HospitalInspections.org

Based on observation and staff interviews it was determined the facility failed to maintain the rating of structural members.
This could place the ground floor mechanical room and third and fourth floor at risk in the event of fire
The findings include:
During a tour of the facility with Staff M on 05/16/2017 between 8:30 am and 1:30 pm observation revealed that the fire proofing on the steel beams had been removed in several areas in the following locations.
1. Ground floor mechanical room
2. Third floor mechanical room located near labor and delivery
These findings were confirmed by Staff M at the time of discovery.
Reference
2012 NFPA 101 Chapter 19 section 19.1.6.1

Based on observation, and staff interviews it was determined the facility failed to maintain doors in exit passageways to close properly.
This could place stair 7, new tower 5th floor and level one at risk in the event of fire
The findings include:
During a tour of the facility with Staff M on 05/16/ 2017 between 8:30am and 1:30 pm observation revealed the following
1. The door to stair 7 on the fourth floor does not close completely
2. 5th floor smoke compartment separation doors missing smoke detector on either side of door
3. Elevator lobby door on new tower does not have a smoke detector on the corridor side within 5 feet of the door
4. Level one new tower smoke compartment 1-3 door 1B-0396 sticks on floor when opened
These findings were confirmed by Staff M at the time of discovery.
Reference
2012 NFPA 101 Chapter 19 section 19.1.1.1.3; 19.2.2.2.7; Chapter 4 section 4.5.8; 4.6.12.1; Chapter 7 section 7.2.1.8.2

Based on observation, and staff interviews it was determined the facility failed to maintain exit signs with continuous illumination.
This could place people using stair 2 at risk in the event of fire or other emergency.
The findings include:
During a tour of the facility with Staff M on 05/16/2017 between 8:30 am and 1:30pm observation revealed that the exit sign at the exterior egress door for stair 2 is not illuminated.
These findings were confirmed by Staff M at the time of discovery.
Reference
2012 NFPA 101 Chapter 19 section 19.2.10.1; Chapter 7 section 7.10.5.2.1

Based on observation, and staff interviews it was determined the facility failed to maintain hazardous areas by smoke resident partitions and doors that will automatically close.
This could place the hypobaric chamber, electrical and fire pump room and third and fourth floor at risk in the event of fire.
The findings include:
During a tour of the facility with Staff M on 05/16/2017 between 8:30 am and 1:30 pm observation revealed the following.
1. The electrical room off the fire pump room has several penetrations in the wall where conduit penetrates the wall.
2. The soiled utility room door at room 492 will not close completely
3. The 3rd floor electrical room has mixed fire stop products in the same penetration in multiple locations
4. The self-closer for the door on the equipment gas operational room for the hypobaric chamber has been removed.
These findings were confirmed by Staff M at the time of discovery.
Reference
2012 NFPA 101 Chapter 19 section 19.3.2.1; 19.3.2.1.3; Chapter 8 section 8.4.4

Womens Imaging Center
Based on observation, and staff interviews it was determined the facility failed to properly identify and mark the circuit for the fire alarm control panel at the fire alarm control panel and identify the circuit for the fire alarm control panel and provide the circuit with mechanical protection

This could place the facility at risk in the event of an electrical malfunction.

The findings include:
During a tour of the facility with Staff M on 05/16/2017 between 8:30 am and 1:30 pm observation revealed the following.
1. The fire alarm control panel in the electrical room of the fire pump room does not have the circuit and circuit location identified at the fire alarm control panel. The circuit breaker is not marked red and does not have a mechanical lock.

These findings were confirmed by Staff M at the time of discovery.

