HospitalInspections.org

Based on observation and interview, the facility failed to separate the new and existing construction in accordance with LCS (2000) Section 18.1.1.4.1. This deficienct practice could affect all patients.

Findings include:

During facility tour between 1:30 PM on 01/24/2011 and 4:30 PM on 01/25/2011, observation revealed that the Adminstration Office is part of the 2-hour fire wall. The door to the administration office and the adjacent Firelite windows are only fire rated for 60 minutes.

This deficient practice was verified by the Senior Manager of Maintenance Operations at the time of the inspection.

Based on observation and interview, the facility has not maintained the corridors in accordance with NFPA 101 (2000 edition), Chapter 19, Section 19.3.6.1. This could affect all patients.

Findings include:

On facility tour between 1:30 PM 01/24/2011 and 4:30 PM on 01/25/2011, observation revealed that the dining room is open to the corridor system and does not have smoke detection in these areas that are open to the corridor.

This deficient practice was verified by the Senior Manager of Maintenance Operations at the time of the inspection.

Based on observation and interview, the facility failed to maintain vertical openings as required by LSC(00) Section 19.3.1.1. This deficient practice could affect all patients.

Findings include:

On facility tour between 1:30 PM on 01/24/2011 and 4:30 PM on 01/25/2011, observation revealed a vertical shaft connecting 8 stories that contains a chain-driven rack system for conveying food trays between floors. It was verified that the doors to the shaft were improperly held open with wooden dowels, and would not automatically close upon activation of the shaft smoke detection system.

This deficient practice was verified by the Senior Manager of Maintenance Operations at the time of the inspection.

Based on observation and interview, the hazardous areas are not maintained in accordance with NFPA 101-2000, Section 19.3.2.1. This deficient practice could affect all patients.

Findings include:

During facility tour between 1:30 PM on 01/24/2011 and 4:30 PM on 01/25/2011, observation revealed that:

1. The ground floor linen room double doors have an astragal, but do not have a door coordinator device.
2. Storage room G662, has double doors with an astragal, but do not have a door coordinator device.
3. The ground floor UPS room has penetrations in the corridor wall that are not firestopped.

These deficient practices were verified by the Senior Manager of Maintenance Operations at the time of the inspection.

Based on observation and interview, the gift shop was not properly separated in accordance with LSC (2000) section 19.3.2.5. This deficient practice could affect all patients.

Findings include:

During facility tour between 1:30 PM on 01/24/2011 and 4:30 PM on 01/25/2011, observation revealed that the Meadow Gift Shop is over 500 square feet and is not properly separated from the corridor.

This deficient practice was verified by the Senior Manager of Maintenance Operations at the time of the inspection.

Based on observation and interview, the facility failed to maintain a fire resistance rating of at least two hours in the exit component accordance with the following requirements of 2000 NFPA 101, Section 19.3.1.1, 8.2.5.2 and 7.1.3.2.1.

Findings include:
On facility tour between 1:30 PM on 01/24/2011 thru 4:00 PM on 01/25/201, it was observed that the 9th floor door from the penthouse into stairwelll G did not have a 1 1/2 hour fire rating, had a louver and was not equipped with a self-closing device.

This deficient practice was verified by the Senior Manager of Maintenance Operations at the time of the inspection.

Based on observation and staff interview, the facility failed to maintain the unlocking requirements in accordance with the requirements of 2000 NFPA 101, Chapter 19.2.2.2.2.

Findings include:
On facility tour between 1:30 PM on 01/24/2011 thru 4:30 PM on 01/25/2011, the following items were found:

1. In the 3rd floor locked labor and delivery area the magnetic locks did not unlock upon the activation of the manual pull stations located in this area,
2. In the 3rd floor locked labor and delivery area, there was no manual unlocking device at the nursing station as required by the 2007 Minnesota State Fire Code, Section 1008.1.11.
3. It was observed that the exit stairwell enclosure door on the 4th floor Pedriatric Unit was locked with a keyed pad. During an interview with maintenance staff and housekeeping staff it was determined that staff could not readily unlock the door at all times.


