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Based on random observation during the survey walk-through, not all doors in exit access corridors are in compliance with 19.3.6.3. This deficiency could affect any staff or visitors in this portion of the First Floor by permitting smoke or fire to pass to the Corridor.

Findings include:

A. 11:29 AM: The door to First Floor Storage Room A100 was observed to not be positive latching as required by 19.3.6.3.2.

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Based on random observation during the survey walk-through, not all doors in smoke barrier walls are resistant to the passage of smoke in accordance with 19.3.7.5., 19.3.7.6., and 19.3.7.7. This deficiency could affect any patients, staff, or visitors in this portion of the First Floor by permitting smoke to pass between separate smoke compartments.

Findings include:

A. 1:06 PM: The door to First Floor CT Scan Room 134C, which is located in a designated smoke barrier wall, was observed to not be self-closing as required by 19.3.7.6. because the closing device is equipped with a hold-open function.

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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 19.3.2.1. These deficiencies could affect any staff members in the Basement by permitting smoke or fire to pass to other portions of the building story.

Findings include:

A. 9:00 AM: Stored materials and equipment were observed in all Basement Corridors (which are not covered by an automatic sprinkler protection), as prohibited by 39.3.2.1 and 8.4.1.1., because the materials are not separated from the remainder of the building by minimum 1 hour fire rated construction. Also see K-072, Item B.

B. 9:27 AM: The fire rated door to Basement Mechanical Shop 76 was observed to be held open by an unapproved device (a wire tied to adjacent shelves) as prohibited by 19.3.2.1. and 8.2.3.2.3.1.(2).

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Based on random observation during the survey walk-through and staff interview, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1. These deficiencies could affect any patients, staff, or visitors in the building by impeding egress under emergency conditions.

Findings include:

A. The following deficiencies were observed at the Fourth Floor Mother/Baby Unit:

1. 2:24 PM: The door to the North Exit Stair (at the north end of the Unit) was observed to be equipped with a delayed egress lock, prohibited by 7.2.1.6.1. because the building is not fully covered by an automatic sprinkler system.
2. 10:12 AM: The south pair of doors to the Unit was observed to be equipped with locking devices on both door leafs. During an interview held at the site at that time, the provider's Director of Facilities stated that the door locks release upon activation of the building fire alarm system; this configuration does not comply with 19.2.2.2.4.

3. 10:15 AM: The southwest door to the Unit (a single door immediately west of the Patient/Staff Elevators) was observed to be equipped in the same manner as the south pair of doors; see Item A.2. above.

B. 9:40 AM: A locking device was observed at the exterior discharge door for the North Exit Stair. A sign on the door reads "If door does not open use release button on back of push handle." The locking mechanism on the door does not comply with 7.2.1.5.1. because special knowledge is required for egress.
C. Due to an ongoing construction project, a series of exterior egress paths have been temporarily eliminated as prohibited by 7.7.1. These include (all First Floor):

1. 12:50 PM: The egress path from the Emergency Department Vestibule.

2. 12:52 PM: The egress path from the Physical Medicine Corridor (immediately north of the Emergency Department.

D. Exterior egress paths were observed which may not be complete to a public way, as required by 7.7.2. under certain weather conditions because no stable, maintainable walking surface to a public way is provided. Locations observed include (all First Floor, east side of the building; all observed at 11:25 AM):
1. Egress path from the East Exit Stair.

2. Egress path from the Laboratory Corridor.
3. Egress path from the Radiology Corridor.

E. 9:36 AM: In Basement Receiving Room 39, a chain link fence and gate were observed at which the gate was secured by a padlock, as prohibited by 7.2.1.5.1., because the gate may be secured against egress.

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Based on random observation during the survey walk-through, not all designated fire barriers are constructed or maintained as fire resistive assemblies. These deficiencies could affect any staff or visitors in the immediate area by permitting smoke or fire to pass through the barriers.

Findings include:

A. Pipe or other penetrations through designated or required 2 hour rated fire barriers were observed that are not sealed against the passage of fire as required by 8.2.3.2.4.2. Locations observed include:

1. 11:25 AM: First Floor Chapel, "Greenfield" conduits serving door closers.
2. 9:06 AM: Basement Electrical Distribution Room 72, several openings in east concrete block wall.

