HospitalInspections.org

Based on observation and staff interview, the facility failed to provide 2-hour rated construction at the building separation walls in accordance with 2000 - NFPA 101, sections 19.1.1.4, 19.1.2.3 and 8.2.3.2.


Findings include:

On facility tour between 10:30 AM on 09/10/12 and 2:00 PM on 09/11/12, observation revealed the following in the 2-hour fire rated building separation wall between the following locations:


1. Lower level - maintenance vehicle garage north wall has an open penetration around the fire sprinkler line.

2. On the 1st floor, in the fire separation wall between the Hospital and the Cannon Valley Clinic, there open penetrations around around electric cables and flex conduit.


These deficient practices were confirmed by the Facilities Manager (TJ) at the time of discovery.

Based on observation and staff interview, this building does not meet the requirements for construction type and height in accordance with 2000 - NFPA 101, section 19.1.6.2.

Findings include:

On facility tour between 10:30 AM on 09/10/12 and 2:00 PM on 09/11/12, observation revealed that in the lower level Electrical Vault Room, the fireproofing is missing from the support beam.

NOTE: The entire facility needs to be checked for this deficiency.


This deficient practice was confirmed by the Facilities Manager (TJ) at the time of discovery.

Based on observation and staff interview, the facility had corridor doors which were impeded from fully closing and latching into their frames in accordance with the requirements of 2000 NFPA 101, Sections 19.3.6.3.2.


FINDINGS INCLUDE:

On facility tour between 10:30 AM on 09/10/12 and 2:00 PM on 09/11/12, observation revealed that the basement, the tunnel door that opens into the corridor does not have positive latching hardware. This door currently has a roller latch.

NOTE: entire facility needs to be checked for this deficiency.


This deficient practice was confirmed by the Facilities Manager (TJ) at the time of discovery.

Based on observation and staff interview, the facility failed to maintain smoke barrier wall in accordance with the following requirements of 2000 NFPA 101, Section 19.3.7.3, and 8.3.4.1.

Findings include:

On facility tour between 10:30 AM on 09/10/12 and 2:00 PM on 09/11/12, observation revealed that the 2nd floor smoke barrier wall inside the Specialty Clinic has an open penetration above the ceiling around a 2 inch fire sprinkler line.

NOTE: All required smoke barrier walls need to be checked for this deficiency.


This deficient practice was confirmed by the Facilities Manager (TJ) at the time of discovery.

Based on observation and staff interview, the facility failed to maintain 1 hour fire rated wall construction in accordance with the following requirements of 2000 NFPA 101, Section 19.3.2.1.

Findings include:

On facility tour between 10:30 AM on 09/10/12 and 2:00 PM on 09/11/12, observation revealed the following:

1. Lower level, Mechanical Room # 1, the south wall has an open penetration around several
cables.

2. 3rd floor, Soiled Linen Holding Room, has a 12" x 12" hole in the north wall

3. The 3rd floor storage room (which is over 50 square feet) across from patient room # 313,
has a 1 inch hole in the south wall below the ceiling.

4. 1st floor Ambulatory Surgery Janitor/Storage Room (which is over 50 sq ft) does not have an
automatic door closer.

5. 1st floor, Retail Pharmacy Storage Area (which is over 50 square feet) is not properly separated
as a hazardous room.

6. The 1st floor ceiling above the NE entrance to Laboratory has:
a. Open penetrations
b. Sheetrock is not properly secured
c. Sheetrock joints are not properly taped

These deficient practices were confirmed by the Facilities Manager (TJ) at the time of discovery.

Based on observation and staff interview, the facility failed to maintain a fire resistance rating of at least one hour in the exit component accordance with the following requirements of 2000 NFPA 101, Section 19.3.1.1, 8.2.5.2.

Findings include:

On facility tour between 10:30 AM on 09/10/12 and 2:00 PM on 09/11/12, observation revealed that the door and frame to the lower level west stairwell do not have a 1 hour fire rating label on them.


This deficient practice was confirmed by the Facilities Manager (TJ) at the time of discovery.

Based on observation and staff interview, the facility failed to provide means of egress in accordance with the following requirements of 2000 NFPA 101, Section 19.2.


