HospitalInspections.org

Based on observation, it was determined the facility failed to maintain the ability of the doors in vertical openings to be self-closing in two of six areas observed. Failure to maintain the ability for the doors to fully self-close had the potential to affect the health and safety of patients, visitors, and staff because the doors' inability to fully close would allow the passage of fire and smoke into or through the vertical opening. The facility had a census of 16 on 10/19/2015. Findings follow:

A. On a tour of the facility with the Director of Plant Operations on 10/21/15 at 1300, the following observations were made and verified:
1) One of the two fire-rated doors in the entrance to the east stairwell on the ground floor was unable to fully close on its own.
2) One of the two fire-rated doors in the entrance to the east stairwell on the second floor was unable to fully close on its own.
B. The Director of Plant Operations verified the doors were unable to fully self-close.

Based on observation, it was determined the facility failed to maintain the smoke and fire resistance rating for 5 of 22 smoke barriers and fire barriers inspected. Failure to properly seal penetrations of the fire and smoke barrier walls had the potential to affect the health and safety of patients, visitors, and staff because a compromised fire or smoke barrier cannot prevent the passage of fire and smoke from one side of the barrier to the other. The facility had a census of 16 on 10/19/2015. Findings follow:

A. On a tour of the facility with the Director of Plant Operations on 10/21/15 at 0945 and on 10/21/15 at 1300, the following observations were made and verified:
1) In the 2-hour fire rated wall separating the chiller/boiler and vacuum rooms 1900 and 1908, two penetrations of the barrier were not sealed with a fire rated material.
2) In the 1-hour fire rated wall on the east side of the Medical Gas Manifold room 1910, one penetration of the barrier wall was not sealed with a fire rated material.
3) In the 2-hour rated wall between the chiller/boilers and the water heater rooms 1900 and 1917, one penetration of the barrier wall was not sealed with a fire rated material.
4) In the south 2-hour fire rated wall of the electrical room 1104 one penetration of the barrier wall was not sealed with a fire rated material.
5) In the north 2-hour fire rated wall of electrical room 1104, a section of the barrier wall on the bottom to the right of the entrance is missing.
6) In the 1-hour smoke barrier above the fire doors in the north corridor on the second floor, one penetration of the smoke barrier was not sealed with a fire rated material.
B. During the tour the Director of Plant Operations was shown the locations of the unsealed penetrations at the time of the tour and confirmed the findings.

Based on observation, it was determined the facility failed to maintain the ability of the doors in smoke compartments to be self-closing in one of five areas observed. Failure to maintain the ability for the doors to fully self-close had the potential to affect the health and safety of patients, visitors, and staff because the doors ' inability to fully close would allow the passage of fire and smoke from one smoke compartment to the other. The facility had a census of 16 on 10/19/2015. Findings follow:

A. On a tour of the facility with the Director of Plant Operations on 10/21/15 at 1300, it was observed one of the two fire-rated doors in the north corridor which separates the smoke compartments on the second floor was unable to fully close on its own.
B. The Director of Plant Operations verified the door was unable to fully self-close.

Based on observation, record review, and interview, it was determined the facility failed to perform annual testing on 3 of 3 (Trauma 1-room 2412, OR #1-room 2646 and OR #2-room 2642) Line Isolation Monitors in accordance with NFPA 99 Section 3-3.3.4.2 (b). The failed practice had the potential to affect all patients admitted for surgery. Failure to test the line isolation monitors had the potential to affect the health and safety of surgical patients because the proper function of the monitors to prevent electric shock was not evaluated. The findings follow:

A. On 10/20/2015 at 1430 while touring the surgical suite, the Line Isolation Monitors were observed in Trauma 1, OR #1, and OR #2 as having no tags indicating an annual inspection.
B. In an interview on 10/21/2015 at 1100, the Director of Plant Operations stated he was not aware of the requirement of annual testing of the Line Isolation Monitors nor was any evidence presented that demonstrated that the required testing had been performed.