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Based on random observation during the survey walk-through, document review, and staff interview, the facility's written plan for the protection of patients is not complete as required by 19.7.1.1. These deficiencies could affect all patients, staff, or visitors in the building because the inaccurate information provided could result in the failure to protect required components or assemblies.

Findings include:

A. During the survey walk-through, it was determined that the provider is not able to accurately identify all life safety components or assemblies within the building. Critical building components, key building data, or elements of building fire protection systems which could not be properly identified include (but are not necessarily limited to):

1. 11:25 AM: The wall which separates the First Floor [Type IV (2HH)] Chapel from the remainder of the Type I (332)] building is indicated on Life Safety Plans as constituting a smoke resistant wall. The wall was observed to carry a 2 hour fire resistance rating.
2. 1:08 PM: The Laboratory is shown on the Life Safety Plans as constituting a series of rooms served by exit access corridors. The Laboratory was observed to constitute a suite.

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

Findings include:

1. Smoke detectors in several locations are not separated from air supply diffusers by at least 3' as required by NFPA-72, Section 2-3.5.1.

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Based on random observation during the survey walk through, not all portions of the sprinkler system are installed in accordance with NFPA-13 (1999), NFPA-20(1999), and NFPA-70(1999). This could effect the safety of all occupants of the building if the sprinkler system did not operate as required during a fire.

Findings include:

1. There is no fire pump remote alarm panel at a constantly monitored location with the four alarm points required by NFPA 20-7-4.7.

2. The fire pump room does not have a battery operated emergency light as required by NFPA 20-2-7.4.

3. The transfer switch for the fire pump is not located at the pump location as required by NFPA 20-6-6.4.

4. The normal electrical feed to the fire pump is not a dedicated feed tapped ahead of the main building service as required by NFPA-70-695-3(a)(1).

5. The fire pump disconnect and controller are not properly marked in accordance with NFPA-70-695-4.

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By direct observation, document review and staff interview, the surveyor finds that not all sprinkler fire protection control valves are electronically supervised as to their normal protective position in compliance with NFPA 101, 2000, 9.7.2.1. The surveyor notes that some control valves are chained and padlocked however this does not meet the requiremnts of NFPA 10, 2000, 19.3.5.

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Based on random observation during the survey walk-through, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency in accordance with 19.2.3.3. or 39.2.3.2. These deficiencies could affect any patients, staff, or visitors attempting to utilize these corridors under emergency conditions by impeding egress.

Findings include:

A. 12:58 PM: Carts, furnishings, and equipment were observed in First Floor Surgical Department Corridor 1010B, as prohibited by 19.2.3.3. and 7.1.10.2.1. Items observed include a shelving unit and several equipment and/or linen carts.

B. 9:00 AM: Carts, furnishings, and equipment were observed in all Basement Corridors, as prohibited by 39.2.3.2. and 7.1.10.2.1. Items observed include linen carts, patient beds, and stored medical equipment. Also see K-029, Item A.

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A. By direct observation on the morning of 11/29/11, the surveyor finds in the 2nd Floor Mechanical Room, the facility failed to install the medical air compressor intake per NFPA 99, 1999, 4-3.1.1.9. (b) 1. The intake is installed to take its makeup air from the downstream side of the surgery air handlers final filters, however ventilating systems having fans with motors or drive belts located in the air stream shall not be used as a source of medical air intake. The deficiencies allow for possible contamination of the breathable medical air system and putting patients at risk needing respiratory assistance.

B. By direct observation on the morning of 11/29/11, the surveyor finds in the 2nd Floor Mechanical Room along the north wall west of the stair tower, a nitrous oxide supply line has been damaged and is being supported with a piece of electrical wire. The facility has failed to support the installed pipe in compliance with NFPA 99, 1999, 4-3.1.2.9, (b.

C. By direct observation on the morning of 11/29/11, the surveyor finds in the 2nd Floor Mechanical Room at the location of the Fire Hose and Fire Extinguisher Cabinet at the south wall, the facility failed to protect medical gas piping installation from physical damage in compliance with NFPA 99, 1999, 4-3.1.2.9, (c as the piping penetrates the floor to the spaces below.

