HospitalInspections.org

Based on observations, it was determined that the facility failed to maintain the minimum Construction Type for this building. This deficient practice could compromise the fire resistant rating of the structure and affect staff and visitors in within a means of egress.

Findings include:

A. On 07/20/17, during the survey walk through while accompanied by the DF and ES , the surveyor observed several structural beams that are not protected with a fire rated assembly to comply with Table 19.1.6.1 and NFPA 220 2012 Ed. Table 4.1.1.

Example locations are as follows:

1. At 9:40 am First Floor Imaging Services / X Ray corridor adjacent to Room 1701 contains an above ceiling support beam which lacks fire proofing on the bottom flange.

2. At 10:00 am First Floor, Outpatient Clinic contains a structural beam above the ceiling. Documentation was not provided to demonstrate apparent unprotected steel has a listed UL fire resistant design.


20224


B. On 07/19/2017, during the survey walk through while accompanied by DF and VP, unprotected steel structure was observed which does not comply with Table 19.1.6.1, 19.1.6.4 and 19.1.6.5:

Example locations include:

1. At 1:15 pm, ground level corridor which leads to Stair A contains a pair of cross corridor doors located between two different corridor ceiling types (suspended and an exposed deck). Above the pair of doors is a steel plate section anchored to a concrete beam. The exposed steel plate does not maintain the construction type.

2. At 10:25 am, exposed structure comprising of metal deck infill was observed on ground floor Receiving Storage room #0324 adjacent to the Loading Dock, which is not fire protected.

3. At 11:15 am steel beams are observed that have the fire proofing scraped off. Location observed Ground floor Dry good storage room - the beam is above the fire extinguisher cabinet.

4. At 11:35 am steel deck beam is observed that is unprotected. The complete length of beam located at the top of a fire rated wall remains unprotected. Location observed: Ground level Storage room located directly adjacent to the Boiler room and the "tunnel".

Based on direct observation not all doors in exit access corridors are available at all times for egress. This deficiency could affect all patients in the locations as well as any staff and visitors present, by compromising the direction of egress within a room or exit access corridor.

The finding is:

On 07/19/2017 at 1:50pm while accompanied by the V.P. a means of egress corridor were observed which does not comply with 19.2.5.1 and 7.1.6.2 for abrupt changes in the means of egress. Location observed: Stair H, floor level 3 contains an approximately 4" elevation change at a door threshold leading to Stair H.

Based on direct observation not all doors in exit access corridors are available at all times for egress. This deficiency could affect all patients in the locations as well as any staff and visitors present, by compromising the direction of egress within a room or exit access corridor.

The finding is:

On 07/21/2017 at 11:50am while accompanied by the V.P. means of egress doors were observed which lack proper egress hardware to comply with 19.2.2.2.4.

Example locations:

1. Ground floor level discharge door located adjacent to Office # 48 (on the life safety floor plan) contains both a panic bar along with a horizontal push bar approximately 8" above it. This condition does not comply with 7.5.2.2.

2. Kitchen sliding door contains a sole thumbturn on the egress side of the door. This condition does not comply with 19.3.6.3.1, 7.2.1.5.10.

Based on observation during the survey walk-through, not all horizontal sliding doors in exit access corridors operate to comply with the requirements to maintain a smoke tight means of egress. This deficiency could affect all patients in the locations as well as any staff and visitors present, by allowing smoke to pass from one side of the corridor wall to the other; either compromising the building's exit access corridors or the rooms occupied.

The finding is:

On 07/19/2017 at 10:45 am while accompanied by the VP an automatic opening horizontal sliding door was observed as part of the means of egress from the kitchen to the exit access corridor. The sliding door does not comply with 19.2.2.2.10 due to the following:

1. The door lacks operable hardware located on both the corridor side and room side requiring no special knowledge. It was observed one thumbturn on the room side of the door.

2. The door lacks latching hardware operable on either corridor side or the room side.

3. No documented evidence that the door drops to a manual operation under fire alarm.

Based on observation during the survey walk-through, not all stair components used within an exit stair are constructed to maintain safe egress. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from evacuating the building under fire conditions.

Findings include:

A. The distance between guardrails in exit stair enclosures was observed to be in excess of 4" which does not comply with 19.2.2.3, 7.2.2.4.5.3.

