HospitalInspections.org

A. The Gift Shop walls utilized a woodgrain finish material which appeared to be in excess of 10% of the total wall and ceiling area was not confirmed to comply with Class A or Class B requirements required by 19.3.3.2 and 10.2. This material was also utilized in the main lobby area.

A. Use areas are not separated from exit access corridors or otherwise protected in accordance with the exceptions under 19.3.6.1. The following conditions were observed:

1. The 1st floor former main lobby area is being utilized as the temporary waiting area for the ER. This area is within a smoke compartment that is not fully protected by sprinklers and is not provided with 24-hour direct observation or provided with adequate smoke detection to comply with 19.3.6.1 Exception No. 2.

2. The 1st floor Imaging/Lab waiting area adjacent the ER waiting area is within a smoke compartment that is not fully protected by sprinklers and is not provided with 24-hour direct observation or provided with adequate smoke detection to comply with 19.3.6.1 Exception No. 2.

3. The 1st floor (new) main lobby area (including the Health Education kiosk area) is within a fully sprinklered smoke compartment but is not provided with 24-hour direct supervision or provided with smoke detection to comply with 19.3.6.1 Exception No. 2.

4. The Basement Nuclear Med waiting area is within a smoke compartment that is not fully protected by sprinklers and is not provided with 24-hour direct observation or smoke detection to comply with 19.3.6.1 Exception No. 2.

5. The 2nd floor corridor area near Elevator S40 & Stair outside the Rehab area was being utilized for patient treatment in non-compliance with 19.3.6.1. A stair simulator was stationed in the corridor area and a patient was observed being assisted using the stair simulator at that time of the survey.

A. The 2nd floor S90 Procedure Room pair of corridor doors is equipped with a power opener and the doors have an astragal. The doors were observed to lack a coordinator which prevented the doors from being closed completely upon manual or power assisted operation.

B. The 2nd floor Stage II Recovery suite north doors S56 are provided with power openers and magnetic locks. Upon testing of the doors and locks, it was possible to disrupt the sequence of operation such that the doors would not open manually or under power operation. The openers were required to be manually turned off and once opened, it was difficult to manually or automatically bring the doors to a closed and latched condition.

A. Hazardous areas are not protected in accordance with 19.3.2.1. Conditions observed include the following:

1. The sprinklered 2nd floor ICU Storage room door is not self-closing.

2. The sprinklered 2nd floor ICU Janitor closet storing combustibles is not self-closing.

3. The 2nd floor sprinklered Soiled Holding room door at the 2005 building elevator core area across from the wheelchair alcove was not self-closing to a latched condition.

4. The 2nd floor sprinklered Equipment Storage room adjacent room 256 was not self-closing.

5. The 2nd floor sprinklered storage closet in the Rehab Administration area was not self-closing.

6. The sprinklered 2nd floor Surgery Implant Storage room door was not self-closing.

7. The springklered 1st floor storage closet door near exit Stair F04 was not self-closing.

8. The sprinklered 1st floor Human Resources office area contained open rolling files deemed to constitute a degree of hazard greater than normal to the general occupancy. The corridor door was a labeled fire rated door, but was not equipped with a closer.

9. The sprinklered 1st floor linen closet near the Critical Decision Unit was not self-closing.

10. The 1st floor corridor extension through the new construction area was not separated from the remainder of the construction area. One of the two temporary doors in the separation wall was not equipped with door (latching) hardware.

11. The sprinklered 1st floor (1974 addition) Med/Surg unit Soiled Utility room door was taped to prevent positive latching.


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Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with NFPA 101 2000 19.3.2.1.

Findings include:

B. The return fan room was observed to have a duct passing through a designated 2-hour fire barrier wall into the elevator equipment room without the penetration being constructed in accordance with 2-hour rating. The duct duct did not have a fire damper to maintain the separation in accordance with 8.2.3.2.4.

A. The open shelving rolling file storage system is not enclosed or separated from other parts of the building by 1-hour rated construction to comply with 39.3.2.1 and 8.4. The file area must be traversed to access/exit a staff lounge/toilet room.

Based on random observation during the survey walk-through, not all hazardous areas are separated in accordance with NFPA 101 2000.

Findings include:

A. The furnace equipment room was observed to have 2 gas fired furnaces installed in a non-sprinkler protected room with the ceiling area open to adjacent areas and lacks 1 hour separation to comply with 8.4.1.1 (1).

A. The 2nd floor Rehab Administration area exiting does not appear to comply with applicable requirements.

1. The area is provided with an exit stair and exit access through a 2-hour barrier into an adjacent suite. If these two exits (horizontal exit and the exit stair) are intended to meet the requirement for two exits, they are not remote from each other to comply with 7.5.1.3.