D. By direct observation and staff interview on the afternoon of 11/29/11, the surveyor finds the facility lacks two medical gas master alarm panels with all the alarm indicators as required by NFPA 99, 1999, 4-3.1.2.2, (b). Failure to alert staff of failed or service needed for medical gas systems will result in compromised patient safety.

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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.

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Based on random observation during the survey walk-through the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised.

Findings include:

1. All of the emergency power panels serve a combination of the life safety, the critical and the equipment branches which does not meet the requirements of NFPA-70, Section 517-31 thru 35.

2. Transfer switches served locations rather than specific branches of the emergency system which does not meet the requirements of NFPA-70, Section 517-30(b)(4).

3. The emergency power supply switchgear is located in the same room as the normal power supply equipment which does not meet the requirements of NFPA-110, Section 5.2.2.

4. All emergency power panels were not properly marked as components of the emergency power supply system as requiredby NFPA-70, Section 700-9(a).

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Based on random observation during the survey walk-through not all portions of the building systems are installed in accordance with NFPA 70 (1999). Improper grounding could create a shock hazard for all occupants of the building.

Findings include:

1. Staff was not able to locate were the med gas piping was bonded as required by NFPA-70, Section 250.104(c).

2. Operating rooms, recovery areas, outpatient surgery, and other critical care areas did not have receptacles from both a normal and a critical power source as required by NFPA-99, Section 3-3.2.1.2(a)(1), and NFPA-70, Section 517-19.

3. All components of the emergency power system, including panels, were not permanently marked as components of the emergency power system as required by NFPA-70, Section 700-9(a).

4. Some patient bed locations did not have receptacles on an emergency source of power as required by NFPA-70-517-18.

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Based on random observation during the survey walk through, portions of the elevator control system are not installed in accordance with ASME A17.1. Any elevator user could be put in a dangerous situation without the proper safety devices installed.

Findings include:

1. The surveyor observed that the elevator machine rooms were equipped with sprinklers, but there was not a heat detector within 2' of each sprinkler head to initiate a shunt trip device to automatically disconnect the main power supply prior to the application of water in the machine room or shaft as required by ASME A17.1-102.2.c.3.

2. The surveyor did not find a single disconnect for each elevator's emergency lighting, receptacle, and ventilation, or proper signage identifying the source feeding these disconnects as required by NFPA-70, Section 620-53. NFPA-99, Section 3-4.2.2.2(b)6 requires these disconnects to be served from the Life Safety branch of the emergency power system

3. Elevator machine rooms were not equipped with GFCI receptacles as required by NFPA-70, Section 620-85.

4. The elevator machine disconnects were not properly marked with the location of the supply side overcurrent protective device as required by NFPA-70, Section 620-51(d).

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Based on random observation during the survey walk-through, not all doors in exit access corridors are in compliance with 19.3.6.3. This deficiency could affect any staff or visitors in this portion of the First Floor by permitting smoke or fire to pass to the Corridor.

Findings include:

A. 11:29 AM: The door to First Floor Storage Room A100 was observed to not be positive latching as required by 19.3.6.3.2.

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Based on random observation during the survey walk-through, not all doors in smoke barrier walls are resistant to the passage of smoke in accordance with 19.3.7.5., 19.3.7.6., and 19.3.7.7. This deficiency could affect any patients, staff, or visitors in this portion of the First Floor by permitting smoke to pass between separate smoke compartments.

Findings include:

A. 1:06 PM: The door to First Floor CT Scan Room 134C, which is located in a designated smoke barrier wall, was observed to not be self-closing as required by 19.3.7.6. because the closing device is equipped with a hold-open function.

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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 19.3.2.1. These deficiencies could affect any staff members in the Basement by permitting smoke or fire to pass to other portions of the building story.

Findings include:

A. 9:00 AM: Stored materials and equipment were observed in all Basement Corridors (which are not covered by an automatic sprinkler protection), as prohibited by 39.3.2.1 and 8.4.1.1., because the materials are not separated from the remainder of the building by minimum 1 hour fire rated construction. Also see K-072, Item B.

B. 9:27 AM: The fire rated door to Basement Mechanical Shop 76 was observed to be held open by an unapproved device (a wire tied to adjacent shelves) as prohibited by 19.3.2.1. and 8.2.3.2.3.1.(2).

