridor door. Furthermore, Exception # 6, requirement (a) of the LSC Section 18-3.6.1 was not met in that the second floor work area was not protected by an electrically supervised automatic smoke detection system. This was acknowledged by the Safety Coordinator at the time of observation.

Based on observation and interview, the facility failed to ensure the corridor doors to 4 of 4 CCU rooms and 2 of 2 operating rooms positively latched into the door frame. This deficient practice affects 4 patients in CCU and 2 patients in the operating rooms.

Findings includes:

Based on observation with the Safety Coordinator on 12/19/13 between 9:57 a.m. and 11:57 a.m., the corridor door to the patient rooms in CCU and the two operating room corridor doors were designed with double corridor doors. One door was equipped with a manual latching device that would latch into the door frame and the remaining door was designed to latch into the stationary door. Each door could not latch automatically, and independent of the other door, into the door frame. This was acknowledged by the Safety Coordinator at the time of observations.

Based on observation and interview, the facility failed to maintain the vertical opening protection of 2 of 3 exit stairwells. LSC 8.2.5.2 requires enclosure of vertical openings including stairwells with fire barrier walls with a fire resistance rating of at least one hour. This deficient practice could affect any patient, visitor or staff using the stairwells.

Findings include:

Based on observation on 12/19/13 with the Manager Support Services during the tour from 9:30 a.m. to 11:00 a.m., the following was noted:
1. The center first floor and Terrace level stairwell doors lacked a door label indicating a fire resistance rating.
2. The south second floor stairwell door lacked a door label indicating a fire resistance rating.
Based on interview during the observations, the Manager Support Services acknowledged the stairwell doors were missing fire door labels and indicated documentation showing the stairwell exit doors provided at least a one hour fire resistance rating was not available.

Based on observation and interview; the facility failed ensure 2 of 3 vertical exit egress towers provided a means of egress which discharged to the exterior or the public way in accordance with requirements of NFPA 101, 2000 edition, section 7.7. 7.7.1 requires exits to discharge directly to a public way or exterior exit discharge. 7.7.2 allows no more than 50 percent of the exits or egress capacity to discharge into areas on the level of exit discharge. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on observation and interview with the Manager Support Services on 12/19/13 from 9:30 a.m. to 11:00 a.m., the north and center exit stairs did not discharge directly to the exterior or through an approved exit passageway at the first floor level.

Based on observation and interview the facility failed to maintain the vertical opening protection of 2 of 3 exit stairwells. LSC 8.2.5.2 requires enclosure of vertical openings including stairwells with fire barrier walls with a fire resistance rating of at least one hour. This deficient practice could affect any patient, visitor or staff using the stairwells.

Findings include:

Based on observation on 12/19/13 with the Manager Support Services during the tour from 9:30 a.m. to 11:00 a.m., the following was noted:
1. The center first floor and Terrace level stairwell doors lacked a door label indicating a fire resistance rating.
2. The south second floor stairwell door lacked a door label indicating a fire resistance rating.
Based on interview during the observations, the Manager Support Services acknowledged the stairwell doors were missing fire door labels and indicated documentation showing the stairwell exit doors provided at least a one hour fire resistance rating was not available.

1. Based on observation and interview, the facility failed to ensure a complete automatic sprinkler system was provided for 2 of 2 elevator equipment rooms in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems to provide complete coverage for all portions of the building. NFPA 13, 5-13.6.2 states automatic sprinklers in elevator machine rooms shall be ordinary or intermediate temperature rating. ASME/ANSI A17.1 permits sprinklers in elevator machine rooms when there is a means for disconnecting the main line power supply to the affected elevator automatically upon, or prior to, the application of water from the sprinkler located in the elevator machine room. The elevator equipment rooms were located in the basement and could affect any number of staff.

Findings include:

Based on interview with the Manager Support Services on 12/18/13 at 2:00 p.m., it was acknowledged the basement service elevator and main elevator machine rooms lacked sprinkler coverage. Based on observation during a tour of the facility on 12/18/13 from 2:15 p.m. to 3:45 p.m. with the Manager Support Services and Safety Coordinator, it was confirmed both elevator machine rooms lacked sprinkler coverage.


