HospitalInspections.org

A. Corrected 2/7/11


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B. Corrected 2/7/11


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C. Corrected 2/7/11

D. Rooms were observed with a change in function. The doors to these rooms are not self closing, smoke tight and do not latch completely. Materials were observed being stored in rooms which were not designed for a storage function and do not comply with 19.3.2.1.(7). Example locations observed:

Pavillion Building, Sixth floor, Surgery - equipment, combustible supplies, etc.
a. O.R. # 2,
UPDATE 2/7/11: door issue corrected, but staff propped door open with O2 tanks
b. O.R. #9,
UPDATE 2/7/11: door did not close to a latched position
c. O.R. # 10
UPDATE 2/7/11: door was propped open with wedge
d. Corrected 2/7/11.
UPDATE 2/7/11, the door to the cysto room was propped open. The facility indicates that this area is NOT a suite. The corridor walls are lined with storage of beds and case carts. In several locations the stored items are blocking access to electrical panels and medical gas shut off valves.

West Building, Fifth floor - mattresses, furnishings, combustible supplies, etc.
a. Corrected 2/7/11
b. Corrected 2/7/11

E. Corrected 2/7/11




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A. Corrected 2/7/11


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B. Corrected 2/7/11

C. During staff interview the surveyor was informed that Stair B, Stair D, Stair K and Stair J are served by exit passageways. The Life Safety floor plans do not show a designation for exit passageways and these corridors do not comply with 7.1.3.2.1 and 7.1.3.2.2 for a continuous separated/protected exit to a discharge due to the following:

1. Corrected 2/7/11
2. Corrected 2/7/11

3. Stair J Pavillion building first floor - exit passageway was observed to contain an opening to an unoccupied area which does not comply with 7.1.3.2.1 (d). The surveyor observed that the entry to the Generator room and the elevator machine room is from the exit passageway.


D. The finding is that the designated exit stairs do not comply with 19.2.2.3 and 7.2.2.3.2 for landing dimensions not less than the width of the stair. The stairs are 44" wide. Multiple stairs on multiple floors have exit width restrictions within the stair at the landings. Surveyor observed stair landings with a dimensional width of approximately 32". Example locations:

Stair K-second floor - 35"

Stair J-second floor - 32"

Stair A-second floor - 38"

UPDATE 2/7/11: FSES previously submitted to correct this item

E. Completed 2/7/11

F. The finding is that the designated exit stairs do not comply with 7.2.1.4.4 for the minimum required swing of a door into a stair. Surveyor observed exit doors for stairs which opened into the landing and project more than 7 inches when the door is fully opened due to the amount of utilites occuping the stair. Example locations observed: Stair K, Stair J and Stair D.

UPDATE 2/7/11: FSES previously submitted to correct this item.

A. Corrected 2/7/11

B. Corrected 2/7/11


20224


C. Corrected 2/7/11


D. The North Wing of the West Building on the Basement, 2nd, 3rd and 4th floors has a dead-end corridor that is 58 feet in length or longer.

UPDATE 2/7/11: FSES previously submitted to correct this issue.




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A. Based on random observation during the survey walk-through, not all suites are constructed or configured to comply with 19.2.5.1. Location observed: The Surgery Suite, Sixth Floor Pavilion Building. The facility representative informed the surveyor that this area constituted a suite (did not indicate as such on the Life Safety Floor Plan). This suite does not comply with 19.2.5 due to the following:

1. Removed, not a suite 2/7/11 per PoC dated 9/23/10

2. Various locations within the suite do not comply with 19.2.5.8 for the allowable travel distance to an exit. Example locations as shown:

a. corrected 2/7/11

b. O.R. 7-8 to Stair K contains two intervening rooms (hallway outside of the O.R, and the small hallway outside of PACU), travel distance exceeds 50 feet.
UPDATE 2/7/11: FSES previously submitted to clear this item

c. O.R. 4 and O.R. 5 contains intervening room(s) - O.R. 4 to Stair C question the travel distance for one intervening room not to exceed 100 feet.
O.R. 5 to the nearest exit (Stair K) question the travel distance for two intervening rooms (hallway outside of the O.R. and the hallway outside of Stair K) the travel distance exceeds 50 feet.
UPDATE 2/7/11: FSES previously submitted to clear this item



B. Corrected 2/7/11



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A. From random observation, the surveyors find that fire barriers (with two hour or greater fire ratings) are not installed and maintained in accordance with 8.2.3. This includes fire barriers that are used as horizontal exits and fire barriers that are used to separate buildings:

1. West Building First floor designated exit from Lab at the North end. Surveyor observed an exit to the exterior which required the passage through a part of the building which is a non compliant construction type. There is no fire rated building separation provided between the type II (222) and the Business use area consisting of wood construction materials (refer to K-Tag 012).
UPDATE 2/7/11: deficiency has been corrected, however the area lacks an exit sign.



B. Corrected 2/7/11










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A. Corrected 2/7/11

B. Corrected 2/7/11


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C. During a review of the facility's fire protection plan documents, compared to the survey walk through it was determined that the facility has not accurately maintained a comprehensive set of building floor plans, which show critical elements of its egress and fire/smoke compartmentalization systems, for compliance with 19.7.1.1. Critical elements of these systems which are not shown or not shown accurately on the facility's Life Safety Master Plans include:

1. Locations and sizes of smoke compartments.
UPDATE 2/7/11: The drawings provided did not clearly identify each smoke compartment or the square footage.

2. Corrected 2/7/11

3. Corrected 2/7/11



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A. Based on direct observation, the facility failed to provide separation of medical gas zone control valves from supplied outlets and inlets. NFPA 99, 1999, 4-3.1.2.3 (d) Locations include:

1. Pavilion Building - Sixth Floor - PACU

2. Pavilion Building - Fifth Floor - ICU North and ICU South

3. Pavilion Building - First Floor: Emergency Department.

4. Basement - Cardiac Catheterization - Recovery Bays.



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B. Medical Gas Zone shut off valves are not readily operable from a standing position to comply with NFPA 99 1999, 4-3.1.2.1. Location observed: East Building Fifth floor corridor zone valve adjacent to room # 550. Surveyor observed a shut off valve which is approximately 6 feet above the floor and not easily grasped.


C. Medical Gas Zone shut off valves are not labeled as to the area they serve to comply with NFPA 99 1999. Location observed: Pavillion Building, Second floor. The corridor zone valve located adjacent to room # 212 contains a label which reads "This valve capped for future services". Upon interviewing the facility staff, they were unsure what the label meant or if the valve was abandoned in place.



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