HospitalInspections.org

By observation on November 9th, 2011 at approximately 2:00 PM onward the following was non-compliant: Room 1-118 has med gas lines penetrating the room and was not properly enclosed in the wall and ceiling.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following building construction type item was non-compliant:

There were unsealed penetration in ceiling 1st floor IST room VP1C118.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following building construction type items were non-compliant:

A. In Patient Service Tower, ground floor above door PST-0-078, there are holes and/or penetrations that were not sealed in order to maintain the required rating of the area.

B. Main Building 7th floor, the Patient Care Managers office is located in the elevator lobby area and not construction in order to maintain the required 1-hr fire resistance rating for the room.

C. Corridor Door Main 4W-4-056 is not a rated door. Door is required to be a ? hour fire rated door in order to meet the construction requirements for the area.

D. 4th floor piping and electrical closet, location 4N-4-034 has holes and penetration that are not sealed and/or protected in order to meet the 2-hr fire rated construction requirements for the area.

E. The two hour rated corridor wall for the Main Computer Room was not properly sealed. Non rated foam insulation was used to seal penetrations in the wall.

F. The rated wall in the UPS Battery Room has a hole that was not sealed in order to maintain the required rating of the wall.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following was non-compliant:

The facility renders one or more incapable of self-preservation by the use of a linear accelerator. Provide plans to confirm Ambulatory Health Care (AHC) with the following items addressed:

A. Area and building construction type to be surveyed as AHC. One side is protected construction, the other area was not protected. Different building area divisions were discussed with no final plan.

B. Ambulatory health care (AHC) occupancies are separated from other tenants and occupancies by fire barriers with at least a 1 hour fire resistance rating. Currently there is one tenant occupying the space on the second floor.

C. Ambulatory health care facilities are divided into at least two smoke compartments with smoke barriers having at least 1 hour fire resistance rating. Identify the smoke compartments for the area rendered AHC or state the exception to be used.

D. Ambulatory health care facilities have heating ventilation and air-conditioning (HVAC) comply with 20.5.2.1 Currently not all spaces have ducted returns.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following interior finish was non-compliant: There was untreated plywood used to mount wall TV in break room, express care area.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following corridor door was non-compliant: Corridor Door OB-18-1-072 did not close, latch and seal.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following corridor doors were non-compliant:

The CT-Scan corridor room door VP-GA026 was not equipped with positive latching hardware.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following corridor doors were non-compliant: The doors to rooms listed did not close and latch tightly in their frames: 402, 418 (family birth center, south tower) 4-217 rehab, and 2-053.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following vertical opening was non-compliant: In the Pent House area, the access door to the 2 hr. fire rated vertical shaft did not close, latch and seal.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following smoke wall was non-compliant:

A. Smoke Wall 7th floor south center section there are penetrations in the rated smoke wall that were not sealed in order to maintain the required rating of the area.

B. Smoke Wall 6th floor south center section there are penetrations in the rated smoke wall that were not sealed in order to maintain the required rating of the area.

C. Smoke wall located above the ceiling in the Soiled holding room Main 3S-3-032 has holes that have not been sealed in order to maintain the required rating of the area.

D. Smoke tight shutters in the labs rated wall did not close after three fire alarm tests were conducted.

E. There was not a rated sleeve on the penetration in the one hour rated wall on 2 South (main 2S-2-2006)

By observation on November 9th, 2011 at approximately 2:00 PM onward the following doors in smoke barriers was non-compliant: The door in smoke wall located next to VP-GD021A did not close smoke tight.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following doors in smoke barriers was non-compliant:

A. Cross corridor doors were not smoke tight in the family birth center, South tower.

B. Cross corridor doors 2S-2-079 did not close with fire alarm activation, 2 South.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following hazardous area was non-compliant: The corridor hall door to the Janitor storage closet OB-18-1-035 was not self closing.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following hazardous areas were non-compliant:

A. The Soiled holding/linen corridor door (Main 5W-5-019) did not close latch and seal.

B. The Soiled utility/linen room corridor door (Main 8-8-096) did not close latch and seal.

C. Housekeeping storage closet corridor door, (Main8-8-010) was not self closing.

D. Corridor door to storage room, location Main 4N-4-046 is not 3/4 hour rated and not self closing. (Room labeled as Women and Children Services)

E. Door to the clean supply room PST 2-057 does not have positive latching.

F. The wall to the clean supply storage room in PACU PST-2-109 had holes that are not sealed.

G. The storage room PST 2-107 does not meet the requirements for hazardous area. Patient care room was converted to storage room.

