HospitalInspections.org

Battery powered emergency lighting in Operating Rooms and Procedure Rooms are not tested to comply with Code requirements. Failure to test battery powered emergency lighting at anesthetizing locations can leave the locations in total darkness until generator systems provide emergency lighting. Total darkness during critical surgical procedures can compromise the safety of patients if surgeons lacked lighting during the switch from normal power to emergency power.

Findings include:

On 11/15/2021 at 10:55am, while in the company of DO and MS it was determined through document review and staff interview that records for battery powered emergency lighting did not include the monthly or annual testing of battery powered emergency lighting in the Operating Rooms or Procedure Rooms to comply with 7.9.3.1.1.

Based on observation, exit signs were not provided as required to identify paths of egress. These deficiencies could affect patients, staff and visitors they cannot readily identify the path to an available exit from the building.

Findings include:

On 11/15/2021 at 12:52pm, while in the company of the DO and MS on the 4th floor of Building B it was observed that approved, readily visible signs which mark access to the 2 required exits are missing within the Sterile Processing Suite. This does not comply with the requirements of 19.2.10, 7.10.1.2.1, or 7.10.1.5.1.

Based an observations, not all exit doors are installed or maintained to provide protection of the exit enclosure. This deficiency could affect patients, staff and visitors if the exit access door did not provide the proper protection during a fire emergency.

The findings are:

A. On 11/15/2021 at 11:31am, while in the company of the DO and MS on the Roof/Penthouse level of Building A it was observed that the elevator shaft insode the elevator vestibule has visible penetrations not sealed against fire. This does not comply with the requirements of Table 8.3.5.1.

B. On 11/15/2021 at 12:37pm, while in the company of the DO and MS on the 3rd floor northeast corner of Building A it was observed that the stair door failed to self-close and self-latch. This does not comply with the requirements of Table 8.3.4.2 and NFPA 80, 2010 6.4.1.1.

C. On 11/15/2021 at 1:10pm, while in the company of the DO and MS on the 2nd floor northeast corner of Building A it was observed that the stair door failed to self-close and self-latch. This does not comply with the requirements of Table 8.3.4.2 and NFPA 80, 2010 6.4.1.1.

Based upon observation, hazardous areas are not properly separated from the remainder of the occupancy and the means of egress. Failure to properly separate hazardous area from required means of egress paths can compromise the safety of all occupants. If a fire were to originate in the hazardous area, then the adjacent corridor necessary for exiting would be compromised due to the areas are not being properly separated.

Findings include:

On 11/15/2021 at 1:08pm, while in the company of DO and MM on the 2nd floor north end of Building A it was observed that the door serving the room labeled Clean Utility as shown on the Life Safety plans provided by the facility failed to self close to comply with 19.3.2.1.3 and 19.3.6.3.5.

Smoke detectors in the facility are not located as required for a compliant fire alarm system installation. Failure to locate devices accordingly may result in failure or delay of alarm initiation device during an emergency event. If alarm initiating devices do not function properly, then the building occupants may not be alerted to an emergency which may result in occupants' safety being compromised.

Findings include:

A. It was observed that detectors are located where airflow may prevent normal operation of the device as stated in NFPA 72-2012, 17.7.4.1. Locations & conditions observed include the following:

1. On 11/15/2021 at 11:35am, while in the company of DO and MS on the 4th floor northwest corner of Building A it was observed that a smoke detector was within 3"-0" of an HVAC diffuser in the room labeled Staff Lounge as shown on the Life Safety plans provided by the facility.

2. On 11/15/2021 at 12:18pm, while in the company of DO and MS on the 4th floor of Building B it was observed that a smoke detector was within 3"-0" of an HVAC diffuser in the corridor serving the space labeled Surgical Waiting as shown on the Life Safety plans provided by the facility. It was also observed that the space was currently in use as a staff dining area.

3. On 11/15/2021 at 12:37pm, while in the company of DO and MS on the 3rd floor of Building A it was observed that a smoke detector was within 3"-0" of an HVAC diffuser in the north corridor serving the space labeled Surgical Department as shown on the Life Safety plans provided by the facility.

4. On 11/15/2021 at 1:15pm, while in the company of DO and MS on the 2nd floor southeast corner of Building A it was observed that a smoke detector was within 3"-0" of an HVAC diffuser in the space labeled Linen as shown on the Life Safety plans provided by the facility.

5. On 11/15/2021 at 1:34pm, while in the company of DO and MS on the 1st floor north end of Building A it was observed that a smoke detector was within 3"-0" of an HVAC diffuser in the space labeled Soiled Utility as shown on the Life Safety plans provided by the facility. It was also observed that the space was currently in use as a staff kitchen.


B. On 11/15/2021 at 12:53pm, while in the company of DO and MS on the 4th floor east end of Building B it was observed that a fire alarm manual pull station is not installed within 5'-0" of horizontal exit doors to comply with NFPA 72-2010, 17.14.6. It was also observed that pull stations were missing at this same horizontal exit location on all other floors.

Based on observation, staff interview, and document review the facility failed to provide maintenance of fire stop protection appliances within the ventilation duct system. Failure to install and maintain these installations as required could result in the passage of fire and products of combustion from one fire compartment to another. This deficient practice could affect patients, staff and visitors during a fire event.

Findings include:

On 11/15/2021 at 11:05am while in the company of the DO and MS it was determined that no documentation was available to indicate a fire/smoke damper inspection had been performed to comply with NFPA 90A-2012, 5.4.8 and NFPA 80 - 2010, 19.4.9.1.

The facility does not provide evidence of verification of the transmission of the fire alarm signal during fire drills. Failure to verify transmission of the fire alarm signal can result in failure of the fire department to respond promptly during an actual fire/smoke condition.

Findings include:

On 11/15/2021 at 10:15am, while in the company of DO and MS during record document review, it was noted that there is no evidence within the paperwork of the completed drills showing verification of the transmission of the fire alarm signal. This does not comply with 19.7.1.4.

Based on observation, the facility failed to install and maintain its piped medical gas system as required. This deficient practice could affect patients, staff, and visitors in the building because the piped medical gas system could fail to operate when needed if not properly installed and maintained.

The finding is:

On 11/15/2021 at 12:07pm while in the company of the DO and MS it was observed in the 4th floor Prep/Hold Suite that medical gas zone valves are located in the same room as the station outlets that the medical gas zone valves control. This condition does not comply with NFPA 99-2012, 5.1.4.8(3).

Based on observation, not all portions of the electrical system are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because the electrical systems could fail to operate properly when needed if they are not properly installed

Findings include:

On 11/15/2021 at 12:41pm, while in the company of the Do and MS on the 4th floor of Builidng B it was observed that a coverplate was missing and electrical wiring is exposed in the room labeled Equipment Storage as shown on the Life Safety Planms provided by the facility. Therefore, the electrical system is not installed in compliance with NFPA 70-2011, 314.28(C).

Based upon observation, ground fault circuit interruption (GFCI) is not provided in accordance with Code requirements. If GFCI protection is not provided, the circuit remains an electrical shock hazard to occupants. This deficient practice could affect the safety of patients, staff, and visitors.

Findings include:

On 11/152021 at 11:45am, while in the company of DO and MS on the 4th floor ICU Suite in Building A it was observed in the room labeled Soiled Utility as shown on the Life Safety plamns provided by the facility that an electrical receptacle is within 6'-0" of a clinical sink fixture and is not provided with GFCI protection to comply with NFPA 70 2011, 210.8(B)(5).