HospitalInspections.org

Based on random observation during the survey walk-through, not all portions of the building are of fire resistive construction in accordance with 19.1.6.2. These deficiencies could affect any patients, staff, or visitors in the building by permitting the building structure to be compromised during fire conditions.

Findings include:

A. At 1:28 PM on April 17, 2013, the roof structure for the First Floor MRI Trailer Entry was observed to be of wood construction, as prohibited by 19.1.6.2.

B. At 9:39 AM on April 17, 2013, an unprotected steel column was observed in the Ground Floor Contaminated Linen Room.

Based on random observation during the survey walk-through, not all doors in exit access corridors are in compliance with 19.3.6.3. These deficiencies could affect any patients, staff, or visitors in the building by allowing smoke or fire to enter the egress corridor.

Findings include:

A. CORRECTED 09/05/2013

B. During a test of the building fire alarm system conducted at 11:01 AM on April 18, 2013, the rolling shutter at the First Floor (1977 Building) Patient Accounts Office was observed to not close as required by 19.3.6.3.2.

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 patients, staff, or visitors in the building by allowing smoke or fire to pass into other occupied portions of the building.

Findings include:

A. At 1:36 PM on April 17, 2013, the door to the First Floor (1977 Building) Laboratory Storage Room was observed to not be self-closing as required by 19.3.2.1. and 8.2.3.2.3.1(1).

B. During a test of the building fire alarm system conducted at 11:09 AM on April 18, 2013, the hold-open feature of the automatic door operator at the Ground Floor (2001 Addition) Loading Dock was observed to not release to close as required by 19.3.2.1. and 8.2.3.2.3.1(1).

Based on random observation during the survey walk-through, 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 preventing them from reaching an exit under fire conditions.

Findings include:

A. CORRECTED 09/05/2013
B. CORRECTED 09/05/2013

C. On April 17, 2013, the following deficiencies were observed in the Ground Floor (1977 Building) Pharmacy:
1. The door to the corridor was observed to be equipped with a locking mechanism which requires special knowledge to operate (a push button release) as prohibited by 7.2.1.5.4.

2. CORRECTED 09/05/2013

Based on random observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 38.2.1. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from reaching an exit under fire conditions.

Findings include:

A. At 8:05 AM on April 18, 2013, a series of doors in the Second Floor egress path were observed to be capable of being secured against passage, thus creating a condition which does not comply with 38.2.4.2. because both required exits could not be reached from any point of the building story. Doors which can be secured against passage include:

1. Door 233A.
2. Door to Therapy Room D218.

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

Findings include:

A. On April 17, 2013, a series of unsealed pipe or other penetrations were observed in 2 hour rated fire barriers as prohibited by 8.2.4.2.4.2. Locations observed include:

1. CORRECTED 09/05/2013
2. CORRECTED 09/05/2013
3. 10:16 AM: Above the First Floor cross-corridor doors between the 1977 Building and the Buildings to the west.

B. During a test of the building fire alarm system conducted at 11:10 AM on April 18, 2013, a pair of doors in the 2 hour fire barrier at the (2001 Addition) Ground Floor, directly north of the Visitor Elevator Lobby, were observed to not be positive latching as required by 8.2.3.2.3.1(1).

Based on random observation during the survey walk-through, exit signs did not illuminate a continuous path of egress in all cases in accordance with 38.2.10.1. and 7.10. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from safely exiting the building under fire conditions.

Findings include:

A. At 8:10 AM on April 18, 2013, no exit signs were observed which direct building occupants toward the Northeast Exit Stair as required by 7.10.

Based on random observation during the survey walk-through, not all portions of the facility's automatic sprinkler system are installed and maintained in accordance with NFPA 13 1999. These deficiencies could affect any patients, staff, or visitors in the area of the conditions cited because the activation of sprinkler heads could be delayed.

Findings include:

A. On April 17, 2013, rooms provided with standard pendant sprinkler heads were observed at which ceiling tile were observed to be missing or at which openings in the drywall ceiling were observed, which compromises sprinkler coverage as prohibited by NFPA 13 1999 5-6.4.1.1. Locations observed include (both First Floor 1977 Building):

1. CORRECTED 09/05/2013
2. 1:24 PM: CT Mechanical Room.

B. CORRECTED 09/05/2013

Based on random observation during the survey walk-through, not all medical gas piping systems are installed and maintained in accordance with NFPA 99. These deficiencies could affect any patients in the cited area because the medical gas system could become compromised.