Example locations observed:

1. 10:15am 07/18/2017 Exit Stair # H
2. 11:15am 07/18/2017 Exit Stair # B
3. 11:35am 07/18/2017 Exit Stair # K
4. 9:50 am 07/20/2017 Exit Stair # L

B. The dimensional criteria for existing exit stairs was observed not to comply with 7.2.2.2.1.1(2). The following are example conditions:

1. 10:15am 07/18/2017 Exit Stair # H riser height is not uniform with some risers at 8 3/8 inch.
2. 11:15am 07/18/2017 Exit Stair # B tread depth is not uniform with some tread depths of 7 5/8 inch.

C. Guardrails and Handrails for existing exit stairs were observed to not comply with 19.2.2.3, 7.2.2.4.1.1. The following are example locations:

1. 10:15am 07/18/2017 Exit Stair # H
2. 11:15am 07/18/2017 Exit Stair # B
3. 11:35am 07/18/2017 Exit Stair # K
4. 9:50 am 07/20/2017 Exit Stair # L

D. On 07/18/2017 at 11:30am while accompanied by VP and an incomplete stair enclosure was observed. Windows within the stair are exposed to windows on the building's floors. The exposure provided is less than 10' apart and less than 180 degrees from window to window. This does not maintain the required fire resistance rating of the stair's enclosing walls to comply with 7.2.2.5.2, 19.1.6.1.

Location observed:
Exit Stair # D- 3rd floor

Based on observation during the survey walk-through, not all corridors are arranged to provide exit access without passing through any intervening rooms other than corridors, lobbies and other spaces permitted to be open to the corridor. These deficiencies could affect all patients in the area of the facility, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the building.

The finding is:

On 07/20/17 at 11:00 AM, while accompanied by the DF and SM, it was observed that one of the designated exit access corridors on the First Floor to the Radiology Unit, is directed through a suite area (MRI). This does not comply with 19.2.1 and 7.5.1.2.

Based on observation during the survey walk-through, while accompanied by facility representatives, not all exterior exit discharges are arranged or maintained to make clear the direction of egress or contained improper walking surfaces. This deficient practice could affect patients, staff and visitors by delaying emergency exiting to a public way.

Findings include:

On 07/20/17 at 9:00AM, while accompanied by the DF and SM, it was observed that the first floor, exterior exit discharge, from Stair H was not arranged to provide a level walking surface with respect to changes in elevation. The elevation of the floor surfaces is not maintained level on both sides of the door opening. There is an immediate 6 inches drop in elevation to grade at the discharge threshold. This does not comply with 7.2.1.3.2 and 7.7.1.

Based on observation during the survey walk-thru, illumination of the exit discharge portion of the means of egress is not maintained. This deficient practice could affect patients, staff and visitors if failure to maintain illumination of the means of egress can cause delays in exiting during an emergency and preventing safe and unimpeded access to the public way.

Findings include:

On 07/20/17 at 10:35 AM, while accompanied by the DF and SM, it was observed that designated Exit Stair # N exterior discharge is not being provided with the required two lamps. This does not comply with 19.2.8, 7.8.1.4 and 7.9.1.2.

Based on observation, document review and staff interview, emergency lighting is not tested and maintained. This deficient practice could affect patients, staff and visitors if failure to test and maintain the installed emergency lighting system can result in failure of the system to perform when needed during loss of normal power.

Finding include:

On 07/20/17 at 9:30AM while in the company of the VP and ES it was observed that battery powered emergency lighting was provided for the facility. Annual testing for the 1.5 hour duration and monthly testing were not conducted and recorded to comply with 7.9.3.1.1 (1) (3) and (5).

Based on observation, document review and staff interview, emergency lighting is not tested and maintained. This deficient practice could affect patients, staff and visitors if failure to test and maintain the installed emergency lighting system can result in failure of the system to perform when needed during loss of normal power.

Finding include:

On 07/20/17 at 9:45 AM while in the company of the VP and ES it was observed that battery powered emergency lighting was provided for the facility. Annual testing for the 1.5 hour duration and monthly testing were not conducted and recorded to comply with 7.9.3.1.1 (1), (3) and (5).

Based on observation, document review and staff review, emergency lighting is not tested and maintained. This deficient practice could affect patients, staff and visitors if failure to test and maintain the installed emergency lighting system can result in failure of the system to perform when needed during loss of normal power.

