HospitalInspections.org

Based on observations and confirmed by staff, corridor walls are not constructed as required.

THE FINDINGS INCLUDE:

WHITCOMB BUILDING

- On 1/12/10 while conducting the morning tour, two basement level offices were noted as being equipped with 3' x 3' sliding type windows. Each of these window units opens to an exit corridor. Note: These offices are not equipped with smoke detecting devices and do not meet the exception to a room open to the corridor.

This was acknowledged by hospital security staff during the building tour.

Based on observations, the facility failed to assure that doors protecting corridor openings close completely and latch tightly in their frames.

THE FINDINGS INCLUDE:

Main Building - South Building:

- Observations on the afternoon of January 12, 2010 revealed that the inactive leaf in the pair of corridor doors to third floor room #3-06-214 is a not self-latching. The door is equipped with a manually operated flush bolt.
This was confirmed by the Director of Security.

Based on observations, the facility failed to assure that smoke barriers are constructed as required.

THE FINDINGS INCLUDE:

Main Building - South Building:

- Observations on the afternoon of January 12, 2010 revealed that vision panels in the third floor smoke barrier doors #3-06-214 and #3-06-200 are not fire rated or wired glass. They have unrated 6" x 34" Tempered Safety Glass vision panels.
This was confirmed by the Director of Security.

Based on observations and confirmed by staff, the facility failed to assure that smoke barrier doors are properly maintained.

THE FINDINGS INCLUDE:

Mugar Building:

- Observations on the morning of January 13, 2010 revealed that the single smoke barrier door in the center core is being held open with a metal frame of a dry mop head .

This was acknowledged by the Director of Facilities.

Based on observations, the facility failed to assure that hazardous areas are enclosed as required.

THE FINDINGS INCLUDE:

Main Building - South Building:

- Observations on the afternoon of January 12, 2010 revealed that the inactive leaf in the pair of doors to the third floor janitor closet #3-06-600 was unlatched.
This was confirmed by the Director of Security.

Based on observations, the facility failed to assure that exit stairways are enclosed as required. Section 8.2.3.2.3.1 requires openings in stairways enclosed with 1-hour fire barriers to be protected by doors having at least a 1-hour fire rating and stairways enclosed with 2-hour fire barriers to be protected by doors having at least a 1-1/2-hour fire rating. Section 8.2.3.2.1(a) requires door assemblies to be of an approved type installed in accordance with NFPA #80.

THE FINDINGS INCLUDE:

Main Building - South Building:

1. Observations on the afternoon of January 12, 2010 revealed that the third floor stairway door #3-06-600 is a "C" labeled, 3/4 hour fire rated door.
This was confirmed by the Director of Security.



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MAIN BUILDING

2. On 1/13/10 while conducting the afternoon tour, the "H" stair door #1-002 which leads into the mechanical room was noted as not being equipped with any latching hardware. The door is currently equipped with a magnetic locking device only which releases upon activation of the fire alarm system.

This was acknowledged by the Director of Engineering during the building tour.

Based on observations, the facility failed to assure that the means of egress is in accordance with Chapter 7. Section 7.1.5 requires headroom in a means of egress to be no less than 7'-6" to ceilings and no less than 6'-8" to any projection from the floor. Ceiling height in existing buildings shall not be less than 7"-0". Section 7.1.10.1 states means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

THE FINDINGS INCLUDE:

Main Building - 1978 Addition:

- Observations on the afternoon of January 13, 2010 revealed that the headroom under display screens mounted on the corridor wall across from room #3-13-401 is 6'-4".
This was confirmed by the Director of Security.

