HospitalInspections.org

Based on observations and confirmed by staff, the facility failed to ensure that buildings are properly separated. Section 19.1.1.4.1 states additions shall be separated from any existing structure not conforming to the provisions within Chapter 19 by a fire barrier having not less than a 2-hour fire resistance rating and constructed of materials as required for the addition.
NFPA 80 section 1.5.1 states listed items shall be identified by a label. Labels shall be applied in locations that are readily visible and convenient for identification by the authority having jurisdiction after installation of the assembly.
Section 2.4.1.1 states where there is an astragal or projecting latch bolt that prevents the inactive door from closing and latching before the active door closes and latches, a coordinating device shall be used. A coordinating device shall not be required where each door closes and latches independently of the other.
Section 2.3.1.7 states the clearance between the edge of the door on the pull side and the frame, and the meeting edges of doors swinging in pairs on the pull side shall be 1/8 in. ± 1/16 in. for steel doors and shall not exceed 1/8 in. for wood doors.

THE FINDINGS INCLUDE:

WEST CAMPUS - Farr Building

1) During the afternoon hours of November 4, 2010 while touring the 1st floor level of the facility, it was noted that the Farr Building & Baker Building are not properly separated. The following two items were noted regarding the building separation:

a) According to the building plans provided, the door (BA-0119) to the 1st floor lobby bathroom is noted as being part of the 2-hour fire wall assembly. When viewing the actual door for integrity, it was noted that a fire rating label was not attached as required. The door appears to be a normal 1-3/4" solid core wood door with a 20-minute rating.
b) The lobby area noted as (FA 0140B) has an approximate 6" x 18" hole in the block wall above the ceiling tiles.

2) During the afternoon hours of November 3, 2010, the 6th floor doors to the bridge connector were noted as not operating properly. The coordinating device was not functioning correctly and holding the doors in the open position.

3) During the morning hours of November 4, 2010, the 3rd floor doors to the bridge connector were noted as not operating properly. The coordinating device was not functioning correctly and holding the doors in the open position.

WEST CAMPUS - Baker Building

4) During the afternoon hours of November 3, 2010, the 3rd floor doors (SP 03C1) separating the Baker & Span buildings were noted as having a gap of 3/8" between the door leafs.

These items were each acknowledged by the Facilities Manager during the facility tour.

Based on observations and confirmed by staff, the facility failed to ensure that all corridor doors close and latch properly into their frames.

THE FINDINGS INCLUDE:

WEST CAMPUS - Farr Building

1) During the afternoon hours of November 3, 2010 while conducting the facility tour of the 7th floor level, the door to patient room #706 was noted as not being properly maintained. When the door was tested for proper operation, it was observed that the door would not latch when in the closed position.

2) During the morning hours of November 4, 2010 while conducting the facility tour of the 5th floor level, the doors to patient rooms #519 and #520 were noted as not being properly maintained. When the doors were tested for proper operation, it was observed that the doors would not latch when in the closed position.

3) During the morning hours of November 4, 2010 while conducting the facility tour of the 3rd floor level, the door to patient room #324 was noted as not being properly maintained. When the door was tested for proper operation, it was observed that the door would not latch when in the closed position.

These items were each acknowledged by the Facilities Manager during the facility tour.

Based on observations, the facility failed to assure that proper smoke barrier walls are provided.

THE FINDINGS INCLUDE:

WEST CAMPUS-Clinical Center

- Observations while conducting the facility tour on the morning of November 4, 2010 revealed the following:

1. The smoke barrier door located along the third floor level reception area, labeled CC-0340, is equipped with a non-rated 22" x 28" plain glass vision panel.

2. The smoke barrier wall, above the door CC-0340, was noted as not being continuous above the ceiling to the roof deck above.

3. Unsealed penetrations were noted around an HVAC duct and wrapped piping.

These items were acknowledged by the Facilities Manager during the facility tour.