Findings include:

On facility tour between 10:30 AM on 09/10/12 and 2:00 PM on 09/11/12, observation revealed, that Classromms B & C, on the lower level, are open as one room and the capacity is over 49 people:

1. There are no exit signs above the two exit doors
2. The doors swing inward against the direction of exit travel
3. there is no exit panic door hardware.


This deficient practice was confirmed by the Facilities Manager (TJ) at the time of discovery.

Based on observation and staff interview, the facility failed to install and maintain the fire alarm system in accordance with the requirements of 2000 NFPA 101, Sections 19.3.4.1 and 9.6, as well as 1999 NFPA 72.

Findings include:

On facility tour between 10:30 AM on 09/10/12 and 2:00 PM on 09/11/12, based on observation and a review of available documentation, the following was found:

1. The following smoke detectors are located with-in 3 feet of of air supply/return vents and not in accordance with NFPA 72(99), Section 2-3.5.1:
a. 3rd floor - patient elevator lobby
b. Lower level - Data room (L04D26)
c. Lower level - in corridor by mechanical room # 2
d. 2nd floor - Dr. sleep room

NOTE: the entire facility needs to be checked for this deficiency

2. 2nd floor - janitor closet - the fire alarm FCPS panel batteries are over 4 years old.
The date on them is 10/2007 (NFPA 72 (99), Table 7-3.2 (6) (d) (1)).

3. 1st floor - Doctors Sleeping Room, there is no automatic smoke detector with a sounder base.


These deficient practices were confirmed by the Facilities Manager (TJ) at the time of discovery.

Based on observation and staff interview, the facility failed to provide proper coverage of the fire sprinkler system as per 2000 NFPA 101 Chapter 19.3.5 and 9.7 and 1999 NFPA 13, 5-13.6

FINDINGS INCLUDE:

On facility tour between 10:30 AM on 09/10/12 and 2:00 PM on 09/11/12, observation revealed that the following was found:

1. In the Lower Level, Main Material room - there are two 4 X 8 foot storage racks that have solid shelving which will not allow the pre-wetting of all levels of storage should the fire sprinker system activate.

2. In the Lower Level Administration Office, the closet by Dana's desk does not have fire sprinkler protection

3. In the 1st floor Electric closet in the corridor by Diagnostic Imaging, there no automatic fire sprinkler protection.

4. Both elevator equipment rooms do not have automatic fire sprinkler protection. Heat detectors are also needed with-in 2 feet of each fire sprinkler head in these rooms.


These deficient practices were confirmed by the Facilities Manager (TJ) at the time of discovery.

Based on observation, documentation review and staff interview, the facility failed to maintain the fire sprinkler system in accordance with the requirements of 2000 NFPA 101, Sections 19.3.4.1 and 9.6, as well as 1998 NFPA 25.

Findings include:

On facility tour between 10:30 AM on 09/10/12 and 2:00 PM on 09/11/12, observation, documentation review and staff interview revealed the following:

1. Gauges on ALL fire sprinkler systems could not be verified if they have been calibrated or replaced with-in the
last 5 years per NFPA 25 (98), Chapter 3-3.1

2. No documentation for 5 year flow test on the standpipe system per NFPA 25 (98), Chapter 3-3.1

3. No documentation if the check valves on the fire sprinkler piping system have been completed with-in the last 5 years
per NFPA 25 (98), Chapter 9-4.2.1

4. No documentation if the internal inspection on the fire sprinkler system has been conducted with-in the
last 5 years per NFPA 25 (98), Chapter 3-3.1

5. There was not two spare sprinkler heads for each type of fire sprinkler head in the spare fire sprinkler head box(e's) per NFPA 25 (98), Chapter 3-3.1


These deficient practices were confirmed by the Facilities Manager (TJ) at the time of discovery.

Based on observations and interview, the facility has compressed gas cylinders not properly stored in compliance with the requirements of NFPA 99.