Based on observations, the facility failed to assure that corridors are at least 8 feet wide. Section 4.6.7 prohibits existing life safety features that exceed the requirements for existing buildings, to be diminished. Section 4.6.7 requiems facilities constructed with corridors up to 8 feet in width maintain the width. Section 7.1.10.1 requires every exit, exit access and exit discharge to be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. Section 7.1.10.2.1 requires that no objects be so placed so as to obstruct exits, access thereto, egress therefrom, or visibility thereof. Large mobile receptacle(s) may be moved along the corridors as collections occur but must be attended by staff. If staff must leave the immediate area the container(s) must be stored in a room designed and maintained as a hazardous area in accordance with 19.3.2.1. CMS S&C-04-41 states that original corridor widths cannot be diminished by any chairs, tables, filling cabinets or any not in use carts or janitorial equipment or devices affixed to the wall that exceed 3.5 inches in thickness.

THE FINDINGS INCLUDE:

Main Building - South Building:

1. Observations on the afternoon of January 12, 2010 revealed that three (3) wall mounted fold down charting stations (trade name WALLaroos) installed on third floor corridor walls reduced the eight (8) foot corridors to 5'-1" when fully open. Although the WALLaroos are equipped with closing devices the shelves did not automatically close when released from the fully open position. At 4:01 p.m. the WALLaroo located by room 3-06-210 was unattended by staff and was held open by charts left on the shelf.
This was confirmed by the Director of Security.

2. Observations on the afternoon of January 12, 2010 and at 6:10 a.m. on January 13, 2010 revealed that three (3) computers on wheels (COWS) and a pole mounted blood pressure monitor are stored in the third floor corridor, plugged into receptacles.
This was confirmed by the Director of Security.

Main Building - Ayling Wing:

3. Observations on the morning of January 13, 2010 revealed that the WALLaroos installed on third floor corridor wall by room #3-02-203 reduced the 8 foot corridors to 63" when fully open. Although the WALLaroo is equipped with closing devices the shelf did not automatically close when released from the fully open position.
This was confirmed by the Director of Security.

4. Observations on the morning of January 13, 2010 revealed that the corridor by stair door #3-E-00 is used as a waiting area with five (5) chairs and two (2) end tables.
This was confirmed by the Director of Security.

Main Building - 1978 Addition:

5. Observations on the afternoon of January 13, 2010 revealed that eight (8) COWS are stored in the third floor corridor, plugged into receptacles. They are located by rooms #3-12-201, 3-12-208, 3-12-209, 3-13-210, 3-12-211,3-13-219 and 3-13-401.
This was confirmed by the Director of Security.

6. Observations on the afternoon of January 13, 2010 revealed that a pole mounted blood pressure monitor is stored in the third floor corridor by room #3-13-210, plugged into a receptacle.
This was confirmed by the Director of Security.

7. Observations on the afternoon of January 13, 2010 revealed that the Iron Mountain paper recycling bin was stored in the corridor by room #3-12-222 reducing the width to 6'-6". When brought to the attention of staff it was promptly moved.
This was confirmed by the Director of Security.

8. Observations on the afternoon of January 13, 2010 revealed that soiled linen carts are stored in the corridor outside of almost every bedroom on the third floor in the Med/Surge unit.
This was confirmed by the Director of Security.

9. Observations on the afternoon of January 13, 2010 revealed that the corridor by room #3-13-216 is used to store carts of supplies and equipment.
This was confirmed by the Director of Security.

Based on observations, the facility did not assure that suites of rooms meet the requirements.
Section 18.2.5.7 requires suites of rooms, other than patient sleeping rooms, to not exceed 10,000 square feet in size.

THE FINDINGS INCLUDE:

Mugar Building - Cardiac Cath Lab Suite:

- Observations on the afternoon of January 15, 2010 revealed that this suite is 14,800 square feet in size.
This was confirmed by the Director of Facilities.

NOTE: This Item will meet the FSES and will not require correction.

Based on observations and confirmed by staff, the facility failed to assure that egress lighting is properly provided. Section 7.8.1.2 requires all illumination in the means of egress be continuous during the time that the conditions of occupancy require that the means of egress be available for use.