A. At 1:51 PM on April 17, 2013, the medical gas area alarm panel serving the Ground Floor of the 1977 Building was observed to be located in the Biomedical Engineering Office (which can be secured against entry), and not in an accessible location as required by by NFPA 99 1999 4-3.1.2.2(c)(2).

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

Findings include:

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

Based on random observation during the survey walk-through and document review, the facility's Type 1 Emergency Electrical System (EES) is not divided into the Life Safety Branch, the Critical Branch, and the Equipment Branch as required by NFPA 99 and NFPA 70. These deficiencies could affect any patients, staff, or visitors in the building because the EES could become compromised.

Findings include:

A. The facility's Type 1 EES was observed to not be divided into a Life Safety, Critical, and Equipment Branch as required by NFPA 99 1999 3-4.2.2.2. and NFPA 70 1999 517-30. All Electrical Panels listed below were observed to serve electrical loads which are required to be served by different branches of the EES. Based on a review of the facilities Electrical Panel Circuit Directories conducted at 9:03 AM on April 18, 2013, Electrical Panels at which this condition exists include, but are not limited to:

1. 1977 Building:
a. Third Floor Electrical Panel 3C, at which Circuit 8 is identified as serving the Nurse Call System [required to be served by the Critical Branch per NFPA 99 1999 3-4.2.2.2(c)(5) and NFPA 70 1999 517-33(a)(5)], Circuit 12 is identified as serving the Fire Alarm System [required to be served by the Critical Branch per NFPA 99 1999 3-4.2.2.2(b)(3)(a) and NFPA 70 1999 517-32(c)(1)], and other circuits are identified as serving other normal electrical loads.
b. Second Floor Electrical Panel 2C, at which Circuit 8 is identified as serving the Nurse Call System [required to be served by the Critical Branch per NFPA 99 1999 3-4.2.2.2(c)(5) and NFPA 70 1999 517-33(a)(5)], and other circuits are identified as serving other normal electrical loads.

c. First Floor Electrical Panel 1C, at which Circuit 32 is identified as serving the Nurse Call System [required to be served by the Critical Branch per NFPA 99 1999 3-4.2.2.2(c)(5) and NFPA 70 1999 517-33(a)(5)], Circuit 34 is identified as serving the Fire Alarm System [required to be served by the Critical Branch per NFPA 99 1999 3-4.2.2.2(b)(3)(a) and NFPA 70 1999 517-32(c)(1)], and other circuits are identified as serving other normal electrical loads.

d. Electrical Panel EL, at which Circuit 5 is identified as serving Nurse Exit Lights [required to be served by the Life Safety Branch per NFPA 99 1999 3-4.2.2.2(b)(2) and NFPA 70 1999 517-32(b)], Circuits 4 and 7 are identified as serving Emergency Lights [required to be served by the Life Safety Branch per NFPA 99 1999 3-4.2.2.2(b)(1) and NFPA 70 1999 517-32(a)], Circuit 6 is shown as serving a Medical Gas Alarm Panel [required to be served by the Life Safety Branch per NFPA 99 1999 3-4.2.2.2(b)(3)(b) and NFPA 70 1999 517-32(c)(2)] and other circuits are identified as serving other normal electrical loads.

e. Ground Floor Electrical Panel 1-EM, identified as being an Emergency Panel, was identified as serving normal electrical loads including:

1) Corridor receptacles (Circuits 1 and 2).

2) Normal Kitchen lighting (Circuits 6, 7, 9, 10, 11, and 12.

2. 2001 Addition/2011 Vertical Expansion:

a. At 9:03 AM on April 18, 2013, Fourth Floor Electrical Panel LS2A, identified as a Life Safety Panel, which was observed to serve the Nurse call System [required to be served by the Critical Branch per NFPA 99 1999 3-4.2.2.2(c)(5) and NFPA 70 1999 517-33(a)(5)], and the Infant Abduction System [which is not permitted to be served by the Life Safety Branch by NFPA 99 1999 3-4.2.2.2(b) and NFPA 70 1999 517-32].

b. At 9:55 Am on April 18, 2013, First Floor Electrical Panel ES1A was observed to serve the Fire Alarm System [required to be served by the Critical Branch per NFPA 99 1999 3-4.2.2.2(b)(3)(a) and NFPA 70 1999 517-32(c)(1)], and other circuits identified as serving other normal electrical loads.