Findings include:

On facility tour between 10:30 AM on 09/10/12 and 2:00 PM on 09/11/12, observation revealed the following:

1. 3rd floor - clean utility room:
a. No signage indicating oxygen storage / no smoking
b. Oxygen was being stored with-in 5 feet of combustibles

2. Lower level - Medical gas storage room:
a. The tanks are not properly nested
b. "E" size oxygen cylinder not properly secured


These deficient practices were confirmed by the Facilities Manager (TJ) at the time of discovery.

Based on observation and staff interview, the facility failed to install isolated power systems per 2000 NFPA 101 -19.3.2.3, 1999 NFPA 99 and 1999 NFPA 70.

Findings include:

On facility tour between 10:30 AM on 09/10/12 and 2:00 PM on 09/11/12, observation revealed that the following was found:

1. In all Operating Rooms there was no isolated power system or ground fault interrupter. The Facilities Manager (TJ)
could not tell me if the operating rooms are considered wet or dry locations. We spoke to the Manager of Surgery
and he explained to us that all operating rooms are considered wet. 1999 NFPA 99 3-3.2.1 and 1999 NFPA 70 -
Article 517-20(a).

2. Open electrical junction boxes in following locations:
a. Lower level - dietary storage room
b. Lower level - material main storage area

NOTE: The entire facility needs to be checked for this deficiency

3. 2nd & 3rd floor Nutrition Centers for patients and visitors have household microwaves
and toasters in use

NOTE: The entire facility needs to be checked for this deficiency

4. Lower Level Administration, under Dana's desk there are (3) electrical power strips
that are interconnect with each other

NOTE: The entire facility needs to be checked for this deficiency


These deficient practices were confirmed by the Facilities Manager (TJ) at the time of discovery.





*TEAM COMPOSITION*
Gary Schroeder, Life Safety Code Spc.

Based on observation and staff interview, the facility failed to provide 2-hour rated construction at the building separation walls in accordance with 2000 - NFPA 101, sections 19.1.1.4, 19.1.2.3 and 8.2.3.2.


Findings include:

On facility tour between 10:30 AM on 09/10/12 and 2:00 PM on 09/11/12, observation revealed the following in the 2-hour fire rated building separation wall between the following locations:


1. Lower level - maintenance vehicle garage north wall has an open penetration around the fire sprinkler line.

2. On the 1st floor, in the fire separation wall between the Hospital and the Cannon Valley Clinic, there open penetrations around around electric cables and flex conduit.


These deficient practices were confirmed by the Facilities Manager (TJ) at the time of discovery.

Based on observation and staff interview, this building does not meet the requirements for construction type and height in accordance with 2000 - NFPA 101, section 19.1.6.2.

Findings include:

On facility tour between 10:30 AM on 09/10/12 and 2:00 PM on 09/11/12, observation revealed that in the lower level Electrical Vault Room, the fireproofing is missing from the support beam.

NOTE: The entire facility needs to be checked for this deficiency.


This deficient practice was confirmed by the Facilities Manager (TJ) at the time of discovery.

Based on observation and staff interview, the facility had corridor doors which were impeded from fully closing and latching into their frames in accordance with the requirements of 2000 NFPA 101, Sections 19.3.6.3.2.


FINDINGS INCLUDE:

On facility tour between 10:30 AM on 09/10/12 and 2:00 PM on 09/11/12, observation revealed that the basement, the tunnel door that opens into the corridor does not have positive latching hardware. This door currently has a roller latch.

NOTE: entire facility needs to be checked for this deficiency.


This deficient practice was confirmed by the Facilities Manager (TJ) at the time of discovery.

Based on observation and staff interview, the facility failed to maintain smoke barrier wall in accordance with the following requirements of 2000 NFPA 101, Section 19.3.7.3, and 8.3.4.1.

Findings include:

On facility tour between 10:30 AM on 09/10/12 and 2:00 PM on 09/11/12, observation revealed that the 2nd floor smoke barrier wall inside the Specialty Clinic has an open penetration above the ceiling around a 2 inch fire sprinkler line.

NOTE: All required smoke barrier walls need to be checked for this deficiency.


This deficient practice was confirmed by the Facilities Manager (TJ) at the time of discovery.

