HospitalInspections.org

Building A3

It was determined by observation during the course of the survey, conducted on 11/08/2016-11/10/2016, the facility failed to maintain the two-hour fire-resistance rating of the fire barrier and occupancy separation as required by NFPA 101. This was evidenced by the following:

1) The third (3rd) floor shell space is being utilized as a storage occupancy and the separation of occupancies currently is only 1 hour and needs to be 2 hour between Health Care and Storage.

2) In the third (3rd) floor shell space, within the separation wall between occupancies, there are two (2) pipes, one (1) metal and one (1) PVC that need to be enclosed in the wall that needs to be a 2 hour rated wall for occupancy separation as stated above.

This deficiency affects all patients, staff and visitors on the 3rd floor.

The fire barrier maintenance deficiency items were discussed during the survey and the exit conference.

Building A3

It was determined by observation during the course of the survey conducted 11/08/2016-11/10/2016, the fire resistive rating of the building structure was not maintained. This was evidenced by the following:

Exposed Structural Steel needing fire resistive spray in the following locations:

1) 1-238 electrical room (repaired during inspection)

2) 1-402 electrical room (repaired during inspection)

3) Boiler room above the boiler (repaired during inspection)

4) Main technology room (repaired during inspection)


This deficiency has the ability to affect all patients, staff and visitors in these areas of the hospital.

Building A5

It was determined by observation during the course of the survey conducted 11/08/2016-11/10/2016, the fire resistive rating of the building structure was not maintained. This was evidenced by the following:

Exposed Structural Steel needing fire resistive spray in various locations. (All repaired during inspection)

This deficiency has the ability to affect all patients, staff and visitors in these areas of the hospital.

Building AA

It was determined by observation during the course of the survey conducted 11/08/2016-11/10/2016, the fire resistive rating of the building structure was not maintained. This was evidenced by the following:

Exposed Structural Steel needing fire resistive spray in the shell space.

This deficiency has the ability to affect all patients, staff and visitors in this area of the hospital.

Building A5

It was determined by observation during the course of the survey on 11/08/2016-11/10/2016, means of egress were not free of obstructions. This was evidenced by the following:

1. The ambulance entrance inner break away doors obstructed with a patient bed. (repaired during inspection)

This deficiency can affect all patients, staff and visitors to this part of the hospital.

This deficiency was discussed during the survey and again at the exit conference.

Building A5

It was determined by observation during the course of the survey on 11/08/2016-11/10/2016, that the delayed egress doors do not comply with NFPA 101. This was evidenced during the survey by:

1) A pre alarm sounds prior to the delayed egress alarm. The sign on the door indicates that the door will alarm and open within 15 seconds of sound of alarm. The pre alarm sound lengthens this time. (repaired during inspection)

This deficiency can affect all patients, staff, and visitors of this ED.

This deficiency was discussed during the survey and again at the exit conference.

Building AA

It was determined by observation during the survey, on 11/08/2016-11/10/2016, the facility failed to properly enclose sprinkler protected hazardous areas with construction that was smoke resisting in accordance with the Life Safety Code. This was evidenced by the following hazardous areas that were sprinkler protected, but were not maintained to be smoke-resistive:

1) The lab storage room has combustible storage and is greater than 50 sqft, a self closer is required.

This deficency affects all patients, staff and visitors within this smoke compartment.

Each of the hazardous area deficiency items was discussed during a tour of the facility and again during the exit conference.

Building A3

It was determined by observation and record review during the course of the survey on 11/08/2016-11/10/2016, cooking appliances were not protected in accordance with NFPA 96. This was evidenced by the following:

1) The ansul system nozzles are not properly adusted to apply proper coverage of extinguishing agent to the cooking surface. (Repaired during inspection)

This deficiency affected all patients, staff and visitors to the kitchen area and within this smoke compartment.

Building A3

It was determined by observation and record review during the course of the survey on 11/08/2016-11/10/2016, control functions of the fire alarm system were not functioning in accordance with NFPA 101. This was evidenced by the following:

1) The Double Doors 1-550B, leading from the hospital to the ED, by the elevator, do not release from the magnetic holds upon activation of the fire alarm from either the hospital or the ED side.

2) ALL delayed egress doors on the 3rd floor, stair #4, Stair #5, double doors 3.311B and 3.239A did not deactivate the delayed egress programming.


This deficiency affected all patients, staff and visitors to the 3rd floor and within 3 smoke compartment.

Building A5

It was determined by observation during the course of the survey on 11/08/2016-11/10/2016, the NFPA 13 automatic fire suppression system did not provide coverage of the entire building. This was evidenced by the following:

The following areas were not provided with automatic fire sprinkler coverage:

1. A Fire Sprinkler head needs to be added to the vestibule outside the Security Management's office to meet the sprinkler head spacing requirements of 7 feet, currently the spacing is at 10 feet.

This deficency can affect all occupants of this building on 2 floors that utilize this exit as an emergency exit.

This deficiency was discussed during the survey and again at the exit conference.

Building AA

It was determined by observation, and documentation review during the course of the survey on 11/08/2016-11/10/2016, the automatic fire suppression system was not maintained in compliance with NFPA 13 and NFPA 25. This was evidenced by the following:

1. There are cables being supported by the sprinkler piping in the telephone equipment room. (repaired during inspection)

This deficiency can affect all patients, staff and visitors in this hospital.

This deficency was discussed during the survey and again at the exit conference.

Building A3

It was determined by observation during the course of the survey on 11/08/2016 - 11/10/2016, doors to the corridor were not capable of resisting the passage of fire and smoke. This was evidenced by the following:

1. Door 1-552C does not positively latch into the frame

This deficiency effected 1 set of doors in 1 smoke compartments and all staff members, residents, and visitors of this facility.

This corridor door deficiency was discussed with the Administrative Director of Facilitiesand the Safety Manager during the survey and again in an exit interview.

Building A5

It was determined by observation during the course of the survey on 11/08/2016 - 11/10/2016, doors to the corridor were not capable of resisting the passage of fire and smoke. This was evidenced by the following:

1. Door to Observation room #7 does not positively latch into the frame

This deficiency effected 1 door in 1 smoke compartments and all staff members, residents, and visitors of this facility.

This corridor door deficiency was discussed with the Administrative Director of Facilitiesand the Safety Manager during the survey and again in an exit interview.

Building AA

It was determined by observation during the course of the survey on 11/08/2016 - 11/10/2016, doors to the corridor were not capable of resisting the passage of fire and smoke. This was evidenced by the following:

1) The door to Patient room #14 is getting hung up and will not close due to a high spot in the floor.

2) The Ultra Sound room #1 door has a gap greater than 1/2" around the door frame. The door is warped creating this gap.

3) The door to the Mammo Reading room did not positively latch into the frame. (repaired during inspection)

4) The door to Environmental Services is propped open. (repaired during inspection)


This deficiency effected 4 doors in 2 smoke compartments and all staff members, residents, and visitors of this facility.

This corridor door deficiency was discussed with the Administrative Director of Facilitiesand the Safety Manager during the survey and again in an exit interview.