Finding include:

On 07/20/17 at 9:30AM while in the company of the VP and ES it was observed that battery powered emergency lighting was provided for the facility. Annual testing was not conducted and recorded to comply with 7.9.3.1.1 (3) and (5).

Based on observation during the survey walk-through, not all portions of the building's Essential Electrical System (EES) are installed as required. This deficient practice could affect patients, staff, and visitors in the building because life support equipment could fail to operate under emergency conditions if the essential electrical system is not installed properly.

The finding is:

On 07/19/2017 at 11:15 am, while accompanied by the VP and ES observation determined not all critical care areas where anesthesia is administered contain battery-powered emergency lights to comply with NFPA 99 2012 6.3.2.2.11.1 and NFPA 70 2011 517-63A.

Locations observed:

1. C-Section Room.
2. ED Trauma room
3. Labor Delivery Recovery rooms

Based on observation during the survey walk-thru, exit signs are not provided to identify access to exits. This deficient practice could affect patients, staff and visitors, failure to mark exit paths can compromise access to available exits and prevent timely and efficient evacuation of the building during a fire/smoke event.

Findings include:

On 07/20/17 at 10:50am, while accompanied by the VP and the ES it was determined that access to exit on the Main Rehab Area is not marked by approved visible signs. A way to reach the exit is not readily apparent to the occupants (the exit sign provided from the vestibule was hidden). This does not comply with 7.10.1.5.2. or 7.10.1.8.

Based upon direct observation, the facility failed to provide protection of vertical openings between floor levels. This deficient practice can affect patients, staff and visitors if the failure to protect vertical openings leads to products of combustion that spread from one floor level to another.

Findings include:

On 07/20/17 at 9:45 AM, while in the company of the DF and SM, the First Floor Mechanical Room 1753 was observed with chilled water pipes that penetrate the above Penthouse floor which are not fire sealed to provide the required 2 hour fire rated floor separation. This does not comply with Section 8.6.5.

Based on observations of hazardous areas, the facility failed to provide separation between hazardous rooms from surrounding areas. This deficient practice could affect patients, staff and visitors if a fire spreads from one area to another without a proper fire separation.

Findings include:

On 7/19/2017, at 2:08 PM while accompanied by DF and VP the Dry Goods storage room in the Kitchen area, is greater than 100 square feet and is indicated to maintain rated wall systems of a minimum 1 hour fire rating. The condition does not comply with 19.3.2.1 and 8.7.1.1 (3) due to the following:

1. The room contained unsealed wall penetrations at duct penetrations.

2. The perimeter walls contained unsealed pipe and conduit penetrations.

Based on observation during the survey walk through the facility failed to correctly install kitchen ventilation equipment. This deficient practice could result in the uncontrolled spread of fire and products of combustion during kitchen cooking operations, which may affect patients, staff and visitors.

The findings are:

A. On 7/19/17 at 10:35 a.m. accompanied by the DF, in the ground level kitchen, it was observed that the grease hood filter segments were separated allowing grease laden vapor to bypass the filters. (19.3.2.5 / NFPA 96, 2008, 6.2.3.3)

B. On 7/19/17 at 10:40 a.m. accompanied by the DF, in the ground level kitchen, it was observed that the manual pull station for the grease hood suppression system was obstructed by carts and kitchen equipment. (19.3.2.5 / NFPA 96, 2008, 10.5.1)

Based on observation during the survey walk through the facility failed to connect auxiliary fire alarm notification devices to the life safety emergency power circuit. Failure to install and protect these components can result in malfunction of the fire alarm system. This deficient practice could affect patients, staff and visitors during a fire event.

The findings include:

A. On 7/18/17 at 1:50 p.m. accompanied by the DF, in electrical room 3301A, it was observed that the fire alarm NAC panel located in this room was connected to circuit #6 of the emergency power critical system and not to the life safety system as require by 19.3.4 / NFPA 99, 2012, 3.4.2.2.2.2 (7). Additionally this circuit was not identified by red markings and not mechanically protected.


16339


B. On 07/20/2017 at 9:34 AM, while accompanied by DF and SM, it was observed several smoke detectors that were located less than 3-feet from a mechanical air supply vent. This does not comply with 9.6, NFPA 70 and NFPA 72 2010 Edition, Section 17.7.3.1.

