HospitalInspections.org

Based on observation and staff interview the facility failed to ensure 1 of 2 smoke barrier walls were smoke resistant. The findings were:

1. Observation of the west smoke barrier wall above the double doors near the nurses station on 5/17/11 at 4:52 PM showed a 24 inch by 48 inch section of wall was missing above the ceiling tile. At the time of observation the maintenance supervisor reported he was aware of the separation requirement and that the barrier were inspected on a quarterly basis. He also confirmed he was aware the section was missing, but it was not repaired because the repair would be very difficult due to the location of the water pipes and ventilation duct work.

2. Observation of the west smoke barrier wall near the emergency room nurses station on 5/17/11 at 4:56 PM showed an unsealed conduit penetration above the ceiling tile. The hole was 1 inch by 3 inches long. At the time of observation the maintenance supervisor could not explain why the hole had not been identified and repaired during the last quarterly inspection.

Based on observation and staff interview the facility failed to ensure hazardous areas were separated from use areas in 1 of 3 smoke compartments. The findings were:

1. Observation of the administration area on 5/17/11 at 9:41 AM showed 20 cardboard boxes filled with financial records were being stored throughout the area. Further review showed the two corridor doors were equipped with automatic closing devices, but they had hold open arms, which did not close with the activation of the fire alarm system. At the time of observation the facilities director reported he was not aware the quantity of combustible materials could deem the area a hazard.

2. Observation of the gift shop on 5/17/11 at 9:52 AM showed the corridor door was obstructed from closing by a rubber wedge. Interview with the gift shop attendant confirmed the door was usually held open by the wedge during business hours. At the time of observation the facilities director reported he was aware corridor doors to hazardous locations were required to automatically close.

Based on observation and staff interview the facility failed to ensure egress corridors were unobstructed in 1 of 3 smoke compartments. The findings were:

Observation of the radiology department on 5/17/11 at 10:49 AM showed four chairs and a small table were placed in the corridor near X-Ray #1. The chairs reduced the corridor width to 6 feet of usable space. At the time of observation the director of radiology reported he was not aware the corridor could not be obstructed. Furthermore, he reported the chairs were used as a waiting area for the radiology patients instead of the front waiting area. The facilities director confirmed he was also unaware permanently placing chairs in the corridor was prohibited.

Based on record review and staff interview the facility failed to ensure emergency battery lights were tested during 12 of the past 12 months. The findings were:

Review of the emergency battery light testing records showed the corridor lights had not been tested for 30 seconds on a monthly basis in the past year. Further review showed the annual 90 minute test had not been conducted in the past year. On 5/17/11 at 4:40 PM a member of the maintenance staff reported the lights had not been tested since December 2008 when the building was first occupied.

Based on observation and staff interview the facility failed to ensure smoke detectors had proper spacing in 1 of 3 smoke compartments. The findings were:

Observation of the radiology emergency department on 5/17/11 at 10:21 AM showed a smoke detector near room #R105 was located less than 36 inches from a ventilation diffuser. The smoke detector was located 12 inches from the diffuser. At the time of observation the facilities director reported he was unaware of the spacing requirement. Furthermore, he reported this section of the corridor was newly added and occupancy was taken in January 2010.

Based on record review and staff interview the facility failed to ensure the smoke detectors were tested annually in 2 of the past 2 years. The findings were:

Review of the fire alarm system testing records showed the smoke detectors in the sleep lab were installed in December 2008 when the building was first occupied. Further review showed the smoke detectors had not been tested with smoke entry into the sensing chamber since the building was approved for occupancy. On 5/17/11 at 4:40 PM the maintenance supervisor confirmed the smoke detectors had not been tested in the past two years. He could not explain why the tests had not been performed.

Based on observation and staff interview the facility failed to ensure 2 of 3 smoke compartments had complete sprinkler coverage. The findings were:

1. Observation of the sprinkler system on 5/17/11 at 10:38 AM showed the closet in the MRI operator's office measured 2 feet by 4 feet. Further review showed a sprinkler head was not installed in the closet. At the time of observation the facilities director could not explain why the sprinkler had not been installed or why the missing head had not been identified during the annual sprinkler inspection conducted by the facility staff.