H. The equipment storage room corridor door did not close, latch and seal. (PST-2-034)

I. The storage room door, to room labeled Main 2N-2-043/045, was not self-closing.

J. The soiled linen room corridor door Main 2N-2-009 did not close, latch and seal.

K. The oxygen storage room Main 2N-2-024 was not self closing.

L. Dry storage room #2 did not have positive latching.

M. Door to janitor's closet PST 1-036 did not have positive latching.

N. Door to soiled utility/linen room AS3-092 (ICU) does not have positive latching.

O. Door to storage room, main 2S-2-052 and 2S-2-019, was a non-rated door.

P. Door to storage room, old cat lab/2 west: 2W-2-023, was a non-rated door.

Q. Door to storage room, Administration: 2W-2-003, was a non-rated door.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following hazardous areas were non-compliant:

A. The corridor door to storage room VP-GA038A does not close, latch and seal.

B. The corridor door to Clean Utility Room 2nd FloorVP-2C226, did not close, latch and seal.

C. The Soiled Utility room door VP-2C225, did not close, latch and seal.

D. The equipment storage room corridor door was not self closing. VP-2A254

E. The Soiled utility room corridor door VP-2A240 did not close, latch and seal.

F. Door to storage room, old peds ed waiting room, was a non-rated door.


G. Doors to environmental room storage on green hall and outside yellow hall ED, were a non-rated doors.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following was non-compliant: The exterior exit access/discharge from the rear of building, near x-ray area, was not a solid path (easily maintained in inclement weather) to a public way.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following exit access was non-compliant:

A. Facility is equipped with special locking and the facility is not 100% sprinkler coverage. Areas not cover by sprinkler coverage will need to be protected with heat and/or smoke detector. The Doctor wash closets located in PST-4-042 Labor and Delivery does not have sprinkler coverage and is not provided with smoke detectors.

B. The override switch for mag locks at nurses station not labeled (ICU)

C. Machine blocking access to override switch for magnetic locking devices at nurses station (express care)

D. The exit cross corridor door Main 2NA-2-011 is equipped with mag locks and when tested did not drop out upon activation of fire alarm. The doors did release with switch at the door and master override switch.

E. Exit door PST 1-006 required more that 15 lbs of force to open.
Doors shall be operable with not more than one releasing operation, 7.2.1.5.4

F. Main Building 4th floor, Flower shop, requires two motions of the hand to exit the room.

G. Clinical educator office and adjoining room has bathroom that requires two motions of the hand exit the room. Location North Hall 4th floor 4-016 and 4-011.

H. The restroom located in the elevator lobby location 3-W-3-080 requires two motions of the hand to exit the room.

I. 2 South door going into old prep room, requires two motions of the hand to exit the room.

J. Rehab bathroom 2-662 and nourishment room 2-038, requires two motions of the hand to exit the room.

K. Door in old cath lab, 2W-2-038, requires two motions of the hand to exit the room.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following exit access was non-compliant:

A. The cross corridor door in the lobby area location VP-GAO25 is in the means of egress and does not have an emergency override switch located within 3 feet of the door.

B. The Red Zone ED area is equipped with magnetic locking devices with Key Override switches. None of the staff when asked could provide keys for the override switched. The center cross corridor control doors did not release with master override switch and switches at the doors did release doors. Doors would release upon activation of fire alarm activation.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following illumination of means of egress was non-compliant:

A. There was not a light on emergency power or a battery operated emergency light located in the two ultra sound rooms.

B. The emergency light near the MRI door did not function properly when tested.

C. There is not proper coverage of emergency illumination in the back hall office area.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following illumination of means of egress was non-compliant:

A. 2D waiting room leaves area in darkness PST4-004 (family birth center, south tower)upon normal power loss.

B. Admin and CS&H waiting room leaves area in darkness upon loss of normal power.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following was non-compliant: There was not emergency egress lighting on the exit discharge path from the back courtyard gate to the front of the building/public way. Lighting must be arranged to provide light from the exit discharge leading to the public way (parking lot). The walking surfaces within the exit discharge shall be illuminated to values of at least 1 ft-candle measured at the floor. Failure of any single lighting unit does not result in an illumination level of less than 0.2 ft-candles in any designated area. NFPA 101 7.8.1.1, 7.8.1.3, and 7.8.1.4.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following exit and directional signs were non-compliant:

A. Additional exit and directional signage is needed from the 4th Floor West Wing corridor back into the NICU unit. At present exit directional signage is provided in one direction only.

