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1) Based on observation and interview with staff, the facility failed to provide and maintain Corridors that are separated from use areas by walls constructed with at least ? hour fire resistance rating in accordance with 19.3.6.1, 19.3.6.2.1, 19.3.6.5. Findings include:

a) Penetrations created by IT wiring is installed and pulled down through wall through out the building; IT staff did not seal those wall with material capable of maintaining the fire resistance of the fire barrier.

1) Based on observation and interview with staff, the facility failed to mark Access to exits by approved, readily visible signs in all cases where the exit or way to reach exit is not readily apparent to the occupants. 7.10.1.4 Findings include:

a) There is no exit sign on the south end of the service corridor of the hospital.

1) Based on observation and interview with staff, the facility failed to provide One hour fire rated construction (with ? hour fire-rated doors) in accordance with 8.4.1 and/or 19.3.5.4 to protects hazardous areas. Doors are required to be self-closing and non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door are permitted. 19.3.2.1 Findings include:

a) The door to Decontamination (Old Decontamination Area for Surgery) did not close in its frame.

b) The door to stairwell in Basement is not provided with a closure.

c) Basement area, that houses the containment area for furnaces and HVAC equipment is separated with a concrete floor, however the penetrations through the floor are not sealed with material capable of maintaining the fire resistance of the fire barrier.

1) Based on observation and interview with staff, the facility failed to maintain Heating, ventilating, and air conditioning systems that comply with the provisions of section 9.2 and are installed in accordance with the manufacturer's specifications. 19.5.2.1, 9.2, NFPA 90A, 19.5.2.2 Findings include:

a) Exhaust in patient rooms was not pulling air through the exhaust grills. The test used was a 4x4 tissue that would not hold against the grill when applied. The test was in the presence of maintenance director.

b) Maintenance Director was unable to show location of Outside Air intakes for building. Maintenance Director indicated that the fresh air intakes were closed.

c) Rooms on patient wings and ED Department air flow was not tested, air exchanges could not be verified ( outside air and overall air exchanges).

1) Based on observation and interview with staff, the facility failed to provide Piped in medical gas systems that comply with NFPA 99, Chapter 4. Findings include:

a) The Medical Gas Supply System is not provided with Duel Line Regulators

b) The bottled reserve was turned off at the time of the survey. Maintenance Director verified that the reserve was turned off.

c) The bottled reserve low level reserve alarm indicator did not work. The Medical gas master alarm was not indicating bottled reserve pressure low or off .

d) There was no area alarm for the ED Department.

e) Master alarm panel alarms was not functioning.

1) Based on observation and interview with staff, the facility failed to provide Hospitals, with life support equipment, that have a Type I Essential Electrical System powered by a generator with a transfer switch and has a separate power supply. The EES is in accordance with NFPA 99, 3.4.2.2, 3.4.2.1.4. Findings include:

a) The battery back up light over the transfer switch in the basement was not working.

b) There is not Remote Annunciator located in the hospital.

1) Based on observation and interview with staff, the facility failed to maintain design features constructed for the building. To continue to meet the performance goals and objectives of this Code, the Building shall be maintained in accordance with performance goals and objectives that include complying with all documented assumptions and design specifications. Any variations shall require the approval of the authority having jurisdiction prior to the actual change in accordance with NFPA 101, 2000 edition, chapter 5.1.7., 5-8.14 Findings include:

a) The Emergency Department is a Critical Care Area and was defined and designed by one room immediately adjacent to the east exit, however rooms that are a part of X-Ray and Old Surgery Suite have been used as part of the Emergency Department over flow. Waiting areas for Emergency Patients are in the egress corridor adjacent to the east exit and in the X-Ray area.

Based on observation and interview with staff, the facility failed to maintain Fixed eye baths that are designed and suitable for quick drenching or flushing of the eyes, and will avoid injurious water pressure in accordance with NFPA 99. 10.6 Findings include:

a) The eye wash in the lab was not being logged and tested monthly.

1) Based on observation and interview with staff, the facility failed to provide Master alarm panels that are in two separate locations and have audible and visible signals. There are high/low alarms for +/- 20% operating pressure. NFPA 99, 4.3.1.2.2 Findings include:

a) There is a master alarm panel at the nurses station, however low level alarm is not connected, other required alarms as defined in NFPA 99 1999 edition Gas Warning chapter 4-3.1.2.2 ( b ) 1,2,3 could not be identified or verified.

b) Area alarm required at the Ed Departments was not installed in accordance Gas Warning 4-3.1.2.2 (c ) .

Based on observation and interview with staff, the facility failed to provide a Type I EES that is divided into the critical branch, life safety branch and the emergency system in accordance with NFPA 99. 3.4.2.2.2. Findings include:


a) Branches that are required to be Life Safety, Critical Care and Equipment could not be identified. New circuits installed to patient rooms were wired and connected to panels that has Life Safety,Critical Care and other miscellaneous Equipment combined on that branch panel.

1) Based on observation and interview with staff, the facility failed to provide Electrical wiring and equipment that is in accordance with NFPA 70, National Electrical Code. 9.1.2 Findings include:

a) The Bio Medical testing is accomplished by an outside staff member under agreements of contract. ?482.12(e) Standard of Contracted Services; requires that the governing body be responsible for services furnished in the hospital whether or not they are furnished under contracts. The governing body must ensure that a contractor of services (including one for shared services and joint ventures) comply with all applicable conditions of participation and standards for the contracted services. The facility could not provide documentation that the contractor tested equipment in accordance with manufactures recommendations (the facility did not verify by comparing manufactures preventive maintenance guidelines with documentation compiled by contractors tests results).