2. Observation of the sprinkler system on 5/17/11 at 11:35 AM showed the sprinkler head installed near the south corridor entrance to the emergency room (ER) was located more than 7 1/2 feet from the double doors. The distance from the sprinkler head to the double doors measured 14 feet. At the time of observation the facilities director reported he could not explain why the sprinkler gap had not been identified during the annual sprinkler inspection conducted by the facility staff.

Based on observation, record review and staff interview the facility failed to ensure sprinklers were provided with escutcheon rings and failed to ensure sprinklers were unobstructed in 1 of 3 smoke compartments. The facility also failed to ensure the sprinkler backflow preventer was tested annually and failed to ensure sprinkler pressure gauges were tested every five years. The findings were:

1. Observation of the sprinkler system on 5/17/11 between 11: 30 AM and 2:30 PM showed the gap around the escutcheon rings in the main lobby and near the south operating room (OR) corridor entrance were larger than 1/8th inch. Two sprinklers in the main lobby were missing escutcheon rings and the facilities director confirmed the gap was 1/4 inch wide for the sprinkler near the OR entrance. At the time of observation he was aware of the gap allowance. He could not explain why the missing rings and gap had not been noticed during the annual sprinkler inspection and repaired.

2. Observation of the sprinkler system on 5/17/11 at 2:40 PM showed the sprinkler heads installed in the kitchen's new walk-in cooler and walk-in freezer were obstructed by the ceiling-mounted fan unit. The sprinklers were located 16 inches away and 4 inches above the bottom of the fan unit. At the time of observation the maintenance supervisor reported he was aware of the spacing requirement. He could not explain why the spacing had not been identified during the annual sprinkler inspection. Record review showed the units had been in service since March 2010.

3. Review of the fire sprinkler system testing records showed the backflow preventer had not been tested in the past year, the device was last tested on 9/11/09. On 5/17/11 at 4:40 PM the maintenance supervisor reported he was aware of the testing requirement, he could not explain why the test had been missed.

4. Review of the fire sprinkler system testing records showed the pressure gauges had not been tested in the past five years. On 5/17/11 at 4:40 PM the maintenance supervisor reported he was not aware of the five year testing requirement. He further reported the gauges had not been tested since the building was first occupied in 2002.

Based on observation and staff interview the facility failed to ensure a manual emergency stop button was provided on 1 of 1 emergency generator. The findings were:

Observation of the emergency generator on 5/17/11 at 2 PM showed it was not equipped with a manual remote stop button located outside of the room the prime mover was housed in. At the time of observation the facilities director was unaware of the aforementioned requirement.

Reference:
NFPA 110 Standard for Emergency and Standby power systems, 1999 edition:
3-5.5.6 All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to the break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building.

Based on observation and staff interview the facility failed to ensure temporary electrical wiring did not replace permanent fixed wiring and failed to ensure outlets in wet locations had ground fault circuit interruption (GFCI) protection in 2 of 3 smoke compartments. The findings were:

1. Observation of the electrical system on 5/17/11 at 10:29 AM showed the two computers in the information technology (IT) office were plugged into surge protectors, which were plugged into second surge protectors. Further review showed the power cord to one of the surge protector had the outer sheath pulled back with inner wires exposed. At the time of observation the maintenance supervisor reported the electrical system was inspected on a quarterly basis. He could not explain why the surge protectors had not been identified and changed.

2. Observation of the electrical system on 5/17/11 at 10:56 AM showed the computer at the ambulance desk/emergency room entrance was plugged into a surge protector, which was plugged into an extension cord.

3. Observation of the electrical system on 5/17/11 at 11:55 AM showed an electrical outlet in the nursery was installed 12 inches from the sink. The outlet did not have GFCI protection. At the time of observation the facilities director reported he was aware of the protection requirement and did not know why the outlet had not been identified during one of the quarterly inspections and replaced.