B. Additional exit and directional signage is needed from the 3rd Floor West Wing corridor back into the Respiratory Therapy Unit. At present exit directional signage is provided in one direction only.

C. Additional exit and directional signage is need in the connecting corridor between NICU and 4th floor west wing.

D. Additional exit and directional signage needed between A and UB Lab 2nd Floor Main Connecting Corridor.

E. Additional exit and directional signage needed in the outer center core of the surgical suite.

F. Exit signage is needed above exit door PST 1-006.

G. Additional exit and directional signage needed In the Medical Records and Health Management suite leading individual to a second means of egress from the area.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following exit and directional signs were non-compliant: Additional exit and exit direction signs are needed in the back corridor and hall.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following fire alarm component was non-compliant:

There was not a smoke detector in old cath lab/2 west storage room.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following fire alarm component was non-compliant:

A. The FACP and it's components had not been inspected and tested in the past year. The last test was conducted in 2008.

B. During the inspection and testing of the facility fire alarm system, that consisted of multiple components, there was not a visual/audible trouble signal at the Fire Alarm Control Panel (FACP) with loss of AC power and battery back-up power.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following was non-compliant: During the inspection and testing of the facility fire alarm system, that consisted of multiple components, the automatic dialer component, when placed in trouble from phone line failure did not send a trouble signal to the main fire alarm control panel (FACP) located at the nurses station.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following sprinkler system and components were non-compliant:

A. The recessed sprinkler head located in the patient room Main 6-634 located in front of patient bed was out of adjustment and would not provide coverage for the area.

B. There is no sprinkler coverage in the sleep lab bathrooms 1, 3, & 5 and in rehab.

C. The sprinkler heads, on the loading dock, are not uniform across the entire area and are not properly rated in all areas. 200 degree (green) heads are mixed in with 155 degree (red) heads. Sprinkler head ratings in the area should be 155 degree (red) unless documentation would indicate otherwise.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following was non-compliant: Curtains in the shower of bedroom 118 did not have 1/2" mesh in the upper eighteen inches to provide sprinkler coverage.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following sprinkler system supervision was non-compliant:

A. In the South Tower there are three valves on the main sprinkler line that are not supervise with an electronically supervised tamper alarms.

B. In the South Tower the tamper alarms on the fire pump did not activate and alarm when tested.

C. In the Patient Service Tower area in main building the tamper alarm on the fire pump did not sound an alarm when tested.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following was non-compliant:

A. The 5th floor elevator equipment room had an individual Heating Ventilating and Air Conditioning (HVAC) unit within the two hour enclosure that did not shut down with fire alarm activation.

B. The 3rd floor HVAC unit did not have an emergency HVAC shut down switch.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following was non-compliant:

A. In Pent House smoke duct detector NS-M1-12 located in the HVAC unit was not maintained clean and in good condition.

B. The smoke duct detector located in the corridor in front of room Main 6S-6-101 was not clean and not maintained in good condition.

C. The smoke duct detector #17 located in pediatric (5N-5-033) was not clean and maintained in good condition.

D. The Phase # Recovery Suite did not have an emergency HVAC shut down switch.

E. The GI Lab 2nd floor main did not have an emergency HVAC shut down switch.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following was non-compliant:

A. The smoke duct detector located in the AC Unit #2 did not have an access door for visual inspection and maintenance. Note: Additional information is needed on the remaining HVAC units concerning CFM output in order to determine if additional smoke duct detectors are need in the units.

B. The Heating Ventilating, and Air Conditioning (HVAC) unit in the main mechanical/electrical room was under replacement during the survey. Mechanical and electrical components were incomplete.

C. The HVAC system did not shut down with fire alarm activation.

D. The HVAC shut down switch located behind the receptionist desk did not function properly when tested.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following means of egress was non-compliant:

A. Multiple items such as equipment and a charting table stored in front of each ICU breakaway door. In an emergency rolling multiple beds out of the suite would be difficult because of multiple items that would be rolled in the exit egress to use the breakaway door.

