HospitalInspections.org

Based on observations and confirmed by staff, patient treatment areas are not separated as required.

THE FINDINGS INCLUDE:

- During the morning hours of 5/26/10 while touring the Radiology area, it was observed that treatment areas are open to the corridor. A total of eight (8) patients are capable of receiving treatment in these areas as combination oxygen/vacuum outlets are provided. The following locations were noted as being open to the corridor:

1) Outside of the Special Procedures Room
2) Outside the Fluoro Room
3) Outside the General Holding across from the Radiology.

These were each acknowledged by the Director of Facilities during the tour.

Based on observations and confirmed by staff, the facility failed to assure that maximum travel distances to exit egress locations are not exceeded. Section 19.2.6.2.1 states the travel distance between any room door required as an exit access and an exit shall not exceed 100 ft (30 m).
Exception: The maximum travel distance shall be permitted to be increased by 50 ft (15 m) in buildings protected throughout by an approved, supervised automatic sprinkler system.
Section 19.2.6.2.2 states the travel distance between any point in a room and an exit shall not exceed 150 ft (45 m).
Exception: The maximum travel distance shall be permitted to be increased by 50 ft (15 m) in buildings protected throughout by an approved, supervised automatic sprinkler system.

THE FINDINGS INCLUDE:

- During the morning of May 25, 2010 while touring the facility, it was noted that the travel distances on both the 2nd & 3rd floors are excessive. Upon measuring the actual distances with a measuring wheel, the following locations were noted as being deficient:

1) Third Floor: The travel distance between the horizontal exit door and stair #5 is 358'. There are numerous patient rooms located within section 3-6 which have distances exceeding 200' from the room door to the exit door.

2) Second Floor: The travel distance between the horizontal exit door and stair #5 is 401'. There are numerous patient rooms located within section 2-3 which have distances exceeding 200' from the room door to the exit door.

These were each acknowledged by the Director of Facilities.

NOTE: These items meet the FSES and do not require correction.

Based on observations and confirmed by staff, the facility failed to assure fire drills are conducted as required.

Vernon Hill Building

THE FINDINGS INCLUDE:

- During the morning hours of 5/25 & 26/10 while performing the record review process, it was noted that the fire drills are not conducted at varied time intervals as required. The fire drills for the 1st, 2nd & 3rd shifts are documented as occurring at the following times:

First Shift (7:00AM-3:00PM): 3/24/10 @ 10:00AM; 12/30/09 @ 2:30PM; 09/24/09 @ 02:59; 6/11/09 @ 7:30AM.

Second Shift (3:00PM -11:00PM): 4/27/10 @ 4:00PM; 1/28/10 @ 4:00PM; 10/29/09 @ 3:30PM; 7/30/09 @ 4:30PM and 4/9/09 @ 4:30PM.

Third Shift (11:00PM-7:00AM): 5/25/10 @ 6:00AM; 2/23/10 @ 6:00AM; 11/20/09 @ 6:00AM: 8/27/09 @ 6:00AM and 5/26/09 @ 6:00AM.

The following deficiencies were noted:

1) Of the four (4) documented fire drills during the 1st shift, two (2) were held between the hours of 2:33PM and 2:59PM. The entire 8-hour shift period is not utilized to perform the fire drills.

2) Of the five (5) documented fire drills during the 2nd shift, all of them were held between the hours of 3:30PM and 4:30PM. The entire 8-hour shift period is not utilized to perform the fire drills.

3) Of the five (5) documented fire drills during the 3rd shift, all of them were held at 6:00AM. The entire 8-hour shift period is not utilized to perform the fire drills.

These were acknowledged by the Director of Facilities.

Based on observations and confirmed by staff, the facility failed to assure fire drills are conducted as required.

