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A. Corridors are not separated from use spaces in accordance with 19.3.6.1. Observed conditions include the following:

1. The ER doctor's sleeping room (near the Lab) door contains an aluminum grille which does not comply with 19.3.6.4 to prevent the passage of fire and smoke.

A. Hazardous areas are not protected in accordance with 19.3.2.1 and 8.4. Conditions observed include but are not necessarily limited to the following:

1. The 1st floor CT Storage room is provided with sprinkler protection but the walls have pentrations which are not sealed to the passage of fire and smoke to comply.

2. The 1st floor Respiratory Therapy storage room located off ER room #6 is provided sprinkler protection but the door is not self-closing to comply.

3. The 1st floor X-ray file storage room door (near the ER doctor's sleeping room) is not self-closing.

4. The 1st floor Pharmacy door is located in a designated 2-hour barrier. The door could not be confirmed to be of minimum 1 1/2-hour rating due to the label being painted.

5. The west door of the Boiler room leading to a former corridor (now part of the X-ray film storage room) is not self-closing.

6. The 2nd floor OR suite "Storage" room (former procedure room) is not provided with sprinkler protection and therefore requires 1-hour rated enclosure. The door is not minimum 3/4-hour rated and is not positive latching to comply.

7. The 2nd floor OR suite clean supply room is not provided with sprinkler protection and therefore requires 1-hour rated enclosure. The door is not minimum 3/4-hour rated and is not self-closing to comply.

A. Exit discharge lighting is not provided in accordance with 19.2.8 and 7.8. Conditions observed include the following:

1. The exit discharge at the Kitchen is provided with only a single lamp fixture. Although a mercury vapor security light is provided, this fixture does not have instant restrike capability.

2. The exit discharge at the room/corridor space north of Materials Management is not provided with a 2-lamp fixture.

3. It was not confirmed that the path from the exit door to the courtyard area between the west wing and the Administrative office/Lab area of the building was provided with lighting for the full length of the path out of the court yard. This path also had a downspout extension across the walk which presents a tripping hazard.

Based on random observation, document review, and staff interview, not all battery powered emergency lights are tested and maintained in accordance with NFPA 101 2000.

Findings include:

A. During the survey walk-through a battery powered emergency light was observed installed in the Maintenance shop. During an interview held in the Maintenance Shop with the Maintenance Technician it was verified that testing was done by the afternoon Maintenance Technician. During an interview held in the Conference room with the afternoon Maintenance Technician it was verified that monthly testing was done by holding the test switch for a couple of seconds and not for 30 seconds in accordance with 7.9.3.

B. During the document review process held in the Conference Room, records for emergency battery light testing were not available for the annual testing for 90 minutes in accordance with 7.9.3.

A. Exit signage is not properly displayed. Conditions observed include the following:

1. The exit signage at the elevator lobby area of the 2nd floor directs occupants into the west wing thru double egress cross corridor doors. A single cross corridor door is encountered just beyond and is not provided with exit signage and swings against the direction of travel for exiting from the center elevator lobby area. The center stair appears to provide the required exiting for the elvator lobby. The exit signage directing travel to the west stair appears to be unnecessary and inappropriate relative to the door swing condition in this path.

2. The exit signage at the elevator lobby area of the 3rd floor is mounted visually backwards relative to the direction it should be viewed from (center lobby side).

Based on random observation during the survey walk-through, not all components of the facilities fire alarm system are installed, tested and maintained in accordance with NFPA 72 1999.

Findings include:

A. During the survey walk-through of the Ray Clinic area, a smoke detector was observed with-in 3' of a supply diffuser. It could not be confirmed that the air flow patterns from the diffuser did not adversely effect the ability for the detector to function properly in accordance with 2-3.5.1.

B. During the document review process records for quarterly sprinkler testing were observed with no alarm activation time documented to show compliance with 2-6.2.

C. Smoke detectors were observed to be mounted approximately 30" below the ceiling and not 4" to 12" from the ceiling in accordance with 2-3.4.3.1. Areas include:

1. First floor Xray File Room.

2. Kitchen Janitors Closet.

A. The facility is partially sprinklered. The installed sprinkler system is not in accordance with NFPA 13 and 25. The following conditions were observed:

1. The sprinkler protection in the Pharmacy has storage shelving positioned in the space which obstructs the spray pattern of at least two heads. The shelving unit top shelves do not allow for 18" clear under the sprinkler head.

