HospitalInspections.org

Based on observation, the facility failed to maintain the integrity of the building construction. This was evidenced by a penetration in the ceiling tile of a waiting room. This affected one of nine smoke compartments and could result in the faster spread of smoke and fire.

Findings:

During a facility tour with Staff from 3/11/14 to 3/12/14, the walls and ceilings were observed.

1. At 11:47 a.m. on 3/11/14, there was an approximately six inch by six inch penetration in the ceiling tile of the west Waiting Room, near the Lobby, with IT conduits going through.

Based on record review and interview, the facility failed to ensure that fire drills are conducted quarterly on each shift. This was evidenced by no NOC shift drills conducted during three of four quarters in 2013. This affected nine of nine smoke compartments and could result in a delay in staff response, in the event of a fire.

Findings:

During record review from 3/11/14 to 3/12/14 with Staff 1, the fire drill records were reviewed.

1. At 8:26 a.m. on 3/11/14, records indicated that all fire drills during the second quarter (April through June) were conducted between 1:57 p.m. and 6:14 p.m. There were no records showing that drills were conducted during the NOC shift.
During an interview at 8:27 a.m., Facilities Staff 1 stated that the NOC shift is between 8 p.m. and 6 a.m. Engineering Staff 1 stated that the NOC shift is between 7 p.m. and 7 a.m.

2. At 8:28 a.m. on 3/11/14, records indicated that all fire drills during the third quarter (July through September) were conducted between 7:18 a.m. and 4:25 p.m. There were no records showing that drills were conducted during the NOC shift.

3. At 8:29 a.m. on 3/11/14, records indicated that all fire drills during the fourth quarter (October through December) were conducted between 9:26 a.m. and 4:11 p.m. There were no records showing that drills were conducted during the NOC shift.

Based on observation and record review, the facility failed to maintain their fire alarm system. This was evidenced by a sprinkler waterflow alarm-initiating device that was not in accordance with NFPA 72. This affected the entire Marian Building and could result in a delay in notification in the event of an automatic sprinkler system activation.

NFPA 72, National Fire Alarm Code, 1999 Edition.
2-6 Sprinkler Waterflow Alarm-Initiating Devices.
2-6.1 The provisions of Section 2-6 shall apply to devices that initiate an alarm indicating a flow of water in a sprinkler system.
2-6.2 Initiation of the alarm signal shall occur within 90 seconds of waterflow at the alarm-initiating device when flow occurs that is equal to or greater than that from a single sprinkler of the smallest orifice size installed in the system. Movement of water due to waste, surges, or variable pressure shall not be indicated.

Findings:

During a facility tour with Staff from 3/11/14 to 3/12/14, the fire alarm system was observed in the Marian Building. The medical records storage was sprinklered and the sprinkler system was supervised by a waterflow alarm that was connected to the fire alarm system.

1. At 5:06 p.m. on 3/11/14, the valve labeled "Inspector's Test Valve" on the riser of the Marian Building was tested. The discharge orifice of the inspector's test valve was a pipe that was approximately 1 1/4 inches in diameter.
At 8:30 a.m. on 3/12/14, building plans indicated that the sprinklers were added to the medical records storage room on 9/27/11. The plans and manufacturer specifications also indicated that 1/2 inch sprinkler heads were installed in the sprinkler system.

Based on observation, the facility failed to ensure that portable space heating devices are not used in staff sleeping areas. This was evidenced by one portable space heating device in a doctor's sleep room. This affected one of nine smoke compartments and could result in the increased risk of a fire.

Findings:

During a facility tour with Staff from 3/11/14 to 3/12/14, the facility was inspected for use of portable space heating devices.

1. At 3:20 p.m. on 3/11/14, there was a portable space heater in the doctor's sleep room located in the Obstetrics and Gynecology corridor.

Based on observation and interview, the facility failed to ensure that paths of egress are free of obstructions. This was evidenced by beds stored in the radiology corridor near the exit door. This affected two of nine smoke compartments and could result in a delay in evacuation.

Findings:

During a facility tour with Staff from 3/11/14 to 3/12/14, the paths of egress were observed.

1. At 10:29 a.m. on 3/11/14, there were two beds in the radiology corridor near the exit door. The beds were observed again at 1:14 p.m.
During an interview at 1:15 p.m., Facilities Staff 1 confirmed that the beds were stored in the corridor and had not been moved or used between 10:29 a.m. and 1:14 p.m.

Based on observation, the facility failed to maintain its electrical wiring. This was evidenced by surge protectors that were used in lieu of permanent wiring. This affected two of nine smoke compartments and could result in an increased risk of an electrical fire.

NFPA 70, National Electrical Code, 1999 Edition.
400-8 Uses Not Permitted
Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code.

Findings:

During a facility tour with Staff from 3/11/14 to 3/12/14, the electrical wiring was observed.

1. At 4:50 p.m. on 3/11/14, there was a refrigerator plugged into a six-plug surge protector that was attached to the wall in Operating Room 3.

2. At 4:52 p.m. on 3/11/14, there was a six-plug surge protector plugged into a second six-plug surge protector, attached to the desk, in the clean side of Sterile Processing.