2. It did not appear that the designation of a single exit (stair) complies with the requirements of the Exceptions to 39.2.4.2.

B. The 1st floor garden area is provided with one marked exit access door. This exit access and the other two doors serving the garden courtyard are locked after hours to prevent access to and exiting from the garden courtyard in non-compliance with 19.2.2.2.4. The marked exit is not provided with hardware that will always allow exiting from the courtyard.

C. The 2nd floor ICU suite is not compliant with 19.2.5. The suite is indicated to be 4200 square feet with only a single compliant exit access to the corridor which does not comply with 19.2.5.2. An exit access is directed through the Recovery room in non-compliance with 19.2.5.1 Exceptions No.2 & 3. The bed stations are equipped with horizontal sliding doors. The aisle within the suite is the first intervening room. The Recovery room is the second intervening room.

A. Exit stair enclosures are not maintained in accordance with 8.2.5.2 and 19.3.1.1.

1. The 2nd floor exit stair door 358 is not positive latching. The panic device latch throw does not adequately engage the strike.

2. An access panel in the stair near Conference rooms B/C is not self-closing to a latched condition due to the removal of the spring closer.

Based on random observation during the survey walk-through, not all stair enclosures used as exits are constructed in accordance with NFPA 101 2000.

Findings include:

A. The ramp at the Penthouse/Roof/Helipad level is not provided with handrails to comply with 7.2.5.4.


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B. The service elevator equipment room was observed with a section of the indicated 2-hour wall between it and the stair enclosure to be incomplete and not in accordance with 7.1.3.2.1 for a rated separation. A duct at this indicated 2-hour barrier was not provided with a fire damper.

A. Magnetic locking devices controlled by key card and push button are utilized which do not comply with 7.2.1.6.2, Access-Controlled Egress Doors. Where the locking device is the only means of securing the door, corridor/storage room doors are not provided with positive latching upon closure when the locks are required to release under fire alarm activation. The doors lack the sensors on the egress side required by 7.2.1.6.2(a). Locations observed include but are not necessarily limited to the following:

1. The 2nd floor ICU Med room.
2. The 2nd floor Stage II Recovery room Med room.
3. The 2nd floor Stage II Recovery room corridor doors.
4. The 2nd floor Med/Surg unit Med rooms.
5. The 2nd floor Stage I Recovery Med room.
6. The 1st floor Pharmacy.
7. The 1st floor Critical Decision Unit Med room.

B. Door hardware is provided that requires more than one operation to release the door in non-compliance with 7.2.1.5.4. Dead bolt locks, combination locks or slide hasp locks are utilized in addition to other latching/locking devices or the dead bolt lock is not self-latching when it is the the only means of providing latching for a corridor door. Locations/devices observed include but are not necessarily limited to the following:

1. At 2nd floor Operating Room doors - dead bolts.
2. At 2nd floor Rehab Administration corridor door - dead bolts.
3. At 1st floor EVS room near Pharmacy - combination lock.
4 At 1st floor X-ray rooms 1 & 2 - dead bolts.
5. The 1st floor Gift Shop - dead bolt.
6. The Basement Respiratory Clinic door B88 - dead bolt.
7. The Basement Central Sterile Processing door B40 (others may also exist) - slide hasp lock.

A. Exit discharge lighting at the Stair (near Elevator #3) did not appear to be provided with 2 lamps to comply with 7.8.1.4.

Based on random observation during the survey walk-through, not all exits to the outside are illuminated in accordance with NFPA 101 2000.

Findings include:

A. The south exit was observed to have no exterior light fixture installed for lighting the egress path from the building in accordance with 7.8.1.4.

A. Exit routes are not clearly defined to comply with 18.2.10. Conditions observed include but are not necessarily limited to the following:

1. The exit sign at the stair on the Penthouse level is not fully visible from the direction of viewing. (Sign is mounted parallel with wall rather than perpendicular to wall)

2. 2nd floor - Exit signage is not visible from the northern section of the ICU suite. (See also K032)

3. 2nd floor - The exit sign at the cross corridor doors near room 228 has a directional arrow when the indicated direction is not approprite.

4. 2nd floor - Exit signage to identify the 2nd available exit path in the corridor is not provided.

5. 2nd floor - The exit signage provided at the Surgery suite is altered/covered due to the temporary closure of the exit stair discharging to the construction area. Only a single exit access is defined for this suite of 9230 square feet. Although Interim Life Safety Measure (ILSM) hazard surveillance is reported to be conducted, available paths can be defined within the suite if signage placement is altered to eliminate deficient dead end and travel distance conditions.