THE FINDINGS INCLUDE:

- During the morning hours of 5/25 & 26/10 while performing the record review process, it was noted that the fire drills are not conducted at varied time intervals as required. The fire drills for the 1st, 2nd & 3rd shifts are documented as occurring at the following times:

First Shift (7:00AM-3:00PM): 5/19/10 @ 10:00AM; 2/12/10 @ 10:30AM; 11/19/09 @ 10:35; 10/6/09 @ 2:00PM; 8/12/09 @ 1:30PM; 6/11/09 @ 9:50AM; 6/10/09 @ 2:47PM.

Second Shift (3:00PM -11:00PM): 3/18/10 @ 8:00PM; 12/16/09 @ 8:00PM; 9/17/09 @ 8:00PM; 7/7/09 @ 6:40PM and 6/9/09 @ 8:00PM.

Third Shift (11:00PM-7:00AM): 4/23/10 @ 6:00AM; 1/12/10 @ 6:00AM; 10/14/09 @ 6:00AM: 7/27/09 @ 2:26AM and 7/16/09 @ 6:00AM.

The following deficiencies were noted:

1) Of the seven (7) documented fire drills during the 1st shift, 4 were held between the hours of 9:50AM and 10:35AM. The entire 8-hour shift period is not utilized to perform the fire drills.

2) Of the five (5) documented fire drills during the 2nd shift, four were held at 8:00PM. The entire 8-hour shift period is not utilized to perform the fire drills.

3) Of the five (5) documented fire drills during the 3rd shift, four were held at 6:00AM. The entire 8-hour shift period is not utilized to perform the fire drills.

These were acknowledged by the Director of Facilities.

The facility failed to assure compliance with NFPA #72 (National Fire Alarm Code). Section 7.1.2 states the owner or the owner's designated representative shall be responsible for inspection, testing, and maintenance of the system and alterations or additions to this system. The delegation of responsibility shall be in writing, with a copy of such delegation provided to the authority having jurisdiction upon request.
Section 7.3.2 and Table 7.3.2 require systems with sealed batteries to have the battery charger tested annually, replace the battery every 4 years, to conduct a 30 minute battery discharge test annually, and to conduct a load voltage test semi-annually.

THE FINDINGS INCLUDE:

Vernon Hill Building

- Based on record review the fire alarm system has not been inspected/tested since May 21, 2009. As a result of no inspection, there is no record of a 30 minute discharge test or a load voltage test of the fire alarm control panel back-up batteries.

These were acknowledged by the Director of Facilities.

Based on record review and confirmed by staff interview, the facility failed to assure that the smoke detectors are maintained and tested as required. NFPA #72, Section 7.3.2.1 requires smoke detector sensitivity to be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years.

THE FINDINGS INCLUDE:

Vernon Hill Building

- The facility had no records substantiating that smoke detector sensitivity is checked. This was confirmed by the Director of Engineering.

These were acknowledged by the Director of Facilities.

Based on observations and confirmed by staff, it was noted that smoke detectors are not installed properly. NFPA 72, section 2-3.5.1 states smoke detectors shall not located in a direct airflow nor closer than three feet (3') from an air supply diffuser or return air opening.

THE FINDINGS INCLUDE:

While touring the Hospital on 5/25/10 and 5/26/10 it was noted that numerous smoke detectors were located within three (3') feet of air supply diffusers. This was noted throughout the entire hospital, including patient bedrooms, corridors, common spaces and all habitable spaces.

These were each acknowledged by the Director of Facilities.

Based on observations and confirmed by staff, the facility failed to assure that all sprinkler valves are protected and maintained as required.

THE FINDINGS INCLUDE:

Vernon Hill Building

- The two (2) Post Indicator Valves (P.I.V.) located on the supply side of the automatic sprinkler system are not electrically supervised to the fire alarm system.
Note: The two valves are currently locked in the open position.

These were acknowledged by the Director of Facilities.

Based on observations and confirmed by staff, the facility failed to assure that sprinkler systems are maintained as required. NFPA #13, Sections 4.7.7 requires a listed pressure gauge to be installed immediately below the control valve of each system.

THE FINDINGS INCLUDE:

Vernon Hill Building

- The Vernon Hill Building has two (2) main sprinkler supplies which feed the main fire control valve. Each of these main feeds has a backflow preventer which is not equipped with the proper pressure gauge prior to the valve.

