HospitalInspections.org

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) 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) Corrected 06/16/10
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) Corrected 1/21/10

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

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