6. 1st floor - The cross corridor doors near Doctors Lounge 122 are single directional swing. These doors are not designated as part of a smoke barrier or horizontal exit. The exit sign on the north side of the doors directs occupants against the direction of door swing in non-compliance with 7.2.1.4.2.

7. 1st floor - The east/west corridor between the Imaging and ER suites is not provided with defined exit route due to the closure of the exterior door now leading into the new ER addition construction area. A dead end of excessive length is also created. Although ILSM hazard surveillance is reported to be conducted, exit signage placement can be altered to direct occupants out of the corridor serving the suites and not direct occupants into the dead end corridor.

8. 1st floor - Exit signage at the corridor near 114 blocked.

9. 1st floor -Exit signage within the nearly completed Med/Surg construction project directs occupants to dead end conditions.

10. Basement - The 4600 square foot Lab suite has only one defined exit access.

11. Basement - The East Boiler room areas consisting of multiple interconnected rooms does not have exit access identified.

12. Basement - Exit signage at the Cardiac Rehab suite is altered/covered due to the temporary closure of the exit stair discharging to the construction area. Although Interim Life Safety Measure (ILSM) hazard surveillance is reported to be conducted, available paths can be defined within the suite if signage placement is altered to redirect exiting to available corridor exit accesses.

13. Basement - Exit signage is not provided at the corridor at the 2005 building addition elevators to define the 2nd path to an exit.

14. Basement - Exit signage is not provided to identify the 2nd path from the area north of doors B38.

A. Exit signage at the north end of the hall is not mounted to be clearly visible from the direction viewed. The sign is mounted flat on the wall rather than perpendicular to the wall.

Based on random observation during the survey walk-through, not all portions of the building fire alarm system are installed in accordance with NFPA 72 1999.

Findings include:

A. Durinng testing of the fire alarm system, the strobes (minimum of 3 within 50') located near the Nuclear Med waiting area were observed not to be synchronized to comply with with NFPA 72, 4-4.4.2.3.


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B. Based on random observation during the survey of the ICU Suite A on second floor a smoke detector was observed installed less than 3' from a supply grill in the small storage room and not in accordance with NFPA 72, 2-3.5.1.

C. The decorative ceiling strip lighting in the ICU suite was observed to be open to the ceiling cavity above which would allow products of combustion to escape into the void above compromising the smoke detection thus not in accordance with NFPA 72, 2-3.6.1.4.

Based on random observation during the document review process, not all portions of the facilities fire protection system and tested and maintained in accordance with NFPA 72 1999.

A. The document review process indicated that the detection devices in the construction area had not been functionally tested in over 1 year and not in accordance with Table 7-3.2 for annually testing.

B. The document review process indicated that the detection devices for elevator recall had not been functionally tested in over 1 year and not in accordance with Table 7-3.2 for annually testing.

Based on random observation during the survey walk-through, not all smoke detectors are installed in accordance with NFPA 72 1999.

Findings include:

A. During the walk-through, smoke detectors installed in the large treatment area were observed to be installed more than 12" below the ceiling and not in accordance with 2-3.4.3.1.

A. The 2nd floor smoke compartment containing the ICU is indicated to be fully sprinklered. However, the small linen closet near the corridor entrance was not provided with sprinkler protection.

B. Data/Comm rooms provided with sprinkler protection were observed to have ceiling tile within the room missing or not set in the grid which allows the space to be open to the ceiling cavity above compromising the activation of the sprinklers. Locations observed include but are not necessarily limited to the following:

1. 2nd floor S71.
2. 2nd floor S39.

C. Sprinkler piping was observed to have other wiring and systems attached to or being supported by the sprinkler system piping in non-compliance with NFPA 13. Locations observed include but are not necessarily limited to the following:

1. 2nd floor near the cross corridor smoke barrier doors near the S90 Procedure room.

2. 1st floor near the Equipment alcove near Radiology Administration F125.

D. The sprinkler piping observed in the Basement 'Tile room' B81 was missing a hanger rod. The clevis was on the pipe but the hanger rod was missing.

E. The sprinkler head in the Surgery housekeeping closet was observed to be obstructed by the surface mounted light fixture installed within inches of head and which extended below the deflector.

F. The 1st floor Pharmacy contained shelving units in the middle of the room in which the required 18" clearance under the sprinkler head(s) was not provided.

Based on random observation during the survey walk-through, not all portions of the facilities air conditioning and ventilation systems are installed in accordance with NFPA 90A 1999.

Findings include:

A. Ductwork access panels through-out the facility were observed without labeling at least 1/2 " high describing the fire safety device within in accordance with 2-3.4.2.

Based on random observation during the survey walk-through, not all portions of the facilities cooking equipment is installed and maintained in accordance with NFPA 96 1998.

