HospitalInspections.org

K-211
Based on staff interviews, record review and observations during the facility survey on February 18th and 19th, 2020, it was determined that the facility failed to meet the life safety protection requirements of the Life Safety Code 101 Section 7.1.10.2.1 by not providing free and clear egress from the facility.

This was evidenced by the following:

1) Storage in the Central Sterile Exit corridor
2) Large (40 gallon) trash can blocking an emergency egress doorway

NFPA101 (2012) 7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits or their access thereto, egress therefrom, or visibility thereof.

This deficiency has the potential to affect occupants, who might include staff and visitors within 2 of the 24 smoke compartments. Deficient items were discussed with the Director of Plant & Engineering during the survey and again during the exit conference.

K-293-
Based on staff interviews, record review and observations during the facility survey on February 18th and 19th, 2020, it was determined that the facility failed to meet the life safety protection requirements of the Life Safety Code (NFPA 101) by not maintaining exit signage with directions.

This was evidenced by:

1) EXIT sign in Radiation/Oncology failed to illuminate upon testing.

This deficiency has the potential to affect occupants, who might include staff and visitors within 1 of the smoke compartments. Deficient items were discussed with the Director of Plant & Engineering during the survey and again during the exit conference.

K-324
Based on staff interviews, record review and observations during the facility survey on February 18th and 19th, 2020, it was determined that the facility failed to meet the life safety protection requirements of NFPA 96 (Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations) 12.1.2.3.1-An approved method shall be provided that will ensure that the cooking appliance is returned to an approved design location.

This was evidenced by:

1) There was no method (wheel chocks, restraints) on all gas-fired, wheel equipped cooking appliances under the kitchen hood to return/verify that the appliance was returned to its designed and specified position.

This deficiency has the potential to affect occupants, who might include staff and visitors within 1 of the smoke compartments. Deficient items were discussed with the Director of Plant & Engineering during the survey and again during the exit conference.

K-0343
Based on staff interviews, record review and observations during the facility survey on February 18th and 19th, 2020, it was determined that the facility failed to meet the life safety protection requirements of the National Fire Alarm and Signaling Code (NFPA 72) and the Life Safety Code (NFPA 101).

This was evidenced by the following:

1) The fire alarm system has a trouble signal on the main panel that indicated a lower level heat detector and also indicated "point disabled". This could result in the failure to transmit a detectors activation to the alarm panel.

26.3.7. NFPA 72, National Fire Alarm and Signaling Code (2012): Upon receipt of trouble signals or other signals pertaining solely to matters of equipment maintenance of the alarm systems, the central station shall perform the following actions:(1)*Communicate immediately with persons designated by the subscriber(2) Dispatch personnel to arrive within 4 hours to initiate maintenance, if necessary (3) When the interruption is more than 8 hours, provide no-tice to the subscriber and the fire department if so required by the authority having jurisdiction as to the nature of the interruption, the time of occurrence, and the restoration of service.

This deficiency has the potential to affect occupants, who might include staff and visitors within 1 of the smoke compartments. Deficient items were discussed with the Director of Plant & Engineering during the survey and again during the exit conference.

K-353
Based on staff interviews, record review and observations during the facility survey on February 18th and 19th, 2020, it was determined that the facility failed to meet the life safety protection requirements of the Life Safety Code (NFPA 101) and the Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems (NFPA 25) by not maintaining the fire sprinkler system.

This was evidenced by:

1) No record of 5 year pipe obstruction test (due in 2019) being performed
2) Wires laying on/in contact with fire sprinkler piping above the ceiling grid in the basement (throughout) and the first floor
(above fire doors by service elevator) and pharmacy (above smoke doors)
3) Lab Sample Collection area - Sprinkler coverage blocked by glass partition creating shadowed/uncovered area and (b) said head
located within 4 inches of glass partition (opposite side)
4) Radiology - Fire sprinkler head obscured/blocked by ceiling mounted x-ray equipment
5) Radiology waiting area, Radiation/Oncology entrance & Stair 5-floor 3 - loaded sprinkler heads (dust and debris)


In accordance with NFPA 101, section 19.3.5, 19.3.5.3 and 9.7, 9.7.5, NFPA 25 for Inspection, Testing and Maintenance of Water-Based Fire Protection Systems.

