HospitalInspections.org

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The facility failed to maintain the corridor walls in non sprinklered sections of a facility per code. Findings include:

During the survey, the following are examples of what was observed:

First Floor
1. In the Data Room on the X ray Hall the corridor wall did not extend to the deck above.
2. The Data Room had a return air grill in the corridor wall, open to the corridor.

Second Floor
3. The right side corridor wall (the Pharmacy side) did not extend to the deck above, an HVAC duct runs between the corridor wall and the deck above. (Per maintenance staff the old plaster ceiling was removed during the renovation of the I.C.U on the third floor - after last survey)

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2000 NFPA 101, 19.3.6.2.1 Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour.
Exception No. 1*: In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.2, a corridor shall be permitted to be separated from all other areas by non-fire-rated partitions and shall be permitted to terminate at the ceiling where the ceiling is constructed to limit the transfer of smoke.
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The facility failed to maintain the doors protecting the corridor openings per code. Findings include:

During the survey, the following are examples of what was observed:

Second Floor
1. North Hall Supply Room's corridor door had an unsealed opening at the door knob.
2. Housekeeping's corridor door did not have positive latching hardware.

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2000 NFPA 101, 19.3.6.3.1
2000 NFPA 101, 19.3.6.3.2
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The facility failed to maintain the hazardous areas per code. Findings include:

During the survey, the following are examples of what was observed:

Second Floor
1. The Stock Room was approximately 144 sq. ft. with combustibles -
a. The walls did not extend to the deck above nor was there a one hour rated ceiling in this room. (Per maintenance staff the old plaster ceiling was removed during the renovation of the I.C.U on the third floor - after last survey)
b. The door to this room did not have a self-closing device.
2. Housekeeping was approximately 168 sq. ft. with combustibles -
a. The walls did not extend to the deck above nor was there a one hour rated ceiling in this room. (Per maintenance staff the old plaster ceiling was removed during the renovation of the I.C.U on the third floor - after last survey)
b. The door to this room did not have a self-closing device
3. Dietary Storage was approximately 192 sq. ft. with combustibles -
a. The walls did not extend to the deck above nor was there a one hour rated ceiling in this room.
b. The door to this room was not 45 minute fire rated.

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2000 NFPA 101, 19.3.2.1 Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.

2000 NFPA 101, 8.4.1.3 Doors in barriers required to have a fire resistance rating shall have a 3/4-hour fire protection rating and shall be self-closing or automatic-closing in accordance with 7.2.1.8.
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The facility failed to maintain the exit access per code. Findings include:

During the survey, the following are examples of what was observed:

Second Floor
The following doors had two releasing operations:
1. The Supply Room's corridor door
2. The Pharmacy's corridor door
3. The Pharmacy's narcotics door

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2000 NFPA 101, 7.2.1.5.4 A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.
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The facility failed to maintain the exit access per code. Findings include:

During the survey, the following is an example of what was observed:

Both Medical Records corridor doors had relasing mechanism at approximately 5'-0" above the finished floor.

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2000 NFPA 101, 7.2.1.5.4 A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.
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The facility failed to maintain the exit access per code. Findings include:

During the survey, the following is an example of what was observed:

The ER Director's Office room 106 - door had two releasing operations.
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2000 NFPA 101, 7.2.1.5.4 A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.
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The facility failed to maintain the horizontal exit per code. Findings include:

During the survey, the following is an example of what was observed:

First Floor
The two hour fire barrier at the chase behind X ray had several unsealed penetrations and several broken concrete blocks.

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2000 NFPA 101, 7.2.4.3.1
2000 NFPA 101, 8.2.3.2.4.2
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The facility failed to provide emergency lighting per code. Findings include:

During the survey, the following is an example of what was observed:

First Floor
All of the corridor emergency lighting was observed connected to switches, that could be turned off.

________________

2000 NFPA 101, 7.9.2.2 The emergency lighting system shall be arranged to provide the required illumination automatically in the event of any of the following:
(1) Interruption of normal lighting such as any failure of a public utility or other outside electrical power supply
(2) Opening of a circuit breaker or fuse
(3) Manual act(s), including accidental opening of a switch controlling normal lighting facilities

2000 NFPA 101, 7.9.2.5 The emergency lighting system shall be either continuously in operation or shall be capable of repeated automatic operation without manual intervention.
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The facility failed to provide a fire alarm system per code. Findings include:

During the survey, the following are examples of what was observed:

1. The ER magnetic locked exit doors failed to release under activation of the fire alarm.
2. The following magnetic locked doors did not release under loss of primary power to the fire alarm:
a. ER exit doors
b. ER corridor doors
c. OR corridor doors

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1999 NFPA 72, 3-9.7.1 Any device or system intended to actuate the locking or unlocking of exits shall be connected to the fire alarm system serving the protected premises.
1999 NFPA 72, 3-9.7.2 All exits connected in accordance with 3-9.7.1 shall unlock upon receipt of any fire alarm signal by means of the fire alarm system serving the protected premises.
Exception: Where otherwise required or permitted by the authority having jurisdiction or other codes.
1999 NFPA 72, 3-9.7.3 All exits connected in accordance with 3-9.7.1 shall unlock upon loss of the primary power to the fire alarm system serving the protected premises. The secondary power supply shall not be utilized to maintain these doors in the locked condition.
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The facility failed to maintain the automatic sprinkler pipe per code. Findings include:

During the survey, the following is an example of what was observed:

First Floor
At the stairs by the Laboratory, above the lay in ceiling there were several wires observed laying on the automatic sprinkler pipe and one black wire attached to the automatic sprinkler pipe.