1) Based on observation and interview with staff, the facility failed to provide and maintain Corridors that are separated from use areas by walls constructed with at least ? hour fire resistance rating in accordance with 19.3.6.1, 19.3.6.2.1, 19.3.6.5. Findings include:

a) Penetrations created by IT wiring is installed and pulled down through wall through out the building; IT staff did not seal those wall with material capable of maintaining the fire resistance of the fire barrier.

1) Based on observation and interview with staff, the facility failed to mark Access to exits by approved, readily visible signs in all cases where the exit or way to reach exit is not readily apparent to the occupants. 7.10.1.4 Findings include:

a) There is no exit sign on the south end of the service corridor of the hospital.

1) Based on observation and interview with staff, the facility failed to provide One hour fire rated construction (with ? hour fire-rated doors) in accordance with 8.4.1 and/or 19.3.5.4 to protects hazardous areas. Doors are required to be self-closing and non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door are permitted. 19.3.2.1 Findings include:

a) The door to Decontamination (Old Decontamination Area for Surgery) did not close in its frame.

b) The door to stairwell in Basement is not provided with a closure.

c) Basement area, that houses the containment area for furnaces and HVAC equipment is separated with a concrete floor, however the penetrations through the floor are not sealed with material capable of maintaining the fire resistance of the fire barrier.

1) Based on observation and interview with staff, the facility failed to maintain Heating, ventilating, and air conditioning systems that comply with the provisions of section 9.2 and are installed in accordance with the manufacturer's specifications. 19.5.2.1, 9.2, NFPA 90A, 19.5.2.2 Findings include:

a) Exhaust in patient rooms was not pulling air through the exhaust grills. The test used was a 4x4 tissue that would not hold against the grill when applied. The test was in the presence of maintenance director.

b) Maintenance Director was unable to show location of Outside Air intakes for building. Maintenance Director indicated that the fresh air intakes were closed.

c) Rooms on patient wings and ED Department air flow was not tested, air exchanges could not be verified ( outside air and overall air exchanges).

1) Based on observation and interview with staff, the facility failed to provide Piped in medical gas systems that comply with NFPA 99, Chapter 4. Findings include:

a) The Medical Gas Supply System is not provided with Duel Line Regulators

b) The bottled reserve was turned off at the time of the survey. Maintenance Director verified that the reserve was turned off.

c) The bottled reserve low level reserve alarm indicator did not work. The Medical gas master alarm was not indicating bottled reserve pressure low or off .

d) There was no area alarm for the ED Department.

e) Master alarm panel alarms was not functioning.

1) Based on observation and interview with staff, the facility failed to provide Hospitals, with life support equipment, that have a Type I Essential Electrical System powered by a generator with a transfer switch and has a separate power supply. The EES is in accordance with NFPA 99, 3.4.2.2, 3.4.2.1.4. Findings include:

a) The battery back up light over the transfer switch in the basement was not working.

b) There is not Remote Annunciator located in the hospital.

1) Based on observation and interview with staff, the facility failed to maintain design features constructed for the building. To continue to meet the performance goals and objectives of this Code, the Building shall be maintained in accordance with performance goals and objectives that include complying with all documented assumptions and design specifications. Any variations shall require the approval of the authority having jurisdiction prior to the actual change in accordance with NFPA 101, 2000 edition, chapter 5.1.7., 5-8.14 Findings include:

a) The Emergency Department is a Critical Care Area and was defined and designed by one room immediately adjacent to the east exit, however rooms that are a part of X-Ray and Old Surgery Suite have been used as part of the Emergency Department over flow. Waiting areas for Emergency Patients are in the egress corridor adjacent to the east exit and in the X-Ray area.

Based on observation and interview with staff, the facility failed to maintain Fixed eye baths that are designed and suitable for quick drenching or flushing of the eyes, and will avoid injurious water pressure in accordance with NFPA 99. 10.6 Findings include:

a) The eye wash in the lab was not being logged and tested monthly.

1) Based on observation and interview with staff, the facility failed to provide Master alarm panels that are in two separate locations and have audible and visible signals. There are high/low alarms for +/- 20% operating pressure. NFPA 99, 4.3.1.2.2 Findings include:

a) There is a master alarm panel at the nurses station, however low level alarm is not connected, other required alarms as defined in NFPA 99 1999 edition Gas Warning chapter 4-3.1.2.2 ( b ) 1,2,3 could not be identified or verified.

b) Area alarm required at the Ed Departments was not installed in accordance Gas Warning 4-3.1.2.2 (c ) .

Based on observation and interview with staff, the facility failed to provide a Type I EES that is divided into the critical branch, life safety branch and the emergency system in accordance with NFPA 99. 3.4.2.2.2. Findings include:


a) Branches that are required to be Life Safety, Critical Care and Equipment could not be identified. New circuits installed to patient rooms were wired and connected to panels that has Life Safety,Critical Care and other miscellaneous Equipment combined on that branch panel.

1) Based on observation and interview with staff, the facility failed to provide Electrical wiring and equipment that is in accordance with NFPA 70, National Electrical Code. 9.1.2 Findings include:

a) The Bio Medical testing is accomplished by an outside staff member under agreements of contract. ?482.12(e) Standard of Contracted Services; requires that the governing body be responsible for services furnished in the hospital whether or not they are furnished under contracts. The governing body must ensure that a contractor of services (including one for shared services and joint ventures) comply with all applicable conditions of participation and standards for the contracted services. The facility could not provide documentation that the contractor tested equipment in accordance with manufactures recommendations (the facility did not verify by comparing manufactures preventive maintenance guidelines with documentation compiled by contractors tests results).