These were acknowledged by the Director of Facilities.


.

Based on observations and confirmed by staff, the facility failed to assure that sprinkler systems are maintained as required. NFPA #13, Sections 4.7.7 requires a listed pressure gauge to be installed immediately below the control valve of each system.

THE FINDINGS INCLUDE:

- The Hospital has two (2) main sprinkler supplies which feed the main fire control valve. Each of these main feeds has a backflow preventer which is not equipped with the proper pressure gauge prior to the valve.

These were acknowledged by the Director of Facilities.


.

Based on observations and confirmed by staff, the facility failed to assure that sprinkler systems are maintained as required. NFPA #13, section 2.2.4.1 states that gauges on wet pipe sprinkler systems shall be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained, and section 2.2.4.2 states that gauges on dry, preaction, and deluge systems shall be inspected weekly to ensure that normal air and water pressures are being maintained.

THE FINDINGS INCLUDE:

-During the morning hours of 5/25 & 26/10 while performing the record review process, it was noted the Hospital did not inspect or record the sprinkler pressure for all of there wet and dry sprinkler systems.

These were acknowledged by the Director of Facilities.

Based on observations and confirmed by staff, the facility failed to assure compliance with NFPA #90A. Section 3.3.1.1 states that approved fire dampers shall be provided where air ducts penetrate or terminate at openings in walls or partitions required to have a fire resistance rating of 2 hours or more. Section 2.3.4.1 states service opening shall be provided in air ducts adjacent to each fire damper, smoke damper, and smoke detector. The opening shall be large enough to permit maintenance and resetting of the device. Section 2.3.4.2 states service openings shall be identified with letters having a minimum height of 1/2 in. to indicate the location of the fire protection device(s) within.

THE FINDINGS INCLUDE:

- While inspecting the two hour fire rated walls on 5/25/10, 5/26/10, and 5/27/10, which separate the Hospital occupancy from the business occupancy, it was noted that not all air handling ducts penetrating the the fire wall are equipped with the required fire dampers. Air handling ducts with out the required fire dampers were found in following but not limited to locations:
1) 2nd floor GI suite above the fire barrier door has a two foot by two foot air handling duct penetrating the 2 hour fire rated wall without the required fire damper.
2) Labor and Delivery area 1-3 has numerous air handling ducts that penetrating the 2 hour fire rated wall, and do not have the required fire dampers.

Note: In addition, the report conducted by an independent HVAC company did not indicate that the ducts listed above were equipped with the proper fire dampers.

These were acknowledged by the Director of Facilities.

Based on observations and confirmed by staff, the hospital failed to assure that mobile soiled linen carts are stored properly within enclosed rooms.

THE FINDINGS INCLUDE:

- During the morning hours of 5/26/10 while touring the 2nd floor and 3rd floor Operating Room suites, two soiled linen carts, one located on each floor, were noted as being stored in the corridor. The carts are three feet in width, four feet in length and three feet in height (3' x 4' x 3') in size. This was acknowledged at the time by the Director of Facilities. It was stated that the cart is stored in this location and used to pick up trash after OR procedures are done.

These were acknowledged by the Director of Facilities.

Based on record review and confirmed by staff, the facility failed to assure generators are maintained & tested as required. NFPA 110, section 6.4.1 states level 1 and level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.

THE FINDINGS INCLUDE:

Vernon Hill Building

- During the morning hours of 5/25 & 26/10 while performing the record review process, it was noted the facility did not inspect the emergency generators weekly. There records show that the inspections was Bi-weekly.

These were acknowledged by the Director of Facilities.

Based on record review and confirmed by staff, the facility failed to assure generators are maintained & tested as required. NFPA 110, section 6.4.1 states level 1 and level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.

THE FINDINGS INCLUDE:

- During the morning hours of 5/25 & 26/10 while performing the record review process, it was noted the Hospital did not inspect the emergency generators weekly. There records show that the inspections was Bi-weekly.

These were acknowledged by the Director of Facilities.

