HospitalInspections.org

Based on visual observation, the facility failed to provide smoke resistive and positive latching doors in 1 of 1 smoke compartment. This deficiency if not corrected could have the opportunity to cause harm to 14 of the 165 patients in the facility.

Findings: During tour of building on 11-29-2012 between 9:00 a.m. and 3:30 p.m. the following corridor doors were observed having no positive latching mechanisms:
2 sets of doors in MRI

Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke.

Based on visual observation, the facility failed to provide smoke resistive and positive latching doors in 3 of 9 smoke compartments. This deficiency if not corrected could have the opportunity to cause harm to 34 of the 165 patients in the facility.

Findings: During tour of building on 11-29-2012 between 9:00 a.m. and 3:30 p.m. the following corridor doors were observed having no positive latching mechanisms:
human resource door, 3 sets of doors in PACU, the 2 OR locker room doors, and OR's 5, 6 and 7.

Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke.

19.3.6.3.2*
Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.

Based on visual observation the facility failed to provide a 1 hour fire rated stairwell in 2 of 9 smoke compartments. This deficiency if not corrected could have the potential to cause harm to 24 of the 165 patients in the hospital.

Findings: During tour of building on 11-29-2012 between 9:00 a.m. and 3:30 p.m. the OR / HR stairwell enclosure was observed having 2 flex duct penetrations which compromises the 1 hour fire rating and both of these ducts are supplying air into the enclosure from a HVAC unit that serves other areas in the hospital.

Based on visual observation the facility failed to maintain the integrity of the 1 hour fire walls protecting hazardous areas in 3 of 9 smoke compartments. This deficiency if not corrected could have the potential to cause harm to 66 of the 164 patients in the building.

Findings: During tour of building on 11-29-2012 between 9:00 a.m. and 3:30 p.m 2 flex duct and 1 conduit penetrations were observed in each of the the soiled utility rooms on 2nd, 3rd, and 4th floors.

Based on visual observation the facility failed to provide special locking which complies with Fire Marshal Memorandum 2009-05 in 1 of 1 smoke compartments. This deficiency if not corrected could have the potential to cause harm to 24 of the 164 patients in the building.

Findings: During tour of building on 11-29-2012 between 9:00 a.m. and 3:30 p.m. the following doors were observed having magnetic locking devices that do not meet the requirements of Fire Marshal Memorandum 2009-05.
ER doors by rooms 6 and 7 and MRI area

K38 Exits Readily Available
Based on visual observation the facility failed to provide the continuation of the exit discharge to include access to the public way from all required exits. The access provides an easier transition for occupants to evacuate from all exits in the building. The deficient practice had the potential to affect 22 of the 164 patients.
The exit discharge was deficient for 1 of 9 smoke compartments.

Findings: During tour of building on 11-29-2012 between 9:00 a.m. and 3:30 p.m. stairwell number 1 was observed having no hard and reliable surface to the public way.

Based on visual observation the facility failed to provide special locking which complies with Fire Marshal Memorandum 2009-05 in 2 of 9 smoke compartments. This deficiency if not corrected could have the potential to cause harm to 24 of the 164 patients in the building.

Findings: During tour of building on 11-29-2012 between 9:00 a.m. and 3:30 p.m. the following doors were observed having magnetic locking devices that do not meet the requirements of Fire Marshal Memorandum 2009-05.
ICU suite
Endo entrance door
OR entrance door

Central Sterile processing

Based on visual observation the facility failed to provide a 2 bulb fixture at 1 exit, of 1 of 2 smoke compartments on the 1st floor. This deficiency if not corrected could have the potential to cause harm to 10 of the 164 patients if not corrected.

Findings: During tour of building on 11-29-2012 the employees exit discharge did not have a 2 bulb fixture connected to the emergence power source.

Based on visual observation the facility failed to provide a 2 bulb fixture at 1 exit, of 1 of 2 smoke compartments on the 2nd floor. This deficiency if not corrected could have the potential to cause harm to 10 of the 164 patients if not corrected.

Findings: During tour of building on 11-29-2012 the labor and delivery exit door did not have a 2 bulb fixture connected to the emergency power source.

Based on visual observation the facility failed to provide sprinkler protection in 1 of 2 smoke compartments on the 1st floor. This deficiency if not corrected could have the potential to cause harm to 22 of the 164 patients in the building.

Findings: During tour of building on 11-30-2012 between 9:00 a.m. and 3:30 p.m. the Women's Center entrance area was observed having no sprinkler protection.

