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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. Corrected 04/26/12.

B. Corrected 04/26/12.
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. Corrected 04/26/12.

E. Corrected 04/26/12.

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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. Corrected 04/26/12.

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. Corrected 04/26/12.

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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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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. Corrected 04/26/12.

C. Corrected 04/26/12.

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. Corrected 04/26/12.

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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