1) NFPA 25 for Inspection, Testing and Maintenance of Water-Based Fire Protection Systems.
14.2.1Except as discussed in 14.2.1.1 and 14.2.1.4 an inspection of piping and branch line conditions shall be conducted every 5
years by opening a flushing connection at the end of one main and by removing a sprinkler toward the end of one branch line for
the purpose of inspecting for the presence of foreign organic and inorganic material.
2) NFPA 25 (2011) for Inspection, Testing and Maintenance of Water-Based Fire Protection Systems.
5.2.2.2 Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.
3) NFPA 25 (2011) for Inspection, Testing and Maintenance of Water-Based Fire Protection Systems.
5.2.1.3Stock, furnishings, or equipment closer to the sprinkler deflector than permitted by the clearance rules of the
installation standard shall be corrected.
3b) NFPA 13 (2012) Installation of Sprinkler Systems
8.6.3.3 - Minimum Distances from Walls.- Sprinklers shall be located a minimum of 4 in. (102 mm) from a wall.
4) NFPA 25 (2011) for Inspection, Testing and Maintenance of Water-Based Fire Protection Systems.
5.2.1.3Stock, furnishings, or equipment closer to the sprinkler deflector than permitted by the clearance rules of the
installation standard shall be corrected.
5) NFPA 25 (2011) for Inspection, Testing and Maintenance of Water-Based Fire Protection Systems.
5.2.1.1 - Sprinklers shall be free of corrosion, foreign materials, paint and physical damage and shall be replaced if these
conditions are identified

This deficiency has the potential to affect occupants, who might include staff and visitors within all of the 24 smoke compartments. Deficient items were discussed with the Director of Plant & Engineering during the survey and again during the exit conference.

Based on staff interviews, record review and observations during the facility survey on February 18th and 19th, 2020, it was determined that the facility failed to meet the life safety protection requirements of the NFPA 80, Standards for Fire Doors and Other Opening Protectives by not maintaining fire doors and recording annual inspections.

This was evidenced by the following:

1) Elevator fire door-right side viewing from exterior (3rd floor) - Fire door does not fully close and latch

This deficiency has the potential to affect occupants, who might include staff and visitors within 1 of the 24 smoke compartments. Deficient items were discussed with the Director of Plant & Engineering during the survey and again during the exit conference.

K-372
Based on staff interviews, record review and observations during the facility survey on February 18th and 19th, 2020, it was determined that the facility failed to meet the life safety protection requirements of the Life Safety Code 101 Section 19.3.7.3 by not maintaining smoke barriers.

This was evidenced by the following:

1) Boiler room (basement) - Top of wall fire stop absent to medical gas room
2) Boiler room (basement) - Top of wall fire stop missing over electric panel GE-2
3) Above grid (basement) - Unprotected penetrations throughout ceiling space
4) Stairwell 3-by fire door (1st floor) - 2 unprotected penetrations
5) Service elevator fire doors (1st floor) - Multiple unprotected penetrations
6) Pharmacy smoke doors - Unprotected penetrations on both sides of wall
7) Electrical room 2-A - Unprotected penetrations in wall
8) Storage (3rd floor) - 2 unprotected wall penetrations

This deficiency has the potential to affect occupants, who might include staff and visitors within 10 of the 24 smoke compartments. Deficient items were discussed with the Director of Plant & Engineering during the survey and again during the exit conference.

K-920
Based on staff interviews, record review and observations during the facility survey on February 18th and 19th, 2020, it was determined that the facility failed to meet the life safety protection requirements of NFPA 70 - the National Electric Code (section 400.8 (1)) by not maintaining safe and accepted wiring within the facility.

This was evidenced by the following:

1) The facility is utilizing a power strip as a substitute for fixed wiring to supply power to a refrigerator.

This deficiency has the potential to affect occupants, who might include staff and visitors within 1 of the smoke compartments. Deficient items were discussed with the Director of Plant & Engineering during the survey and again during the exit conference.

K-929-Oxygen cylinders not restrained
Based on staff interviews, record review and observations during the facility survey on February 18th and 19th, 2020, it was determined that the facility failed to meet the life safety protection requirements of the Health Care Facilities Code (NFPA 99, Section 11.6.2.3(11)) by not protecting oxygen cylinders from damage.

This was evidenced by the following:

1) Oxygen cylinder on gurney by the helipad elevator was not restrained or secured.

This deficiency has the potential to affect occupants, who might include staff and visitors within 1 of the 24 smoke compartments. Deficient items were discussed with the Director of Plant & Engineering during the survey and again during the exit conference.