THE FINDINGS INCLUDE:

MAIN BUILDING

- On 1/13/10 while conducting the afternoon tour, the following stairwells were found to be deficient:

1) The stairwell leading from the rear of the new 3rd floor pharmacy is currently equipped with a light switch. When the switch was tested for operation, the stairwell was placed into complete darkness with no egress lighting available.

2) The "C" stairwell on the 1st floor level is currently equipped with a light switch. When the switch was tested for operation, the stairwell was placed into complete darkness with no egress lighting available.

These items were each acknowledged by the Director of Facilities during the building tour.

Based on record review and confirmed by Engineering staff, it was revealed that the facility failed to assure compliance with NFPA #72 (National Fire Alarm Code). Section 7.1.2 states the owner or the owner's designated representative shall be responsible for inspection, testing, and maintenance of the system and alterations or additions to this system. The delegation of responsibility shall be in writing, with a copy of such delegation provided to the authority having jurisdiction upon request. Section 7.3.2 requires testing to be preformed in accordance with the schedules in Chapter 7 and Table 7-3.2. Section 7.3.2 and Table 7.3.2 require systems with sealed batteries to have a load voltage test conducted on them semi-annually and a 30 minute discharge test annually.

THE FINDINGS INCLUDE:

Records provided by the Hospital, and reviewed on January 14, 2010, revealed that fire alarm devices are not maintain and tested as required. The following is a summary of deficiencies found:

All buildings:

1) The inspection and testing reports from the Hospital's fire alarm vendor, reported a inventory of 2096 fire alarm devices. Out of the 2096 devices, 71 had a test date of November 2009. The other 2025 devices have a test date between November 2008 and November 2007.

2) The inspection and testing report from the Hospital's fire alarm vendor do not show the type of battery testing performed. The report uses the word "pass" on battery testing, and does not indicate whether it was a semi-annual test or an annual 30 min discharge test.

These items were each acknowledged by the Director of Facilities and Engineering Staff during record review.

Based on record review and confirmed by staff, the facility failed to assure compliance with NFPA #72. Section 7.3.2.1 states smoke detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.

THE FINDING INCLUDE:

All buildings:

- During a review of the Fire Alarm System Inspection Reports provided by the Hospital on January 14, 2010, it was revealed that smoke detectors are not subjected to a sensitivity check.

This was acknowledged by the Director of Facilities and Engineering Staff.

Based on observations and confirmed by staff, the facility failed to assure that non-sprinklered electrical rooms/closets are properly separated. NFPA 13 section 5.13.11 states that sprinkler protection shall be required in electrical equipment rooms. Hoods or shields installed to protect important electrical equipment from sprinkler discharge shall be noncombustible.
The exception states sprinklers shall not be required where all of the following conditions are met:
(a) The room is dedicated to electrical equipment only.
(b) Only dry-type electrical equipment is used.
(c) Equipment is installed in a 2-hour fire-rated enclosure including protection for penetrations.
(d) No combustible storage is permitted to be stored in the room.

THE FINDINGS INCLUDE:

Main Building - South Building:

1. Observations on the afternoon of January 12, 2010 revealed that the fourth floor non-sprinklered electrical room #4-02-800 is equipped with a 3/4 hour rated door.
This was confirmed by the Security Officer.

Main Building - Operating Room Suite:

2. Observations on the morning of January 13, 2010 revealed that the janitor's closet by toilet room #G-058 is not protected by sprinkler(s).
This was confirmed by the Director of Security.

Main Building - 1978 Addition:

3. Observations on the afternoon of January 13, 2010 revealed that the third floor non-sprinklered electrical room #3-08-800 is equipped with a 20 minute door.
This was confirmed by the Security Officer.

Main Building - Radiology Suite:

4. Observations on the morning of January 14, 2010 revealed that the non-sprinklered electrical rooms:
- #1-12-801 and 1-12-805 are equipped with a 3/4 hour rated doors.
- #1-12-803 is equipped with a 20 minute door.
- #1-12-802 and 1-12-804 are equipped with unrated doors.
This was confirmed by the Security Officer.