B. IST workstation did not close, blocking exit path between rooms 2 & 3 (express care).

C. IST workstation did not close, blocking exit path across from fire door main 2S-2-701.

D. IST workstation did not close, blocking exit path from CSICU/2 west.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following trash collection was non-compliant:

Trash containers greater than 32 gallons were found stored in the corridor area leading to central supply.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following medical gas storage was non-compliant:

A. Full and empty oxygen cylinders were stored together. If stored within the same enclosure, empty cylinders shall be segregated and designated (with signage) from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly. [NFPA 99 4-3.5.2.2b(2)] (8th and 5th floor oxygen storage rooms)

B. Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation. [NFPA 99 4-3.1.1.2 a(3)] Medical gas cylinders located in room Main 3W-3-080 were found gang chained together.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following was non-compliant: The bulk oxygen room had H tanks gang chained together. Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation. [NFPA 99 4-3.1.1.2 a(3)]

By observation on November 9th, 2011 at approximately 2:00 PM onward the following was non-compliant:

A. In CYSTO 2 surgery room the Relative Humidity gauge was not operational.

B. In the OR suites the Relative Humidity gauges were not operational.

C. In Short Stay surgical suite there were not Relative Humidity gauges present.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following operational inspection and testing was non-compliant:

Documentation for monthly load test was conducted without recording percent rated load or temperature rise. A load bank test had not been completed within the past year.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following was noted: Documentation for monthly load test was conducted without recording percent rated load or temperature rise. A load bank test had not been completed within the past year.

NFPA 99 3-4.4.2 Record keeping. A written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction.
NFPA 110 6-4.2 (1999 edition) generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer.
NFPA 110 6-4.2.2 (1999 edition) Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPPS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours. (load bank testing)

By observation on November 9th, 2011 at approximately 2:00 PM onward the following was non-compliant:

A. The medication refrigerator located on 4th floor in the intermediate NICU unit (small refrigerator) is not connected to emergency power.

B. The pyxis station at old nursery and med room is not connected to emergency power.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following was non-compliant: In the pre-surgery suite there are receptacles throughout the suite that are cracked and/or broken and not maintained in good repair.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following was non-compliant: The electrical ground was not a consistent green ground throughout, it was taped at both ends with green tape. 1st floor IST room VP1C118 and near VP1C120 to the copper water line.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following was non-compliant: Room 1-118 has med gas lines penetrating the room and was not properly enclosed in the wall and ceiling.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following building construction type item was non-compliant:

There were unsealed penetration in ceiling 1st floor IST room VP1C118.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following building construction type items were non-compliant:

A. In Patient Service Tower, ground floor above door PST-0-078, there are holes and/or penetrations that were not sealed in order to maintain the required rating of the area.

B. Main Building 7th floor, the Patient Care Managers office is located in the elevator lobby area and not construction in order to maintain the required 1-hr fire resistance rating for the room.

C. Corridor Door Main 4W-4-056 is not a rated door. Door is required to be a ? hour fire rated door in order to meet the construction requirements for the area.

D. 4th floor piping and electrical closet, location 4N-4-034 has holes and penetration that are not sealed and/or protected in order to meet the 2-hr fire rated construction requirements for the area.

E. The two hour rated corridor wall for the Main Computer Room was not properly sealed. Non rated foam insulation was used to seal penetrations in the wall.

F. The rated wall in the UPS Battery Room has a hole that was not sealed in order to maintain the required rating of the wall.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following was non-compliant:

The facility renders one or more incapable of self-preservation by the use of a linear accelerator. Provide plans to confirm Ambulatory Health Care (AHC) with the following items addressed:

A. Area and building construction type to be surveyed as AHC. One side is protected construction, the other area was not protected. Different building area divisions were discussed with no final plan.

B. Ambulatory health care (AHC) occupancies are separated from other tenants and occupancies by fire barriers with at least a 1 hour fire resistance rating. Currently there is one tenant occupying the space on the second floor.

C. Ambulatory health care facilities are divided into at least two smoke compartments with smoke barriers having at least 1 hour fire resistance rating. Identify the smoke compartments for the area rendered AHC or state the exception to be used.