Findings include:

A. The Second Floor Re-Hab Area was observed with a room identified as Kitchen with an operable electric stove installed, without a hood to exhaust possible grease laden vapors and hood suppression system in accordance with NFPA 96.

A. The stair near Conference rooms B/C was observed with traffic cones at the intermediate and bottom landings obstructing the stairs.

B. The exit stair serving the Penthouse/Roof/Helipad level is provided with a chain at the intermediate landing above the 2nd floor level to discourage public access to the upper level. The chain across the stair is not an easily removable device in the direction of egress due to the method of attachment and when removed can be a tripping hazard on the stair.

C. The designated exit passageway serving the stair discharging near the ER entrance contained wheelchair storage and an unbrella bag dispensor. The infection control dispensors may remain provided they are located not to obstruct the corridor. The stair discharge did not otherwise comply with 7.7.2 due to lack of complete sprinkler protection of the area.

D. The 2nd floor Med/Surg corridors contained numerous unattended equipment stationed or being charged which obstructed the clear width of the corridor.

E. The 2nd floor corridor at the nurse station near room 224 contained numerous carts and equipment not in use which obstructed the clear width of the corridor.

A. Medical gas storage is not in compliance with NFPA 99, 1999, 8-3.1.11.2. Oxygen tanks stored in sprinklered areas are not separated by minimum 5'-0" from combustibles. Locations observed include but are not necessarily limited to the following:

1. At the 2nd floor Equipment storage room across from the Med room adjacent the center nurse station of the Med/Surg unit.

2. At the 2nd floor Clean Holding room near 237.

3. At the 2nd floor Stage I Recovery room storage room. (Signage also indicated that a maximum of 4 tanks are to be stored, but 10 tanks were stationed at this location).

Based on random observation during the survey walk-through, not all portions of the piped medical gas system are installed in accordance with NFPA 99 1999.

Findings include:

A. The Master Medical Gas Panel in the Emergency Room Area was observed to only display Oxygen and Medical Vacuum and not all piped medical gases in accordance with 4-3.1.2.2 (b) 2.

Based on random observation and staff interview, not all portions of the facilities emergency generators are installed in accordance with NFPA 99 and 110 1999.

Findings include:

A. The room housing Emergency Generator # 1 was observed to have a battery powered light installed over the door and cord connected to an outlet. NFPA 110 requires the Battery light and charger to be wired to the load side of the transfer switch in accordance with 5-3.1.

B. During an interview held in the generator #1 room with the Director of Facilities it could not be determined if the room lighting is powered from the load side of the transfer switch in accordance with 5-3.1.

C. During the facility walk-through it could not be determined if the shared fuel supply tank for the 3 generators and boilers was provided with a low level alarm set at the minimum level to provide the run time for the generators in accordance with 3-4.2.2.

D. Generators #2 and #3 were provided with remote emergency stop switches mounted in the enclosure for the paralleling gear. Chain link fence was provided on both sides and across the back allowing the only access from one end that required passing both generator enclosures to reach the remote stops for the generators. This arrangement was not clear to the surveyor and staff as to how access to the remote stops was provided if a possible malfunction of one generator prevented access to the remote stop before the other may be affected. Compliance with the intent of NFPA 110 5-2.6 did not appear to be met.

E. During a staff interview held with the Director of Facilities in the boiler room it was discovered the generators were connected to only a single remote monitor in the Operator location and not one in the maintenance work area in accordance with NFPA 99 3-4.1.1.15.

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 facilities emergency electrical system are installed and maintained in accordance with NFPA 99 1999.

Findings include:

A. The main fire alarm control panel was observed to be powered from the critical branch of the emergency electrical system and not from the life safety branch in accordance with 3-4.2.2.2 (b) 3 a.

A. Open junction boxes were observed above the ceiling near the smoke barrier at the west end of the connecting hall near door S52.

B. Panel directories observed on the 2nd floor did not label the specific use of the circuits as to room locations or areas served. "Receptacles" and "lighting" does not adequately define the individual use of the circuits. All panel directories should be reviewed and updated or revised.

C. The wiring and lighting provided within the short section of the corridor extending through the new construction area was not in comformance with NFPA 70. This corridor was still unfinished at the time of the survey, but was being utilized as a required exit route to the exterior. Lighting provided was non-functional. No exit discharge lighting was provided. Connections and support of wiring systems was by wire-nuts only without conduits or boxes.


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

Findings include:

A. During the survey walk-through data, voice and fire alarm cabling was observed to be supported by ceiling grid and other items and not from the structure in accordance with 800-6.