2. Sprinkler heads located in the Dietary Storage room off the Kitchen appear to be obstructed. Several heads are located adjacent to a solid column or between other piping systems which prevent the full development of the sprinkler spray pattern.

3. The Data closet adjacent the Physical Therapy suite had ceiling tile displaced which compromises the activation of the sprinkler head.

Based on random observation and document review, not all portable fire extinguishers are installed and maintained in accordance with NFPA 10 1998.

A. During the document review process of the annual maintenance records for portable fire extinguishers it was discovered that only 15 CO2 fire extinguishers' hoses were provided with conductivity testing and not all 26 listed CO2 extinguishers in accordance with 4-4.1.2.

Based on random observation during the survey walk-through, not all components of the facilities ventilation system are installed in accordance with NFPA 90A 1999.

Findings include:

A. During the survey walk-through of equipment rooms, access panels in ductwork were observed to not be labeled with letters at least 1/2" high identifying the fire safety device with-in in accordance with 2-3.4.2.

Based on random observation and document review, not all components of the facilities commercial cooking equipment are installed and maintained in accordance with NFPA 96 1998.

Findings include:

A. During the document review process it was discovered the hood system was not inspected to determine the need for cleaning at 6 month intervals in accordance with Table 8-3.1 for moderate cooking facilities.


B. The solenoid valve for the gas fuel shut-off of the cooking appliances under the hood could not be located at the time of the survey.

A. Trash and soiled linen chute facilities are not maintained in accordance with 9.5 and NFPA 82. The following conditions were observed:

1. The Trash chute discharge room door was not provided with a fire rating label.

2. The 2nd floor trash chute access door was observed in the open position and was not positive latching upon self-closing. The chute access room corridor door was not able to be confirmed to carry the minimum 1 1/2-hour rating due to the label on the door being painted.

3. The 3nd floor trash chute access door was observed in the open position and was not positive latching upon self-closing.

A. Exit Access Corridors are not maintained in accordance with 19.2.3.3 and 7.1.3.2.3. Conditions observed include the following:

1. The 2nd floor patient sleeping room corridor was observed to have chairs, scale, portable fan, walkers, linen carts, and IV/BP equipment stands stored in the corridor.

Based on random observation during the survey walk-through, not all portions of the facilities piped medical gas system are installed in accordance with NFPA 99 1999.

Findings include:

A. During the walk-through medical gas systems sources were observed to be installed with no labeling on the valves to identify the type of medical gas and the areas served by the system in accordance with 4-3.1.2.3. Systems include:

1. The medical air manifold system.

2. The nitrous oxide manifold system.

3. The medical vacuum system.

B. Oxygen piping in the second floor patient care wing corridor was observed with no labeling to identify the medical gas in accordance with 4-3.1.2.14.

Based on random observation and staff interview, not all components of the facilities emergency electrical system are maintained and tested in accordance with NFPA 110 1999.

Findings include:

A. During the document review it was found the log sheet for generator testing contained 3 columns for voltage and amperage (for each phase) but only one column was completed. No way to calculate the percentage of load on the generator to verify compliance with 6-4.2 for 30% of name plate rating was documented.

Based on random observation during the survey walk-through and staff interview, not all portions of the facilities emergency electrical system are installed in accordance with NFPA 70 1999.

Findings include:

A. During the survey walk-through with the facilities Maintenance Technician it could not be verified which electrical panels were emergency and which were normal power in accordance with 700-9 for being readily identifiable as to the branch served.

B. Emergency power outlets were observed in critical care areas which were not labeled as to the panel and circuit serving them in accordance with 517-19.

Based on random observation during the survey walk-through, not all the facilities electrical system were installed and maintained in accordance with NFPA 70 1999.

Findings include:

A. Electrical panels throughout the facility were observed to have incorrect and modified directories which were not legible and not in accordance with 384-13.

B. During the survey walk-through wires were observed in the second floor patient wing that appeared to be supported by the ceiling grid system instead of the structure in accordance with 300-11 (a) (2).

