HospitalInspections.org

Based on an isolated observation the facility failed to ensure the room interior finish has a flame spread of Class A or Class B as it pertains to missing ceiling tiles and penetrations in the wall/ceiling in two (2) isolated locations

The findings include:

A. It was observed at approximately 11:00 AM through 2:00 PM on April 17, 2013, that three (3) ceiling tiles were missing in the Information Technology (IT) closet across from the Outpatient Pharmacy.

B. It was observed at approximately 11:00 AM through 2:00 PM on April 17, 2013 and April 18, 2013, penetrations in the ceiling/walls in the following isolated areas:

Closet located across from the Outpatient Pharmacy.
Closet located in the Research/Speech area across from 1024.

This observation was made in the presence of Employee #1.

Based on observation it was determine in an isolated instance that one (1) of 10 entrance doors on unit 3 West, failed to close and latch into frame when tested (room 3436). This was noted on one (1) of three (3) patient floors.

The findings include:

It was observed at approximately 8:00 AM through 12:00 PM on April 18, 2013, that one (1) of 10 entrance doors to patient rooms did not close flush and latch into the frame at the entrance of room 3436 on unit 3 West.

This observation was made in the presence of Employee #2.

2000 LIFE SAFETY CODE-LSC 4.6.12.1
Maintenance and Testing (Fire Alarm)
Whenever or wherever any device, equipment,
system, condition, arrangement, level of
protection, or any feature is required for
compliance with the provisions of this code, such
device, equipment, system, condition,
arrangement level of protection, other feature
shall thereafter be continuously maintained in
accordance with applicable NFPA requirements
or as directed by authority having jurisdiction.


Based on observation the facility's main fire alarm annunciator panel was indicating "Trouble" within the system, failing to ensure that all components of the fire alarm system are maintained in proper working order.

The findings include:

It was observed at approximately 11:00 AM through 2:00 PM on April 17, 2013, that the facility's main fire alarm annunciator panel (in the fire control room) was indicating a "Trouble" within the system. It was determined through record review and interview with the engineer, employee #1 that a faulty wire to the secondary remote mic (1 of 2), located in the Operator's Office, was the cause of the "Trouble" .

These findings were observed in the presence of Employee #1.

Based on isolated observations the facility failed to ensure all components of the automatic sprinkler system are continuously maintained in proper operating condition as it pertains to: missing escutcheon plates (5 of 8); tightening of standpipe caps (5 of 10), there was one (1) spare upright sprinkler; the sprinkler water flow valve was not accessible in one (1) area, and items were stored 18 inches from the ceiling sprinkler head in three (3) instances (2 of 4 floors).

The findings include:

A. An isolated observation at approximately 11:00 AM through 2:00 PM on April 17, 2013 and April 18, 2013, noted five (5) of eight (8) escutcheon plates were missing in the following areas:

Patient room 3324 located on 3 South (one (1) of three (3) patient floors),

Electrical closet 1070 and 1063 both located in the Research Office Area.

In the Independence Square area, two (2) of eight (8) escutcheon plates were missing as follows: above the Capitol picture and above the Mobile gas pump.

B. It was observed at approximately 11:00 AM through 2:00 PM on April 17, 2013 and April 18, 2013, the facility's standpipe caps in five (5) of 10 were not hand tightened.

C. It was observed at approximately 11:00 AM through 2:00 PM on April 17, 2013 and April 18, 2013, that the facility's spare sprinkler head box had one spare upright sprinkler. This observation was made in room G063 noting one (1) sprinkler instead of the required three (3) sprinkler heads.

D. An isolated observation was made at approximately 11:00 AM through 2:00 PM on April 17, 2013 and April 18, 2013, in the Penthouse, that the facility's sprinkler water flow valve could not be accessed.

E. Items were stored 18 inches from the ceiling sprinkler head on unit 3 West and the ground floor as follows:

Storage closet located in 3 West Pediatrics.
Storage closet 3174 located in 3 West Atrium.
Storage closet G092 located inside of Environmental Services.

These observations were made in the presence of Employee # 1.

Based on observation the facility failed to ensure all fire protection equipment e.g., fire extinguisher was accessible in an isolated instance.

The findings include:

It was observed at approximately 11:00 AM through 2:00 PM on April 17, 2013 and April 18, 2013, that the facility's portable fire extinguisher cabinet was obstructed by a napkin dispenser (impeded the access) in the Cafeteria located on the ground level.

This observation was made in the presence of Employee # 1.

2006 IFC-605.5 Extension cords-extension cords and flexible cords shall not be a substitute for permanent wiring. Extension cords and flexible cords shall not be affixed to structures, extended through walls, ceilings or floors, or under doors or floor coverings, nor shall such cords be subject to environmental damage.

Based on observations during the Life Safety Code inspection, an extension cord was noted in an office (1) of (1),

The findings include:

It was observed at approximately 11:00 AM thru 2:00 PM on April 17, 2013 and April 18, 2013 that one (1) extension cord was observed being used as a permanent fixture in the Director of Pharmacy's office.


This finding was observed in the presence of Employee #1.

Based on observation it was determine that two of two electrical panels were obstructed by storage.
The findings include:

Stored items were obstructing access to the electrical panels in room G063 located in the mechanical/pump room.

These findings were observed in the presence of Employee #1.