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MAIN BUILDING

- On 1/13/10 while conducting the afternoon tour, the following sprinkler system items were found to be deficient:

5. The Ayling Wing non-sprinklered electrical closet #2-02-801 has a six foot by six inch (6' x 6") penetration along the entire ceiling where it meets the rear wall. (Note: This space is currently filled with non-rated Owen Cornings insulation) This closet also has a set of non-rated doors which are not equipped with any self closing devices.

6. The Ayling Wing non-sprinklered electrical closet #2-01-800 is equipped with a pair of doors which do not have self closing devices installed.

7. The 1st floor non-sprinklered electrical room #1-12-804 is equipped with a 3/4 hour rated door.

8. The Ayling closet next to the IT weekend office is non-sprinklered.

9. The Fire Extinguisher office located within the mechanical room is non-sprinklered.

10. The newly constructed closet within the Hospitalist sleeping room is non-sprinklered.

11. The 1st floor level corridor outside of the "B" stairwell door is not protected by the sprinkler system. The current configuration of the sprinkler head placement does not protect this area as another sprinkler head is needed for proper protection. Note: This compartment is currently equipped with plain glass requiring complete protection from the automatic sprinkler system.

These items were each acknowledged by the Director of Facilities during the building tour.

Based on record review and confirmed by facility's and engineering staff, the facility failed to assure that sprinkler systems are maintained as required. NFPA 25 Section 1.4.2 states the responsibility for properly maintaining a water-based fire protection system shall be that of the owner(s) of the property. By means of periodic inspections, tests, and maintenance, the equipment shall be shown to be in good operating condition, or any defects or impairments shall be revealed. Inspection, testing, and maintenance shall be implemented in accordance with procedures meeting or exceeding those established in this document and in accordance with the manufacturer's instructions. These tasks shall be performed by personnel who have developed competence through training and experience. Section 2.3.3.1 states that testing the waterflow alarms on wet pipe systems shall be accomplished by opening the inspector's test connection quarterly. Section 9.3.5 states the operating stems of outside screw and yoke valves shall be lubricated annually. Section 2.2.4.2 states that gauges on dry, preaction, and deluge systems shall be inspected weekly to ensure that normal air and water pressures are being maintained. Section 2.2.4.1 states that gauges on wet pipe sprinkler systems shall be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained. Section 2.3.2 states gauges on sprinkler systems shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Section 9.4.4.2.2 states each dry pipe valve shall be trip tested annually during warm weather. Section 9.4.4.2.2.1 states that every 3 years and whenever the system is altered, the dry pipe valve shall be trip tested with the control valve fully open and the quick-opening device, if provided, in service. Section 5.3.3.1 states that an annual test of each pump assembly shall be conducted under minimum, rated, and peak flows of the fire pump by controlling the quantity of water discharged through approved test devices. Section 5.3.5.2 states the pump test curve shall be compared to the unadjusted field acceptance test curve and the previous annual test curve(s). Section 2.2.1.1 states sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

THE FINDINGS INCLUDE:

Main Building - South Building:

1. Observations on the afternoon of January 12, 2010 revealed that the covers on the recessed sprinkler heads in the Delivery Room #M4-013 and Toilet room #4-01-603 are painted.
This was confirmed by the security officer.

Main Building - Ayling Wing:

2. Observations on the morning of January 13, 2010 revealed that the cover on the recessed sprinkler head in closet #3-02-501 is painted.
This was confirmed by the security officer.

Main Building - Operating Room Suite:

3. Observations on the morning of January 13, 2010 revealed that the covers on the recessed sprinkler heads in the PACU recovery room and operating rooms #10, 11 and 12 are painted.
This was confirmed by the security officer.

Main Building - Med/Surg Unit:

4. Observations on the afternoon of January 13, 2010 revealed that the cover on the recessed sprinkler head in toilet #3-12-209 is painted:
This was confirmed by the security officer.