Based on observation and staff interview the facility failed to ensure 1 of 2 smoke barrier walls were smoke resistant. The findings were:

1. Observation of the west smoke barrier wall above the double doors near the nurses station on 5/17/11 at 4:52 PM showed a 24 inch by 48 inch section of wall was missing above the ceiling tile. At the time of observation the maintenance supervisor reported he was aware of the separation requirement and that the barrier were inspected on a quarterly basis. He also confirmed he was aware the section was missing, but it was not repaired because the repair would be very difficult due to the location of the water pipes and ventilation duct work.

2. Observation of the west smoke barrier wall near the emergency room nurses station on 5/17/11 at 4:56 PM showed an unsealed conduit penetration above the ceiling tile. The hole was 1 inch by 3 inches long. At the time of observation the maintenance supervisor could not explain why the hole had not been identified and repaired during the last quarterly inspection.

Based on observation and staff interview the facility failed to ensure hazardous areas were separated from use areas in 1 of 3 smoke compartments. The findings were:

1. Observation of the administration area on 5/17/11 at 9:41 AM showed 20 cardboard boxes filled with financial records were being stored throughout the area. Further review showed the two corridor doors were equipped with automatic closing devices, but they had hold open arms, which did not close with the activation of the fire alarm system. At the time of observation the facilities director reported he was not aware the quantity of combustible materials could deem the area a hazard.

2. Observation of the gift shop on 5/17/11 at 9:52 AM showed the corridor door was obstructed from closing by a rubber wedge. Interview with the gift shop attendant confirmed the door was usually held open by the wedge during business hours. At the time of observation the facilities director reported he was aware corridor doors to hazardous locations were required to automatically close.

Based on observation and staff interview the facility failed to ensure egress corridors were unobstructed in 1 of 3 smoke compartments. The findings were:

Observation of the radiology department on 5/17/11 at 10:49 AM showed four chairs and a small table were placed in the corridor near X-Ray #1. The chairs reduced the corridor width to 6 feet of usable space. At the time of observation the director of radiology reported he was not aware the corridor could not be obstructed. Furthermore, he reported the chairs were used as a waiting area for the radiology patients instead of the front waiting area. The facilities director confirmed he was also unaware permanently placing chairs in the corridor was prohibited.

Based on record review and staff interview the facility failed to ensure emergency battery lights were tested during 12 of the past 12 months. The findings were:

Review of the emergency battery light testing records showed the corridor lights had not been tested for 30 seconds on a monthly basis in the past year. Further review showed the annual 90 minute test had not been conducted in the past year. On 5/17/11 at 4:40 PM a member of the maintenance staff reported the lights had not been tested since December 2008 when the building was first occupied.

Based on observation and staff interview the facility failed to ensure smoke detectors had proper spacing in 1 of 3 smoke compartments. The findings were:

Observation of the radiology emergency department on 5/17/11 at 10:21 AM showed a smoke detector near room #R105 was located less than 36 inches from a ventilation diffuser. The smoke detector was located 12 inches from the diffuser. At the time of observation the facilities director reported he was unaware of the spacing requirement. Furthermore, he reported this section of the corridor was newly added and occupancy was taken in January 2010.

Based on record review and staff interview the facility failed to ensure the smoke detectors were tested annually in 2 of the past 2 years. The findings were:

Review of the fire alarm system testing records showed the smoke detectors in the sleep lab were installed in December 2008 when the building was first occupied. Further review showed the smoke detectors had not been tested with smoke entry into the sensing chamber since the building was approved for occupancy. On 5/17/11 at 4:40 PM the maintenance supervisor confirmed the smoke detectors had not been tested in the past two years. He could not explain why the tests had not been performed.

Based on observation and staff interview the facility failed to ensure 2 of 3 smoke compartments had complete sprinkler coverage. The findings were:

1. Observation of the sprinkler system on 5/17/11 at 10:38 AM showed the closet in the MRI operator's office measured 2 feet by 4 feet. Further review showed a sprinkler head was not installed in the closet. At the time of observation the facilities director could not explain why the sprinkler had not been installed or why the missing head had not been identified during the annual sprinkler inspection conducted by the facility staff.