D. Ambulatory health care facilities have heating ventilation and air-conditioning (HVAC) comply with 20.5.2.1 Currently not all spaces have ducted returns.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following interior finish was non-compliant: There was untreated plywood used to mount wall TV in break room, express care area.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following corridor door was non-compliant: Corridor Door OB-18-1-072 did not close, latch and seal.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following corridor doors were non-compliant:

The CT-Scan corridor room door VP-GA026 was not equipped with positive latching hardware.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following corridor doors were non-compliant: The doors to rooms listed did not close and latch tightly in their frames: 402, 418 (family birth center, south tower) 4-217 rehab, and 2-053.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following vertical opening was non-compliant: In the Pent House area, the access door to the 2 hr. fire rated vertical shaft did not close, latch and seal.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following smoke wall was non-compliant:

A. Smoke Wall 7th floor south center section there are penetrations in the rated smoke wall that were not sealed in order to maintain the required rating of the area.

B. Smoke Wall 6th floor south center section there are penetrations in the rated smoke wall that were not sealed in order to maintain the required rating of the area.

C. Smoke wall located above the ceiling in the Soiled holding room Main 3S-3-032 has holes that have not been sealed in order to maintain the required rating of the area.

D. Smoke tight shutters in the labs rated wall did not close after three fire alarm tests were conducted.

E. There was not a rated sleeve on the penetration in the one hour rated wall on 2 South (main 2S-2-2006)

By observation on November 9th, 2011 at approximately 2:00 PM onward the following doors in smoke barriers was non-compliant: The door in smoke wall located next to VP-GD021A did not close smoke tight.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following doors in smoke barriers was non-compliant:

A. Cross corridor doors were not smoke tight in the family birth center, South tower.

B. Cross corridor doors 2S-2-079 did not close with fire alarm activation, 2 South.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following hazardous area was non-compliant: The corridor hall door to the Janitor storage closet OB-18-1-035 was not self closing.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following hazardous areas were non-compliant:

A. The Soiled holding/linen corridor door (Main 5W-5-019) did not close latch and seal.

B. The Soiled utility/linen room corridor door (Main 8-8-096) did not close latch and seal.

C. Housekeeping storage closet corridor door, (Main8-8-010) was not self closing.

D. Corridor door to storage room, location Main 4N-4-046 is not 3/4 hour rated and not self closing. (Room labeled as Women and Children Services)

E. Door to the clean supply room PST 2-057 does not have positive latching.

F. The wall to the clean supply storage room in PACU PST-2-109 had holes that are not sealed.

G. The storage room PST 2-107 does not meet the requirements for hazardous area. Patient care room was converted to storage room.

H. The equipment storage room corridor door did not close, latch and seal. (PST-2-034)

I. The storage room door, to room labeled Main 2N-2-043/045, was not self-closing.

J. The soiled linen room corridor door Main 2N-2-009 did not close, latch and seal.

K. The oxygen storage room Main 2N-2-024 was not self closing.

L. Dry storage room #2 did not have positive latching.

M. Door to janitor's closet PST 1-036 did not have positive latching.

N. Door to soiled utility/linen room AS3-092 (ICU) does not have positive latching.

O. Door to storage room, main 2S-2-052 and 2S-2-019, was a non-rated door.

P. Door to storage room, old cat lab/2 west: 2W-2-023, was a non-rated door.

Q. Door to storage room, Administration: 2W-2-003, was a non-rated door.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following hazardous areas were non-compliant:

A. The corridor door to storage room VP-GA038A does not close, latch and seal.

B. The corridor door to Clean Utility Room 2nd FloorVP-2C226, did not close, latch and seal.

C. The Soiled Utility room door VP-2C225, did not close, latch and seal.

D. The equipment storage room corridor door was not self closing. VP-2A254

E. The Soiled utility room corridor door VP-2A240 did not close, latch and seal.

F. Door to storage room, old peds ed waiting room, was a non-rated door.


G. Doors to environmental room storage on green hall and outside yellow hall ED, were a non-rated doors.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following was non-compliant: The exterior exit access/discharge from the rear of building, near x-ray area, was not a solid path (easily maintained in inclement weather) to a public way.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following exit access was non-compliant:

A. Facility is equipped with special locking and the facility is not 100% sprinkler coverage. Areas not cover by sprinkler coverage will need to be protected with heat and/or smoke detector. The Doctor wash closets located in PST-4-042 Labor and Delivery does not have sprinkler coverage and is not provided with smoke detectors.

B. The override switch for mag locks at nurses station not labeled (ICU)

C. Machine blocking access to override switch for magnetic locking devices at nurses station (express care)

D. The exit cross corridor door Main 2NA-2-011 is equipped with mag locks and when tested did not drop out upon activation of fire alarm. The doors did release with switch at the door and master override switch.