Based on observations, the facility failed to assure that smoke barriers are constructed to restrict the movement of smoke. Section 8.3.4.1 requires doors in smoke barriers shall close the opening leaving only the minimum clearance necessary for proper operation and to be without undercuts, louvers, or grilles. The clearance for proper operation of smoke doors is defined as 1/8 in.

THE FINDINGS INCLUDE:

WEST CAMPUS-Clinical Center

1. Observations while conducting the facility tour on the afternoons of November 3 & 4, 2010 revealed that the third floor level smoke barrier doors, labeled CC-03C21 and CC-03C16, failed to close and latch when released from the open position. Both doors latch mechanisms failed to overcome the resistance at the strike plate.

2. Observations while conducting the facility tour on the afternoon of November 4, 2010, revealed that while testing smoke barrier door closing the set of seventh floor level smoke barrier doors, labeled CC-07C04 failed to close and meet at the leading edges, due to unbalanced air pressure. A space of 1" between the door leafs at the meeting edges remained when released from the open position.

3. Observations while conducting the facility tour on the afternoon of November 4, 2010, revealed that while testing smoke barrier door closing the set of sixth floor level smoke barrier doors, labeled CC-06C12 (1"), CC-06C14 (1") and CC-06C15 (1-3/4") they failed to close and meet at the leading edges, due to unbalanced air pressure. A space of 1" to 1-3/4" between the door leafs at the meeting edges remained when released from the open position.

4. Observations while conducting the facility tour on the afternoon of November 4, 2010, revealed that while testing smoke barrier door closing the horizontal sliding first floor level smoke barrier door, labeled CC-01L1, failed to close and set in the bottom channel. Of the seven attempts to close the sliding door only one time did the door close properly.

5. Observations while conducting the facility tour on the morning of November 4, 2010, revealed that the smoke barriers door located along the third floor level reception area, labeled CC-0340, is equipped a non-rated 22" x 28" plain glass vision panel.

These items were each acknowledged by the Facilities Manager during the facility tour.

Based on observations and confirmed by staff, the facility failed to ensure that stairwell doors are maintained in the proper operating condition.
NFPA 80 section 2.4.1.1 states where there is an astragal or projecting latch bolt that prevents the inactive door from closing and latching before the active door closes and latches, a coordinating device shall be used. A coordinating device shall not be required where each door closes and latches independently of the other.

THE FINDINGS INCLUDE:

WEST CAMPUS - Farr Building

1) During the morning hours of November 3, 2010 while performing the facility tour, the doors to stairwell #3 on the 11th floor level were noted as not operating correctly. The doors are equipped with a mal-functioning coordinating device which held the doors in the open position when tested for proper operation.

2) During the afternoon hours of November 3, 2010 while performing the facility tour, the doors to stairwell #1 on the 7th floor level were noted as not operating correctly. The doors are equipped with a mal-functioning coordinating device which held the doors in the open position when tested for proper operation.

3) During the morning hours of November 4, 2010 while performing the facility tour, the doors to stairwell #1 on the 5th floor level were noted as not operating correctly. The doors are equipped with a mal-functioning coordinating device which held the doors in the open position when tested for proper operation.

4) During the morning hours of November 4, 2010 while performing the facility tour, the doors to stairwell #2 on the 4th floor level were noted as not operating correctly. The doors are equipped with a mal-functioning coordinating device which held the doors in the open position when tested for proper operation.

5) During the morning hours of November 4, 2010 while performing the facility tour, the doors to stairwell #1, #2 and #3 on the 3rd floor level were noted as not operating correctly. The doors are equipped with a mal-functioning coordinating device which held the doors in the open position when tested for proper operation.

6) During the afternoon hours of November 4, 2010 while performing the facility tour, the doors to stairwell #1 and #2 on the 2nd floor level were noted as not operating correctly. The doors are equipped with a mal-functioning coordinating device which held the doors in the open position when tested for proper operation.

