HospitalInspections.org

A. Corrected 03/06/12
B. Deleted 03/06/12



14290


Based on random observation during the survey walk-through, not all exit access corridors are separated from use areas in accordance with 19.3.6.1.

Findings include:

C. (Modified 03/06/12) The North Building First Floor (Northwest Wing) Cashier's Booths were observed to constitute staff work areas open to the exit access corridor. Although smoke detection in the open area is provided, sprinkler protection or direct supervision is not provided and the space does not comply with 19.3.6.1.

A) Moved from K018 on 03/06/12: The cafeteria tray return opening is located in an exit access corridor and is equipped with a fire rated shutter that does not release upon activation of the sprinkler system, local smoke detector and/or the fire alarm. Through interview with hospital staff, it was determined the shutter is closed manually when the cafeteria is closed.

Updated 3/05/12: The tray return space is also a storage room and is a hazardous area that must comply with 8.4 of NFPA 101 per 13.3.2 (assembly) and/or 39.3.2 (business). The shutter installation is a fire shutter that must comply with 8.4.1.2 (the fire shutter must close automatically to maintain a smoke tight separation from the corridor. A smoke detector is required within five feet of the shutter.






10130


Based upon observation, hazardous areas are not properly protected.

Basement-North Building

A. Corrected 03/06/12

1st Floor South ED

B. Modified 03/06/12: The door to the emergency department supply room is not fire rated (3/4 hour) and the vision panel is not fire rated glazing.



14290


Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1.

Findings include:

C. Hazardous areas not covered by a sprinkler system were observed at which doors do not carry a minimum fire resistance rating of 3/4 hour as required by 19.3.2.1. and 8.2.3.2.3.1.(2). Locations observed include (all North Building):

1. Fifth Floor (West) Supply Room, 2 doors.

2. Corrected 03/06/12

3. Corrected 03/06/12

4. Corrected 03/06/12

5. Second Floor (Northwest Wing) Storage Room Room N238, corridor door.

6. Corrected 03/06/12

Based on direct observation, fire doors are not properly installed and operated.

1st & 2nd Floors

A. The fire rated double doors enclosing the 2 story area at the entrance to the building were equipped with non-approved hold-open devices (foot pegs) and closers that do not release upon activation of a local smoke detector and/or fire alarm.

Based upon random observation and staff interview, the exit stair enclosures could not be confirmed to meet the requirement of a 2 hour fire rated enclosure.

Basement- North Building

A. Deleted 03/06/12 - openings are in an outside wall.

B. Corrected 03/06/12

Based upon random observation, exit stair enclosures do not comply with a 1 hour fire resistance rating.

1st Floor-South Building

C. (Modified 03/06/12): Exit stair #5 has an aluminum door and a full glass panel at the discharge of the stair. This 2 story exit stair assembly does not appear to meet the requirement of 1 hour fire resistance rating. The Life Safety Code drawings provided by the provider identify this door as a 4 hour fire barrier.

The stair was identified by the provider as a four story stair. The stair discharges into a foyer. This foyer is a required two hour fire rated exit enclosure. The door from the foyer to the adjacent waiting room is a 1 1/2 hour fire doors, however the wall above this door above the ceiling is not a two hour fire barrier.





14290


Based on random observation during the survey walk-through, not all exit stair shafts are constructed or maintained as fire resistive assemblies in accordance with 19.3.1.1.

Findings include:

D. (Modified 03/06/12) The 7th Floor is used for conference rooms; there are no patient uses on the 7th Floor. Two of two exit stairs from the 7th Floor discharge into two separate 6th Floor exit access corridors. The corridors are in separate fire compartments (with at least two hour separation). The exit travel continues in the 6rh Floor corridor to two separate complying exit stairs.

The 6th Floor corridors are not designed to comply as exit passageways and the two 7th Floor stairs below do not comply with 7.7.1 or 7.7.2.

1. Exit Stair 14 (Southwest Wing).

2. Exit Stair 13 (Southeast Wing).



E. Corrected 03/06/12

Based on observation, exits are not readily available for use.

