HospitalInspections.org

A) 1) a) Corrected 8/28/08
b) Corrected 8/28/08

2) Corrected 9/17/08
3) Corrected 8/28/08
4) a) Corrected 8/28/08
b) Corrected 8/28/08

5) a) Corrected 8/28/08
b) Corrected 9/17/09

c) Duct penetrations vertically and/or
horizontally lack fire dampers (including
niche in front of 2316)

5) Level B1 - Cafeteria Corridor: There is a shaft opposite B1-45A with multiple voids in the shaft wall above the ceiling.

a) One duct penetration above the ceiling
has an access panel that does not permit
full access (too much stuff in the way).
The fire damper at this location is
installed well inside the shaft wall and
beyond the plane of the fire barrier. The
installation does not comply with NFPA
90A.

6) Corrected 9/17/09
7) Corrected 02/04/09
8) Corrected 9/17/09
9) Corrected 02/04/09






12798


A. Corrected 02/04/09


14416

corrected 02/04/09 .

A)1) Corrected 8/28/08
2) Corrected 8/28/08
3) 1/21/10, storage removed.
4) 1/21/10, storage removed
5) Corrected 1/21/10

The above conditions are not identified in the FSES that was previously submitted for this area - see K048.

B) From random observation, the surveyor finds that hazardous areas are not enclosed in accordance with 19.3.2.1:

1) 2nd Floor Room 2304: The Cardio records area is open to the waiting area and is not separated from the waiting area by smoke tight construction.

UPDATE 1/21/10: This deficiency was not corrected in accordance with the last POC. No change to this condition was observed. The facility's Architect provided written judgement based on several parameters. The judgement only included the first part of the NFPA 101 section 19.3.2.1. The last sentence states "Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors." See deficiency statement above for corrective action. (See also K-056)

2) Corrected 02/04/09






12798


A. 1. Corrected 8/28/08
2 .Corrected 8/28/08
3. Corrected 02/04/09
4. Corrected 9/17/09
5. a. Corrected 8/28/08
b. Corrected 8/28/08
c. Corrected 02/04/09
6. Corrected 8/28/08
7. Corrected 8/28/08
8. Corrected 9/17/09
B. 1. Corrected 8/28/08
2. Corrected 9/17/09

A) From direct observation, the surveyor finds that the Basement Level and 2nd Floor tenant spaces have two exit stairs. Neither exit complies with Chapter 7 of NFPA 101.

1) One stair is an open stair in the middle of the building (open to three of three floor levels without any enclosure) that discharges into a 1st Floor interior corridor. This exit neither complies with 8.2 nor Chapter 7 of NFPA 101.

2) The 2nd exit is an enclosed stair for three levels. The stair discharges into a 1st Floor foyer that does not comply with 7.7.1 or 7.7.2 (2) Exception (b).

A) From observation in one exit stair, the surveyor finds that the stair has penetrations that are not permitted under 7.1.3.2.1 e):

Level B3, the exit stair near AC-9 has no stair identification. The surveyor finds that there is new electrical conduit installed in this stair along with a new plastic flexible conduit, neither of which complies with 7.1.3.2.1. Also, a low pressure steam pipe has been terminated in the stair instead of being removed.






12798


A. Access panels in stair or ventilation shafts that are 4 or more stories in height were observed that are not constructed as minimum 2 hour fire rated assemblies in accordance with 8.2.3.2.3.1 (1).
5th floor, Stair 5 (NE) at landing between floors, the installation of the access panel does not appear to maintain the 2 hour fire rating. The door frame does not fit the depth of the opening, the block is not mortar filled and/or capped. Surveyor was unable to verify that this meets the manufacturers installation.
Update 09/17/09: The access panel did not latch to close.
B. Pipe or other penetration through stair shaft walls were observed that do not serve the stair and / or are not sealed against the passage of fire. Locations observed include:

1. 5th floor, Stair 4 (5N) by U5100, 2 large pipes (ducts) which pass through the stair enclosure.