These deficient practices were verified by the Senior Manager of Maintenance Operations at the time of the inspection.

Based on observation and staff interview, the facility failed to install the fire alarm system in accordance with the requirements of 2000 NFPA 101, Chapters 19.3.4.1 and 9.6, as well as 1999 NFPA 72. This deficient practice could affect all patients.

Findings include:

On facility tour between 1:30 PM on 01/24/2011 thru 4:00 PM on 01/25/2011, observation revealed that numerous smoke detectors were within 36" of supply and return air HVAC vents. These smoke detectors were found throughout the hospital on all floors.

This deficient practice was verified by the Senior Manager of Maintenance Operations at the time of the inspection.



28120

Based on observation and interview, the facility's fire alarm system is not installed in conformance with NFPA 72. This deficient practice could affect all residents.

Findings include:

During facility tour between 1:30 PM on 01/24/2010 and 4:30 PM on 01/24/2010, observation revealed that there are numerous smoke detectors located within 36 inches of HVAC diffusers.

This deficient practice was verified by the maintenance director at the time of the inspection.

Based on observations and document review, the automatic sprinkler system in not installed in accordance with NFPA 13. This deficient practice could affect some patients.

Findings include:

During facility tour between 9:30 PM on 01/24/2011 and 4:30 PM on 01/25/2011, observation revealed that:

1. There are fire sprinkler heads of different type and manufacturer located on the first floor near the old pharmacy.
2. There are no pressure gauges at the top of the fire standpipes in stairwells B, E and G.
3. In room G-215, the sidewall fire sprinkler head is located 7 feet down from the ceiling deck above.
4. The decorative wood slatted ceiling in the first floor lobby and corridor has 1" gaps between the slats that may affect the proper operation of the fire sprinkler system.

These deficient practices were verified by the Senior Manager of Maintenance Operations at the time of the inspection.

Based on observations and interviews, it could not be verified that the facility's general ventilating and air conditioning system (HVAC) is installed in accordance with the LSC, Section 19.5.2.1 and NFPA 90A, Section 2-3.11. A noncompliant HVAC system could affect all patients.

Findings include:

On facility tour between 1:30 PM on 01/24/2011 and 4:30 PM on 01/25/2011, observation revealed that the corridor on the seventh floor is being used as a return air plenum above the suspended ceiling grid. The seventh floor is not completely fire sprinkler protected.

This deficiency practice was verified by the Senior Manager of Maintenance Operations at the time of the inspection.

Based on observation and interview, the facility has egress corridor obstructions which violates LSC 7.1.10. These obstructions could interfere with the convenient and effective removal of the patients in an emergency situation.

Findings include:

On facility tour between 1:30 PM on 01/24/2011 and 4:30 PM on 01/25/2011, observation revealed that there are unattended, wheeled computer work stations stored in the corridors for more than 30 minutes during all times of the day on all floors of the hospital.

This deficient practice was verified by the Senior Manager of Maintenance Operations at the time of the inspection.

Based on observations and interview, the facility has compressed gas cylinders not properly stored in compliance with the requirements of NFPA 99. This deficient practice could affect some patients.

Findings include:

On facility tour between 1:30 PM on 01/24/2011 and 4:30 PM on 01/25/2011, observation revealed that:

1. In room G0236, there are 3 - E size oxygen storage tanks being stored without proper signage on the room door, and there are combustibles stored within 5 feet of the cylinders.
2. In room G-215, there are multiple H size oxygen tanks that are stored upright but are not property secured to prevent the cylinders from falling and damaging the valve assemblies.
3. The CO2 tanks in the kitchen are not properly secured to prevent the cylinders from falling.

These deficient practices were verified by the Senior Manager of Maintenance Operations at the time of the inspection.