1st Floor

A. The back exit stair was found to have the following items stored in the exit, under the stair:
ladder, ceiling tile, bucket, boxes of Christmas decorations.

1st & 2nd Floor

B. The exit path from Suite 100 was found to have obstructions (chair & scale) in the path of egress.

Based on observation, exits are obstructed and not ready for immediate use.

Basement-North Building

A. Corrected 03/06/12

B. The double fire rated doors from the north building to the power house were equipped with a door coordinator which did not operate to close the two doors in the proper sequence.

03/06/12 - the above pair of doors did not close to latch due to differential air pressure and because a new latchset did not latch.

1st Floor-South Building

C. Corrected 03/06/12

1st Floor-West Building

D. The exit discharge path from Occupational Therapy and Exit Stair #3 had sloping surfaces appearing to exceed the permissible limit of 1:20.

Temporary ramp removed. One small step and one big step 8 1/2" to 9" no railing open railing at other end of stoop no exterior lighting pictures





14290


Based on random observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1.

Findings include:

E. Corrected 03/06/12

F. Corrected 03/06/12 - surveyors note: 19.2.2.2.4 was referenced in the provider's PoC for this item. 19.2.2.2.4 is not applicable to the cited deficiency and the provider did not use 19.2.2.2.4 to correct this item - the PoC was not accurate.

G. Deleted 3/06/12 .

There was no plan of correction identified for the above item.

H. Exit stairs were observed at which an interrupter gate is not provided at the level of exit discharge as required by 7.7.3. Locations observed include (all North Building):

1. Exit Stair 1 (Northwest Wing).

2. Corrected 03/06/12

3. Exit Stair 10 (Southeast Wing).

4. Corrected 03/06/12

5. Exit Stair # 6

I. Corrected 03/06/12

J. Corrected 03/06/12

Base on observation, the fire barriers in the building are not fully protected.

1st Floor South ED

A. On Tuesday (01/04/10) at approximately 10:30 am, the door to the financial counselor's office, which is part of a fire separation was found to be wedged open with a non approved hold-open device.

Basement

B. The fire door in the separation wall near the linen chute room appears to have a door sill clearance greater than 3/4" permitted per code.

Based on random observation, emergency lighting to illumionate the path of egress was not provided;

1st Floor-North Building

A. Two sources of emergency lighting were not found at the exit discharge of Stair #8 at the exterior of the building in accordance with 7.8.1.1 through 7.8.1.4.

5th Floor-South Building

B. Corrected 03/06/12

1st Floor West Building

C. Two sources of emergency lighting were not provided at the exit discharge of Stair #3 at the exterior of the building in accordance with 7.8.1.1 through 7.8.1.4.




14416


D. Corrected 03/06/12


.

Based on random observation during the survey walk-through, staff interview, and document review, not all portions of the building fire alarm system are installed in accordance with 19.3.4.

Findings include:

A. Modified on 03/06/12, based on testing on 03/06/12 -

1. The fire alarm system does not comply
with NFPA 72.

a. North Building Third Floor South
Corridor: The activation of a
manual fire alarm pull station
located at the Exit Stair within the
North Building did not result in the
closure of the fire rated door (to the
West Building) immediately south
of that location.

03/06/12 - the above item was un-
corrected. The fire alarm was not
audible in all portions of the
referenced south corridor
including near Stair # 8, near
Room N343A and near Room
W301.
b. Corrected 03/06/12

c. Corrected 03/06/12

2. Deleted 03/06/12


a. The Life Safety Master Plans presented to surveyors do not show the boundaries of those portions of the building served by the North and West Fire Alarm Control Panel at the:

1. Second Floor.

2. First Floor.

3. Basement.

North building extends at Bsemnt and 1st Floor extends well under 2nd Floor of West Bldg????????

b. Corrected 03/06/12

c. Corrected 03/06/12

B. Corrected 03/06/12
C. Corrected 03/06/12

A. Corrected 03/06/12 look thhis one up!!!!!

Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.