22524

2. Based on observation and interview, the facility failed to ensure complete coverage was provided for 3 of 3 second floor housekeeping closets in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, to provide complete coverage for all portions of the building. This deficient practice was not in a patient area but could affect facility staff.

Findings include:

Based on an observation with the Safety Coordinator on 12/19/13 from 9:45 a.m. to 10:22 a.m., all three second floor housekeeping closets lack sprinkler coverage. This was acknowledged by the Safety Coordinator at the time of observations.

Based on record review and interview, the facility failed to ensure 1 of 1 kitchen range hood's fire extinguishing equipment was inspected and approved every 6 months by properly trained and qualified persons. LSC 9.2.3 refers to NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. NFPA 96, in 8-2 requires the inspection and servicing of the fire extinguishing system and listed exhaust hoods containing a constant or fire actuated water system shall be made at least every 6 months by properly trained and qualified persons. NFPA 96, 8-2.1 requires all actuation components, including remote manual pull stations, mechanical or electrical devices, detectors, actuators, and fire actuated dampers shall be checked for proper operation during the inspection in accordance with the manufacturer's listed procedures. This deficient practice affects occupants of the kitchen.

Findings include:

Based on review of the kitchen range hood suppression system testing documentation with the Manager Support Services and the Safety Coordinator during record review from 11:45 a.m. to 2:15 p.m. on 12/18/13, a range hood fire suppression equipment inspection was last performed by the facility's vendor on 05/06/13. Based on interview at the time of record review, the Manager Support Services acknowledged the 05/06/13 inspection was the most recent kitchen range hood fire suppression equipment inspection.

1. Based on record review and interview, the facility failed to provide the complete documentation for testing 1 of 1 emergency generators providing power to the emergency power system. LSC 7.9.2.3 and NFPA 99, Health Care Facilities, 3-4.1.1.8 requires the generator set(s) shall have sufficient capacity to pick up the load and meet the minimum frequency and voltage stability requirements of the emergency system within 10 seconds after loss of normal power. This deficient practice affects all occupants

Findings include:

Based on review of the "Generator Weekly Load Test" log with the Manager Support Services on 12/18/13 at 1:30 p.m., the weekly load test log indicated the transfer of power from the main source to the emergency generator but lacked documentation of the length of time for generator to start and transfer power. Based on interview at the time of record review, the Manager Support Services acknowledged the length of time for the generator to start and transfer power was generally 10 seconds or less but it was not documented.

2. Based on observation and interview, the facility failed to ensure 1 of 1 emergency generators was provided with an alarm annunciator in a location readily observed by operating personnel at a regular work station such as a nurses' station. NFPA 99, Health Care Facilities, 3-4.1.1.15 requires a remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station. The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate:
1. When the emergency or auxiliary power source is operating to supply power to load.
2. When the battery charger is malfunctioning.
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate:
1. Low lubricating oil pressure.
2. Low water temperature.
3. Excessive water temperature.
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply.
5. Overcrank (failed to start).
6. Overspeed.
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur but need not display these conditions individually. This deficient practice could affect all the patients as well as visitors and staff.

Findings include:

Based on observation on 12/19/13 during the tour from 9:30 a.m. to 11:00 a.m. with the Manager Support Services, a remote alarm annunciator for the generator was provided in the maintenance shop, however, based on interview at the time of observation, the Manager Support Services stated the maintenance shop is not staffed from 11:30 p.m. to 4:00 a.m. but has a security office checking the area on an hourly basis.

Based on observation and interview, the facility failed to ensure 1 of 1 flexible cords was not used as a substitute for fixed wiring to provide power for medical equipment or equipment with a high current draw. NFPA 70, National Electrical Code, 1999 Edition, Article 400-8 requires, unless specifically permitted, flexible cords and cables shall not be used as a substitute for fixed wiring of a structure. This deficient practice was not in a patient care area but could affect therapy staff.

Findings include:

Based on observation and interview with the Safety Coordinator on 12/19/13 at 10:35 a.m., the Safety Coordinator acknowledged a refrigerator was supplied electricity by an extension cord power strip in the therapy department storage room.