Locations observed include:

1. First Floor - Laboratory Data IT Room 1024
2. First Floor - Corridor entry to ICU

Based on observation during the survey walk-thru, the fire pull stations are not properly located. This could affect patients, staff and visitors of the areas served if the fire alarm system does not operate properly during a fire emergency.

The finding is:

On 07/19/2017 at 11:30am while in the company of the DF, a manual pull station was observed not located within 5 feet of the designated exit door to comply with 9.6.2.3 Location observed: Surgery corridor leading to Stair E

Based on observation during the survey walk through the facility lacks complete sprinkler protection. Failure to install and maintain system could result in delayed response and fire suppression. This deficient practice could affect patients, staff and visitors during a fire event.

The findings include:

A. On 7/19/17 at varying times as listed below accompanied by the DF, it was observed sprinkler protection is not provided beneath the lowest landing of the following stairs: (19.3.5 / NFPA 13 2010, 8 .15.3.2.1)

1. At 10:10 a.m. Stair L
2. At 11:30 a.m. Stair G
3. At 9:30 am on 07/20/2017 Stair H

B. On 7/19/17 at 10:45 a.m. accompanied by the DF, it was observed sprinkler protection is not provided beneath ventilation ducts more than 4 feet wide in the kitchen dry storage room. (19.3.5 / NFPA 13, 2010, 8.5.5.3.1)

C. On 7/19/17 at 10:45 a.m. accompanied by the DF, it was observed sprinkler protection is not provided for the area well now covered by roof outside the main electrical switch gear room as accessed from the ground level. (19.3.5 / NFPA 13, 2010, 8.1)


16339


D. On 07/20/17 at 9:40 am, while accompanied by the DF and SM, First Floor at the Chapel Main Entry , the surveyor finds the escutcheon plate of the sidewall sprinkler head was not installed properly to the wall. This does not comply with 19.3.5.3 and NFPA 13 2010.


20224


E. On 07/19/2017 at 9:50 am while accompanied by the VP a stored stuffed animal was observed which obstructs the sprinkler head. This condition does not comply with NFPA 13-2010, 4.1. Location observed: Ground floor Gift Shop Storage room.

F. On 07/19/2017 at 1:50 pm while accompanied by the VP a gypsum board ceiling was observed with a large hole which permits the ceiling to be open to the cavity above. The above ceiling cavity is not sprinklered. This condition does not comply with NFPA 13-2011, 8.6.4.1. Location observed Ground floor "old morgue bathroom" located within Storage room #0757.

G. On 07/19/2017 at 10:50 am while accompanied by the VP and DF the drygood storage room was observed which contained a hazardous amount of combustible materials (cardboard boxes) which were stacked and piled to the ceiling. This condition does not comply with NFPA 13 8.9.5.3 providing required clearances for sprinkler protection and removal of obstructions.

Based on observation during the survey walkthrough not all Portable wall hung fire extinguishers are maintained and accessible for use. This deficient practice could jeopardize the protection of patients, visitors and staff during a fire event by delaying access to a means of extinguishment.

The finding is:

On 07/19/2017 at 11:10am while accompanied by the DF and VP obstructions to the wall hung fire extinguisher cabinet were observed within the Dry Goods storage room. Access to the fire extinguisher was blocked by numerous cardboard boxes, this condition does not comply with 19.3.5.12, 9.7.4.1 and NFPA 10, 2010, 3.3.12.

Based on observation the facility failed to provide properly operating doors within the means of egress. This deficiency could affect all patients in the locations as well as any staff and visitors present, by compromising a person's access to an exit.

Findings include:

On 07/20/17 at 10:45 AM, while accompanied by the DF ans SM, the pair of designated exit doors from the MRI Suite on the first floor were observed to have a magnetic locking device, without the delayed egress feature. This does not comply with 19.2.2.2.4, 7.2.1.6. and 7.2.1.6.2.

Based on an observation it was determined that the facility failed to properly manage and maintain the existing Air-conditioning and Ventilating Systems. This deficient practice could affect patients, staff and visitors if fire dampers are not installed in wall locations to limit the fire and smoke from a fire event in hazardous areas.

Findings Include:

A. On 07/18/2017 at 1:40pm , while accompanied by VP and DF, it was determined that Stair D contains a supply duct which passes through the third floor stair landing leading to an adjacent chase. Upon opening the access panel for the chase it is determined that the duct lacks access to the damper installation. This condition does not comply with NFPA 90A, 5.3.1.2.