A. Corridors are not separated from use spaces in accordance with 19.3.6.1. Observed conditions include the following:

1. The ER doctor's sleeping room (near the Lab) door contains an aluminum grille which does not comply with 19.3.6.4 to prevent the passage of fire and smoke.

A. Hazardous areas are not protected in accordance with 19.3.2.1 and 8.4. Conditions observed include but are not necessarily limited to the following:

1. The 1st floor CT Storage room is provided with sprinkler protection but the walls have pentrations which are not sealed to the passage of fire and smoke to comply.

2. The 1st floor Respiratory Therapy storage room located off ER room #6 is provided sprinkler protection but the door is not self-closing to comply.

3. The 1st floor X-ray file storage room door (near the ER doctor's sleeping room) is not self-closing.

4. The 1st floor Pharmacy door is located in a designated 2-hour barrier. The door could not be confirmed to be of minimum 1 1/2-hour rating due to the label being painted.

5. The west door of the Boiler room leading to a former corridor (now part of the X-ray film storage room) is not self-closing.

6. The 2nd floor OR suite "Storage" room (former procedure room) is not provided with sprinkler protection and therefore requires 1-hour rated enclosure. The door is not minimum 3/4-hour rated and is not positive latching to comply.

7. The 2nd floor OR suite clean supply room is not provided with sprinkler protection and therefore requires 1-hour rated enclosure. The door is not minimum 3/4-hour rated and is not self-closing to comply.

A. Exit discharge lighting is not provided in accordance with 19.2.8 and 7.8. Conditions observed include the following:

1. The exit discharge at the Kitchen is provided with only a single lamp fixture. Although a mercury vapor security light is provided, this fixture does not have instant restrike capability.

2. The exit discharge at the room/corridor space north of Materials Management is not provided with a 2-lamp fixture.

3. It was not confirmed that the path from the exit door to the courtyard area between the west wing and the Administrative office/Lab area of the building was provided with lighting for the full length of the path out of the court yard. This path also had a downspout extension across the walk which presents a tripping hazard.

Based on random observation, document review, and staff interview, not all battery powered emergency lights are tested and maintained in accordance with NFPA 101 2000.

Findings include:

A. During the survey walk-through a battery powered emergency light was observed installed in the Maintenance shop. During an interview held in the Maintenance Shop with the Maintenance Technician it was verified that testing was done by the afternoon Maintenance Technician. During an interview held in the Conference room with the afternoon Maintenance Technician it was verified that monthly testing was done by holding the test switch for a couple of seconds and not for 30 seconds in accordance with 7.9.3.

B. During the document review process held in the Conference Room, records for emergency battery light testing were not available for the annual testing for 90 minutes in accordance with 7.9.3.

A. Exit signage is not properly displayed. Conditions observed include the following:

1. The exit signage at the elevator lobby area of the 2nd floor directs occupants into the west wing thru double egress cross corridor doors. A single cross corridor door is encountered just beyond and is not provided with exit signage and swings against the direction of travel for exiting from the center elevator lobby area. The center stair appears to provide the required exiting for the elvator lobby. The exit signage directing travel to the west stair appears to be unnecessary and inappropriate relative to the door swing condition in this path.

2. The exit signage at the elevator lobby area of the 3rd floor is mounted visually backwards relative to the direction it should be viewed from (center lobby side).

Based on random observation during the survey walk-through, not all components of the facilities fire alarm system are installed, tested and maintained in accordance with NFPA 72 1999.

Findings include:

A. During the survey walk-through of the Ray Clinic area, a smoke detector was observed with-in 3' of a supply diffuser. It could not be confirmed that the air flow patterns from the diffuser did not adversely effect the ability for the detector to function properly in accordance with 2-3.5.1.

B. During the document review process records for quarterly sprinkler testing were observed with no alarm activation time documented to show compliance with 2-6.2.

C. Smoke detectors were observed to be mounted approximately 30" below the ceiling and not 4" to 12" from the ceiling in accordance with 2-3.4.3.1. Areas include:

1. First floor Xray File Room.

2. Kitchen Janitors Closet.

A. The facility is partially sprinklered. The installed sprinkler system is not in accordance with NFPA 13 and 25. The following conditions were observed:

1. The sprinkler protection in the Pharmacy has storage shelving positioned in the space which obstructs the spray pattern of at least two heads. The shelving unit top shelves do not allow for 18" clear under the sprinkler head.

