HospitalInspections.org

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 and May 7, 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.

NOTE: The completion date for this item was 4/15/10.

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 and May 7, 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.



16934


MAIN BUILDING

2. CORRECTED.

Based on observations and confirmed by facility staff, the facility failed to assure egress routes are maintained. NFPA 101, section 7.1.3.2.1 states that Where this Code requires an exit to be separated from other parts of the building, the separating construction shall meet the requirements of Section 8.2 and the following:
(a) The separation shall have not less than a 1-hour fire resistance rating where the exit connects three stories or less.
(b) The separation shall have not less than a 2-hour fire resistance rating where the exit connects four or more stories. The separation shall be constructed of an assembly of noncombustible or limited-combustible materials and shall be supported by construction having not less than a 2-hour fire resistance rating. Door assembly in 2-hour fire resistance separation must be at least 90 minutes.

THE FINDINGS INCLUDE:

Mugar Building:

- Observations on the morning of January 13, 2010 and afternoon of May 7, 2010 revealed that the door assemblies in the first floor corridor, that make up the exit passageway from Stairwell "K", are not properly fire rated. One door assembly is only rated for 45 minutes.

NOTE: The completion date for this item was 4/1/10.

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 and May 7, 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.
This was confirmed by the Director of Security.
NOTE: The completion date for this item was 5/1/10.

2. Observations on the afternoon of January 12, 2010 and May 7, 2010 revealed that three (3) computers on wheels (COWS) are stored in the third floor corridor, plugged into receptacles.
This was confirmed by the Director of Security.
NOTE: The completion date for this item was 1/14/10.

Main Building - Ayling Wing:

3. Observations on the afternoon of January 12, 2010 and May 7, 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.
NOTE: The completion date for this item was 5/1/10.

4. CORRECTED.

Main Building - 1978 Addition:

5. CORRECTED.

6. CORRECTED.

7. CORRECTED.

8. CORRECTED.

9. CORRECTED.

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, the facility did not assure that suites of rooms meet the requirements.
Section 19.2.5.7 requires suites of rooms, other than patient sleeping rooms, to not exceed 10,000 square feet in size.

THE FINDINGS INCLUDE:

Main Building - Operating Room/PACU/Open Heart Suite:

1. Observations on the afternoon of January 15, 2010 revealed that this suite is 13,800 square feet in size.

Main Building - Emergency Department:

2. Observations on the afternoon of January 15, 2010 revealed that this suite is 15,500 square feet in size.

Main Building - Radiology Suite:

3. Observations on the afternoon of January 15, 2010 revealed that this suite is 12,500 square feet in size.

Main Building - Ambulatory Surgery Suite:

4. Observations on the afternoon of January 15, 2010 revealed that this suite is 12,900 square feet in size.

These were confirmed by the Director of Facilities.

NOTE: These items meet the FSES and do not require correction.

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 and May 7, 2010, revealed that fire alarm devices are not maintain and tested as required.

All buildings:

1) CORRECTED.

2) The inspection and testing report from the Hospital's fire alarm vendor documents that a load test was done but does not document that an annual 30 minute discharge test is performed on the batteries.

NOTE: The completion date for this item was 3/2/10.

This item was acknowledged by the Director of Engineering.

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 and May 7, 2010, revealed that fire alarm devices are not maintain and tested as required.

All buildings:

1) CORRECTED.

2) The inspection and testing report from the Hospital's fire alarm vendor documents that a load test was done but does not document that an annual 30 minute discharge test is performed on the batteries.

NOTE: The completion date for this item was 3/2/10.

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

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 and May 7, 2010, revealed that fire alarm devices are not maintain and tested as required. The

Mugar Building:

1) CORRECTED.

2) The inspection and testing report from the Hospital's fire alarm vendor documents that a load test was done but does not document that an annual 30 minute discharge test is performed on the batteries.

NOTE: The completion date for this item was 3/2/10.

This item was acknowledged by the Director of Engineering.

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. Table 7.2.2(13)(2)(b) requires the switch on suppression system(s) to be mechanically or electrically operated. Table 7.3.2(15)(c) requires suppression system(s) to be tested annually.

THE FINDINGS INCLUDE:

Records provided by the Hospital, and reviewed on January 14, 2010 and May 7, 2010, revealed that fire alarm devices are not maintain and tested as required.

All buildings:

1) CORRECTED.

2) The inspection and testing report from the Hospital's fire alarm vendor documents that a load test was done but does not document that an annual 30 minute discharge test is performed on the batteries.

NOTE: The completion date for this item was 3/2/10.

This item was acknowledged by the Director of Engineering.

