HospitalInspections.org

Based on observation, interview and record review with facility maintenance director on 7-28-2011 and 8-2-2011 between the hours of 0900 and 1300 hours, this facility does not provide 2 hour separation in approximately 10% of the fire walls examined. This penetration ranged in size from 1/4 inch to 1 inch in diameter. Maintenance director provided hospital policy for "Above Ceiling Work Permit Policy, Policy # EC.02.03.01.1.a, effective 1/2011" and only able to locate 3 incomplete above ceiling work permits identified and required in the policy.

Finding include:

Penetration found at 4th floor level fire wall across from room E422 was not properly firestopped with a listed firestop product and design.


During an interview, documentation is requested for the report from the plant services director for the inspection of above ceiling penetrations, this penetration is not identified and report is not available at time of survey.

Based on observation, interview and record review with facility maintenance director on 7-28-2011 and 8-2-2011 between the hours of 0900 and 1300 hours, this facility does not provide corridor separation in approximately 30% of the corridors examined. These penetrations ranged in size from 1/4 inch to 1 inch in diameter to a section of wall missing. Maintenance director provided hospital policy for "Above Ceiling Work Permit Policy, Policy # EC.02.03.01.1.a, effective 1/2011" and only able to locate 3 incomplete above ceiling work permits identified and required in the policy.

Finding include:

Penetration found at 5th floor level nurses station across from room E523 was not properly firestopped with a listed firestop product and design.

Penetration found at 5th floor level corridor across from room W581 was not properly firestopped with a listed firestop product and design.

Penetration found at 4th floor level nurses station across room E424 was not properly firestopped with a listed firestop product and design.

Penetrations fournd at 3rd floor level post partum wing door.
Corridor wall section missing on 1st floor level corridor at volunteer services office (approx. 2 feet X 3 feet).

Penetration found on 1st floor level corridor at cardiovascular door was not properly firestopped with a listed firestop product and design.

Penetration found on 1st floor level corridor at CT Scan door was not properly firestopped with a listed firestop product and design.


During an interview, documentation is requested for the report from the plant services director for the inspection of above ceiling penetrations, this penetration is not identified and report is not availible at time of survey.

Based on observation, interview and record review with facility maintenance director on 7-28-2011 and 8-2-2011 between the hours of 0900 and 1300 hours, this facility does not provide separation of 1 hour in approximately 30% of the smoke barriers examined. These penetrations ranged in size from 1/4 inch to 1 inch in diameter. Maintenance director provided hospital policy for "Above Ceiling Work Permit Policy, Policy # EC.02.03.01.1.a, effective 1/2011" and only able to locate 3 incomplete above ceiling work permits identified and required in the policy.


Finding include:

Penetration found at 5th floor level smoke barrier adjacent to room W581 was not properly firestopped with a listed firestop product and design.

Penetration found at 2nd floor level smoke barrier at behavioral health was not properly firestopped with a listed firestop product and design.

Penetrations fournd at 2nd floor level smoke barrier at LDR was not properly firestopped with a listed firestop product and design.



During an interview, documentation is requested for the report from the plant services director for the inspection of above ceiling penetrations, this penetration is not identified and report is not availible at time of survey.

Based on observation on 7/28/11 at approximately 1100 hours, a wall was installed in the operating room storage room to divide the storage room into 2 rooms with 1 sprinkler head in each room.

This condition was also observed by the maintenance supervisor.

Finding include:

Wall is installed in the operating room storage room to divide the storage room into 2 rooms with 1 sprinkler head in each room. With the storage room divided into 2 rooms, one storage room measured 15x20 and the other storage room measured 17x20 with 1 sprinkler head in each room. This area exceeds the maxim allowable coverage in section 5-7.2.1 NFPA 13 (1999 Ed.)

Based on observation and interview with facility maintenance director on 7-28-2011 and 8-2-2011 between the hours of 0900 and 1300 hours, this facility did not submit construction documents or obtain a permit for construction of any type as required by section 109 and 110 of the Virginia Construction Code (2009 Ed.). Facility added or relocated walls, doors and added or relocated plumbling, electrical, sprinklers and cabling causing penetrations ranged in size from 1/4 inch to 1 inch in diameter in fire wall, smoke barriers and smoke tight walls. Maintenance director provided hospital policy for "Interim Life Safety Policy, Policy #LS.01.02.01.3, effective date 1/09", facility could not provide documentation of construction identified and required in the policy.


Finding include:

Observation and interview with plant services director indicated a wall and door relocated in quality/case management, facility did not submit the construction documents and obtain the required building permit(s) from the City of Petersburg.

Observation and interview with plant services director indicated a wall and door added in plant services corridor, facility did not submit the construction documents and obtain the required building permit(s) from the City of Petersburg.


Observation and interview with plant services director indicated a wall added to divide an existing storage room in the operating room area, facility did not submit the construction documents and obtain the required building permit(s) from the City of Petersburg.


Observation and interview with plant services director indicated a wall added in EMS room at emergency department blocking existing exterior door and relocating plumbing and electrical, facility did not submit the construction documents and obtain the required building permit(s) from the City of Petersburg.

Based on observation the electrical equipment and electrical systems are not being maintained.

Finding include:

During observation above ceiling on 8/2/11 between 10:00am and 1:00pm electrical box cover is missing at 1st floor level emergency department at smoke barrier wall.

During observation above ceiling on 8/2/11 between 10:00am and 1:00pm electrical box cover missing from control box at 1st floor level emergency department at smoke tight corridor door.

During observation above ceiling on 8/2/11 between 10:00am and 1:00pm electrical cover missing from 4x4 junction box on 5th floor level nurses station across from room W567.

