HospitalInspections.org

Based on observation the facility failed to provide an adequate elevator enclosure.

The inspector observed, while accompanied by the Regional Director of Support Services, Facilities Lead Technician, and the System Life Safety Specialist during the hours of the inspection from 10:00 am to 4:30 pm on 2/26/2012 that there were penetrations in the fire wall of the elevator shaft from inside the elevator equipment room. Also, the fire door to the stair in the basement did not latch correctly.

Based on observation the facility failed to provide adequate smoke barrier separations.

The inspector observed, while accompanied by the Regional Director of Support Services, Facilities Lead Technician, and the System Life Safety Specialist during the hours of the inspection from 10:00 am to 4:30 pm on 2/26/2012 that there were the following issues. There were penetrations in the smoke barriers above the following cross corridor locations: 1) outside of room 2.427, i.e. west corridor of PT area, 2) outside of room 1.232, main corridor from the lobby, and 3) outside of stair, 1.S03, southwest stair.

Based on observation the facility failed to provide adequate hazardous areas.

The inspector observed, while accompanied by the Regional Director of Support Services, Facilities Lead Technician, and the System Life Safety Specialist during the hours of the inspection from 10:00 am to 4:30 pm on 2/26/2012 that there were the following issues. They were: 1) the supply storage, 2.338, did not have a rated door, a closer, and the not all walls went to the deck, 2) the bath, 2.332, is an equipment storage that needs a closer and a rated door, 3) the Pharmacy Storage, 2.452, and Records, 2.454, were used as storage and open to one another above the ceiling both doors need closers, 4) Records, 2.268, need a closer, a 45 minute rated door, and the walls must go to the deck, 5) PT Storage, 2.429, needs walls to deck, closer, rated door and one of the doors was filled in but not with a 1 hour rated wall, 6) the Dry Storage Room, 1.164, needs a closer, 7) Materials Management, 1.135, requires a closer on the north door, 8) Credit and Collections, 1.143, is a part of Materials Management and needs a closer, 9) the Mail Room, 1.133, is a part of Materials Management and needs a closer, 10) the Old Meds Room, now Storage, 2.409, does not have a rated door and the walls do not go to deck, 11) the E.D. Par (Supply) Room, 1.232, did not have a rated door and frame, closer, and the walls did not go to deck, 12) the Soiled Utility in E.D., 1.221, did not have latching door, 13) the File Storage Area, 1.256, did not have rated doors and closers, 14) Sterile Storage, 1.314, did not have closers, 15) there was a penetration in the 1 hour wall above the ceiling in the Soiled Utility, 2.308, on the north wall.

Based on observation the facility failed to provide an adequate stair enclosure.

The inspector observed, while accompanied by the Regional Director of Support Services, Facilities Lead Technician, and the System Life Safety Specialist during the hours of the inspection from 10:00 am to 4:30 pm on 2/26/2012 that the fire door to the stair in the basement did not latch correctly.

Based on observation the facility failed to provide an adequate medical gas system.

The inspector observed, while accompanied by the Regional Director of Support Services, Facilities Lead Technician, and the System Life Safety Specialist during the hours of the inspection from 10:00 am to 4:30 pm on 2/26/2012 that there were the following issues. They were as follows.

A. The medical gas lines were not labeled in multiple locations. All lines must be checked throughout the facility. Specific locations observed were as follows: 1) on the east side of the 2 hour wall in corridor 2.301, 2) on the west side of the 2 hour wall in corridor 1.301, and 3) in the basement adjacent to the tunnel to the mechanical building.
B. There was dissimilar metal contact between the copper lines and the steel supports in multiple locations throughout the facility. All lines must be checked and isolated. Specific locations observed were as follows: 1) on the west side of the 2 hour wall in corridor 1.301, and 2) in the basement adjacent to the tunnel to the mechanical building.
C. The nitrous oxide lines were un-insulated in the exterior med gas yard.
D. The nitrous oxide bottles were not individually secured.
E. The medical gas alarm was not correctly labeled in the Stress Testing area.

Labeling Med Gas Piping: " The gas content of medical gas piping systems shall be readily identifiable by appropriate labeling with the name and pressure of the gas contained. Such labeling shall be by means of metal tags, stenciling, stamping, or adhesive markers, in a manner that is not readily removable. Labeling shall appear on the piping at intervals of not more than 20 ft and at least once in each room and each story traversed by the piping system. " - NFPA 99, 1999: 4-3.1.2.13.

" Connections of surface-mounted medical gas rail systems to piping systems of dissimilar metals shall require plating of the connecting components to prevent interaction between dissimilar metals. " - NFPA 99, 1999, 4-3.1.2.5(f).

" Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over. " - NFPA 99, 1999: 4-3.1.1.1.

" Identification. (b) Shutoff Valves. Shutoff valves shall be identified as to the following. 3. The rooms or areas served. " - NFPA 99, 1999, 4-3.1.2.14.

Central supply systems for nitrous oxide and carbon dioxide shall be prevented from reaching temperatures lower than the recommendations of the central supply system ' s manufacturer, but shall never be lower than 20 degrees F or greater than 130 degrees F - NFPA 99, 2002, 5.1.3.3.1.8. (Note that this is not a design temperature such as a 97 ? percentile, but an absolute minimum temperature.)

Based on observation the facility failed to provide an adequate enclosure for the emergency generator.

The inspector observed, while accompanied by the Regional Director of Support Services, Facilities Lead Technician, and the System Life Safety Specialist during the hours of the inspection from 10:00 am to 4:30 pm on 2/26/2012 that there were the following issues. They were: 1) the room did not have a door with a closer and a latch (a rated fire door was present but was propped open), 2) the room did not have a complete 2 hour enclosure (cardboard was present over an old air intake that connected to an adjacent storage room), and 3) there was not a light with battery backup on the life safety branch.

" The emergency generator location shall have task illumination, battery charger for emergency battery powered lighting unit(s), and selected receptacles at the generator set location " - NFPA 99, 1999: 3-4.2.2.2.(b)5.

" The room shall have a minimum 2-hour fire rating or be located in an adequate enclosure located outside the building capable of resisting the entrance of snow or rain at a maximum wind velocity required by local codes. " - NFPA 110, 2002; 7.2.1.1.

Storage of Flammable Liquids

Established laboratory practices shall limit working supplies of flammable or combustible liquids. The total volume of Class I, II, and IIIA liquids outside of approved storage cabinets and safety cans shall not exceed 1 gal (3.78 L) per 100 ft2 (9.23 m2). The total volume of Class I, II, and IIIA liquids, including those contained in approved storage cabinets and safety cans, shall not exceed 2 gal (7.57 L) per 100 ft2 (9.23 m2). No flammable or combustible liquid shall be stored or transferred from one vessel to another in any exit corridor or passageway leading to an exit. At least one approved flammable or combustible liquid storage room shall be available within any health care facility regularly maintaining a reserve storage capacity in excess of 300 gal (1135.5 L). Quantities of flammable and combustible liquids for disposal shall be included in the total inventory. (NFPA 99, 1999, 10-7.2.2)

Based on observation the facility failed to limit the quantity of flammable liquids within a given area.

The inspector observed, while accompanied by the Regional Director of Support Services, Facilities Lead Technician, and the System Life Safety Specialist during the hours of the inspection from 10:00 am to 4:30 pm on 2/26/2012 that there were two, 1 gallon containers of alcohol stored in the Lab, 1.372.


Egress from Mechanical Basement

" Mechanical equipment rooms, boiler rooms, furnace rooms, and similar spaces shall be arranged to limit common path of travel to a distance not exceeding 50 ft. Exception No.(3): This requirement shall not apply to rooms or spaces in existing health care occupancies complying with the arrangement of means of egress provisions of 19.2.5 and the travel distance limits of 19.2.6. " - NFPA 101, 2000, 7.12.1. " The travel distance between any point in a room and an exit shall not exceed 150 ft. " - NFPA 101, 2000, 19.2.6.2.2. " Fire Escape Ladders. General. Fire escape ladders complying with 7.2.9.2 and 7.2.9.3 shall be permitted in the means of egress only where providing on of the following: (4) A secondary means of egress from boiler rooms or similar spaces subject to occupancy not to exceed three persons who are all capable of using the ladder. " - NFPA 101, 2000, 7.2.9. " Access. The lowest rung of any ladder shall not be more than 12 in. above the level of the surface beneath it. " - NFPA 101, 2000, 7.2.9.3.

Based on observation the facility failed to provide adequate exiting from the basement.

The inspector observed, while accompanied by the Regional Director of Support Services, Facilities Lead Technician, and the System Life Safety Specialist during the hours of the inspection from 10:00 am to 4:30 pm on 2/26/2012 that the basement had only one stair exiting the space. There were escape openings going down into the basement, however, the ladder for the openings did not go to the floor of the basement.


Receptacle Testing in Patient Care Areas - NFFA 99, 1999, 3-3.3.3

(a) The physical integrity of each receptacle shall be confirmed by visual inspection.
(b) The continuity of the grounding circuit in each electrical receptacle shall be verified.
(c) Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
(d) The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).