E. Exit door PST 1-006 required more that 15 lbs of force to open.
Doors shall be operable with not more than one releasing operation, 7.2.1.5.4

F. Main Building 4th floor, Flower shop, requires two motions of the hand to exit the room.

G. Clinical educator office and adjoining room has bathroom that requires two motions of the hand exit the room. Location North Hall 4th floor 4-016 and 4-011.

H. The restroom located in the elevator lobby location 3-W-3-080 requires two motions of the hand to exit the room.

I. 2 South door going into old prep room, requires two motions of the hand to exit the room.

J. Rehab bathroom 2-662 and nourishment room 2-038, requires two motions of the hand to exit the room.

K. Door in old cath lab, 2W-2-038, requires two motions of the hand to exit the room.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following exit access was non-compliant:

A. The cross corridor door in the lobby area location VP-GAO25 is in the means of egress and does not have an emergency override switch located within 3 feet of the door.

B. The Red Zone ED area is equipped with magnetic locking devices with Key Override switches. None of the staff when asked could provide keys for the override switched. The center cross corridor control doors did not release with master override switch and switches at the doors did release doors. Doors would release upon activation of fire alarm activation.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following illumination of means of egress was non-compliant:

A. There was not a light on emergency power or a battery operated emergency light located in the two ultra sound rooms.

B. The emergency light near the MRI door did not function properly when tested.

C. There is not proper coverage of emergency illumination in the back hall office area.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following illumination of means of egress was non-compliant:

A. 2D waiting room leaves area in darkness PST4-004 (family birth center, south tower)upon normal power loss.

B. Admin and CS&H waiting room leaves area in darkness upon loss of normal power.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following was non-compliant: There was not emergency egress lighting on the exit discharge path from the back courtyard gate to the front of the building/public way. Lighting must be arranged to provide light from the exit discharge leading to the public way (parking lot). The walking surfaces within the exit discharge shall be illuminated to values of at least 1 ft-candle measured at the floor. Failure of any single lighting unit does not result in an illumination level of less than 0.2 ft-candles in any designated area. NFPA 101 7.8.1.1, 7.8.1.3, and 7.8.1.4.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following exit and directional signs were non-compliant:

A. Additional exit and directional signage is needed from the 4th Floor West Wing corridor back into the NICU unit. At present exit directional signage is provided in one direction only.

B. Additional exit and directional signage is needed from the 3rd Floor West Wing corridor back into the Respiratory Therapy Unit. At present exit directional signage is provided in one direction only.

C. Additional exit and directional signage is need in the connecting corridor between NICU and 4th floor west wing.

D. Additional exit and directional signage needed between A and UB Lab 2nd Floor Main Connecting Corridor.

E. Additional exit and directional signage needed in the outer center core of the surgical suite.

F. Exit signage is needed above exit door PST 1-006.

G. Additional exit and directional signage needed In the Medical Records and Health Management suite leading individual to a second means of egress from the area.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following exit and directional signs were non-compliant: Additional exit and exit direction signs are needed in the back corridor and hall.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following fire alarm component was non-compliant:

There was not a smoke detector in old cath lab/2 west storage room.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following fire alarm component was non-compliant:

A. The FACP and it's components had not been inspected and tested in the past year. The last test was conducted in 2008.

B. During the inspection and testing of the facility fire alarm system, that consisted of multiple components, there was not a visual/audible trouble signal at the Fire Alarm Control Panel (FACP) with loss of AC power and battery back-up power.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following was non-compliant: During the inspection and testing of the facility fire alarm system, that consisted of multiple components, the automatic dialer component, when placed in trouble from phone line failure did not send a trouble signal to the main fire alarm control panel (FACP) located at the nurses station.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following sprinkler system and components were non-compliant:

A. The recessed sprinkler head located in the patient room Main 6-634 located in front of patient bed was out of adjustment and would not provide coverage for the area.

B. There is no sprinkler coverage in the sleep lab bathrooms 1, 3, & 5 and in rehab.

C. The sprinkler heads, on the loading dock, are not uniform across the entire area and are not properly rated in all areas. 200 degree (green) heads are mixed in with 155 degree (red) heads. Sprinkler head ratings in the area should be 155 degree (red) unless documentation would indicate otherwise.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following was non-compliant: Curtains in the shower of bedroom 118 did not have 1/2" mesh in the upper eighteen inches to provide sprinkler coverage.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following sprinkler system supervision was non-compliant:

A. In the South Tower there are three valves on the main sprinkler line that are not supervise with an electronically supervised tamper alarms.