Based on observation and staff interview, the facility failed to maintain 1 hour fire rated wall construction in accordance with the following requirements of 2000 NFPA 101, Section 19.3.2.1.

Findings include:

On facility tour between 10:30 AM on 09/10/12 and 2:00 PM on 09/11/12, observation revealed the following:

1. Lower level, Mechanical Room # 1, the south wall has an open penetration around several
cables.

2. 3rd floor, Soiled Linen Holding Room, has a 12" x 12" hole in the north wall

3. The 3rd floor storage room (which is over 50 square feet) across from patient room # 313,
has a 1 inch hole in the south wall below the ceiling.

4. 1st floor Ambulatory Surgery Janitor/Storage Room (which is over 50 sq ft) does not have an
automatic door closer.

5. 1st floor, Retail Pharmacy Storage Area (which is over 50 square feet) is not properly separated
as a hazardous room.

6. The 1st floor ceiling above the NE entrance to Laboratory has:
a. Open penetrations
b. Sheetrock is not properly secured
c. Sheetrock joints are not properly taped

These deficient practices were confirmed by the Facilities Manager (TJ) at the time of discovery.

Based on observation and staff interview, the facility failed to maintain a fire resistance rating of at least one hour in the exit component accordance with the following requirements of 2000 NFPA 101, Section 19.3.1.1, 8.2.5.2.

Findings include:

On facility tour between 10:30 AM on 09/10/12 and 2:00 PM on 09/11/12, observation revealed that the door and frame to the lower level west stairwell do not have a 1 hour fire rating label on them.


This deficient practice was confirmed by the Facilities Manager (TJ) at the time of discovery.

Based on observation and staff interview, the facility failed to provide means of egress in accordance with the following requirements of 2000 NFPA 101, Section 19.2.


Findings include:

On facility tour between 10:30 AM on 09/10/12 and 2:00 PM on 09/11/12, observation revealed, that Classromms B & C, on the lower level, are open as one room and the capacity is over 49 people:

1. There are no exit signs above the two exit doors
2. The doors swing inward against the direction of exit travel
3. there is no exit panic door hardware.


This deficient practice was confirmed by the Facilities Manager (TJ) at the time of discovery.

Based on documentation review and staff interview, the facility failed to assure fire drills were conducted once per shift per quarter for all staff under varying times and conditions as required by 2000 NFPA 101, Section 19.7.1.2.

Findings include:

On facility tour between 10:30 AM on 09/10/12 and 2:00 PM on 09/11/12, the review of the fire drill documentation for the past 12 months September 2011 to August 2012) revealed the following:

1. Fire drills were missed on the following shifts:
a. 2011 - 4th quarter - night
b. 2012 - 2nd quarter - night

2. Fire drills did not sufficiently vary the times that the drills were conducted:
a. Day - 1350, 1340, 1400 and 0750 hours
b. Evening - 2031, 1630, 2103 and 1609 hours



These deficient practices were confirmed by the Facilities Manager (TJ) at the time of discovery.

Based on observation and staff interview, the facility failed to install and maintain the fire alarm system in accordance with the requirements of 2000 NFPA 101, Sections 19.3.4.1 and 9.6, as well as 1999 NFPA 72.

Findings include:

On facility tour between 10:30 AM on 09/10/12 and 2:00 PM on 09/11/12, based on observation and a review of available documentation, the following was found:

1. The following smoke detectors are located with-in 3 feet of of air supply/return vents and not in accordance with NFPA 72(99), Section 2-3.5.1:
a. 3rd floor - patient elevator lobby
b. Lower level - Data room (L04D26)
c. Lower level - in corridor by mechanical room # 2
d. 2nd floor - Dr. sleep room

NOTE: the entire facility needs to be checked for this deficiency

2. 2nd floor - janitor closet - the fire alarm FCPS panel batteries are over 4 years old.
The date on them is 10/2007 (NFPA 72 (99), Table 7-3.2 (6) (d) (1)).

3. 1st floor - Doctors Sleeping Room, there is no automatic smoke detector with a sounder base.


These deficient practices were confirmed by the Facilities Manager (TJ) at the time of discovery.