Based on observation, interview and record review with facility maintenance director on 7-28-2011 and 8-2-2011 between the hours of 0900 and 1300 hours, this facility does not provide 2 hour separation in approximately 10% of the fire walls examined. This penetration ranged in size from 1/4 inch to 1 inch in diameter. Maintenance director provided hospital policy for "Above Ceiling Work Permit Policy, Policy # EC.02.03.01.1.a, effective 1/2011" and only able to locate 3 incomplete above ceiling work permits identified and required in the policy.

Finding include:

Penetration found at 4th floor level fire wall across from room E422 was not properly firestopped with a listed firestop product and design.


During an interview, documentation is requested for the report from the plant services director for the inspection of above ceiling penetrations, this penetration is not identified and report is not available at time of survey.

Based on observation, interview and record review with facility maintenance director on 7-28-2011 and 8-2-2011 between the hours of 0900 and 1300 hours, this facility does not provide corridor separation in approximately 30% of the corridors examined. These penetrations ranged in size from 1/4 inch to 1 inch in diameter to a section of wall missing. Maintenance director provided hospital policy for "Above Ceiling Work Permit Policy, Policy # EC.02.03.01.1.a, effective 1/2011" and only able to locate 3 incomplete above ceiling work permits identified and required in the policy.

Finding include:

Penetration found at 5th floor level nurses station across from room E523 was not properly firestopped with a listed firestop product and design.

Penetration found at 5th floor level corridor across from room W581 was not properly firestopped with a listed firestop product and design.

Penetration found at 4th floor level nurses station across room E424 was not properly firestopped with a listed firestop product and design.

Penetrations fournd at 3rd floor level post partum wing door.
Corridor wall section missing on 1st floor level corridor at volunteer services office (approx. 2 feet X 3 feet).

Penetration found on 1st floor level corridor at cardiovascular door was not properly firestopped with a listed firestop product and design.

Penetration found on 1st floor level corridor at CT Scan door was not properly firestopped with a listed firestop product and design.


During an interview, documentation is requested for the report from the plant services director for the inspection of above ceiling penetrations, this penetration is not identified and report is not availible at time of survey.

Based on observation, interview and record review with facility maintenance director on 7-28-2011 and 8-2-2011 between the hours of 0900 and 1300 hours, this facility does not provide separation of 1 hour in approximately 30% of the smoke barriers examined. These penetrations ranged in size from 1/4 inch to 1 inch in diameter. Maintenance director provided hospital policy for "Above Ceiling Work Permit Policy, Policy # EC.02.03.01.1.a, effective 1/2011" and only able to locate 3 incomplete above ceiling work permits identified and required in the policy.


Finding include:

Penetration found at 5th floor level smoke barrier adjacent to room W581 was not properly firestopped with a listed firestop product and design.

Penetration found at 2nd floor level smoke barrier at behavioral health was not properly firestopped with a listed firestop product and design.

Penetrations fournd at 2nd floor level smoke barrier at LDR was not properly firestopped with a listed firestop product and design.



During an interview, documentation is requested for the report from the plant services director for the inspection of above ceiling penetrations, this penetration is not identified and report is not availible at time of survey.

Based on observation on 7/28/11 at approximately 1100 hours, a wall was installed in the operating room storage room to divide the storage room into 2 rooms with 1 sprinkler head in each room.

This condition was also observed by the maintenance supervisor.

Finding include:

Wall is installed in the operating room storage room to divide the storage room into 2 rooms with 1 sprinkler head in each room. With the storage room divided into 2 rooms, one storage room measured 15x20 and the other storage room measured 17x20 with 1 sprinkler head in each room. This area exceeds the maxim allowable coverage in section 5-7.2.1 NFPA 13 (1999 Ed.)

Based on observation and interview with facility maintenance director on 7-28-2011 and 8-2-2011 between the hours of 0900 and 1300 hours, this facility did not submit construction documents or obtain a permit for construction of any type as required by section 109 and 110 of the Virginia Construction Code (2009 Ed.). Facility added or relocated walls, doors and added or relocated plumbling, electrical, sprinklers and cabling causing penetrations ranged in size from 1/4 inch to 1 inch in diameter in fire wall, smoke barriers and smoke tight walls. Maintenance director provided hospital policy for "Interim Life Safety Policy, Policy #LS.01.02.01.3, effective date 1/09", facility could not provide documentation of construction identified and required in the policy.


Finding include:

Observation and interview with plant services director indicated a wall and door relocated in quality/case management, facility did not submit the construction documents and obtain the required building permit(s) from the City of Petersburg.

Observation and interview with plant services director indicated a wall and door added in plant services corridor, facility did not submit the construction documents and obtain the required building permit(s) from the City of Petersburg.


Observation and interview with plant services director indicated a wall added to divide an existing storage room in the operating room area, facility did not submit the construction documents and obtain the required building permit(s) from the City of Petersburg.


Observation and interview with plant services director indicated a wall added in EMS room at emergency department blocking existing exterior door and relocating plumbing and electrical, facility did not submit the construction documents and obtain the required building permit(s) from the City of Petersburg.

Based on observation the electrical equipment and electrical systems are not being maintained.

Finding include:

During observation above ceiling on 8/2/11 between 10:00am and 1:00pm electrical box cover is missing at 1st floor level emergency department at smoke barrier wall.

During observation above ceiling on 8/2/11 between 10:00am and 1:00pm electrical box cover missing from control box at 1st floor level emergency department at smoke tight corridor door.

During observation above ceiling on 8/2/11 between 10:00am and 1:00pm electrical cover missing from 4x4 junction box on 5th floor level nurses station across from room W567.