Based on observations and confirmed by staff, patient treatment areas are not separated as required.

THE FINDINGS INCLUDE:

- During the morning hours of 5/26/10 while touring the Radiology area, it was observed that treatment areas are open to the corridor. A total of eight (8) patients are capable of receiving treatment in these areas as combination oxygen/vacuum outlets are provided. The following locations were noted as being open to the corridor:

1) Outside of the Special Procedures Room
2) Outside the Fluoro Room
3) Outside the General Holding across from the Radiology.

These were each acknowledged by the Director of Facilities during the tour.

Based on observations and confirmed by staff, the facility failed to assure that maximum travel distances to exit egress locations are not exceeded. Section 19.2.6.2.1 states the travel distance between any room door required as an exit access and an exit shall not exceed 100 ft (30 m).
Exception: The maximum travel distance shall be permitted to be increased by 50 ft (15 m) in buildings protected throughout by an approved, supervised automatic sprinkler system.
Section 19.2.6.2.2 states the travel distance between any point in a room and an exit shall not exceed 150 ft (45 m).
Exception: The maximum travel distance shall be permitted to be increased by 50 ft (15 m) in buildings protected throughout by an approved, supervised automatic sprinkler system.

THE FINDINGS INCLUDE:

- During the morning of May 25, 2010 while touring the facility, it was noted that the travel distances on both the 2nd & 3rd floors are excessive. Upon measuring the actual distances with a measuring wheel, the following locations were noted as being deficient:

1) Third Floor: The travel distance between the horizontal exit door and stair #5 is 358'. There are numerous patient rooms located within section 3-6 which have distances exceeding 200' from the room door to the exit door.

2) Second Floor: The travel distance between the horizontal exit door and stair #5 is 401'. There are numerous patient rooms located within section 2-3 which have distances exceeding 200' from the room door to the exit door.

These were each acknowledged by the Director of Facilities.

NOTE: These items meet the FSES and do not require correction.

Based on observations and confirmed by staff, the facility failed to assure fire drills are conducted as required.

Vernon Hill Building

THE FINDINGS INCLUDE:

- During the morning hours of 5/25 & 26/10 while performing the record review process, it was noted that the fire drills are not conducted at varied time intervals as required. The fire drills for the 1st, 2nd & 3rd shifts are documented as occurring at the following times:

First Shift (7:00AM-3:00PM): 3/24/10 @ 10:00AM; 12/30/09 @ 2:30PM; 09/24/09 @ 02:59; 6/11/09 @ 7:30AM.

Second Shift (3:00PM -11:00PM): 4/27/10 @ 4:00PM; 1/28/10 @ 4:00PM; 10/29/09 @ 3:30PM; 7/30/09 @ 4:30PM and 4/9/09 @ 4:30PM.

Third Shift (11:00PM-7:00AM): 5/25/10 @ 6:00AM; 2/23/10 @ 6:00AM; 11/20/09 @ 6:00AM: 8/27/09 @ 6:00AM and 5/26/09 @ 6:00AM.

The following deficiencies were noted:

1) Of the four (4) documented fire drills during the 1st shift, two (2) were held between the hours of 2:33PM and 2:59PM. The entire 8-hour shift period is not utilized to perform the fire drills.

2) Of the five (5) documented fire drills during the 2nd shift, all of them were held between the hours of 3:30PM and 4:30PM. The entire 8-hour shift period is not utilized to perform the fire drills.

3) Of the five (5) documented fire drills during the 3rd shift, all of them were held at 6:00AM. The entire 8-hour shift period is not utilized to perform the fire drills.

These were acknowledged by the Director of Facilities.

Based on observations and confirmed by staff, the facility failed to assure fire drills are conducted as required.

THE FINDINGS INCLUDE:

- During the morning hours of 5/25 & 26/10 while performing the record review process, it was noted that the fire drills are not conducted at varied time intervals as required. The fire drills for the 1st, 2nd & 3rd shifts are documented as occurring at the following times:

First Shift (7:00AM-3:00PM): 5/19/10 @ 10:00AM; 2/12/10 @ 10:30AM; 11/19/09 @ 10:35; 10/6/09 @ 2:00PM; 8/12/09 @ 1:30PM; 6/11/09 @ 9:50AM; 6/10/09 @ 2:47PM.

