HospitalInspections.org

Based on random observation during the survey walk-through, staff interview and review of Life Safety Plans dated 10-15-10 produced by Shive-Hattery Architects in Moline, IL, the construction type of the building does not comply with NFPA 101 - 2000, 19.1.6.2. This deficiency could affect all in-patients in the facility, as well as those residents of the Long Term Care portion of the building and any staff and visitors present, because the lack of protection of the building structure from the effects of fire exposure can cause building collapse prior to evacuation.

Findings include:

A. The original 1934 building area is partially sprinklered and indicated to be of Type III (000) construction type and is two stories with a basement. The building construction type is not permitted under Table 19.1.6.2. Surveyor notes that the original building area is not otherwise separated from the Hospital by 2-hour rated construction on all floor levels to allow it to be classified as a separate non-healthcare occupancy building. The 2-hour separation is indicated to only exist on the 2nd floor.

B. The 1954 and 1974 building areas are indicated to be of Type II (000) construction type. These building areas are also two stories with a basement. The building construction type is not permitted under Table 19.1.6.2 without full sprinkler protection. The building areas are only partially sprinkler protected.

UPDATE 3/7/13: Pending the facility architect has not completed the "assessment". This was to have been completed by 1/31/13 and is now scheduled to be completed by 3/31/13.
Formal Documentation Preparation and submission to IDPH due 11/1/12 revised date 7/1/13
IDPH Review due 1/1/12 revised date 8/15/13
Bidding and award of project to take place on 3/1/13 revised to 10/1/13
Construction start date was anticipated 4/1/13 revised to 12/1/13
Completion date 6/30/13 revised to 12/1/14.

Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1 and 8.4.1. These deficiencies could affect all patients on the 1st and 2nd floors of the facility, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into the building's exit access corridors.

Findings include:

A. Corrected 04/20/2012.

B. Corrected 04/20/2012.

C. Corrected 04/20/2012.

D. The 2nd floor south wing Clean Storage area is not separated from adjacent areas by 1-hour rated construction to comply with 19.3.2.1. The walls to adjacent areas contain windows and the doors are non-rated and have louvers. The corridor door is rated but is damaged to where the fire rating can not be verified to be maintained. The door si equipped with a "helper wheel" to keep it from dragging on the floor. The closer on this door is equipped with a hold-open feature.

UPDATES 08/22/2012: The corridor door to this Clean Storage Room which is required to be self-closing has beeen corrected but part of the plan of correction is to sprinkler the area and has yet to be completed.

E. The 2nd floor south wing "Women's Patient room" bathroom area utilized as a storage area was not separated by 1-hour rated wall construction and the corridor door was not minimum 3/4-hour rated to comply with 19.3.2.1.

F. The 2nd floor Linen Storage room (former Seclusion room) was not verified to be separated by 1-hour rated wall construction. The corridor door was not minimum 3/4-hour rated to comply with 19.3.2.1.

G. Corrected 04/20/2012.

H. The 2nd floor Pharmacy area constitutes a hazardous area due to the storage of combustible materials. The Pharmacy was not protected by 1-hour rated construction in accordance with 19.3.2.1 or otherwise sprinklered in accordance with 8.4.1.

UPDATE 3/7/13:The corridor doors required to be self-closing has beeen corrected but part of the plan of correction is to sprinkler the area which has not been completed.
Pending sprinkler coverage or building replacement. The facility architect has not completed the "assessment". This assessment was to have been completed by 1/31/13 and is now scheduled to be completed by 3/31/13.
Formal Documentation Preparation and submission to IDPH due 11/1/12 revised date 7/1/13
IDPH Review due 1/1/12 revised date 8/15/13
Bidding and award of project due 3/1/13 revised to 10/1/13
Construction start date was anticipated 4/1/13 revised to 12/1/13
Completion date 6/30/13 revised to 12/1/14.

Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

Based on random observation during the survey walk-through, not all portions of the facility's electrical distribution system are in accordance with NFPA 70 1999.

Findings include:

A. Corrected 04/20/2012.
B. Corrected 04/20/2012.

C. During the facility walk-through on the afternoon of July 5th 2011 the emergency power breaker panels were observed with non-essential circuits powered from them with no separation of the 3 required branches of Critical, Life Safety and Equipment branches in accordance with 517-30 (b).

This deficiency could cause the overloading of the emergency generator causing failure which could result in patient injury.

UPDATE 3/7/13: Pending the facility architect has not completed the "assessment". This was to have been completed by 1/31/13 and is now scheduled to be completed by 3/31/13.
Formal Documentation Preparation and submission to IDPH due 11/1/12 revised date 7/1/13
IDPH Review due 1/1/12 revised date 8/15/13
Bidding and award of project to take place on 3/1/13 revised to 10/1/13
Construction start date was anticipated 4/1/13 revised to 12/1/13
Completion date 6/30/13 revised to 12/1/14.