NFPA 99, 1999, 3-3.4.2.3(a) states that testing shall be performed after initial installation, replacement or servicing of a device, and that additional testing shall be performed at intervals defined by documented performance data. Since data is not typically available from the manufacturer, the facility may document the failure rates of the receptacles and provide a testing schedule that will safeguard their patients. This shall be done by the Safety Committee, approved by the Governing Board, and written into the safety policies and procedures. H.L.R. 2007, ?133.142. Until this assessment has been done, receptacle testing shall be performed in all general care areas every 12 months and in critical care areas every 6 months. (NFPA 99, 1984).

Based on observation the facility failed to provide a history of records for receptacle testing per NFPA 99: 3-3.3.3. in patient care areas.

The inspector observed, while accompanied by the Regional Director of Support Services, Facilities Lead Technician, and the System Life Safety Specialist during the hours of the inspection from 10:00 am to 4:30 pm on 2/26/2012 that there were no records of receptacle testing and the tests were not being performed.

Based on observation the facility failed to provide an adequate EES.

The inspector observed, while accompanied by the Regional Director of Support Services, Facilities Lead Technician, and the System Life Safety Specialist during the hours of the inspection from 10:00 am to 4:30 pm on 2/26/2012 that there were the following issues. They were: 1) the PACU room, 1.319, did not have hospital grade receptacles, 2) the receptacles in the critical areas, i.e., the PACU and the O.R.s were not labeled with the panel and breaker that supplies power to those outlets, and 3) the EES panels were not all labeled.

In critical care areas, emergency system receptacles must be labeled to indicate the panel board and circuit number supplying them in accordance with NFPA 70, 1999: 517-19(a). The identification label shall be permanent either by engraving the cover plates or permanent adhesive engraved laminated labels.

All receptacles, whether four or more, shall be listed " hospital grade " and so identified. Each receptacle shall be grounded by means of an insulted copper conductor sized in accordance the Table 250-122. NFPA 70, 1999, 517-18 (b).

Emergency panels shall be distinctively marked so that they are readily identifiable as a component of the essential electrical system - NFPA 70, 1999 700-9(a). They shall be labeled "LIFE SAFETY", "CRITICAL", or "EQUIPMENT" as applicable.

Based on observation the facility failed to provide an adequate elevator enclosure.

The inspector observed, while accompanied by the Regional Director of Support Services, Facilities Lead Technician, and the System Life Safety Specialist during the hours of the inspection from 10:00 am to 4:30 pm on 2/26/2012 that there were penetrations in the fire wall of the elevator shaft from inside the elevator equipment room. Also, the fire door to the stair in the basement did not latch correctly.

Based on observation the facility failed to provide adequate smoke barrier separations.

The inspector observed, while accompanied by the Regional Director of Support Services, Facilities Lead Technician, and the System Life Safety Specialist during the hours of the inspection from 10:00 am to 4:30 pm on 2/26/2012 that there were the following issues. There were penetrations in the smoke barriers above the following cross corridor locations: 1) outside of room 2.427, i.e. west corridor of PT area, 2) outside of room 1.232, main corridor from the lobby, and 3) outside of stair, 1.S03, southwest stair.

Based on observation the facility failed to provide adequate hazardous areas.

The inspector observed, while accompanied by the Regional Director of Support Services, Facilities Lead Technician, and the System Life Safety Specialist during the hours of the inspection from 10:00 am to 4:30 pm on 2/26/2012 that there were the following issues. They were: 1) the supply storage, 2.338, did not have a rated door, a closer, and the not all walls went to the deck, 2) the bath, 2.332, is an equipment storage that needs a closer and a rated door, 3) the Pharmacy Storage, 2.452, and Records, 2.454, were used as storage and open to one another above the ceiling both doors need closers, 4) Records, 2.268, need a closer, a 45 minute rated door, and the walls must go to the deck, 5) PT Storage, 2.429, needs walls to deck, closer, rated door and one of the doors was filled in but not with a 1 hour rated wall, 6) the Dry Storage Room, 1.164, needs a closer, 7) Materials Management, 1.135, requires a closer on the north door, 8) Credit and Collections, 1.143, is a part of Materials Management and needs a closer, 9) the Mail Room, 1.133, is a part of Materials Management and needs a closer, 10) the Old Meds Room, now Storage, 2.409, does not have a rated door and the walls do not go to deck, 11) the E.D. Par (Supply) Room, 1.232, did not have a rated door and frame, closer, and the walls did not go to deck, 12) the Soiled Utility in E.D., 1.221, did not have latching door, 13) the File Storage Area, 1.256, did not have rated doors and closers, 14) Sterile Storage, 1.314, did not have closers, 15) there was a penetration in the 1 hour wall above the ceiling in the Soiled Utility, 2.308, on the north wall.

