HospitalInspections.org

Based upon observation locking arrangements are not in accordance with code requirements. Failure to properly install approved locks can result in a failure of occupants to egress during a fire/smoke emergency.

Findings include:

A. On August 8, 2022, at 3:00pm while in the company of the VPSP, it was observed that the door serving the Lower-Level fan room near Building E was provided with a chain and pad lock and secured against free egress from occupants. This is not in accordance with 7.2.1.5.1.

B. On August 9, 2022, at 10:29am while in the company of the EL, it was observed that the horizontal exit between second floor Building F and Building A is provided with delayed egress locking. The second floor of Building A is not sprinkler protected, and Building F is unoccupied space, previously used as Mother-Baby Unit. This is not in accordance with 7.2.1.6.1.

Based upon observation and staff interview, Exit Signage is not being inspected, tested, and maintained in accordance with code requirements. Failure to properly performing testing and maintenance activities can result in failure to correctly identify exit paths which can result in occupants not being able to identify and reach available exit paths during a fire/smoke emergency.

Findings include:

On August 8, 2022, at 1:45 pm while in the company of the DOFN, the documentation for 30-day visual inspection for the Exit Signage in accordance with Section 7.9.3, is not available for review.

Based upon observation, hazardous areas are not separated from the remainder of the occupancy and the means of egress. Failure to properly separate hazardous areas from required means of egress paths can compromise the safety of occupants during a fire emergency.

Findings include:

A. On August 8. 2022, at 3:05pm, while in the company of the EL, it was observed in the first-floor large mechanical room in Building B, that pipe penetrations are not sealed with fire stopping to provide a one-hour fire rated enclosure in accordance with 8.3.5.1.

B. On August 9. 2022, at 10:00am, while in the company of the VPSP, it was observed in the Mechanical Penthouse of Building F that the door serving the space was not self-closing. Therefore, this storage room does not comply with Section 19.3.2.1.3.


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C. On August 8. 2022, at 3:05pm, while in the company of the VPSP, it was observed in the lower level of Building E that the space labeled Medical Records on the Life Safety plans is used for the storage of combustible materials. The walls do not close to deck above; chain link fence is used at the tops of two walls to provide enclosure for security. The room was also observed without sprinkler protection. Therefore, this storage room does not comply with Section 19.3.2.

D. On August 9, 2022, at 10:14am, while In the company of the VPSP, it was observed on the second floor of Building A that the space labeled Orthopedic Operating Room #1 on the life Safety plans is used for the storage of combustible materials. An open access hatch was observed in the ceiling and the door serving the room was not self-closing and self-latching. The room was also observed without sprinkler protection. Therefore, this storage room does not comply with Section 19.3.2.

Based on observation the facility failed to provide required smoke detection protection. This deficient practice can result in failure of the system to operate as intended and delay proper initiation when necessary.

Findings include:

A. On August 8. 2022, at 10:10am, while in the company of the VPSP, it was observed in the Operating Room suite hallway on the second floor of Building A that no complete and continuous physical separation from the room to the ceiling cavity above exists. The missing ceiling material would allow heat and products of combustion to bypass the installed smoke detector and therefore does not comply with NFPA 72-2012, 17.7.3.2.4.2.

B. On August 9. 2022, at 2:45pm, while in the company of the VPSP, it was observed in the space labeled Telephone Equipment room on the first floor of Building E that no complete and continuous physical separation from the room to the ceiling cavity above exists. The missing ceiling material would allow heat and products of combustion to bypass the installed smoke detector and therefore does not comply with NFPA 72-2012, 17.7.3.2.4.2.

Based on observation during the building tour the facility lacks complete sprinkler protection. Failure to install and maintain this installation could result in delayed response and fire suppression. This deficient practice could affect patients, staff and visitors during a fire event.

Findings include:

On August 8, 2022, at 2:08pm, while in the company of the VPSP, it was observed in the Soiled Utility on the fourth floor of Building E that a cap on a concealed sprinkler head was loose. This installation does not comply with NFPA 13-2010, 6.2.7.2.