Second Shift (3:00PM -11:00PM): 3/18/10 @ 8:00PM; 12/16/09 @ 8:00PM; 9/17/09 @ 8:00PM; 7/7/09 @ 6:40PM and 6/9/09 @ 8:00PM.

Third Shift (11:00PM-7:00AM): 4/23/10 @ 6:00AM; 1/12/10 @ 6:00AM; 10/14/09 @ 6:00AM: 7/27/09 @ 2:26AM and 7/16/09 @ 6:00AM.

The following deficiencies were noted:

1) Of the seven (7) documented fire drills during the 1st shift, 4 were held between the hours of 9:50AM and 10:35AM. The entire 8-hour shift period is not utilized to perform the fire drills.

2) Of the five (5) documented fire drills during the 2nd shift, four were held at 8:00PM. The entire 8-hour shift period is not utilized to perform the fire drills.

3) Of the five (5) documented fire drills during the 3rd shift, four were held at 6:00AM. The entire 8-hour shift period is not utilized to perform the fire drills.

These were acknowledged by the Director of Facilities.

The facility failed to assure compliance with NFPA #72 (National Fire Alarm Code). Section 7.1.2 states the owner or the owner's designated representative shall be responsible for inspection, testing, and maintenance of the system and alterations or additions to this system. The delegation of responsibility shall be in writing, with a copy of such delegation provided to the authority having jurisdiction upon request.
Section 7.3.2 and Table 7.3.2 require systems with sealed batteries to have the battery charger tested annually, replace the battery every 4 years, to conduct a 30 minute battery discharge test annually, and to conduct a load voltage test semi-annually.

THE FINDINGS INCLUDE:

Vernon Hill Building

- Based on record review the fire alarm system has not been inspected/tested since May 21, 2009. As a result of no inspection, there is no record of a 30 minute discharge test or a load voltage test of the fire alarm control panel back-up batteries.

These were acknowledged by the Director of Facilities.

Based on record review and confirmed by staff interview, the facility failed to assure that the smoke detectors are maintained and tested as required. NFPA #72, Section 7.3.2.1 requires smoke detector sensitivity to be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years.

THE FINDINGS INCLUDE:

Vernon Hill Building

- The facility had no records substantiating that smoke detector sensitivity is checked. This was confirmed by the Director of Engineering.

These were acknowledged by the Director of Facilities.

Based on observations and confirmed by staff, it was noted that smoke detectors are not installed properly. NFPA 72, section 2-3.5.1 states smoke detectors shall not located in a direct airflow nor closer than three feet (3') from an air supply diffuser or return air opening.

THE FINDINGS INCLUDE:

While touring the Hospital on 5/25/10 and 5/26/10 it was noted that numerous smoke detectors were located within three (3') feet of air supply diffusers. This was noted throughout the entire hospital, including patient bedrooms, corridors, common spaces and all habitable spaces.

These were each acknowledged by the Director of Facilities.

Based on observations and confirmed by staff, the facility failed to assure that all sprinkler valves are protected and maintained as required.

THE FINDINGS INCLUDE:

Vernon Hill Building

- The two (2) Post Indicator Valves (P.I.V.) located on the supply side of the automatic sprinkler system are not electrically supervised to the fire alarm system.
Note: The two valves are currently locked in the open position.

These were acknowledged by the Director of Facilities.

Based on observations and confirmed by staff, the facility failed to assure that sprinkler systems are maintained as required. NFPA #13, Sections 4.7.7 requires a listed pressure gauge to be installed immediately below the control valve of each system.

THE FINDINGS INCLUDE:

Vernon Hill Building

- The Vernon Hill Building has two (2) main sprinkler supplies which feed the main fire control valve. Each of these main feeds has a backflow preventer which is not equipped with the proper pressure gauge prior to the valve.