2. Corrected 1/21/10

3. 1st floor, Stair 9 (CVICU) abandon conduit and piping

4. B2, Stair 4, pipe passes through stair at this level.

C. Corrected 02/04/09.

A) From random observation, the surveyor finds that two of two exit stairs do not provide a protected path to the outside and/or they have deficiencies that are not in compliance with Chapter 7 of NFPA 101:

1) Two of two exit stair enclosures both have a wood paneling wainscot. The surveyor is not able to determine how this material complies as a Class A or B Interior Finish (39.3.3.2).

2) The Southeast Stair has a storage area under the stair at the Lower Level. Although sprinklered, the storage area is not separated from the stair by one hour fire rated construction. The storage area is accessed from the stair and is therefore not permitted under 7.1.3.2.1 d).

3) Southeast Stair - The stair door to the Loading Dock/access foyer to attic is not a U L rate door of at least 60 Minutes.

4) Southwest Stair Lower Level: The stair door from the Gym area to the stair is not a U L fire rate door of at least 60 Minutes.

A) The Southeast Stair discharges to the outside at the Lower Level and then requires travel up a zig-zig concrete ramp. The ramp is partially protected with a fabric structure and has lighting mounted above the ramp. The surveyor was not able to determine how emergency lighting is provided along this exterior path.

A) The provider lacks a comprehensive set of Life Safety Master Plans that accurately identify the following:

Smoke Barriers (w/ ratings), the size of smoke compartments, Fire Barriers w/ ratings, locations of vertical shafts along with the fire ratings, locations of all exit enclosures, including the fire ratings and including all exit passageways, the size and location of all suites, etc.

1) The 8 1/2 x 11 drawings that were available from the provided some of the above information but not all of it. The surveyors found from random observation that the information on these 8 1/2 x 11 drawings were not entirely accurate.

The size of smoke compartments was not provided

The locations of some fire barriers, some shaft enclosures, some suites and some rooms was not accurate. Location includes:

a) Corrected 02/04/09

b) 3rd floor PICU, sliding doors do not contain latching hardware, suite not defined.
UPDATE 1/21/10: The facilities Architect indicated that the sliding doors are to the ante room and are not the corridor wall. The PICU is not a suite and therefore not defined. The surveyor has requested revised drawings which define the corridor walls and corridor doors. The drawings need to clearly indicate any/all exit passageways.

c) Corrected 02/04/09

Locations of exit passageways were not identified.

B) Cleared 1/21/10: The FSES (see K029) is no longer required since the storage has been removed from the patient rooms.

A) Based upon random observation, the surveyor finds that the sprinkler system is not installed or is not maintained in accordance with NFPA 13:

1) Corrected 02/04/09

2) Level B1

a) Corrected 9/17/09
b) Corrected 02/04/09
3) Corrected 9/17/09
a) Electrical Room B102: The door to this electrical room is not a 1 1/2 hour fire rated door and the room is used for storage. Therefore the room does not comply with the exceptions under NFPA 13 as an unsprinklered electrical room.

Update 09/17/09: A sprinkler head was installed but the door to this room is not labeled.

b) Corrected 02/04/09
c) Corrected 02/04/09
d) Corrected 9/17/09

A) From random observation, the surveyor finds that sprinkler systems are not installed and maintained in accordance with NFPA 13 and 25:

1) Corrected 1/21/10

2) 2nd Floor: At or near Room 2304: The rolling file system in the Cardio Records area is only 12" below the single sprinkler head that protects this area. The sprinkler head is obstructed by the file system.

UPDATE 1/21/10: The Records area contains two sprinkler heads, however the arrangement does not meet with the requirements of NFPA 13, 5-13.10 exception 2. The heads are not placed between every possible aisle, and are not located 18" above the top shelf. (Refer also to K29)

3) Corrected 02/04/09
4) Corrected 02/04/09

5) Level B1 MRI Equipment Room: There is a niche in the back of this room. The niche is open to the ceiling cavity of the room. The niche lacks sprinkler protection and the ceiling cavity is either not sprinklered or not separated from the niche by a draft stop.