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1998 NFPA 25, 2-2.2 Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.

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The facility failed to maintain the automatic sprinkler system per code. Findings include:

During the survey, the following is an example of what was observed:

The gauge for the Geri-Psych Unit's automatic sprinkler riser had not been replaced or calibrated since 2008 per documentation.

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1998 NFPA 25, 2-3.2 Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced.
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The facility failed to maintain the anesthetizing locations per code. Findings include:

During the survey, the following is an example of what was observed:

Per administrative and maintenance staff the three second floor windowless ORs did not have a smoke venting system. This addition was done in 1995.
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1999 NFPA 99, 5-4.1.2 Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically vent smoke and products of combustion.
1999 NFPA 99, 5-4.1.3 Ventilating systems for anesthetizing locations shall be provided that automatically (a) prevent recirculation of smoke originating within the surgical suite and (b) prevent the circulation of smoke entering the system intake, without in either case interfering with the exhaust function of the system.
1999 NFPA 99, 5-4.1.4 The electric supply to the ventilating system shall be served by the equipment system of the essential electrical system specified in Chapter 3, " Electrical Systems. "
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The facility failed to maintain the generator per code. Findings include:

During the survey, the following are examples of what was observed:

1. Per maintenance staff no weekly visual inspections were done in the past twelve months.
2. The facility failed to provide documentation of the December 2013's load test.

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1999 NFPA 110, 6-4.1 Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
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The facility failed to maintain the electrical wiring and equipment per code. Findings include:

During the survey, the following is an example of what was observed:

The ER Financial Counseling Office had a multi-plug adapter with three devices plugged into this device.

___________

1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip.
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The facility failed to maintain the electrical wiring and equipment per code. Findings include:

During the survey, the following is an example of what was observed:

The outside Maintenance Office had a refrigerator and a microwave plugged into a surge protector (extension cord).

___________

1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip.

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The facility failed to maintain the corridor walls in non sprinklered sections of a facility per code. Findings include:

During the survey, the following are examples of what was observed:

First Floor
1. In the Data Room on the X ray Hall the corridor wall did not extend to the deck above.
2. The Data Room had a return air grill in the corridor wall, open to the corridor.

Second Floor
3. The right side corridor wall (the Pharmacy side) did not extend to the deck above, an HVAC duct runs between the corridor wall and the deck above. (Per maintenance staff the old plaster ceiling was removed during the renovation of the I.C.U on the third floor - after last survey)

_______________

2000 NFPA 101, 19.3.6.2.1 Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour.
Exception No. 1*: In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.2, a corridor shall be permitted to be separated from all other areas by non-fire-rated partitions and shall be permitted to terminate at the ceiling where the ceiling is constructed to limit the transfer of smoke.
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The facility failed to maintain the doors protecting the corridor openings per code. Findings include:

During the survey, the following are examples of what was observed:

Second Floor
1. North Hall Supply Room's corridor door had an unsealed opening at the door knob.
2. Housekeeping's corridor door did not have positive latching hardware.

_________________

2000 NFPA 101, 19.3.6.3.1
2000 NFPA 101, 19.3.6.3.2
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The facility failed to maintain the hazardous areas per code. Findings include:

During the survey, the following are examples of what was observed:

Second Floor
1. The Stock Room was approximately 144 sq. ft. with combustibles -
a. The walls did not extend to the deck above nor was there a one hour rated ceiling in this room. (Per maintenance staff the old plaster ceiling was removed during the renovation of the I.C.U on the third floor - after last survey)
b. The door to this room did not have a self-closing device.
2. Housekeeping was approximately 168 sq. ft. with combustibles -
a. The walls did not extend to the deck above nor was there a one hour rated ceiling in this room. (Per maintenance staff the old plaster ceiling was removed during the renovation of the I.C.U on the third floor - after last survey)
b. The door to this room did not have a self-closing device
3. Dietary Storage was approximately 192 sq. ft. with combustibles -
a. The walls did not extend to the deck above nor was there a one hour rated ceiling in this room.
b. The door to this room was not 45 minute fire rated.

_______________

2000 NFPA 101, 19.3.2.1 Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.

2000 NFPA 101, 8.4.1.3 Doors in barriers required to have a fire resistance rating shall have a 3/4-hour fire protection rating and shall be self-closing or automatic-closing in accordance with 7.2.1.8.
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The facility failed to maintain the exit access per code. Findings include:

During the survey, the following are examples of what was observed:

Second Floor
The following doors had two releasing operations:
1. The Supply Room's corridor door
2. The Pharmacy's corridor door
3. The Pharmacy's narcotics door

______________

2000 NFPA 101, 7.2.1.5.4 A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.
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The facility failed to maintain the exit access per code. Findings include:

During the survey, the following is an example of what was observed:

Both Medical Records corridor doors had relasing mechanism at approximately 5'-0" above the finished floor.