Based on observation and staff interview, the facility failed to provide proper coverage of the fire sprinkler system as per 2000 NFPA 101 Chapter 19.3.5 and 9.7 and 1999 NFPA 13, 5-13.6

FINDINGS INCLUDE:

On facility tour between 10:30 AM on 09/10/12 and 2:00 PM on 09/11/12, observation revealed that the following was found:

1. In the Lower Level, Main Material room - there are two 4 X 8 foot storage racks that have solid shelving which will not allow the pre-wetting of all levels of storage should the fire sprinker system activate.

2. In the Lower Level Administration Office, the closet by Dana's desk does not have fire sprinkler protection

3. In the 1st floor Electric closet in the corridor by Diagnostic Imaging, there no automatic fire sprinkler protection.

4. Both elevator equipment rooms do not have automatic fire sprinkler protection. Heat detectors are also needed with-in 2 feet of each fire sprinkler head in these rooms.


These deficient practices were confirmed by the Facilities Manager (TJ) at the time of discovery.

Based on observation, documentation review and staff interview, the facility failed to maintain the fire sprinkler system in accordance with the requirements of 2000 NFPA 101, Sections 19.3.4.1 and 9.6, as well as 1998 NFPA 25.

Findings include:

On facility tour between 10:30 AM on 09/10/12 and 2:00 PM on 09/11/12, observation, documentation review and staff interview revealed the following:

1. Gauges on ALL fire sprinkler systems could not be verified if they have been calibrated or replaced with-in the
last 5 years per NFPA 25 (98), Chapter 3-3.1

2. No documentation for 5 year flow test on the standpipe system per NFPA 25 (98), Chapter 3-3.1

3. No documentation if the check valves on the fire sprinkler piping system have been completed with-in the last 5 years
per NFPA 25 (98), Chapter 9-4.2.1

4. No documentation if the internal inspection on the fire sprinkler system has been conducted with-in the
last 5 years per NFPA 25 (98), Chapter 3-3.1

5. There was not two spare sprinkler heads for each type of fire sprinkler head in the spare fire sprinkler head box(e's) per NFPA 25 (98), Chapter 3-3.1


These deficient practices were confirmed by the Facilities Manager (TJ) at the time of discovery.

Based on observations and interview, the facility has compressed gas cylinders not properly stored in compliance with the requirements of NFPA 99.

Findings include:

On facility tour between 10:30 AM on 09/10/12 and 2:00 PM on 09/11/12, observation revealed the following:

1. 3rd floor - clean utility room:
a. No signage indicating oxygen storage / no smoking
b. Oxygen was being stored with-in 5 feet of combustibles

2. Lower level - Medical gas storage room:
a. The tanks are not properly nested
b. "E" size oxygen cylinder not properly secured


These deficient practices were confirmed by the Facilities Manager (TJ) at the time of discovery.

Based on observation and staff interview, the facility failed to install isolated power systems per 2000 NFPA 101 -19.3.2.3, 1999 NFPA 99 and 1999 NFPA 70.

Findings include:

On facility tour between 10:30 AM on 09/10/12 and 2:00 PM on 09/11/12, observation revealed that the following was found:

1. In all Operating Rooms there was no isolated power system or ground fault interrupter. The Facilities Manager (TJ)
could not tell me if the operating rooms are considered wet or dry locations. We spoke to the Manager of Surgery
and he explained to us that all operating rooms are considered wet. 1999 NFPA 99 3-3.2.1 and 1999 NFPA 70 -
Article 517-20(a).

2. Open electrical junction boxes in following locations:
a. Lower level - dietary storage room
b. Lower level - material main storage area

NOTE: The entire facility needs to be checked for this deficiency

3. 2nd & 3rd floor Nutrition Centers for patients and visitors have household microwaves
and toasters in use

NOTE: The entire facility needs to be checked for this deficiency

4. Lower Level Administration, under Dana's desk there are (3) electrical power strips
that are interconnect with each other

NOTE: The entire facility needs to be checked for this deficiency


These deficient practices were confirmed by the Facilities Manager (TJ) at the time of discovery.





*TEAM COMPOSITION*
Gary Schroeder, Life Safety Code Spc.