HospitalInspections.org

Based on observation the facility failed to provide adequate smoke barriers.

The inspector observed, while accompanied by the Director of human resource, laboratory manager, Bio med manager, imaging service director, and registered nurse during the hours of the inspection from 2:00 pm to 5:30 pm on 6/13/2013 that there were penetrations not sealed in the fire rated partitions at the following locations: 1) The Med Gas room. 2) The Electrical room L103. 3) The Mechanical Room. 4) The cross corridor door at ER suite by room L107. 5) The cross corridor door by staff lounge L213A. 6) The cross corridor door by Room M336. 7) The cross corridor door by room M237.

There were doors or frame fire rated labels missing at the following locations: 1) Electrical Room L132.

Based on observation the facility failed to provide a complete sprinkler system.

The inspector observed, while accompanied by the Director of human resource, laboratory manager, Bio med manager, imaging service director, and registered nurse during the hours of the inspection from 2:00 pm to 5:30 pm on 6/13/2013 that there were the following issues.

A.) There were sprinkler heads at the following location that were less than 4 inches from the wall: 1) ER manager room L103.


Sprinklers shall be located a minimum of 4 in. (102 mm) from a wall. - NFPA 13, 1999, 5-6.3.3.

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

The inspector observed, while accompanied by the Director of human resource, laboratory manager, Bio med manager, imaging service director, and registered nurse during the hours of the inspection from 2:00 pm to 5:30 pm on 6/13/2013 that there was the following issues.

A.) It was that there was incorrect signage at the nitrous closet door.

CAUTION
Medical Gases
NO Smoking or Open Flame
Room may have Insufficient Oxygen
Open Door and Allow Room to Ventilate before Entering

See NFPA 99, 2002: 5.1.3.1.5.

B.) Based on observation the facility failed to provide individual chains for the medical gases bottles. This does not comply with the following NFPA code. " 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.

Based on observation the facility failed to provide adequate receptacles.

The inspector observed, while accompanied by the Director of human resource, laboratory manager, Bio med manager, imaging service director, and registered nurse during the hours of the inspection from 2:00 pm to 5:30 pm on 6/13/2013 that there was the following issue: (1). There was a missing battery powered lighting units at the essential automatic transfer switch at the electrical room. (2). There was a missing battery powered lighting units and a missing receptacle powered from life safety branch at the essential automatic transfer switch at the generator location. (3). FACP breaker was not provided in red breaker and labeled in red signage permanently.

" 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 and essential automatic transfer switch location " - NFPA 99, 1999: 3-4.2.2.2.(b)5.

" NFPA 72, 2002: 4.4.1.4.2.2 -The electrical connection between the panel/breaker and the FACP must be cross referenced correctly. " The circuit breaker at the electrical panel board for the fire alarm shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as "FIRE ALARM CIRCUIT CONTROL" " - NFPA 72, 2002: 4.4.1.4.2.2. " The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit. " - NFPA 72, 2002: 4.4.1.4.2.3 "

Based on observation the facility failed to provide adequate smoke barriers.

The inspector observed, while accompanied by the Director of human resource, laboratory manager, Bio med manager, imaging service director, and registered nurse during the hours of the inspection from 2:00 pm to 5:30 pm on 6/13/2013 that there were penetrations not sealed in the fire rated partitions at the following locations: 1) The Med Gas room. 2) The Electrical room L103. 3) The Mechanical Room. 4) The cross corridor door at ER suite by room L107. 5) The cross corridor door by staff lounge L213A. 6) The cross corridor door by Room M336. 7) The cross corridor door by room M237.

There were doors or frame fire rated labels missing at the following locations: 1) Electrical Room L132.

Based on observation the facility failed to provide a complete sprinkler system.

The inspector observed, while accompanied by the Director of human resource, laboratory manager, Bio med manager, imaging service director, and registered nurse during the hours of the inspection from 2:00 pm to 5:30 pm on 6/13/2013 that there were the following issues.

A.) There were sprinkler heads at the following location that were less than 4 inches from the wall: 1) ER manager room L103.


Sprinklers shall be located a minimum of 4 in. (102 mm) from a wall. - NFPA 13, 1999, 5-6.3.3.

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

The inspector observed, while accompanied by the Director of human resource, laboratory manager, Bio med manager, imaging service director, and registered nurse during the hours of the inspection from 2:00 pm to 5:30 pm on 6/13/2013 that there was the following issues.

A.) It was that there was incorrect signage at the nitrous closet door.

CAUTION
Medical Gases
NO Smoking or Open Flame
Room may have Insufficient Oxygen
Open Door and Allow Room to Ventilate before Entering

See NFPA 99, 2002: 5.1.3.1.5.

B.) Based on observation the facility failed to provide individual chains for the medical gases bottles. This does not comply with the following NFPA code. " 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.

Based on observation the facility failed to provide adequate receptacles.

The inspector observed, while accompanied by the Director of human resource, laboratory manager, Bio med manager, imaging service director, and registered nurse during the hours of the inspection from 2:00 pm to 5:30 pm on 6/13/2013 that there was the following issue: (1). There was a missing battery powered lighting units at the essential automatic transfer switch at the electrical room. (2). There was a missing battery powered lighting units and a missing receptacle powered from life safety branch at the essential automatic transfer switch at the generator location. (3). FACP breaker was not provided in red breaker and labeled in red signage permanently.

" 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 and essential automatic transfer switch location " - NFPA 99, 1999: 3-4.2.2.2.(b)5.

" NFPA 72, 2002: 4.4.1.4.2.2 -The electrical connection between the panel/breaker and the FACP must be cross referenced correctly. " The circuit breaker at the electrical panel board for the fire alarm shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as "FIRE ALARM CIRCUIT CONTROL" " - NFPA 72, 2002: 4.4.1.4.2.2. " The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit. " - NFPA 72, 2002: 4.4.1.4.2.3 "