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. Table 7.2.2(13)(2)(b) requires the switch on suppression system(s) to be mechanically or electrically operated. Table 7.3.2(15)(c) requires suppression system(s) to be tested annually.

THE FINDINGS INCLUDE:

Records provided by the Hospital, and reviewed on January 14, 2010 and May 7, 2010, revealed that fire alarm devices are not maintain and tested as required.

All buildings:

1) CORRECTED.

2) The inspection and testing report from the Hospital's fire alarm vendor documents that a load test was done but does not document that an annual 30 minute discharge test is performed on the batteries.
NOTE: The completion date for this item was 3/2/10.


Main Building - South Building:

3) The inspection and testing report from the Hospital fire alarm vendor and the kitchen range extinguishing sytem vender do not list the kitchen exhaust hood suppression system as being tested annually.
NOTE: The completion date for this item was 3/2/10.

These items were acknowledged by the Director of Engineering.

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. CORRECTED.

Main Building - Operating Room Suite:

2. CORRECTED.

Main Building - 1978 Addition:

3. CORRECTED.

Main Building - Radiology Suite:

4. CORRECTED.



16934

MAIN BUILDING

5. CORRECTED.

6. CORRECTED.

7. CORRECTED.

8. CORRECTED.

9. CORRECTED.

10. The newly constructed closet within the Hospitalist sleeping room is non-sprinklered.
This was confirmed by the Director of Security.

NOTE: The completion date for this item is 7/1/10.

11. CORRECTED.

Based on observations and confirmed by staff, the facility failed to assure that sprinkler heads are installed as required. NFPA 13 section 5-6.4.1.1 states under unobstructed construction, the distance between the sprinkler deflector and the ceiling shall be a minimum of 1 in. (25.4 mm) and a maximum of 12 in. (305 mm). 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.
NFPA 101 section 19.3.6.2.3 permits fire windows in accordance with section 8.2.3.2.2 to be used in corridor doors. The exception to section 19.3.6.2.3 permits the fire resistance of the glass and area size of the glass to have no restrictions if the smoke compartment is protected throughout by an approved, supervised automatic sprinkler system.

THE FINDINGS INCLUDE:

WHITCOMB BUILDING

- On 1/12/10 and 5/7/10 while conducting a tour, the following sprinkler system items were found to be deficient:

1) There are numerous locations within the basement level which are missing 2' x 2' ceiling tiles. These areas include but are not limited to the following locations: a) Group Room; b) office next to the repair shop; c) main corridor; d) old record room; e) old dining room

NOTE: The completion date for this item was 1/14/10.

2) CORRECTED.

3) CORRECTED.

4) No sprinkler protection is provided in the closet of room #107 and the HP shower room on the
occupied unit. Note: Plain glass vision panels are used in numerous locations throughout the compartment, requiring the unit to be fully sprinklered.

NOTE: The completion date for this item is 6/1/10.

These were each acknowledged by hospital security staff during the building tour.

Based on observations and confirmed by staff, the facility failed to assure that sprinkler heads are installed as required. NFPA 13 section 5.6.4.1.1 states under unobstructed construction, the distance between the sprinkler deflector and the ceiling shall be a minimum of 1 in. and a maximum of 12 in.

THE FINDINGS INCLUDE:

Mugar Building:

- During the building tour on January 13 and May 7, 2010, it was found that there is a 12 inch gap between the suspended ceiling and light soffit. The space between the suspended ceiling and the deck above is approximate 4 feet in height.

NOTE: The completion date for this item was 4/1/10.

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. Section 9.4.1.2 states alarm valves and their associated strainers, filters, and restriction orifices shall be inspected internally every 5 years unless tests indicate a greater frequency is necessary. Section 9.3.5 states the operating stems of outside screw and yoke valves shall be lubricated annually. 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.

THE FINDINGS INCLUDE:

WHITCOMB BUILDING

1) After reviewing sprinkler records on May 7, 2010, it was determined that the valve has not had a 5-year internal inspection. The records do not indicate any inspection of the valve has been performed.

NOTE: The completion date for this item is 6/1/10.



17078


Whitcomb Pavilion:


2) CORRECTED.

3) CORRECTED.

4) CORRECTED.

5) CORRECTED.

6) CORRECTED.

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.

NOTE: The completion date for this item is 7/1/10.

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:

Main 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.

NOTE: The completion date for this item is 7/1/10.

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:

Radiation Therapy 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.

NOTE: The completion date for this item is 7/1/10.

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:

Whitcomb Pavilion:

- 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.

NOTE: The completion date for this item is 7/1/10.