Based on observation the facility failed to provide an adequate stair enclosure.

The inspector observed, while accompanied by the Regional Director of Support Services, Facilities Lead Technician, and the System Life Safety Specialist during the hours of the inspection from 10:00 am to 4:30 pm on 2/26/2012 that the fire door to the stair in the basement did not latch correctly.

Based on observation the facility failed to provide an adequate medical gas system.

The inspector observed, while accompanied by the Regional Director of Support Services, Facilities Lead Technician, and the System Life Safety Specialist during the hours of the inspection from 10:00 am to 4:30 pm on 2/26/2012 that there were the following issues. They were as follows.

A. The medical gas lines were not labeled in multiple locations. All lines must be checked throughout the facility. Specific locations observed were as follows: 1) on the east side of the 2 hour wall in corridor 2.301, 2) on the west side of the 2 hour wall in corridor 1.301, and 3) in the basement adjacent to the tunnel to the mechanical building.
B. There was dissimilar metal contact between the copper lines and the steel supports in multiple locations throughout the facility. All lines must be checked and isolated. Specific locations observed were as follows: 1) on the west side of the 2 hour wall in corridor 1.301, and 2) in the basement adjacent to the tunnel to the mechanical building.
C. The nitrous oxide lines were un-insulated in the exterior med gas yard.
D. The nitrous oxide bottles were not individually secured.
E. The medical gas alarm was not correctly labeled in the Stress Testing area.

Labeling Med Gas Piping: " The gas content of medical gas piping systems shall be readily identifiable by appropriate labeling with the name and pressure of the gas contained. Such labeling shall be by means of metal tags, stenciling, stamping, or adhesive markers, in a manner that is not readily removable. Labeling shall appear on the piping at intervals of not more than 20 ft and at least once in each room and each story traversed by the piping system. " - NFPA 99, 1999: 4-3.1.2.13.

" Connections of surface-mounted medical gas rail systems to piping systems of dissimilar metals shall require plating of the connecting components to prevent interaction between dissimilar metals. " - NFPA 99, 1999, 4-3.1.2.5(f).

" Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over. " - NFPA 99, 1999: 4-3.1.1.1.

" Identification. (b) Shutoff Valves. Shutoff valves shall be identified as to the following. 3. The rooms or areas served. " - NFPA 99, 1999, 4-3.1.2.14.

Central supply systems for nitrous oxide and carbon dioxide shall be prevented from reaching temperatures lower than the recommendations of the central supply system ' s manufacturer, but shall never be lower than 20 degrees F or greater than 130 degrees F - NFPA 99, 2002, 5.1.3.3.1.8. (Note that this is not a design temperature such as a 97 ? percentile, but an absolute minimum temperature.)

Based on observation the facility failed to provide an adequate enclosure for the emergency generator.

The inspector observed, while accompanied by the Regional Director of Support Services, Facilities Lead Technician, and the System Life Safety Specialist during the hours of the inspection from 10:00 am to 4:30 pm on 2/26/2012 that there were the following issues. They were: 1) the room did not have a door with a closer and a latch (a rated fire door was present but was propped open), 2) the room did not have a complete 2 hour enclosure (cardboard was present over an old air intake that connected to an adjacent storage room), and 3) there was not a light with battery backup on the life safety branch.

" The emergency generator location shall have task illumination, battery charger for emergency battery powered lighting unit(s), and selected receptacles at the generator set location " - NFPA 99, 1999: 3-4.2.2.2.(b)5.

" The room shall have a minimum 2-hour fire rating or be located in an adequate enclosure located outside the building capable of resisting the entrance of snow or rain at a maximum wind velocity required by local codes. " - NFPA 110, 2002; 7.2.1.1.

Storage of Flammable Liquids

Established laboratory practices shall limit working supplies of flammable or combustible liquids. The total volume of Class I, II, and IIIA liquids outside of approved storage cabinets and safety cans shall not exceed 1 gal (3.78 L) per 100 ft2 (9.23 m2). The total volume of Class I, II, and IIIA liquids, including those contained in approved storage cabinets and safety cans, shall not exceed 2 gal (7.57 L) per 100 ft2 (9.23 m2). No flammable or combustible liquid shall be stored or transferred from one vessel to another in any exit corridor or passageway leading to an exit. At least one approved flammable or combustible liquid storage room shall be available within any health care facility regularly maintaining a reserve storage capacity in excess of 300 gal (1135.5 L). Quantities of flammable and combustible liquids for disposal shall be included in the total inventory. (NFPA 99, 1999, 10-7.2.2)

Based on observation the facility failed to limit the quantity of flammable liquids within a given area.