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Based on random observation during the survey walk-through and staff interview, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1. These deficiencies could affect any patients, staff, or visitors in the building by impeding egress under emergency conditions.

Findings include:

A. The following deficiencies were observed at the Fourth Floor Mother/Baby Unit:

1. 2:24 PM: The door to the North Exit Stair (at the north end of the Unit) was observed to be equipped with a delayed egress lock, prohibited by 7.2.1.6.1. because the building is not fully covered by an automatic sprinkler system.
2. 10:12 AM: The south pair of doors to the Unit was observed to be equipped with locking devices on both door leafs. During an interview held at the site at that time, the provider's Director of Facilities stated that the door locks release upon activation of the building fire alarm system; this configuration does not comply with 19.2.2.2.4.

3. 10:15 AM: The southwest door to the Unit (a single door immediately west of the Patient/Staff Elevators) was observed to be equipped in the same manner as the south pair of doors; see Item A.2. above.

B. 9:40 AM: A locking device was observed at the exterior discharge door for the North Exit Stair. A sign on the door reads "If door does not open use release button on back of push handle." The locking mechanism on the door does not comply with 7.2.1.5.1. because special knowledge is required for egress.
C. Due to an ongoing construction project, a series of exterior egress paths have been temporarily eliminated as prohibited by 7.7.1. These include (all First Floor):

1. 12:50 PM: The egress path from the Emergency Department Vestibule.

2. 12:52 PM: The egress path from the Physical Medicine Corridor (immediately north of the Emergency Department.

D. Exterior egress paths were observed which may not be complete to a public way, as required by 7.7.2. under certain weather conditions because no stable, maintainable walking surface to a public way is provided. Locations observed include (all First Floor, east side of the building; all observed at 11:25 AM):
1. Egress path from the East Exit Stair.

2. Egress path from the Laboratory Corridor.
3. Egress path from the Radiology Corridor.

E. 9:36 AM: In Basement Receiving Room 39, a chain link fence and gate were observed at which the gate was secured by a padlock, as prohibited by 7.2.1.5.1., because the gate may be secured against egress.

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Based on random observation during the survey walk-through, not all designated fire barriers are constructed or maintained as fire resistive assemblies. These deficiencies could affect any staff or visitors in the immediate area by permitting smoke or fire to pass through the barriers.

Findings include:

A. Pipe or other penetrations through designated or required 2 hour rated fire barriers were observed that are not sealed against the passage of fire as required by 8.2.3.2.4.2. Locations observed include:

1. 11:25 AM: First Floor Chapel, "Greenfield" conduits serving door closers.
2. 9:06 AM: Basement Electrical Distribution Room 72, several openings in east concrete block wall.

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Based on random observation during the survey walk-through, document review, and staff interview, the facility's written plan for the protection of patients is not complete as required by 19.7.1.1. These deficiencies could affect all patients, staff, or visitors in the building because the inaccurate information provided could result in the failure to protect required components or assemblies.

Findings include:

A. During the survey walk-through, it was determined that the provider is not able to accurately identify all life safety components or assemblies within the building. Critical building components, key building data, or elements of building fire protection systems which could not be properly identified include (but are not necessarily limited to):

1. 11:25 AM: The wall which separates the First Floor [Type IV (2HH)] Chapel from the remainder of the Type I (332)] building is indicated on Life Safety Plans as constituting a smoke resistant wall. The wall was observed to carry a 2 hour fire resistance rating.
2. 1:08 PM: The Laboratory is shown on the Life Safety Plans as constituting a series of rooms served by exit access corridors. The Laboratory was observed to constitute a suite.

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

Findings include:

1. Smoke detectors in several locations are not separated from air supply diffusers by at least 3' as required by NFPA-72, Section 2-3.5.1.

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Based on random observation during the survey walk through, not all portions of the sprinkler system are installed in accordance with NFPA-13 (1999), NFPA-20(1999), and NFPA-70(1999). This could effect the safety of all occupants of the building if the sprinkler system did not operate as required during a fire.

Findings include:

1. There is no fire pump remote alarm panel at a constantly monitored location with the four alarm points required by NFPA 20-7-4.7.