6) Corrected 02/04/09






12798


A. 1. Corrected 9/17/09
2. Corrected 9/17/09
3. Corrected 02/04/09

B. 1. Corrected 8/28/08
2. Corrected 9/17/09
3. Corrected 8/28/08
C. Corrected 02/04/09


14416

Based on direct observation the surveyor finds:

A.
1. Corrected 1/21/10
2. Corrected 1/21/10
3. Corrected 1/21/10

B. Corrected 02/04/09

A) The surveyor finds that the building is fully sprinklered. The surveyor observed a gabled attic area that has wood planks and combustible storage in an otherwise non-combustible area. This space with concealed combustibles lacks sprinkler protection in accordance with NFPA 13.

A) Corrected 1/21/10

B) The existing sprinkler protection is compromised by missing ceiling tiles (example: Lab 204).

A) The surveyors find that the sprinkler system in not tested and maintained in accordance with NFPA 25:

1) From random testing the surveyor observed that of two devices tested, one sprinkler flow switch took up to 95 seconds before the fire alarm system activated.

2) Corrected 9/17/09

A) K130 Interim Life Safety Measures: Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through see K033), 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.

1) Corrected 1/21/10
2) Corrected 1/21/10
3) Corrected 1/21/10

A) Based upon observation and personnel interview, the surveyors find that multiple elevators do not have automatic recall in accordance with ANSI A17.3

1) The provider identified three elevators (elevators 3, 4 & 5) that have been modified to comply with the automatic recall requirements of ANSI A17.3. The provider indicated that one of these three elevators did not comply with the shunt-trip requirements of A17.3 and that all other elevators in the Hospital do not comply with the recall requirements of ANSI A17.3..

2) Corrected 02/04/09

A) The Southeast Stair discharges to the outside at the Lower Level and then requires travel up a zig-zig concrete ramp. The ramp is partially protected with a fabric structure and has lighting mounted above the ramp. The surveyor was not able to determine how emergency lighting is provided along this exterior path.

A) The provider lacks a comprehensive set of Life Safety Master Plans that accurately identify the following:

Smoke Barriers (w/ ratings), the size of smoke compartments, Fire Barriers w/ ratings, locations of vertical shafts along with the fire ratings, locations of all exit enclosures, including the fire ratings and including all exit passageways, the size and location of all suites, etc.

1) The 8 1/2 x 11 drawings that were available from the provided some of the above information but not all of it. The surveyors found from random observation that the information on these 8 1/2 x 11 drawings were not entirely accurate.

The size of smoke compartments was not provided

The locations of some fire barriers, some shaft enclosures, some suites and some rooms was not accurate. Location includes:

a) Corrected 02/04/09

b) 3rd floor PICU, sliding doors do not contain latching hardware, suite not defined.
UPDATE 1/21/10: The facilities Architect indicated that the sliding doors are to the ante room and are not the corridor wall. The PICU is not a suite and therefore not defined. The surveyor has requested revised drawings which define the corridor walls and corridor doors. The drawings need to clearly indicate any/all exit passageways.

c) Corrected 02/04/09

Locations of exit passageways were not identified.

B) Cleared 1/21/10: The FSES (see K029) is no longer required since the storage has been removed from the patient rooms.

A) Corrected 1/21/10

B) The existing sprinkler protection is compromised by missing ceiling tiles (example: Lab 204).

A) Based upon observation and personnel interview, the surveyors find that multiple elevators do not have automatic recall in accordance with ANSI A17.3

1) The provider identified three elevators (elevators 3, 4 & 5) that have been modified to comply with the automatic recall requirements of ANSI A17.3. The provider indicated that one of these three elevators did not comply with the shunt-trip requirements of A17.3 and that all other elevators in the Hospital do not comply with the recall requirements of ANSI A17.3..

2) Corrected 02/04/09