Reference
2012 NFPA 101 Chapter 19 section 19.3.4.1; Chapter 9 section 9.6.1.3
2012 NFPA 72 Chapter 10 section 10.5.5.2; 10.5.5.3

Based on observation, and staff interviews it was determined the facility failed to properly identify and mark the circuit for the fire alarm control panel at the fire alarm control panel and identify the circuit for the fire alarm control panel and provide the circuit with mechanical protection
This could place the facility at risk in the event of an electrical malfunction.
The findings include:
During a tour of the facility with Staff M on 05/16/2017 between 8:30 am and 1:30 pm observation revealed the following.
1. The fire alarm control panel in the electrical room of the fire pump room does not have the circuit and circuit location identified at the fire alarm control panel. The circuit breaker is not marked red and does not have a mechanical lock.
2. The fire alarm control panel in the maintenance room does not have the circuit and circuit location identified at the fire alarm control panel. The circuit breaker is not marked red and does not have a mechanical lock.
These findings were confirmed by Staff M at the time of discovery.
Reference
2012 NFPA 101 Chapter 19 section 19.3.4.1; Chapter 9 section 9.6.1.3
2010 NFPA 72 Chapter 10 section 10.5.5.2; 10.5.5.3

Based on observation, review of facility records, and staff interviews it was determined the facility failed to maintain the fire alarm system.
This could place the facility at risk in the event of fire.
The findings include:
During a tour of the facility with Staff M on 05/16/2017 between 8:30 am and 1:30 pm observation revealed the following.
1. There is a trouble signal on the fire alarm control panel; located in the electrical room off the fire pump room and on the fire alarm control panel located in the maintenance office.
2. There are no records of sensitivity testing being conducted on the smoke detectors.
These findings were confirmed by Staff M at the time of discovery.
Reference
2012 NFPA 101 Chapter 19 section 19.3.4.1; Chapter 9 section 9.6.1.3; 9.6.1.5, 9.6.2.10.1.1
2010 NFPA 72 Chapter 14 section 14.4.5.3.1; 14.4.5.3.2

Based on observation, and staff interviews it was determined the facility failed to supervise the control valve in the fire main pit.
This could place the facility at risk in the event of fire.
The findings include:
During a tour of the facility with Staff M on 05/16/2017 between 8:30 am and 1:30 pm observation revealed that fire sprinkler control valves in the valve pit do not have supervisory attachments to monitor for integrity.
These findings were confirmed by Staff M at the time of discovery.
Reference
NFPA 101 2012 edition Chapter 19 Section 19.3.5.1, Chapter 9 section 9.7.2.1, NFPA 72 2010 edition Chapter 23 Section 23.8.5.6.1

Based on observation, review of facility records, and staff interviews it was determined the facility failed to conduct the 5 year internal inspection on the fire sprinkler system.
This could place the facility at risk in the event of fire.
The findings include:
During a review of records with Staff M on 05/16/2017 between 8:30 am and 1:30 pm observation revealed that there are no records of a 5 year internal inspection on the fire sprinkler system.
These findings were confirmed by Staff M at the time of discovery.
Reference
2012 NFPA 101 Chapter 19 section 19.3.7.3; Chapter 9 section 9.7.5
2011 NFPA 25 Chapter 14 section 14.2.1

Based on observation, and staff interviews it was determined the facility failed to maintain smoke barriers to a ½ hour fire resistant rating.
This could place the smoke compartment for and adjacent to the physical therapy room and smoke compartment 3-3 and the smoke compartment adjacent to 3-3 at risk in the event of fire.
The findings include:
During a tour of the facility with Staff M on 05/16/2017 between 8:30 am and 1:30 pm observation revealed the following.
1. There is an unsealed penetration in the smoke wall above the ceiling at the cross corridor doors at the physical therapy room.
2. There is an unsealed penetration above the ceiling at the cross corridor doors to smoke compartment 3-3 located near room 366.
These findings were confirmed by Staff M at the time of discovery.
Reference
2012 NFPA 101 Chapter 19 section 19.3.7.3; Chapter 8 section 8.5.6

Based on observation, review of facility records, and staff interviews it was determined the facility failed to hold fire drills at unexpected times under varying conditions, at least quarterly on each shift.
This could place the 3rd shift at risk in the event of fire.
The findings include:
During a review of facility records with Staff M on 05/16/2017 between 8:30 am and 1:30 pm observation revealed that the 3rd shift did not participate in a fire drill during the first quarter of 2017.
These findings were confirmed by Staff M at the time of discovery.
Reference
2012 NFPA 101 Chapter 19 section 19.7.1.6