B. Electrical outlets were observed in critical patient care areas which were not labeled with the panel and circuit serving them in accordance with 517-19. Areas include:

1. The Emergency Rooms.

2. The ICU Suite was observed without clear panel identification to match outlet labeling.

A. The Gift Shop walls utilized a woodgrain finish material which appeared to be in excess of 10% of the total wall and ceiling area was not confirmed to comply with Class A or Class B requirements required by 19.3.3.2 and 10.2. This material was also utilized in the main lobby area.

A. Use areas are not separated from exit access corridors or otherwise protected in accordance with the exceptions under 19.3.6.1. The following conditions were observed:

1. The 1st floor former main lobby area is being utilized as the temporary waiting area for the ER. This area is within a smoke compartment that is not fully protected by sprinklers and is not provided with 24-hour direct observation or provided with adequate smoke detection to comply with 19.3.6.1 Exception No. 2.

2. The 1st floor Imaging/Lab waiting area adjacent the ER waiting area is within a smoke compartment that is not fully protected by sprinklers and is not provided with 24-hour direct observation or provided with adequate smoke detection to comply with 19.3.6.1 Exception No. 2.

3. The 1st floor (new) main lobby area (including the Health Education kiosk area) is within a fully sprinklered smoke compartment but is not provided with 24-hour direct supervision or provided with smoke detection to comply with 19.3.6.1 Exception No. 2.

4. The Basement Nuclear Med waiting area is within a smoke compartment that is not fully protected by sprinklers and is not provided with 24-hour direct observation or smoke detection to comply with 19.3.6.1 Exception No. 2.

5. The 2nd floor corridor area near Elevator S40 & Stair outside the Rehab area was being utilized for patient treatment in non-compliance with 19.3.6.1. A stair simulator was stationed in the corridor area and a patient was observed being assisted using the stair simulator at that time of the survey.

A. The 2nd floor S90 Procedure Room pair of corridor doors is equipped with a power opener and the doors have an astragal. The doors were observed to lack a coordinator which prevented the doors from being closed completely upon manual or power assisted operation.

B. The 2nd floor Stage II Recovery suite north doors S56 are provided with power openers and magnetic locks. Upon testing of the doors and locks, it was possible to disrupt the sequence of operation such that the doors would not open manually or under power operation. The openers were required to be manually turned off and once opened, it was difficult to manually or automatically bring the doors to a closed and latched condition.

A. Hazardous areas are not protected in accordance with 19.3.2.1. Conditions observed include the following:

1. The sprinklered 2nd floor ICU Storage room door is not self-closing.

2. The sprinklered 2nd floor ICU Janitor closet storing combustibles is not self-closing.

3. The 2nd floor sprinklered Soiled Holding room door at the 2005 building elevator core area across from the wheelchair alcove was not self-closing to a latched condition.

4. The 2nd floor sprinklered Equipment Storage room adjacent room 256 was not self-closing.

5. The 2nd floor sprinklered storage closet in the Rehab Administration area was not self-closing.

6. The sprinklered 2nd floor Surgery Implant Storage room door was not self-closing.

7. The springklered 1st floor storage closet door near exit Stair F04 was not self-closing.

8. The sprinklered 1st floor Human Resources office area contained open rolling files deemed to constitute a degree of hazard greater than normal to the general occupancy. The corridor door was a labeled fire rated door, but was not equipped with a closer.

9. The sprinklered 1st floor linen closet near the Critical Decision Unit was not self-closing.

10. The 1st floor corridor extension through the new construction area was not separated from the remainder of the construction area. One of the two temporary doors in the separation wall was not equipped with door (latching) hardware.

11. The sprinklered 1st floor (1974 addition) Med/Surg unit Soiled Utility room door was taped to prevent positive latching.


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Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with NFPA 101 2000 19.3.2.1.

Findings include:

B. The return fan room was observed to have a duct passing through a designated 2-hour fire barrier wall into the elevator equipment room without the penetration being constructed in accordance with 2-hour rating. The duct duct did not have a fire damper to maintain the separation in accordance with 8.2.3.2.4.

A. The open shelving rolling file storage system is not enclosed or separated from other parts of the building by 1-hour rated construction to comply with 39.3.2.1 and 8.4. The file area must be traversed to access/exit a staff lounge/toilet room.

Based on random observation during the survey walk-through, not all hazardous areas are separated in accordance with NFPA 101 2000.

Findings include:

A. The furnace equipment room was observed to have 2 gas fired furnaces installed in a non-sprinkler protected room with the ceiling area open to adjacent areas and lacks 1 hour separation to comply with 8.4.1.1 (1).

A. The 2nd floor Rehab Administration area exiting does not appear to comply with applicable requirements.

1. The area is provided with an exit stair and exit access through a 2-hour barrier into an adjacent suite. If these two exits (horizontal exit and the exit stair) are intended to meet the requirement for two exits, they are not remote from each other to comply with 7.5.1.3.