2. The fire pump room does not have a battery operated emergency light as required by NFPA 20-2-7.4.

3. The transfer switch for the fire pump is not located at the pump location as required by NFPA 20-6-6.4.

4. The normal electrical feed to the fire pump is not a dedicated feed tapped ahead of the main building service as required by NFPA-70-695-3(a)(1).

5. The fire pump disconnect and controller are not properly marked in accordance with NFPA-70-695-4.

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By direct observation, document review and staff interview, the surveyor finds that not all sprinkler fire protection control valves are electronically supervised as to their normal protective position in compliance with NFPA 101, 2000, 9.7.2.1. The surveyor notes that some control valves are chained and padlocked however this does not meet the requiremnts of NFPA 10, 2000, 19.3.5.

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Based on random observation during the survey walk-through, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency in accordance with 19.2.3.3. or 39.2.3.2. These deficiencies could affect any patients, staff, or visitors attempting to utilize these corridors under emergency conditions by impeding egress.

Findings include:

A. 12:58 PM: Carts, furnishings, and equipment were observed in First Floor Surgical Department Corridor 1010B, as prohibited by 19.2.3.3. and 7.1.10.2.1. Items observed include a shelving unit and several equipment and/or linen carts.

B. 9:00 AM: Carts, furnishings, and equipment were observed in all Basement Corridors, as prohibited by 39.2.3.2. and 7.1.10.2.1. Items observed include linen carts, patient beds, and stored medical equipment. Also see K-029, Item A.

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A. By direct observation on the morning of 11/29/11, the surveyor finds in the 2nd Floor Mechanical Room, the facility failed to install the medical air compressor intake per NFPA 99, 1999, 4-3.1.1.9. (b) 1. The intake is installed to take its makeup air from the downstream side of the surgery air handlers final filters, however ventilating systems having fans with motors or drive belts located in the air stream shall not be used as a source of medical air intake. The deficiencies allow for possible contamination of the breathable medical air system and putting patients at risk needing respiratory assistance.

B. By direct observation on the morning of 11/29/11, the surveyor finds in the 2nd Floor Mechanical Room along the north wall west of the stair tower, a nitrous oxide supply line has been damaged and is being supported with a piece of electrical wire. The facility has failed to support the installed pipe in compliance with NFPA 99, 1999, 4-3.1.2.9, (b.

C. By direct observation on the morning of 11/29/11, the surveyor finds in the 2nd Floor Mechanical Room at the location of the Fire Hose and Fire Extinguisher Cabinet at the south wall, the facility failed to protect medical gas piping installation from physical damage in compliance with NFPA 99, 1999, 4-3.1.2.9, (c as the piping penetrates the floor to the spaces below.

D. By direct observation and staff interview on the afternoon of 11/29/11, the surveyor finds the facility lacks two medical gas master alarm panels with all the alarm indicators as required by NFPA 99, 1999, 4-3.1.2.2, (b). Failure to alert staff of failed or service needed for medical gas systems will result in compromised patient safety.

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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.

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Based on random observation during the survey walk-through the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised.

Findings include:

1. All of the emergency power panels serve a combination of the life safety, the critical and the equipment branches which does not meet the requirements of NFPA-70, Section 517-31 thru 35.

2. Transfer switches served locations rather than specific branches of the emergency system which does not meet the requirements of NFPA-70, Section 517-30(b)(4).

3. The emergency power supply switchgear is located in the same room as the normal power supply equipment which does not meet the requirements of NFPA-110, Section 5.2.2.

4. All emergency power panels were not properly marked as components of the emergency power supply system as requiredby NFPA-70, Section 700-9(a).

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Based on random observation during the survey walk-through not all portions of the building systems are installed in accordance with NFPA 70 (1999). Improper grounding could create a shock hazard for all occupants of the building.

Findings include:

1. Staff was not able to locate were the med gas piping was bonded as required by NFPA-70, Section 250.104(c).

2. Operating rooms, recovery areas, outpatient surgery, and other critical care areas did not have receptacles from both a normal and a critical power source as required by NFPA-99, Section 3-3.2.1.2(a)(1), and NFPA-70, Section 517-19.

3. All components of the emergency power system, including panels, were not permanently marked as components of the emergency power system as required by NFPA-70, Section 700-9(a).

4. Some patient bed locations did not have receptacles on an emergency source of power as required by NFPA-70-517-18.

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