B. In the South Tower the tamper alarms on the fire pump did not activate and alarm when tested.

C. In the Patient Service Tower area in main building the tamper alarm on the fire pump did not sound an alarm when tested.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following was non-compliant:

A. The 5th floor elevator equipment room had an individual Heating Ventilating and Air Conditioning (HVAC) unit within the two hour enclosure that did not shut down with fire alarm activation.

B. The 3rd floor HVAC unit did not have an emergency HVAC shut down switch.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following was non-compliant:

A. In Pent House smoke duct detector NS-M1-12 located in the HVAC unit was not maintained clean and in good condition.

B. The smoke duct detector located in the corridor in front of room Main 6S-6-101 was not clean and not maintained in good condition.

C. The smoke duct detector #17 located in pediatric (5N-5-033) was not clean and maintained in good condition.

D. The Phase # Recovery Suite did not have an emergency HVAC shut down switch.

E. The GI Lab 2nd floor main did not have an emergency HVAC shut down switch.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following was non-compliant:

A. The smoke duct detector located in the AC Unit #2 did not have an access door for visual inspection and maintenance. Note: Additional information is needed on the remaining HVAC units concerning CFM output in order to determine if additional smoke duct detectors are need in the units.

B. The Heating Ventilating, and Air Conditioning (HVAC) unit in the main mechanical/electrical room was under replacement during the survey. Mechanical and electrical components were incomplete.

C. The HVAC system did not shut down with fire alarm activation.

D. The HVAC shut down switch located behind the receptionist desk did not function properly when tested.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following means of egress was non-compliant:

A. Multiple items such as equipment and a charting table stored in front of each ICU breakaway door. In an emergency rolling multiple beds out of the suite would be difficult because of multiple items that would be rolled in the exit egress to use the breakaway door.

B. IST workstation did not close, blocking exit path between rooms 2 & 3 (express care).

C. IST workstation did not close, blocking exit path across from fire door main 2S-2-701.

D. IST workstation did not close, blocking exit path from CSICU/2 west.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following trash collection was non-compliant:

Trash containers greater than 32 gallons were found stored in the corridor area leading to central supply.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following medical gas storage was non-compliant:

A. Full and empty oxygen cylinders were stored together. If stored within the same enclosure, empty cylinders shall be segregated and designated (with signage) from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly. [NFPA 99 4-3.5.2.2b(2)] (8th and 5th floor oxygen storage rooms)

B. Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation. [NFPA 99 4-3.1.1.2 a(3)] Medical gas cylinders located in room Main 3W-3-080 were found gang chained together.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following was non-compliant: The bulk oxygen room had H tanks gang chained together. Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation. [NFPA 99 4-3.1.1.2 a(3)]

By observation on November 9th, 2011 at approximately 2:00 PM onward the following was non-compliant:

A. In CYSTO 2 surgery room the Relative Humidity gauge was not operational.

B. In the OR suites the Relative Humidity gauges were not operational.

C. In Short Stay surgical suite there were not Relative Humidity gauges present.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following operational inspection and testing was non-compliant:

Documentation for monthly load test was conducted without recording percent rated load or temperature rise. A load bank test had not been completed within the past year.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following was noted: Documentation for monthly load test was conducted without recording percent rated load or temperature rise. A load bank test had not been completed within the past year.

NFPA 99 3-4.4.2 Record keeping. A written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction.
NFPA 110 6-4.2 (1999 edition) generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer.
NFPA 110 6-4.2.2 (1999 edition) Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPPS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours. (load bank testing)

By observation on November 9th, 2011 at approximately 2:00 PM onward the following was non-compliant:

A. The medication refrigerator located on 4th floor in the intermediate NICU unit (small refrigerator) is not connected to emergency power.

B. The pyxis station at old nursery and med room is not connected to emergency power.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following was non-compliant: In the pre-surgery suite there are receptacles throughout the suite that are cracked and/or broken and not maintained in good repair.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following was non-compliant: The electrical ground was not a consistent green ground throughout, it was taped at both ends with green tape. 1st floor IST room VP1C118 and near VP1C120 to the copper water line.