2. It did not appear that the designation of a single exit (stair) complies with the requirements of the Exceptions to 39.2.4.2.

B. The 1st floor garden area is provided with one marked exit access door. This exit access and the other two doors serving the garden courtyard are locked after hours to prevent access to and exiting from the garden courtyard in non-compliance with 19.2.2.2.4. The marked exit is not provided with hardware that will always allow exiting from the courtyard.

C. The 2nd floor ICU suite is not compliant with 19.2.5. The suite is indicated to be 4200 square feet with only a single compliant exit access to the corridor which does not comply with 19.2.5.2. An exit access is directed through the Recovery room in non-compliance with 19.2.5.1 Exceptions No.2 & 3. The bed stations are equipped with horizontal sliding doors. The aisle within the suite is the first intervening room. The Recovery room is the second intervening room.

A. Exit stair enclosures are not maintained in accordance with 8.2.5.2 and 19.3.1.1.

1. The 2nd floor exit stair door 358 is not positive latching. The panic device latch throw does not adequately engage the strike.

2. An access panel in the stair near Conference rooms B/C is not self-closing to a latched condition due to the removal of the spring closer.

Based on random observation during the survey walk-through, not all stair enclosures used as exits are constructed in accordance with NFPA 101 2000.

Findings include:

A. The ramp at the Penthouse/Roof/Helipad level is not provided with handrails to comply with 7.2.5.4.


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B. The service elevator equipment room was observed with a section of the indicated 2-hour wall between it and the stair enclosure to be incomplete and not in accordance with 7.1.3.2.1 for a rated separation. A duct at this indicated 2-hour barrier was not provided with a fire damper.

A. Magnetic locking devices controlled by key card and push button are utilized which do not comply with 7.2.1.6.2, Access-Controlled Egress Doors. Where the locking device is the only means of securing the door, corridor/storage room doors are not provided with positive latching upon closure when the locks are required to release under fire alarm activation. The doors lack the sensors on the egress side required by 7.2.1.6.2(a). Locations observed include but are not necessarily limited to the following:

1. The 2nd floor ICU Med room.
2. The 2nd floor Stage II Recovery room Med room.
3. The 2nd floor Stage II Recovery room corridor doors.
4. The 2nd floor Med/Surg unit Med rooms.
5. The 2nd floor Stage I Recovery Med room.
6. The 1st floor Pharmacy.
7. The 1st floor Critical Decision Unit Med room.

B. Door hardware is provided that requires more than one operation to release the door in non-compliance with 7.2.1.5.4. Dead bolt locks, combination locks or slide hasp locks are utilized in addition to other latching/locking devices or the dead bolt lock is not self-latching when it is the the only means of providing latching for a corridor door. Locations/devices observed include but are not necessarily limited to the following:

1. At 2nd floor Operating Room doors - dead bolts.
2. At 2nd floor Rehab Administration corridor door - dead bolts.
3. At 1st floor EVS room near Pharmacy - combination lock.
4 At 1st floor X-ray rooms 1 & 2 - dead bolts.
5. The 1st floor Gift Shop - dead bolt.
6. The Basement Respiratory Clinic door B88 - dead bolt.
7. The Basement Central Sterile Processing door B40 (others may also exist) - slide hasp lock.

A. Exit discharge lighting at the Stair (near Elevator #3) did not appear to be provided with 2 lamps to comply with 7.8.1.4.

Based on random observation during the survey walk-through, not all exits to the outside are illuminated in accordance with NFPA 101 2000.

Findings include:

A. The south exit was observed to have no exterior light fixture installed for lighting the egress path from the building in accordance with 7.8.1.4.

A. Exit routes are not clearly defined to comply with 18.2.10. Conditions observed include but are not necessarily limited to the following:

1. The exit sign at the stair on the Penthouse level is not fully visible from the direction of viewing. (Sign is mounted parallel with wall rather than perpendicular to wall)

2. 2nd floor - Exit signage is not visible from the northern section of the ICU suite. (See also K032)

3. 2nd floor - The exit sign at the cross corridor doors near room 228 has a directional arrow when the indicated direction is not approprite.

4. 2nd floor - Exit signage to identify the 2nd available exit path in the corridor is not provided.

5. 2nd floor - The exit signage provided at the Surgery suite is altered/covered due to the temporary closure of the exit stair discharging to the construction area. Only a single exit access is defined for this suite of 9230 square feet. Although Interim Life Safety Measure (ILSM) hazard surveillance is reported to be conducted, available paths can be defined within the suite if signage placement is altered to eliminate deficient dead end and travel distance conditions.

6. 1st floor - The cross corridor doors near Doctors Lounge 122 are single directional swing. These doors are not designated as part of a smoke barrier or horizontal exit. The exit sign on the north side of the doors directs occupants against the direction of door swing in non-compliance with 7.2.1.4.2.