Based upon observation and staff interview, the sprinkler system is not being inspected, tested, and maintained in accordance with code requirements. Failure to inspect, test and maintain the sprinkler system can result in failure of the system to operate as required when needed to control a fire event.

Findings include:

A. On August 8, 2022, at 3:00pm, while in the company of the VPSP, it was observed on the Lower Level of Building E, that the facility had failed to maintain the sprinkler heads free of foreign materials. Typical sprinkler heads in the corridor were covered in an excessive amount of lint and foreign debris. This condition does not comply with NFPA 25-2011, 5.2.1.1.1.

B. On August 9, 2022, at 10:27am, while in the company of the VPSP, it was observed on the third floor of Building A, that the facility had failed to maintain the sprinkler heads free of foreign materials. The sprinkler head in the trash room was covered in an excessive amount of lint and foreign debris. This condition does not comply with NFPA 25-2011, 5.2.1.1.1.


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C. On August 9, 2022, while in the company of the DOFN, it was observed that the following documentation are not available for review:

1. At 8:15 am, the documentation for weekly Sprinkler System Control Valves Inspection in accordance with NFPA 25, 2011 Edition, Section 13.3.3 and Table 13.1.1.2, is not available for review.

2. At 8:20 am, the documentation for 5-Year Fire Sprinkler Pressure Gauges Calibration/Replacement in accordance with NFPA 25, 2011 Edition, Section 5.3.2, and Table 5.1.1.2, is not available for review.

3. At 8:25 am, the documentation for 5-Year Check Valves Inspection (FDC check valve, fire pump discharge check valve, fire pump bypass check valve, jockey pump check valve) in accordance with NFPA 25, 2011 Edition, Section 14.2, and Table 5.1.1.2, is not available for review.

4. At 8:30 am, the documentation for 5-Year Fire Department Connection (FDC) Hydrostatic Piping Test in accordance with NFPA 25, 2011 Edition, Section 6.3.2.1, and Table 13.8.1, is not available for review.

5. At 8:40 am, the documentation for Weekly Fire Pump Visual Inspection in accordance with NFPA 25, 2011 Edition, Section 8.2.1, and Table 8.1.1.2, is not available for review.

Based upon observation, portable fire extinguishers are not inspected and maintained in accordance with Code requirements. Failure to document inspection and maintenance of portable fire extinguishers can result in failure of equipment to perform as intended when needed during a fire event.

Findings include:

A. On August 9. 2022, at 9:42am, while in the company of the VPSP, it was observed in the mechanical penthouse in Building A that a fire extinguisher was missing initials to indicate an inspection had been performed within the last 30 days to comply with NFPA 10-2010, 7.2.1.2 and 7.2.4.

B. On August 9. 2022, at 9:53am, while in the company of the VPSP, it was observed in the second-floor recovery room in Building A that a fire extinguisher was missing initials to indicate an inspection had been performed within the last 30 days to comply with NFPA 10-2010, 7.2.1.2 and 7.2.4.

Based upon observation and staff interview, fire and smoke doors are not being inspected, tested, and maintained in accordance with code requirements. Failure to conduct and document fire and smoke door inspection and maintenance can compromise the safety of any building occupants if the door assemblies are not maintained as intended to restrict the spread of fire & smoke during a fire emergency.

Findings include:

On August 9, 2022, at 8:45 am, while in the company of the DOFN, the documentation for Annual Fire and Smoke Door Inspections in accordance with Section 19.7.6, 8.3.3.1, 7.2.1.15, and NFPA 80-2010, Section 5.2.4.2, is not available for review.

Based on observation the piped medical gas system manifold room is not separated from other areas in the facility as required. This deficient practice can affect the safety of all patients, staff, and visitors.

The Finding is:

On August 9, 2022, at 9:30am while accompanied by VPSP, it was observed in the Medical Gas manifold room that multiple pipe pentrations are not sealed to provide the room with a one-hour fire rated enclosure. This condition does not comply with NFPA 99-2012, 5.1.3.3.2(4).