B. On 07/18/2017 at 11:40pm , while accompanied by VP and DF, it was determined that the Gift Shop storage room contains a diffuser for which the flexible duct is not connected. The duct passes through a smoke tight wall construction. The open duct condition allows air transfer between a room and exit access corridor for healthcare which does not comply with 19.3.2.1, NFPA 90A, 2012, 4.3.12.1.3.

Based on observation during the survey walk through the facility failed to install components for the elevator firefighter service and recall systems. Failure to install and maintain these systems could result in malfunction and response of the recall function. This deficient practice could affect patients, staff and visitors during a fire event.
The finding is:

A. On 7/18/17 at 1:00 p.m. accompanied by the DF, it was observed in the penthouse elevator machine rooms 1 thru 4 that heat detectors are not installed within 2 feet of each sprinkler head for elevator shutdown. (19.5.3 / ANSI A17.1, 2007, 2.8.3.3.2 & NFPA 72, 2010, 21.4.2)

Based on observation during the survey walk through the facility failed to install required electrical disconnects. Failure to install a single means to disconnect as required could leave the elevator car without power for the services required. This deficient practice could affect patients, staff and visitors.
The finding is:

B. On 7/18/17 at 1:10 p.m. accompanied by the DF, in elevators 3 & 4 machine room it was observed that a lockable disconnecting means is not provided for the car lights, receptacles and ventilation. (19.5.3 / NFPA 70, 2011, 620.53)

Based on observation during the survey walk-through, and document review, the facility's written plan for the protection of patients is not completely accurate. These deficiencies could affect any patients, staff, or visitors in the building because the failure to identify key life safety components could result in the failure to protect them properly.

The finding is:

On 07/19/2017, at 1:15pm while in the company of the DF VP and ES during review of the facility's written fire plan it was observed that the plan did not accurately reflect all conditions present at this facility.
The written Fire Plan indicates the Interim Life Safety requirements that whenever the Hospital's sprinkler or fire alarm system is down 4 or more hours within a 24 hour time period they are to notify the city fire inspector and the city fire department. IDPH is not included in the authorities to be notified which does not comply with 9.6.1.6.

Based on observation during the survey walk through the facility failed to identify components of the Category 1 medical gas systems. This deficient practice could affect patients during treatment while using these systems.
The finding is:

On 7/19/17 at 9:35 a.m. accompanied by the DF, in the ground level mechanical room, it was observed that the source valves for the piped medical air and medical vacuum systems are not labeled or identified as to their function to comply with 19.3.2.4 / NFPA 99 2012, 5.1.11.

Based upon observation, the electrical installations and materials are not installed and maintained. This could affect all occupants of the building if the emergency power system does not operate and are not properly identified.
Findings include:

On 07/20/17 at 9:35 AM, while accompanied by the DF and SM, First Floor - Laboratory, the Electrical Panel directories are missing or are not labeled correctly, circuits are not identified to comply with NFPA 99, 2012 6.3.1, 6.3.2, NFPA 70 2011 408.4. Locations observed:

1. Electrical Panel N1A
2. Electrical Panel C1
3. Electrical Panel C1A.

Based on observation during the survey walk-through, not all electrical receptacles are installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the rooms because electrical equipment required for their care may fail to operate under emergency conditions if the electrical receptacles are not properly installed and maintained.

The finding is:

On 07/19/2017, while accompanied by the V.P., observation determined that critical care patient beds lack electrical receptacles served by normal power as required by NFPA 70 2011 517-19(A). Locations observed:

1. 1:05pm Operating Room 1
2. 1:40pm C-Section procedure room
3. 1:45pm Labor Delivery Recovery (LDR) rooms

Based on observation during the survey walk-through, not all components of the essential electrical system is installed and maintained. This deficient practice could affect patients, staff, and visitors in the rooms because electrical equipment required for their care may fail to operate under emergency conditions without a response.

The finding is:

On 07/20/2017 at 10:10am while accompanied by the V.P., for the annunciator for the emergency generatoris located within the Boiler room. This does not comply with 19.7.2.1 and NFPA 99, 2012, 6.4.1.1.17 requirements for a prompt and effective response.