7) During the afternoon hours of November 4, 2010 while performing the facility tour, the basement level door in stairwell #3 leading into the kitchen was noted as having a broken latch. When examined closer, it was noted that the spring assembly is broken keeping the throw in the retracted position. As a result, the door could not be latched when in the closed position.

These items were each acknowledged by the Facilities Manager during the facility tour.

Based on observations and confirmed by staff, the facility failed to ensure that all exit egress routes are properly constructed & maintained. Section 7.2.5.2 states that existing ramps maximum slope is 1 inch rise for every 10 inch run.

THE FINDINGS INCLUDE:

WEST CAMPUS - Farr Building

- Observations while touring the facility on November 4, 2010 revealed that the fifth floor level evacuation floor plan indicates that one exit is though a two hour fire barrier (horizontal exit) at door # BA-05C2. The slope of the ramp, two (2) feet of rise over 15 feet of run exceeds allowable design slope of one (1) foot of rise over a ten (10) foot run.

These deficiencies were confirmed by hospital engineering staff.

NOTE: This item meets the FSES and therefore does not require correction.

Based on observations, the facility failed to ensure that corridors are no less than 48 inches in width.

THE FINDINGS INCLUDE:

WEST CAMPUS - Baker Building

- Observations while touring the facility on November 4, 2010 revealed that the fifth floor level is used for inpatient services. The corridor in front of stairwell exit door #BA-S2 narrows to 36 inches.

These deficiencies were confirmed by hospital engineering staff.

NOTE: This item meets the FSES and therefore does not require correction.

Based on record review and confirmed by staff, it was revealed that the facility failed to ensure the fire alarm system is maintained as required. NFPA #72 (National Fire Alarm Code) section 7.1.2 states the owner or the owner's designated representative shall be responsible for inspection, testing, and maintenance of the system and alterations or additions to this system. The delegation of responsibility shall be in writing, with a copy of such delegation provided to the authority having jurisdiction upon request.

THE FINDINGS INCLUDE:

WEST CAMPUS - Farr Building

- During the afternoon hours of November 4, 2010 while touring the main kitchen area, a smoke detecting device was noted as being covered with a plastic dust cap. The device was again checked during the morning hours of November 8, 2010 and still found to be covered.
Note: The device is located approximately 18' from the stove tops and ovens.

This was acknowledged by the Facilities Manager during the facility tour.

Based on observation, the facility failed to assure that the automatic sprinkler system is maintained and inspected as required by NFPA #25. NFPA 25 section 2.1.1 states sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

THE FINDINGS INCLUDE:

WEST CAMPUS-Clinical Center

- Observations while conducting the facility tour on the morning of November 4, 2010, revealed painted sprinkler covers in the Emergency Department bays labeled, ED-CC0174, and ED-CC0180.

This item was acknowledged by the Facilities Manager during the facility tour.

Based on record review and confirmed by staff, the facility failed to assure compliance with NFPA 90A. Section 3.3.1.1 requires approved fire dampers to be provided where air ducts penetrate or terminate at openings in walls or partitions required to have a fire resistance rating of 2 hours or more. Section 3.3.1.2 requires approved fire dampers to be provided in all air transfer openings in partitions that are required to have a fire resistance rating and in which other openings are required to be protected.

THE FINDINGS INCLUDE:

WEST CAMPUS-Clinical Center

- Interview with the facilities Director of Maintenance Operations on the morning of November 4, 2010 revealed that several specific HVAC penetrations of the 2-hour fire barrier are neither equipped with service openings nor fire dampers.

Note: This deficiency was previously cited during a survey completed on May 11, 2009 after reviewing documentation from the facilities vendor dated September 2007 and October 2007. At that time the facility indicated that it had a Plan for Improvement (PFI) to correct the deficiency. The facility has corrected a portion of the original penetration deficiencies, but still has a number of corrections to address.