7. 1st floor - The east/west corridor between the Imaging and ER suites is not provided with defined exit route due to the closure of the exterior door now leading into the new ER addition construction area. A dead end of excessive length is also created. Although ILSM hazard surveillance is reported to be conducted, exit signage placement can be altered to direct occupants out of the corridor serving the suites and not direct occupants into the dead end corridor.

8. 1st floor - Exit signage at the corridor near 114 blocked.

9. 1st floor -Exit signage within the nearly completed Med/Surg construction project directs occupants to dead end conditions.

10. Basement - The 4600 square foot Lab suite has only one defined exit access.

11. Basement - The East Boiler room areas consisting of multiple interconnected rooms does not have exit access identified.

12. Basement - Exit signage at the Cardiac Rehab suite is altered/covered due to the temporary closure of the exit stair discharging to the construction area. Although Interim Life Safety Measure (ILSM) hazard surveillance is reported to be conducted, available paths can be defined within the suite if signage placement is altered to redirect exiting to available corridor exit accesses.

13. Basement - Exit signage is not provided at the corridor at the 2005 building addition elevators to define the 2nd path to an exit.

14. Basement - Exit signage is not provided to identify the 2nd path from the area north of doors B38.

A. Exit signage at the north end of the hall is not mounted to be clearly visible from the direction viewed. The sign is mounted flat on the wall rather than perpendicular to the wall.

Based on random observation during the survey walk-through, not all portions of the building fire alarm system are installed in accordance with NFPA 72 1999.

Findings include:

A. Durinng testing of the fire alarm system, the strobes (minimum of 3 within 50') located near the Nuclear Med waiting area were observed not to be synchronized to comply with with NFPA 72, 4-4.4.2.3.


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B. Based on random observation during the survey of the ICU Suite A on second floor a smoke detector was observed installed less than 3' from a supply grill in the small storage room and not in accordance with NFPA 72, 2-3.5.1.

C. The decorative ceiling strip lighting in the ICU suite was observed to be open to the ceiling cavity above which would allow products of combustion to escape into the void above compromising the smoke detection thus not in accordance with NFPA 72, 2-3.6.1.4.

Based on random observation during the document review process, not all portions of the facilities fire protection system and tested and maintained in accordance with NFPA 72 1999.

A. The document review process indicated that the detection devices in the construction area had not been functionally tested in over 1 year and not in accordance with Table 7-3.2 for annually testing.

B. The document review process indicated that the detection devices for elevator recall had not been functionally tested in over 1 year and not in accordance with Table 7-3.2 for annually testing.

Based on random observation during the survey walk-through, not all smoke detectors are installed in accordance with NFPA 72 1999.

Findings include:

A. During the walk-through, smoke detectors installed in the large treatment area were observed to be installed more than 12" below the ceiling and not in accordance with 2-3.4.3.1.

A. The 2nd floor smoke compartment containing the ICU is indicated to be fully sprinklered. However, the small linen closet near the corridor entrance was not provided with sprinkler protection.

B. Data/Comm rooms provided with sprinkler protection were observed to have ceiling tile within the room missing or not set in the grid which allows the space to be open to the ceiling cavity above compromising the activation of the sprinklers. Locations observed include but are not necessarily limited to the following:

1. 2nd floor S71.
2. 2nd floor S39.

C. Sprinkler piping was observed to have other wiring and systems attached to or being supported by the sprinkler system piping in non-compliance with NFPA 13. Locations observed include but are not necessarily limited to the following:

1. 2nd floor near the cross corridor smoke barrier doors near the S90 Procedure room.

2. 1st floor near the Equipment alcove near Radiology Administration F125.

D. The sprinkler piping observed in the Basement 'Tile room' B81 was missing a hanger rod. The clevis was on the pipe but the hanger rod was missing.

E. The sprinkler head in the Surgery housekeeping closet was observed to be obstructed by the surface mounted light fixture installed within inches of head and which extended below the deflector.

F. The 1st floor Pharmacy contained shelving units in the middle of the room in which the required 18" clearance under the sprinkler head(s) was not provided.

Based on random observation during the survey walk-through, not all portions of the facilities air conditioning and ventilation systems are installed in accordance with NFPA 90A 1999.

Findings include:

A. Ductwork access panels through-out the facility were observed without labeling at least 1/2 " high describing the fire safety device within in accordance with 2-3.4.2.

Based on random observation during the survey walk-through, not all portions of the facilities cooking equipment is installed and maintained in accordance with NFPA 96 1998.