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MAIN BUILDING

5. Observations on the afternoon of January 13, 2010 revealed that the covers on the recessed sprinkler heads in the corridor of the Ayling Wing outside of the rear door to the Medical Records Department are painted.
This was confirmed by the Director of Facilities.

6. Observations on the afternoon of January 13, 2010 revealed that the covers on the recessed sprinkler heads in Ayling patient rooms #805 and #810 are painted.
This was confirmed by the Director of Facilities.


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- During a review of the fire sprinkler maintenance records on the morning of January 15, 2009 it was revealed that the automatic sprinkler systems are not maintained, tested and inspected as required.

7. The wet sprinkler system gauges are not inspected monthly and the dry sprinkler system gauges are not inspected weekly and documented.

- Sprinkler inspection reports provided by the Hospital dated 12/3/09; 6/17/09; and 2/19/09 and the fire pump inspection report dated 9/16/09 revealed the following deficiencies:

8. A quarterly sprinkler inspection was not conducted in the third quarter of 2009, therefore a quarterly water flow alarm test was not conducted.

9. The sprinkler inspection forms that were provided, do not indicate that the OS&Y valves are lubricated, closed and reopened annually.

10. The sprinkler inspection forms that were provided, do not indicate that the dry valves have had a 3-year full flow trip tested performed.

11. The sprinkler inspection forms that were provided, do not indicate that a full trip tested is conducted every 3 years on the dry valves.

12. The sprinkler inspection forms that were provided, do not indicate that the pressure gangues are replaced or check for calibration.

13. The annual fire pump inspection report does not include a test pump curve.

These items were each acknowledged by the Director of Facilities and Engineering Staff during record review.

Based on observations, record review and confirmed by staff, the facility failed to assure compliance with NFPA #90A. Section 3.3.4.4 states fire dampers shall be installed at each direct or ducted opening into or out of enclosures required by section 3.3.4.1. Section 3.3.4.1 states air ducts that pass through the floors of buildings that require the protection of vertical openings shall be enclosed with partitions or walls constructed of materials as permitted by the building code of the authority having jurisdiction. The enclosure shall have a minimum fire resistance rating (based on possible fire exposure from either side of the partition or wall) of 1 hour where such air ducts are located in a building less than four stories in height and a minimum rating of 2 hours where such air ducts are located in a building four stories or more in height. Section 2.3.4.1 states service opening shall be provided in air ducts adjacent to each fire damper, smoke damper, and smoke detector. The opening shall be large enough to permit maintenance and resetting of the device. Section 2.3.4.2 states service openings shall be identified with letters having a minimum height of 1/2 in. to indicate the location of the fire protection device(s) within. Section 3.4.7 states that at least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.
NFPA 101A section 4.4.12.2 states: A vertical opening or penetration shall be classified as an open or incomplete enclosure, provided it is
(a) Unenclosed
(b) Enclosed but does not have doors
(c) Enclosed but has openings other than doorways
(d) Enclosed with cloth, paper, or similar materials without any sustained firestopping capabilities

THE FINDINGS INCLUDE:

MRI Building:

- The hospital failed to provide a detailed list of all fire dampers and documentation that the required maintenance has been performed on them.

This was acknowledged by the Director of Facilities and Engineering Staff.

Based on observations, the facility did not assure that portable electric heaters are prohibited from the building.

THE FINDINGS INCLUDE:

Main Building - Ayling Wing:

1. While touring the building on January 13, 2010 at 11:00 A.M. a portable electric heater was found in office #3-04-401.

Main Building - Endoscopy Suite:

2. While touring the facility on January 14, 2010 at 10:35 A.M. a portable electric heater was found in office #1-29-300.

Main Building - Emergency Department:

3. While touring the facility on January 14, 2010 at 10:55 A.M. a portable electric heater was found in office #1-12-404.

These were confirmed by the Director of Security.