Based on observations and confirmed by staff, the facility failed to ensure that linen chutes are properly maintained. NFPA 82 (Standards for waste & linen handling systems) states that all chute loading doors into a waste chute shall be provided with a self-closing, positive latching frame and gasketed fire door assembly approved for Class B openings and having a fire resistance rating of not less than 1 hour. The door frame shall be fastened into the chute and the shaft wall. The design and installation shall be such that no part of the frame or door projects into the chute.

THE FINDINGS INCLUDE:

WEST CAMPUS - Farr Building

- During the afternoon hours of November 3, 2010 while performing the facility tour, the linen chute door located on the 7th floor was noted as not operating as designed. When the door was opened & released to test for proper operation, the door would not close and latch. The self closing device appeared to be out of adjustment and prevented the door from latching into the frame.

This was acknowledged by the Facilities Manager during the facility tour.

Based on observations and confirmed by staff, the facility failed to ensure that egress corridors are kept clear of all obstructions.

THE FINDINGS INCLUDE:

WEST CAMPUS - Farr Building

1) During the afternoon hours of November 3, 2010 while conducting the facility tour of the 9th floor level, a total of three (3) Work Stations on Wheels (Wow's) were noted as charging in the corridor. These stations were located in the path of egress by room FA-0818.

2) During the afternoon hours of November 4, 2010 while conducting the facility tour of the 2nd floor level, a total of three (3) Work Stations on Wheels (Wow's) were noted as charging in the corridor. These stations were located in the path of egress by room FA-0220.

These items were each acknowledged by the Facilities Manager during the facility tour.

Based on observations and confirmed by staff, the facility failed to ensure that mobile paper recycle containers are stored in properly enclosed rated rooms.

THE FINDINGS INCLUDE:

WEST CAMPUS - Farr Building

1) During the morning hours of November 3, 2010 while conducting the facility tour of the 10th floor level, it was noted that a sixty gallon (60-gal) paper recycle container is located in the corridor alcove. This area is open to the corridor and not equipped with any doors for proper separation as required.

2) During the afternoon hours of November 3, 2010 while conducting the facility tour of the 8th floor level, it was noted that a sixty gallon (60-gal) paper recycle container is located in the corridor alcove. This area is open to the corridor and not equipped with any doors for proper separation as required.

3) During the afternoon hours of November 3, 2010 while conducting the facility tour of the 7th floor level, it was noted that a sixty gallon (60-gal) paper recycle container is located in the corridor alcove. This area is open to the corridor and not equipped with any doors for proper separation as required.

These items were each acknowledged by the Facilities Manager during the facility tour.

Note: The facility currently has a plan underway to eliminate these recycle containers from each of the buildings.

Based on observations and confirmed by staff, the facility failed to ensure that oxygen cylinders are properly secured. NFPA 99, section 4.3.5.2.1(b) 27 requires free-standing cylinders to be properly chained or supported in a stand or cart.

THE FINDINGS INCLUDE:

EAST CAMPUS - Feldberg Building

-Observations while touring the 11th floor on the afternoon of November 3, 2010 revealed that bedroom #1175 had a free standing "E" cylinder of oxygen.

This deficiency was confirmed by the Director of Facilities Planning.

Based on observations and confirmed by staff, the facility failed to ensure compliance with NFPA #70 "National Electric Code".
Section 300-15 states where the wiring method is conduit, electrical metallic tubing, Type AC cable, Type MC cable, Type MI cable, nonmetallic-sheathed cable, or other cables, a box or conduit body complying with Article 370 shall be installed at each conductor splice point, outlet, switch point, junction point, or pull point, unless otherwise permitted in (b) through (n). A box shall be installed at each outlet and switch point for concealed knob-and-tube wiring.

THE FINDINGS INCLUDE:

WEST CAMPUS - Farr Building

- During the afternoon hours of November 4, 2010 while touring the 1st floor level, a live wire was found within the closet FA-01M1. The wire did not terminate within a box as required, it was protruding from the ceiling of the closet with wire caps attached to all three individual wires.

This was acknowledged by the Facilities Manager during the facility tour.