Based on observation, the facility failed to install and maintain its piped medical gas system as required. This deficient practice could affect patients, staff, and visitors in the building because the piped medical gas system could fail to operate when needed if not properly installed and maintained.

Findings include:

A. On August 8, 2022, at 2:55pm, while in the company of the VPSP, it was observed on the lower level of Building E that medical gas outlets are present in the Physical Therapy Department, however gas zone valves serving these outlets could not be located. This in not in accordance with NFPA 99-2012, 5.1.4.8.4

B. On August 9, 2022, at 10:10am, while in the company of the VPSP, it was observed on the second floor of Building A in the O.R. suite, that medical gas outlets are in an area labeled Clean Utility on the Life Safety Plans. This space is open to the medical gas zone valves controls. This condition does not comply with NFPA 99-2012, 5.1.4.8(3).

Based on observation, not all portions of the electrical system are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because the electrical systems could fail to operate properly when needed if they are not properly installed.

Findings include:

A. On August 8, 2022, at 2:39pm, while in the company of the VPSP, it was observed on the second floor of Building E in the patient toilet room at the south end of the building, that the light fixture above the lavatory had a receptacle removed but was missing a cover plate. The hole leaves expose wiring. This installation is not in compliance with NFPA 70-2011, 314.28(C).

B. On August 8, 2022, at 2:30pm, while in the company of the VPSP, it was observed on the third floor of Building E in typical patient rooms, the existing outlets are not identified as to the panel which served them. The condition does not comply with NFPA 70-2011, 408.4, for the installation of emergency critical powered outlets.

C. On August 9, 2022, at 9:45am, while in the company of the VPSP, it was observed on the second floor of Building A in the ICU Isolation room, the existing outlets are not identified as to the panel which served them. The condition does not comply with NFPA 70-2011, 408.4, for the installation of emergency critical powered outlets.

Based upon observation and staff interview, not all electrical receptacles are installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the rooms because electrical equipment required for their care may fail to operate under emergency conditions if the electrical receptacles are not properly installed and maintained.

Findings include:

C. On August 8, 2022, at 2:35pm, while in the company of the VPSP, it was observed on the third floor of Building E that an electrical receptacle in patient toilet room west of the Soiled Utility room is not provided with GFCI protection in accordance with NFPA 70-2011, 210.8(B)(1).

D. On August 8, 2022, at 2:52pm, while in the company of the VPSP, it was observed on the lower level of Building E that an electrical receptacle in patient toilet room in the Physical Therapy Department is not provided with GFCI protection in accordance with NFPA 70-2011, 210.8(B)(1).

E. On August 9, 2022, at 9:52am, while in the company of the VPSP, it was observed on the second floor of Building A that an electrical receptacle in Clean Utility within Recovery room is within 6'-0" of a sink and is not provided with GFCI protection in accordance with NFPA 70-2011, 210.8(B)(5).

F. On August 9, 2022, at 9:56am, while in the company of the VPSP, it was observed on the second floor of Building A that an electrical receptacle in the workstation labeled Control on the Life Safety Plans is within 6'-0" of a sink and is not provided with GFCI protection in accordance with NFPA 70-2011, 210.8(B)(5).

G. On August 9, 2022, at 10:00am, while in the company of the VPSP, it was observed on the second floor of Building A that an electrical receptacle in the Decontamination Room of the O.R. Suite is within 6'-0" of a sink and is not provided with GFCI protection in accordance with NFPA 70-2011, 210.8(B)(5).

H. On August 9, 2022, at 10:15am, while in the company of the VPSP, it was observed on the second floor of Building A that an electrical receptacle east of Operating Room B is within 6'-0" of the scrub sink and is not provided with GFCI protection in accordance with NFPA 70-2011, 210.8(B)(5).

I. On August 9, 2022, at 11:10am, while in the company of the VPSP, it was observed on the lower level of Building A that an electrical receptacle in the Micro Lab is within 6'-0" of a sink and is not provided with GFCI protection in accordance with NFPA 70-2011, 210.8(B)(5).