Based on observation and interview, the facility failed to separate the new and existing construction in accordance with LCS (2000) Section 18.1.1.4.1. This deficienct practice could affect all patients.

Findings include:

During facility tour between 1:30 PM on 01/24/2011 and 4:30 PM on 01/25/2011, observation revealed that the Adminstration Office is part of the 2-hour fire wall. The door to the administration office and the adjacent Firelite windows are only fire rated for 60 minutes.

This deficient practice was verified by the Senior Manager of Maintenance Operations at the time of the inspection.

Based on observation and interview, the facility has not maintained the corridors in accordance with NFPA 101 (2000 edition), Chapter 19, Section 19.3.6.1. This could affect all patients.

Findings include:

On facility tour between 1:30 PM 01/24/2011 and 4:30 PM on 01/25/2011, observation revealed that the dining room is open to the corridor system and does not have smoke detection in these areas that are open to the corridor.

This deficient practice was verified by the Senior Manager of Maintenance Operations at the time of the inspection.

Based on observation and interview, the facility failed to maintain vertical openings as required by LSC(00) Section 19.3.1.1. This deficient practice could affect all patients.

Findings include:

On facility tour between 1:30 PM on 01/24/2011 and 4:30 PM on 01/25/2011, observation revealed a vertical shaft connecting 8 stories that contains a chain-driven rack system for conveying food trays between floors. It was verified that the doors to the shaft were improperly held open with wooden dowels, and would not automatically close upon activation of the shaft smoke detection system.

This deficient practice was verified by the Senior Manager of Maintenance Operations at the time of the inspection.

Based on observation and interview, the hazardous areas are not maintained in accordance with NFPA 101-2000, Section 19.3.2.1. This deficient practice could affect all patients.

Findings include:

During facility tour between 1:30 PM on 01/24/2011 and 4:30 PM on 01/25/2011, observation revealed that:

1. The ground floor linen room double doors have an astragal, but do not have a door coordinator device.
2. Storage room G662, has double doors with an astragal, but do not have a door coordinator device.
3. The ground floor UPS room has penetrations in the corridor wall that are not firestopped.

These deficient practices were verified by the Senior Manager of Maintenance Operations at the time of the inspection.

Based on observation and interview, the gift shop was not properly separated in accordance with LSC (2000) section 19.3.2.5. This deficient practice could affect all patients.

Findings include:

During facility tour between 1:30 PM on 01/24/2011 and 4:30 PM on 01/25/2011, observation revealed that the Meadow Gift Shop is over 500 square feet and is not properly separated from the corridor.

This deficient practice was verified by the Senior Manager of Maintenance Operations at the time of the inspection.

Based on observation and interview, the facility failed to maintain a fire resistance rating of at least two hours in the exit component accordance with the following requirements of 2000 NFPA 101, Section 19.3.1.1, 8.2.5.2 and 7.1.3.2.1.

Findings include:
On facility tour between 1:30 PM on 01/24/2011 thru 4:00 PM on 01/25/201, it was observed that the 9th floor door from the penthouse into stairwelll G did not have a 1 1/2 hour fire rating, had a louver and was not equipped with a self-closing device.

This deficient practice was verified by the Senior Manager of Maintenance Operations at the time of the inspection.

Based on observation and staff interview, the facility failed to maintain the unlocking requirements in accordance with the requirements of 2000 NFPA 101, Chapter 19.2.2.2.2.

Findings include:
On facility tour between 1:30 PM on 01/24/2011 thru 4:30 PM on 01/25/2011, the following items were found:

1. In the 3rd floor locked labor and delivery area the magnetic locks did not unlock upon the activation of the manual pull stations located in this area,
2. In the 3rd floor locked labor and delivery area, there was no manual unlocking device at the nursing station as required by the 2007 Minnesota State Fire Code, Section 1008.1.11.
3. It was observed that the exit stairwell enclosure door on the 4th floor Pedriatric Unit was locked with a keyed pad. During an interview with maintenance staff and housekeeping staff it was determined that staff could not readily unlock the door at all times.