Based on observations and confirmed by staff, the facility failed to assure that exit egress routes are properly maintained. Section 7.1.10.1 states means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

THE FINDINGS INCLUDE:

MAIN BUILDING

- On 1/14/10 @ 3:00PM, the outside asphalt walkway leading from the "H" stair egress corridor was found to be covered in ice. There is a condensate pipe which drains onto this walkway, the water is accumulating at a low point before the catch basis and freezing.

This was acknowledged by hospital's Facility Director during the building tour.

Based on observations, the facility failed to properly store oxygen. NFPA 99, Sections 16.3.8.1, 8.3.1.11.2(h), and 4.3.5.2.1(b)27 requires freestanding cylinders to be properly chained or supported in a proper cylinder stand or cart.

THE FINDINGS INCLUDE:

Main Building - Med/Surg Unit:

- Observations on January 13, 2010 at 2:32 P.M. revealed that an "E" size cylinder of oxygen is standing upright unsupported (not in a stand or rack) on the floor by room #3-12-503.
This was confirmed by the Director of Security.

Based on observations and confirmed by facility staff, the facility failed to test electrical appliances as required and per the facilities schedule. NFPA 99, Section 7.6.2.1.2 requires facilities to establish policies and protocols for the type of test and intervals of testing for each appliance. All appliances used in patient care areas shall be tested in accordance with 7-5.1.3 or 7-5.2.2.1 before being put into service for the first time and after repair or modification. Patient-care-related electrical appliances shall be retested at intervals determined by their normal location or area of normal use, but not exceeding the following intervals: General care areas - 12 months; Critical care areas - 6 months, and Wet locations - 6 months.
Exception No. 1: The testing intervals listed are intended to be nominal values, and facilities shall be permitted to adopt a protocol using either longer or shorter intervals provided that there is a documented justification based on previous safety testing records for the equipment in question, unusually light or heavy utilization, or similar considerations.

THE FINDINGS INCLUDE:

Main Building - South Building - Labor & Delivery Suite:

1. Observations on the afternoon of January 12, 2010 revealed the following:
a. Fetal monitor #CTS-4240 and the one in the maternity recovery room have tags on them indicating that they were due for testing in 9/09.
b. Incubator #CTS-5139 had no tag on it indicating when it is due for testing. Records reviewed with the Clinical Equipment Director revealed that it was last tested on 9/1/08 and was due for retesting in 9/09.
c. Epidural Pumps #CTS-5667 and #CTS-5901 have tags on them indicating that they were due for testing in 7/09.

Main Building Operating Room Suite:

2. Observations in the PACU recovery room on the morning of January 13, 2010 revealed that ten (10) heart rate monitors were due for testing in 10/09.

3. Observations in the O'Keefe Post-Op room on the morning of January 13, 2010 revealed that twelve (12) heart rate monitors were due for testing in 10/09.

Main Building - Coronary Care Unit:

4. Observations on the afternoon of January 13, 2010 revealed that ultrasound machine #CTS-0437 in room #3-10-204 was due for testing in 5/09.

These were confirmed by Clinical Equipment Director

Based on observations, the facility failed to properly install alcohol based hand sanitizing dispensers.

THE FINDINGS INCLUDE:

Main Building - Ayling Wing:

1. Observations on the third floor on the morning of January 13, 2010 revealed that an alcohol based hand sanitizing dispenser is mounted above receptacle #CPC-37 (located by toilet room #3-02-604).
This was confirmed by the Director of Security.

Main Building - Operating Room Suite:

2. Observations on the morning of January 13, 2010 revealed that an alcohol based hand sanitizing dispenser is mounted above a receptacle in operating room #11 and over a light switch by door frame #1-22-00.
This was confirmed by the Safety Officer.

Main Building - Pediatric Suite:

3. Observations on the morning of January 14, 2010 in the revealed that an alcohol based hand sanitizing dispenser is mounted above a receptacle by the door to room #1-29-207.
This was confirmed by the Director of Security.