The inspector observed, while accompanied by the Regional Director of Support Services, Facilities Lead Technician, and the System Life Safety Specialist during the hours of the inspection from 10:00 am to 4:30 pm on 2/26/2012 that there were two, 1 gallon containers of alcohol stored in the Lab, 1.372.


Egress from Mechanical Basement

" Mechanical equipment rooms, boiler rooms, furnace rooms, and similar spaces shall be arranged to limit common path of travel to a distance not exceeding 50 ft. Exception No.(3): This requirement shall not apply to rooms or spaces in existing health care occupancies complying with the arrangement of means of egress provisions of 19.2.5 and the travel distance limits of 19.2.6. " - NFPA 101, 2000, 7.12.1. " The travel distance between any point in a room and an exit shall not exceed 150 ft. " - NFPA 101, 2000, 19.2.6.2.2. " Fire Escape Ladders. General. Fire escape ladders complying with 7.2.9.2 and 7.2.9.3 shall be permitted in the means of egress only where providing on of the following: (4) A secondary means of egress from boiler rooms or similar spaces subject to occupancy not to exceed three persons who are all capable of using the ladder. " - NFPA 101, 2000, 7.2.9. " Access. The lowest rung of any ladder shall not be more than 12 in. above the level of the surface beneath it. " - NFPA 101, 2000, 7.2.9.3.

Based on observation the facility failed to provide adequate exiting from the basement.

The inspector observed, while accompanied by the Regional Director of Support Services, Facilities Lead Technician, and the System Life Safety Specialist during the hours of the inspection from 10:00 am to 4:30 pm on 2/26/2012 that the basement had only one stair exiting the space. There were escape openings going down into the basement, however, the ladder for the openings did not go to the floor of the basement.


Receptacle Testing in Patient Care Areas - NFFA 99, 1999, 3-3.3.3

(a) The physical integrity of each receptacle shall be confirmed by visual inspection.
(b) The continuity of the grounding circuit in each electrical receptacle shall be verified.
(c) Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
(d) The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).

NFPA 99, 1999, 3-3.4.2.3(a) states that testing shall be performed after initial installation, replacement or servicing of a device, and that additional testing shall be performed at intervals defined by documented performance data. Since data is not typically available from the manufacturer, the facility may document the failure rates of the receptacles and provide a testing schedule that will safeguard their patients. This shall be done by the Safety Committee, approved by the Governing Board, and written into the safety policies and procedures. H.L.R. 2007, ?133.142. Until this assessment has been done, receptacle testing shall be performed in all general care areas every 12 months and in critical care areas every 6 months. (NFPA 99, 1984).

Based on observation the facility failed to provide a history of records for receptacle testing per NFPA 99: 3-3.3.3. in patient care areas.

The inspector observed, while accompanied by the Regional Director of Support Services, Facilities Lead Technician, and the System Life Safety Specialist during the hours of the inspection from 10:00 am to 4:30 pm on 2/26/2012 that there were no records of receptacle testing and the tests were not being performed.

Based on observation the facility failed to provide an adequate EES.

The inspector observed, while accompanied by the Regional Director of Support Services, Facilities Lead Technician, and the System Life Safety Specialist during the hours of the inspection from 10:00 am to 4:30 pm on 2/26/2012 that there were the following issues. They were: 1) the PACU room, 1.319, did not have hospital grade receptacles, 2) the receptacles in the critical areas, i.e., the PACU and the O.R.s were not labeled with the panel and breaker that supplies power to those outlets, and 3) the EES panels were not all labeled.

In critical care areas, emergency system receptacles must be labeled to indicate the panel board and circuit number supplying them in accordance with NFPA 70, 1999: 517-19(a). The identification label shall be permanent either by engraving the cover plates or permanent adhesive engraved laminated labels.

All receptacles, whether four or more, shall be listed " hospital grade " and so identified. Each receptacle shall be grounded by means of an insulted copper conductor sized in accordance the Table 250-122. NFPA 70, 1999, 517-18 (b).

Emergency panels shall be distinctively marked so that they are readily identifiable as a component of the essential electrical system - NFPA 70, 1999 700-9(a). They shall be labeled "LIFE SAFETY", "CRITICAL", or "EQUIPMENT" as applicable.