2. Sprinkler heads located in the Dietary Storage room off the Kitchen appear to be obstructed. Several heads are located adjacent to a solid column or between other piping systems which prevent the full development of the sprinkler spray pattern.

3. The Data closet adjacent the Physical Therapy suite had ceiling tile displaced which compromises the activation of the sprinkler head.

Based on random observation and document review, not all portable fire extinguishers are installed and maintained in accordance with NFPA 10 1998.

A. During the document review process of the annual maintenance records for portable fire extinguishers it was discovered that only 15 CO2 fire extinguishers' hoses were provided with conductivity testing and not all 26 listed CO2 extinguishers in accordance with 4-4.1.2.

Based on random observation during the survey walk-through, not all components of the facilities ventilation system are installed in accordance with NFPA 90A 1999.

Findings include:

A. During the survey walk-through of equipment rooms, access panels in ductwork were observed to not be labeled with letters at least 1/2" high identifying the fire safety device with-in in accordance with 2-3.4.2.

Based on random observation and document review, not all components of the facilities commercial cooking equipment are installed and maintained in accordance with NFPA 96 1998.

Findings include:

A. During the document review process it was discovered the hood system was not inspected to determine the need for cleaning at 6 month intervals in accordance with Table 8-3.1 for moderate cooking facilities.


B. The solenoid valve for the gas fuel shut-off of the cooking appliances under the hood could not be located at the time of the survey.

A. Trash and soiled linen chute facilities are not maintained in accordance with 9.5 and NFPA 82. The following conditions were observed:

1. The Trash chute discharge room door was not provided with a fire rating label.

2. The 2nd floor trash chute access door was observed in the open position and was not positive latching upon self-closing. The chute access room corridor door was not able to be confirmed to carry the minimum 1 1/2-hour rating due to the label on the door being painted.

3. The 3nd floor trash chute access door was observed in the open position and was not positive latching upon self-closing.

A. Exit Access Corridors are not maintained in accordance with 19.2.3.3 and 7.1.3.2.3. Conditions observed include the following:

1. The 2nd floor patient sleeping room corridor was observed to have chairs, scale, portable fan, walkers, linen carts, and IV/BP equipment stands stored in the corridor.

Based on random observation during the survey walk-through, not all portions of the facilities piped medical gas system are installed in accordance with NFPA 99 1999.

Findings include:

A. During the walk-through medical gas systems sources were observed to be installed with no labeling on the valves to identify the type of medical gas and the areas served by the system in accordance with 4-3.1.2.3. Systems include:

1. The medical air manifold system.

2. The nitrous oxide manifold system.

3. The medical vacuum system.

B. Oxygen piping in the second floor patient care wing corridor was observed with no labeling to identify the medical gas in accordance with 4-3.1.2.14.

Based on random observation and staff interview, not all components of the facilities emergency electrical system are maintained and tested in accordance with NFPA 110 1999.

Findings include:

A. During the document review it was found the log sheet for generator testing contained 3 columns for voltage and amperage (for each phase) but only one column was completed. No way to calculate the percentage of load on the generator to verify compliance with 6-4.2 for 30% of name plate rating was documented.

Based on random observation during the survey walk-through and staff interview, not all portions of the facilities emergency electrical system are installed in accordance with NFPA 70 1999.

Findings include:

A. During the survey walk-through with the facilities Maintenance Technician it could not be verified which electrical panels were emergency and which were normal power in accordance with 700-9 for being readily identifiable as to the branch served.

B. Emergency power outlets were observed in critical care areas which were not labeled as to the panel and circuit serving them in accordance with 517-19.

Based on random observation during the survey walk-through, not all the facilities electrical system were installed and maintained in accordance with NFPA 70 1999.

Findings include:

A. Electrical panels throughout the facility were observed to have incorrect and modified directories which were not legible and not in accordance with 384-13.

B. During the survey walk-through wires were observed in the second floor patient wing that appeared to be supported by the ceiling grid system instead of the structure in accordance with 300-11 (a) (2).