2. Observation of the sprinkler system on 5/17/11 at 11:35 AM showed the sprinkler head installed near the south corridor entrance to the emergency room (ER) was located more than 7 1/2 feet from the double doors. The distance from the sprinkler head to the double doors measured 14 feet. At the time of observation the facilities director reported he could not explain why the sprinkler gap had not been identified during the annual sprinkler inspection conducted by the facility staff.

Based on observation, record review and staff interview the facility failed to ensure sprinklers were provided with escutcheon rings and failed to ensure sprinklers were unobstructed in 1 of 3 smoke compartments. The facility also failed to ensure the sprinkler backflow preventer was tested annually and failed to ensure sprinkler pressure gauges were tested every five years. The findings were:

1. Observation of the sprinkler system on 5/17/11 between 11: 30 AM and 2:30 PM showed the gap around the escutcheon rings in the main lobby and near the south operating room (OR) corridor entrance were larger than 1/8th inch. Two sprinklers in the main lobby were missing escutcheon rings and the facilities director confirmed the gap was 1/4 inch wide for the sprinkler near the OR entrance. At the time of observation he was aware of the gap allowance. He could not explain why the missing rings and gap had not been noticed during the annual sprinkler inspection and repaired.

2. Observation of the sprinkler system on 5/17/11 at 2:40 PM showed the sprinkler heads installed in the kitchen's new walk-in cooler and walk-in freezer were obstructed by the ceiling-mounted fan unit. The sprinklers were located 16 inches away and 4 inches above the bottom of the fan unit. At the time of observation the maintenance supervisor reported he was aware of the spacing requirement. He could not explain why the spacing had not been identified during the annual sprinkler inspection. Record review showed the units had been in service since March 2010.

3. Review of the fire sprinkler system testing records showed the backflow preventer had not been tested in the past year, the device was last tested on 9/11/09. On 5/17/11 at 4:40 PM the maintenance supervisor reported he was aware of the testing requirement, he could not explain why the test had been missed.

4. Review of the fire sprinkler system testing records showed the pressure gauges had not been tested in the past five years. On 5/17/11 at 4:40 PM the maintenance supervisor reported he was not aware of the five year testing requirement. He further reported the gauges had not been tested since the building was first occupied in 2002.

Based on observation and staff interview the facility failed to ensure a manual emergency stop button was provided on 1 of 1 emergency generator. The findings were:

Observation of the emergency generator on 5/17/11 at 2 PM showed it was not equipped with a manual remote stop button located outside of the room the prime mover was housed in. At the time of observation the facilities director was unaware of the aforementioned requirement.

Reference:
NFPA 110 Standard for Emergency and Standby power systems, 1999 edition:
3-5.5.6 All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to the break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building.

Based on observation and staff interview the facility failed to ensure temporary electrical wiring did not replace permanent fixed wiring and failed to ensure outlets in wet locations had ground fault circuit interruption (GFCI) protection in 2 of 3 smoke compartments. The findings were:

1. Observation of the electrical system on 5/17/11 at 10:29 AM showed the two computers in the information technology (IT) office were plugged into surge protectors, which were plugged into second surge protectors. Further review showed the power cord to one of the surge protector had the outer sheath pulled back with inner wires exposed. At the time of observation the maintenance supervisor reported the electrical system was inspected on a quarterly basis. He could not explain why the surge protectors had not been identified and changed.

2. Observation of the electrical system on 5/17/11 at 10:56 AM showed the computer at the ambulance desk/emergency room entrance was plugged into a surge protector, which was plugged into an extension cord.

3. Observation of the electrical system on 5/17/11 at 11:55 AM showed an electrical outlet in the nursery was installed 12 inches from the sink. The outlet did not have GFCI protection. At the time of observation the facilities director reported he was aware of the protection requirement and did not know why the outlet had not been identified during one of the quarterly inspections and replaced.