HospitalInspections.org

Based on random observation during the survey walk-through, not all portions of the facility's air conditioning and ventilating systems are installed in accordance with NFPA 90A. These deficiencies could affect any patients, staff, or visitors in the First Floor Surgical Department because smoke and fire could pass into it from the Mechanical Room above.

Findings include:

A. At 8:57 AM on June 18, 2013, 13 ducts which penetrate the floor/ceiling assembly of the Second Floor Surgical Mechanical Room were observed to lack fire dampers required by NFPA 90A 1999 3-3.2.

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. These deficiencies could affect any patients, staff, or visitors in the areas cited because they could be prevented from reaching exits.

Findings include:

A. At 10:45 AM on June 18, 2013, equipment was observed being stored in Surgical Department Corridors prohibited by 19.2.3.3. and 7.1.10.2.1. Locations and items observed include:

1. South East-West Corridor: Three gurneys; signs were observed above each location which identified it as the location at which the gurney for a specific Operating Room was to be stored. Similar signs were observed in the north East-West Corridor.

2. Corrected 1/30/14

3. NEW 8/12/14: A patient bed, linen cart and hampers were observed to be stationed in the corridor at the intersection of the south east-west corridor and the east north-south corridor near the control station/entry to the restricted area. Staff indicated the bed was for the patient in the OR but the linen cart/hampers were normally stationed at this location.

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 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 by the loss of a single transfer switch.

Findings include:

A. The surveyor observed that life safety panel ESC-1 next to the surgical director's office, (109), serves loads other than those specifically allowed by NFPA70, Section 517-32.

B. The surveyor observed that the following critical panels were serving items other than those allowed by NFPA-70, Section 517-33:

1. Critical panels EC1A, serving the ER, was serving loads such as med gas and emergency and exit lights, which are required to be served from the life safety panel.
2. Critical panels ELA and ELB which are supplied from a critical transfer switch, had circuits feeding exit lights that are required to be served from the life safety branch panel.
3. Critical panels ECID and ECID1 were serving several fire alarm circuits, all of which are required to be served from the life safety panels.
4. Critical panel EC12 is serving all kitchen equipment and is required to be served from an equipment panel to comply with NFPA-70, Section 517-34.

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:

A. The elevator machine room for elevator 82008 for Same Day Surgery was observed to be equipped with sprinklers, but there was not a heat detector within 2' of the 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.

B. Elevators were observed to lack single, lockable disconnects for emergency cab lighting, receptacles, and ventilation, located in the elevator machine rooms, required by NFPA-70, Section 620-53. (This deficiency reformated 8/12/14 to clarify individual PoC responses for each elevator location.)

1. At Elevator 1.
2. At Elevator 2.
3. At Elevator 82001 (Cath Lab).
4. At Elevator 82003 (Family Practice)

C. Corrected 8/12/14.

D. The elevator machine rooms were observed to not be equipped with smoke detectors for the elevator recall system as required by ASME A17.1-211.3. (This deficiency reformated 8/12/14 to clarify individual PoC responses for each elevator location.)

1. At the Family Practice (elevator 82003).
2. At the Same Day Surgery (elevator 82008).