These deficient practices were verified by the Senior Manager of Maintenance Operations at the time of the inspection.

Based on observation and staff interview, the facility failed to install the fire alarm system in accordance with the requirements of 2000 NFPA 101, Chapters 19.3.4.1 and 9.6, as well as 1999 NFPA 72. This deficient practice could affect all patients.

Findings include:

On facility tour between 1:30 PM on 01/24/2011 thru 4:00 PM on 01/25/2011, observation revealed that numerous smoke detectors were within 36" of supply and return air HVAC vents. These smoke detectors were found throughout the hospital on all floors.

This deficient practice was verified by the Senior Manager of Maintenance Operations at the time of the inspection.



28120

Based on observation and interview, the facility's fire alarm system is not installed in conformance with NFPA 72. This deficient practice could affect all residents.

Findings include:

During facility tour between 1:30 PM on 01/24/2010 and 4:30 PM on 01/24/2010, observation revealed that there are numerous smoke detectors located within 36 inches of HVAC diffusers.

This deficient practice was verified by the maintenance director at the time of the inspection.

Based on observations and document review, the automatic sprinkler system in not installed in accordance with NFPA 13. This deficient practice could affect some patients.

Findings include:

During facility tour between 9:30 PM on 01/24/2011 and 4:30 PM on 01/25/2011, observation revealed that:

1. There are fire sprinkler heads of different type and manufacturer located on the first floor near the old pharmacy.
2. There are no pressure gauges at the top of the fire standpipes in stairwells B, E and G.
3. In room G-215, the sidewall fire sprinkler head is located 7 feet down from the ceiling deck above.
4. The decorative wood slatted ceiling in the first floor lobby and corridor has 1" gaps between the slats that may affect the proper operation of the fire sprinkler system.

These deficient practices were verified by the Senior Manager of Maintenance Operations at the time of the inspection.

Based on observations and interviews, it could not be verified that the facility's general ventilating and air conditioning system (HVAC) is installed in accordance with the LSC, Section 19.5.2.1 and NFPA 90A, Section 2-3.11. A noncompliant HVAC system could affect all patients.

Findings include:

On facility tour between 1:30 PM on 01/24/2011 and 4:30 PM on 01/25/2011, observation revealed that the corridor on the seventh floor is being used as a return air plenum above the suspended ceiling grid. The seventh floor is not completely fire sprinkler protected.

This deficiency practice was verified by the Senior Manager of Maintenance Operations at the time of the inspection.

Based on observation and interview, the facility has egress corridor obstructions which violates LSC 7.1.10. These obstructions could interfere with the convenient and effective removal of the patients in an emergency situation.

Findings include:

On facility tour between 1:30 PM on 01/24/2011 and 4:30 PM on 01/25/2011, observation revealed that there are unattended, wheeled computer work stations stored in the corridors for more than 30 minutes during all times of the day on all floors of the hospital.

This deficient practice was verified by the Senior Manager of Maintenance Operations at the time of the inspection.

Based on observations and interview, the facility has compressed gas cylinders not properly stored in compliance with the requirements of NFPA 99. This deficient practice could affect some patients.

Findings include:

On facility tour between 1:30 PM on 01/24/2011 and 4:30 PM on 01/25/2011, observation revealed that:

1. In room G0236, there are 3 - E size oxygen storage tanks being stored without proper signage on the room door, and there are combustibles stored within 5 feet of the cylinders.
2. In room G-215, there are multiple H size oxygen tanks that are stored upright but are not property secured to prevent the cylinders from falling and damaging the valve assemblies.
3. The CO2 tanks in the kitchen are not properly secured to prevent the cylinders from falling.

These deficient practices were verified by the Senior Manager of Maintenance Operations at the time of the inspection.