Based on visual observation, the facility failed to provide smoke resistive and positive latching doors in 1 of 1 smoke compartment. This deficiency if not corrected could have the opportunity to cause harm to 14 of the 165 patients in the facility.

Findings: During tour of building on 11-29-2012 between 9:00 a.m. and 3:30 p.m. the following corridor doors were observed having no positive latching mechanisms:
2 sets of doors in MRI

Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke.

Based on visual observation, the facility failed to provide smoke resistive and positive latching doors in 3 of 9 smoke compartments. This deficiency if not corrected could have the opportunity to cause harm to 34 of the 165 patients in the facility.

Findings: During tour of building on 11-29-2012 between 9:00 a.m. and 3:30 p.m. the following corridor doors were observed having no positive latching mechanisms:
human resource door, 3 sets of doors in PACU, the 2 OR locker room doors, and OR's 5, 6 and 7.

Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke.

19.3.6.3.2*
Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.

Based on visual observation the facility failed to provide a 1 hour fire rated stairwell in 2 of 9 smoke compartments. This deficiency if not corrected could have the potential to cause harm to 24 of the 165 patients in the hospital.

Findings: During tour of building on 11-29-2012 between 9:00 a.m. and 3:30 p.m. the OR / HR stairwell enclosure was observed having 2 flex duct penetrations which compromises the 1 hour fire rating and both of these ducts are supplying air into the enclosure from a HVAC unit that serves other areas in the hospital.

Based on visual observation the facility failed to maintain the integrity of the 1 hour fire walls protecting hazardous areas in 3 of 9 smoke compartments. This deficiency if not corrected could have the potential to cause harm to 66 of the 164 patients in the building.

Findings: During tour of building on 11-29-2012 between 9:00 a.m. and 3:30 p.m 2 flex duct and 1 conduit penetrations were observed in each of the the soiled utility rooms on 2nd, 3rd, and 4th floors.

Based on visual observation the facility failed to provide special locking which complies with Fire Marshal Memorandum 2009-05 in 1 of 1 smoke compartments. This deficiency if not corrected could have the potential to cause harm to 24 of the 164 patients in the building.

Findings: During tour of building on 11-29-2012 between 9:00 a.m. and 3:30 p.m. the following doors were observed having magnetic locking devices that do not meet the requirements of Fire Marshal Memorandum 2009-05.
ER doors by rooms 6 and 7 and MRI area

K38 Exits Readily Available
Based on visual observation the facility failed to provide the continuation of the exit discharge to include access to the public way from all required exits. The access provides an easier transition for occupants to evacuate from all exits in the building. The deficient practice had the potential to affect 22 of the 164 patients.
The exit discharge was deficient for 1 of 9 smoke compartments.

Findings: During tour of building on 11-29-2012 between 9:00 a.m. and 3:30 p.m. stairwell number 1 was observed having no hard and reliable surface to the public way.

Based on visual observation the facility failed to provide special locking which complies with Fire Marshal Memorandum 2009-05 in 2 of 9 smoke compartments. This deficiency if not corrected could have the potential to cause harm to 24 of the 164 patients in the building.

Findings: During tour of building on 11-29-2012 between 9:00 a.m. and 3:30 p.m. the following doors were observed having magnetic locking devices that do not meet the requirements of Fire Marshal Memorandum 2009-05.
ICU suite
Endo entrance door
OR entrance door

Central Sterile processing

Based on visual observation the facility failed to provide a 2 bulb fixture at 1 exit, of 1 of 2 smoke compartments on the 1st floor. This deficiency if not corrected could have the potential to cause harm to 10 of the 164 patients if not corrected.

Findings: During tour of building on 11-29-2012 the employees exit discharge did not have a 2 bulb fixture connected to the emergence power source.

Based on visual observation the facility failed to provide a 2 bulb fixture at 1 exit, of 1 of 2 smoke compartments on the 2nd floor. This deficiency if not corrected could have the potential to cause harm to 10 of the 164 patients if not corrected.

Findings: During tour of building on 11-29-2012 the labor and delivery exit door did not have a 2 bulb fixture connected to the emergency power source.

Based on visual observation the facility failed to provide sprinkler protection in 1 of 2 smoke compartments on the 1st floor. This deficiency if not corrected could have the potential to cause harm to 22 of the 164 patients in the building.

Findings: During tour of building on 11-30-2012 between 9:00 a.m. and 3:30 p.m. the Women's Center entrance area was observed having no sprinkler protection.