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Based on observation and interview with staff, the facility failed to provide corridors that are separated from use areas by walls constructed with at least 1/2 hour fire resistance rating. Findings:

1) Walls in the existing structure and existing tower (non-sprinklered building) do not have at least 1/2 hour fire resistance rating. Non-rated expanding foam was found in several locations in the corridor walls.

Based on observation and interview with staff, the facility failed to provide smoke barriers constructed to provide at least a 1/2 hour fire resistance rating in accordance with 8.3. Findings:

1) Smoke Compartment 01A wall near the Emergency Department has an open gap between the top of the gypsum board and the bottom of the fireproofing over the metal deck above.

2) Smoke Compartment 01E wall east of Recovery is not sealed with fire rated sealant between the top of the gypsum board and the bottom of the metal deck above. Non-rated expanding foam was found along the length of the wall.

Based on review of the Fire Drill Critique Form, the facility failed to properly document fire drills. Findings:

1) The facility failed to complete the critique form for the fire drill conducted on 3-3-2011 at 3:05 pm. The form was not signed by participants.

Based on observation and interview with staff, the facility failed to provide a fire alarm system maintained in accordance with NFPA 72 National Fire Alarm Code. Findings:

1) The fire alarm system was found with a system default on November 16, 2011( a ground fault was detected and corrected in the boiler room), however, the outside vendor failed to conduct an acceptance test for the repair of the system in accordance with NFPA 72 7-1.6.2. an acceptance test shall be conducted after repairs and a system test shall be preformed with documentation.

2) The annual test provided did not include combination fire and smoke dampers connected to the fire alarm system. All components connected to the fire alarm system shall be tested annually.

Based on observation and interview with staff, the facility failed to provide an automatic sprinkler system in accordance with NFPA 13. Findings include:

1) The facility failed to provide coverage to the Equipment Room entering the surgery suite and to the loading dock adjacent to the hospital.

2) New tower, third floor, south corridor near Clean Supply and Soiled Utility: Fire sprinkler piping is in physical contact and under load from unistrut members running perpendicular to the sprinkler piping. NFPA 25, Section 5.2.2.2 states that "sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe."

Based on observation and interview with staff, the facility failed to provide anesthetizing locations protected in accordance with NFPA 99. Findings:

1) The facility had multiple days in January and February of 2011 that were under the minimum 35 % humidity levels based on records provided on January 17, 2012 by the Director of Engineering. The ranges were from single digits to just under the minimum requirements.

2) The facility failed to provide operating rooms that could automatically prevent recirculation of smoke originating within the surgical suite back into the intake with out interfering with the exhaust function and to vent products of combustion out of the suite.

3) The humidifier were out of service for Operating Rooms 1 and 2 at the time of survey.

Based on observation , interview with the Director of Surgery, Director of Plant Operations, and the Chief Operating Officer at 11:45 am, and review of records on January 17, 2012, the facility failed to provide staff, physicians, and surgeons with a continuing safety education and supervision program in accordance with NFPA 99 1999 edition chapter 12-4.1.2.10.
Findings:

(1) The Circulating Registered Nurse was asked to identify and explain the purpose of the Line Isolation Monitor. She could not and explained she had not been provided with inservice and orientation to that piece of equipment.

2) In an interview with the Director of Surgery and Chief Operating Officer at 11:50 on January 17, 2012, they stated that the physicians and surgeons had not been provided with inservice education of the hazards that could be encountered during surgical procedures

Based on observation and interview with staff, the facility failed to provide Fume hoods that are in accordance with NFPA 99. 5.4.2.1, 5.4.3, 5.6.2, Findings:

1) The hood in the Microbiology Room in the Lab was not balanced with the room to provide a negative pressure with respect to the surrounding area. The exhaust for that room was not functioning at the time of the survey.

2) Warning signs for the fume hood exhaust were not posted on the roof.