_____________

2000 NFPA 101, 7.2.1.5.4 A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.
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The facility failed to maintain the exit access per code. Findings include:

During the survey, the following is an example of what was observed:

The ER Director's Office room 106 - door had two releasing operations.
______________

2000 NFPA 101, 7.2.1.5.4 A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.
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The facility failed to maintain the horizontal exit per code. Findings include:

During the survey, the following is an example of what was observed:

First Floor
The two hour fire barrier at the chase behind X ray had several unsealed penetrations and several broken concrete blocks.

______________

2000 NFPA 101, 7.2.4.3.1
2000 NFPA 101, 8.2.3.2.4.2
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The facility failed to provide emergency lighting per code. Findings include:

During the survey, the following is an example of what was observed:

First Floor
All of the corridor emergency lighting was observed connected to switches, that could be turned off.

________________

2000 NFPA 101, 7.9.2.2 The emergency lighting system shall be arranged to provide the required illumination automatically in the event of any of the following:
(1) Interruption of normal lighting such as any failure of a public utility or other outside electrical power supply
(2) Opening of a circuit breaker or fuse
(3) Manual act(s), including accidental opening of a switch controlling normal lighting facilities

2000 NFPA 101, 7.9.2.5 The emergency lighting system shall be either continuously in operation or shall be capable of repeated automatic operation without manual intervention.
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The facility failed to conduct fire drills per code. Findings include:

During the survey, the following is an example of what was observed:

Per maintenance staff not all staff participated when silient drills were conducted on third shift:
1. Third shift second quarter of 2014
2. Third shift fourth quarter of 2013

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2000 NFPA 101, 19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
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The facility failed to provide a fire alarm system per code. Findings include:

During the survey, the following are examples of what was observed:

1. The ER magnetic locked exit doors failed to release under activation of the fire alarm.
2. The following magnetic locked doors did not release under loss of primary power to the fire alarm:
a. ER exit doors
b. ER corridor doors
c. OR corridor doors

______________

1999 NFPA 72, 3-9.7.1 Any device or system intended to actuate the locking or unlocking of exits shall be connected to the fire alarm system serving the protected premises.
1999 NFPA 72, 3-9.7.2 All exits connected in accordance with 3-9.7.1 shall unlock upon receipt of any fire alarm signal by means of the fire alarm system serving the protected premises.
Exception: Where otherwise required or permitted by the authority having jurisdiction or other codes.
1999 NFPA 72, 3-9.7.3 All exits connected in accordance with 3-9.7.1 shall unlock upon loss of the primary power to the fire alarm system serving the protected premises. The secondary power supply shall not be utilized to maintain these doors in the locked condition.
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The facility failed to maintain the automatic sprinkler pipe per code. Findings include:

During the survey, the following is an example of what was observed:

First Floor
At the stairs by the Laboratory, above the lay in ceiling there were several wires observed laying on the automatic sprinkler pipe and one black wire attached to the automatic sprinkler pipe.

____________

1998 NFPA 25, 2-2.2 Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.

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The facility failed to maintain the automatic sprinkler system per code. Findings include:

During the survey, the following is an example of what was observed:

The gauge for the Geri-Psych Unit's automatic sprinkler riser had not been replaced or calibrated since 2008 per documentation.

____________

1998 NFPA 25, 2-3.2 Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced.
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The facility failed to maintain the anesthetizing locations per code. Findings include:

During the survey, the following is an example of what was observed:

Per administrative and maintenance staff the three second floor windowless ORs did not have a smoke venting system. This addition was done in 1995.
_______________

1999 NFPA 99, 5-4.1.2 Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically vent smoke and products of combustion.
1999 NFPA 99, 5-4.1.3 Ventilating systems for anesthetizing locations shall be provided that automatically (a) prevent recirculation of smoke originating within the surgical suite and (b) prevent the circulation of smoke entering the system intake, without in either case interfering with the exhaust function of the system.
1999 NFPA 99, 5-4.1.4 The electric supply to the ventilating system shall be served by the equipment system of the essential electrical system specified in Chapter 3, " Electrical Systems. "
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The facility failed to maintain the generator per code. Findings include:

During the survey, the following are examples of what was observed:

1. Per maintenance staff no weekly visual inspections were done in the past twelve months.
2. The facility failed to provide documentation of the December 2013's load test.

____________

1999 NFPA 110, 6-4.1 Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
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The facility failed to maintain the electrical wiring and equipment per code. Findings include:

During the survey, the following is an example of what was observed:

The ER Financial Counseling Office had a multi-plug adapter with three devices plugged into this device.

___________

1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip.
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The facility failed to maintain the electrical wiring and equipment per code. Findings include:

During the survey, the following is an example of what was observed:

The outside Maintenance Office had a refrigerator and a microwave plugged into a surge protector (extension cord).

___________

1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip.

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