Based on observation, the facility failed to maintain the integrity of the building construction. This was evidenced by a penetration in the ceiling tile of a waiting room. This affected one of nine smoke compartments and could result in the faster spread of smoke and fire.

Findings:

During a facility tour with Staff from 3/11/14 to 3/12/14, the walls and ceilings were observed.

1. At 11:47 a.m. on 3/11/14, there was an approximately six inch by six inch penetration in the ceiling tile of the west Waiting Room, near the Lobby, with IT conduits going through.

Based on record review and interview, the facility failed to ensure that fire drills are conducted quarterly on each shift. This was evidenced by no NOC shift drills conducted during three of four quarters in 2013. This affected nine of nine smoke compartments and could result in a delay in staff response, in the event of a fire.

Findings:

During record review from 3/11/14 to 3/12/14 with Staff 1, the fire drill records were reviewed.

1. At 8:26 a.m. on 3/11/14, records indicated that all fire drills during the second quarter (April through June) were conducted between 1:57 p.m. and 6:14 p.m. There were no records showing that drills were conducted during the NOC shift.
During an interview at 8:27 a.m., Facilities Staff 1 stated that the NOC shift is between 8 p.m. and 6 a.m. Engineering Staff 1 stated that the NOC shift is between 7 p.m. and 7 a.m.

2. At 8:28 a.m. on 3/11/14, records indicated that all fire drills during the third quarter (July through September) were conducted between 7:18 a.m. and 4:25 p.m. There were no records showing that drills were conducted during the NOC shift.

3. At 8:29 a.m. on 3/11/14, records indicated that all fire drills during the fourth quarter (October through December) were conducted between 9:26 a.m. and 4:11 p.m. There were no records showing that drills were conducted during the NOC shift.

Based on observation and record review, the facility failed to maintain their fire alarm system. This was evidenced by a sprinkler waterflow alarm-initiating device that was not in accordance with NFPA 72. This affected the entire Marian Building and could result in a delay in notification in the event of an automatic sprinkler system activation.

NFPA 72, National Fire Alarm Code, 1999 Edition.
2-6 Sprinkler Waterflow Alarm-Initiating Devices.
2-6.1 The provisions of Section 2-6 shall apply to devices that initiate an alarm indicating a flow of water in a sprinkler system.
2-6.2 Initiation of the alarm signal shall occur within 90 seconds of waterflow at the alarm-initiating device when flow occurs that is equal to or greater than that from a single sprinkler of the smallest orifice size installed in the system. Movement of water due to waste, surges, or variable pressure shall not be indicated.

Findings:

During a facility tour with Staff from 3/11/14 to 3/12/14, the fire alarm system was observed in the Marian Building. The medical records storage was sprinklered and the sprinkler system was supervised by a waterflow alarm that was connected to the fire alarm system.

1. At 5:06 p.m. on 3/11/14, the valve labeled "Inspector's Test Valve" on the riser of the Marian Building was tested. The discharge orifice of the inspector's test valve was a pipe that was approximately 1 1/4 inches in diameter.
At 8:30 a.m. on 3/12/14, building plans indicated that the sprinklers were added to the medical records storage room on 9/27/11. The plans and manufacturer specifications also indicated that 1/2 inch sprinkler heads were installed in the sprinkler system.

Based on observation, the facility failed to ensure that portable space heating devices are not used in staff sleeping areas. This was evidenced by one portable space heating device in a doctor's sleep room. This affected one of nine smoke compartments and could result in the increased risk of a fire.

Findings:

During a facility tour with Staff from 3/11/14 to 3/12/14, the facility was inspected for use of portable space heating devices.

1. At 3:20 p.m. on 3/11/14, there was a portable space heater in the doctor's sleep room located in the Obstetrics and Gynecology corridor.

Based on observation and interview, the facility failed to ensure that paths of egress are free of obstructions. This was evidenced by beds stored in the radiology corridor near the exit door. This affected two of nine smoke compartments and could result in a delay in evacuation.

Findings:

During a facility tour with Staff from 3/11/14 to 3/12/14, the paths of egress were observed.

1. At 10:29 a.m. on 3/11/14, there were two beds in the radiology corridor near the exit door. The beds were observed again at 1:14 p.m.
During an interview at 1:15 p.m., Facilities Staff 1 confirmed that the beds were stored in the corridor and had not been moved or used between 10:29 a.m. and 1:14 p.m.

Based on observation, the facility failed to maintain its electrical wiring. This was evidenced by surge protectors that were used in lieu of permanent wiring. This affected two of nine smoke compartments and could result in an increased risk of an electrical fire.

NFPA 70, National Electrical Code, 1999 Edition.
400-8 Uses Not Permitted
Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code.

Findings:

During a facility tour with Staff from 3/11/14 to 3/12/14, the electrical wiring was observed.

1. At 4:50 p.m. on 3/11/14, there was a refrigerator plugged into a six-plug surge protector that was attached to the wall in Operating Room 3.

2. At 4:52 p.m. on 3/11/14, there was a six-plug surge protector plugged into a second six-plug surge protector, attached to the desk, in the clean side of Sterile Processing.