Findings include:

A. The Second Floor Re-Hab Area was observed with a room identified as Kitchen with an operable electric stove installed, without a hood to exhaust possible grease laden vapors and hood suppression system in accordance with NFPA 96.

A. The stair near Conference rooms B/C was observed with traffic cones at the intermediate and bottom landings obstructing the stairs.

B. The exit stair serving the Penthouse/Roof/Helipad level is provided with a chain at the intermediate landing above the 2nd floor level to discourage public access to the upper level. The chain across the stair is not an easily removable device in the direction of egress due to the method of attachment and when removed can be a tripping hazard on the stair.

C. The designated exit passageway serving the stair discharging near the ER entrance contained wheelchair storage and an unbrella bag dispensor. The infection control dispensors may remain provided they are located not to obstruct the corridor. The stair discharge did not otherwise comply with 7.7.2 due to lack of complete sprinkler protection of the area.

D. The 2nd floor Med/Surg corridors contained numerous unattended equipment stationed or being charged which obstructed the clear width of the corridor.

E. The 2nd floor corridor at the nurse station near room 224 contained numerous carts and equipment not in use which obstructed the clear width of the corridor.

A. Medical gas storage is not in compliance with NFPA 99, 1999, 8-3.1.11.2. Oxygen tanks stored in sprinklered areas are not separated by minimum 5'-0" from combustibles. Locations observed include but are not necessarily limited to the following:

1. At the 2nd floor Equipment storage room across from the Med room adjacent the center nurse station of the Med/Surg unit.

2. At the 2nd floor Clean Holding room near 237.

3. At the 2nd floor Stage I Recovery room storage room. (Signage also indicated that a maximum of 4 tanks are to be stored, but 10 tanks were stationed at this location).

Based on random observation during the survey walk-through, not all portions of the piped medical gas system are installed in accordance with NFPA 99 1999.

Findings include:

A. The Master Medical Gas Panel in the Emergency Room Area was observed to only display Oxygen and Medical Vacuum and not all piped medical gases in accordance with 4-3.1.2.2 (b) 2.

Based on random observation and staff interview, not all portions of the facilities emergency generators are installed in accordance with NFPA 99 and 110 1999.

Findings include:

A. The room housing Emergency Generator # 1 was observed to have a battery powered light installed over the door and cord connected to an outlet. NFPA 110 requires the Battery light and charger to be wired to the load side of the transfer switch in accordance with 5-3.1.

B. During an interview held in the generator #1 room with the Director of Facilities it could not be determined if the room lighting is powered from the load side of the transfer switch in accordance with 5-3.1.

C. During the facility walk-through it could not be determined if the shared fuel supply tank for the 3 generators and boilers was provided with a low level alarm set at the minimum level to provide the run time for the generators in accordance with 3-4.2.2.

D. Generators #2 and #3 were provided with remote emergency stop switches mounted in the enclosure for the paralleling gear. Chain link fence was provided on both sides and across the back allowing the only access from one end that required passing both generator enclosures to reach the remote stops for the generators. This arrangement was not clear to the surveyor and staff as to how access to the remote stops was provided if a possible malfunction of one generator prevented access to the remote stop before the other may be affected. Compliance with the intent of NFPA 110 5-2.6 did not appear to be met.

E. During a staff interview held with the Director of Facilities in the boiler room it was discovered the generators were connected to only a single remote monitor in the Operator location and not one in the maintenance work area in accordance with NFPA 99 3-4.1.1.15.

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 facilities emergency electrical system are installed and maintained in accordance with NFPA 99 1999.

Findings include:

A. The main fire alarm control panel was observed to be powered from the critical branch of the emergency electrical system and not from the life safety branch in accordance with 3-4.2.2.2 (b) 3 a.

A. Open junction boxes were observed above the ceiling near the smoke barrier at the west end of the connecting hall near door S52.

B. Panel directories observed on the 2nd floor did not label the specific use of the circuits as to room locations or areas served. "Receptacles" and "lighting" does not adequately define the individual use of the circuits. All panel directories should be reviewed and updated or revised.

C. The wiring and lighting provided within the short section of the corridor extending through the new construction area was not in comformance with NFPA 70. This corridor was still unfinished at the time of the survey, but was being utilized as a required exit route to the exterior. Lighting provided was non-functional. No exit discharge lighting was provided. Connections and support of wiring systems was by wire-nuts only without conduits or boxes.


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

Findings include:

A. During the survey walk-through data, voice and fire alarm cabling was observed to be supported by ceiling grid and other items and not from the structure in accordance with 800-6.

B. Electrical outlets were observed in critical patient care areas which were not labeled with the panel and circuit serving them in accordance with 517-19. Areas include:

1. The Emergency Rooms.

2. The ICU Suite was observed without clear panel identification to match outlet labeling.