These were acknowledged by the Director of Facilities.


.

Based on observations and confirmed by staff, the facility failed to assure that sprinkler systems are maintained as required. NFPA #13, Sections 4.7.7 requires a listed pressure gauge to be installed immediately below the control valve of each system.

THE FINDINGS INCLUDE:

- The Hospital has two (2) main sprinkler supplies which feed the main fire control valve. Each of these main feeds has a backflow preventer which is not equipped with the proper pressure gauge prior to the valve.

These were acknowledged by the Director of Facilities.


.

Based on observations and confirmed by staff, the facility failed to assure that sprinkler systems are maintained as required. NFPA #13, section 2.2.4.1 states that gauges on wet pipe sprinkler systems shall be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained, and section 2.2.4.2 states that gauges on dry, preaction, and deluge systems shall be inspected weekly to ensure that normal air and water pressures are being maintained.

THE FINDINGS INCLUDE:

-During the morning hours of 5/25 & 26/10 while performing the record review process, it was noted the Hospital did not inspect or record the sprinkler pressure for all of there wet and dry sprinkler systems.

These were acknowledged by the Director of Facilities.

Based on observations and confirmed by staff, the facility failed to assure compliance with NFPA #90A. Section 3.3.1.1 states that approved fire dampers shall be provided where air ducts penetrate or terminate at openings in walls or partitions required to have a fire resistance rating of 2 hours or more. Section 2.3.4.1 states service opening shall be provided in air ducts adjacent to each fire damper, smoke damper, and smoke detector. The opening shall be large enough to permit maintenance and resetting of the device. Section 2.3.4.2 states service openings shall be identified with letters having a minimum height of 1/2 in. to indicate the location of the fire protection device(s) within.

THE FINDINGS INCLUDE:

- While inspecting the two hour fire rated walls on 5/25/10, 5/26/10, and 5/27/10, which separate the Hospital occupancy from the business occupancy, it was noted that not all air handling ducts penetrating the the fire wall are equipped with the required fire dampers. Air handling ducts with out the required fire dampers were found in following but not limited to locations:
1) 2nd floor GI suite above the fire barrier door has a two foot by two foot air handling duct penetrating the 2 hour fire rated wall without the required fire damper.
2) Labor and Delivery area 1-3 has numerous air handling ducts that penetrating the 2 hour fire rated wall, and do not have the required fire dampers.

Note: In addition, the report conducted by an independent HVAC company did not indicate that the ducts listed above were equipped with the proper fire dampers.

These were acknowledged by the Director of Facilities.

Based on observations and confirmed by staff, the hospital failed to assure that mobile soiled linen carts are stored properly within enclosed rooms.

THE FINDINGS INCLUDE:

- During the morning hours of 5/26/10 while touring the 2nd floor and 3rd floor Operating Room suites, two soiled linen carts, one located on each floor, were noted as being stored in the corridor. The carts are three feet in width, four feet in length and three feet in height (3' x 4' x 3') in size. This was acknowledged at the time by the Director of Facilities. It was stated that the cart is stored in this location and used to pick up trash after OR procedures are done.

These were acknowledged by the Director of Facilities.

Based on record review and confirmed by staff, the facility failed to assure generators are maintained & tested as required. NFPA 110, section 6.4.1 states level 1 and level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.

THE FINDINGS INCLUDE:

Vernon Hill Building

- During the morning hours of 5/25 & 26/10 while performing the record review process, it was noted the facility did not inspect the emergency generators weekly. There records show that the inspections was Bi-weekly.

These were acknowledged by the Director of Facilities.

Based on record review and confirmed by staff, the facility failed to assure generators are maintained & tested as required. NFPA 110, section 6.4.1 states level 1 and level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.

THE FINDINGS INCLUDE:

- During the morning hours of 5/25 & 26/10 while performing the record review process, it was noted the Hospital did not inspect the emergency generators weekly. There records show that the inspections was Bi-weekly.

These were acknowledged by the Director of Facilities.