Based on observation, it was determined the facility failed to maintain the ability of the doors in vertical openings to be self-closing in two of six areas observed. Failure to maintain the ability for the doors to fully self-close had the potential to affect the health and safety of patients, visitors, and staff because the doors' inability to fully close would allow the passage of fire and smoke into or through the vertical opening. The facility had a census of 16 on 10/19/2015. Findings follow:

A. On a tour of the facility with the Director of Plant Operations on 10/21/15 at 1300, the following observations were made and verified:
1) One of the two fire-rated doors in the entrance to the east stairwell on the ground floor was unable to fully close on its own.
2) One of the two fire-rated doors in the entrance to the east stairwell on the second floor was unable to fully close on its own.
B. The Director of Plant Operations verified the doors were unable to fully self-close.

Based on observation, it was determined the facility failed to maintain the smoke and fire resistance rating for 5 of 22 smoke barriers and fire barriers inspected. Failure to properly seal penetrations of the fire and smoke barrier walls had the potential to affect the health and safety of patients, visitors, and staff because a compromised fire or smoke barrier cannot prevent the passage of fire and smoke from one side of the barrier to the other. The facility had a census of 16 on 10/19/2015. Findings follow:

A. On a tour of the facility with the Director of Plant Operations on 10/21/15 at 0945 and on 10/21/15 at 1300, the following observations were made and verified:
1) In the 2-hour fire rated wall separating the chiller/boiler and vacuum rooms 1900 and 1908, two penetrations of the barrier were not sealed with a fire rated material.
2) In the 1-hour fire rated wall on the east side of the Medical Gas Manifold room 1910, one penetration of the barrier wall was not sealed with a fire rated material.
3) In the 2-hour rated wall between the chiller/boilers and the water heater rooms 1900 and 1917, one penetration of the barrier wall was not sealed with a fire rated material.
4) In the south 2-hour fire rated wall of the electrical room 1104 one penetration of the barrier wall was not sealed with a fire rated material.
5) In the north 2-hour fire rated wall of electrical room 1104, a section of the barrier wall on the bottom to the right of the entrance is missing.
6) In the 1-hour smoke barrier above the fire doors in the north corridor on the second floor, one penetration of the smoke barrier was not sealed with a fire rated material.
B. During the tour the Director of Plant Operations was shown the locations of the unsealed penetrations at the time of the tour and confirmed the findings.

Based on observation, it was determined the facility failed to maintain the ability of the doors in smoke compartments to be self-closing in one of five areas observed. Failure to maintain the ability for the doors to fully self-close had the potential to affect the health and safety of patients, visitors, and staff because the doors ' inability to fully close would allow the passage of fire and smoke from one smoke compartment to the other. The facility had a census of 16 on 10/19/2015. Findings follow:

A. On a tour of the facility with the Director of Plant Operations on 10/21/15 at 1300, it was observed one of the two fire-rated doors in the north corridor which separates the smoke compartments on the second floor was unable to fully close on its own.
B. The Director of Plant Operations verified the door was unable to fully self-close.

Based on observation, record review, and interview, it was determined the facility failed to perform annual testing on 3 of 3 (Trauma 1-room 2412, OR #1-room 2646 and OR #2-room 2642) Line Isolation Monitors in accordance with NFPA 99 Section 3-3.3.4.2 (b). The failed practice had the potential to affect all patients admitted for surgery. Failure to test the line isolation monitors had the potential to affect the health and safety of surgical patients because the proper function of the monitors to prevent electric shock was not evaluated. The findings follow:

A. On 10/20/2015 at 1430 while touring the surgical suite, the Line Isolation Monitors were observed in Trauma 1, OR #1, and OR #2 as having no tags indicating an annual inspection.
B. In an interview on 10/21/2015 at 1100, the Director of Plant Operations stated he was not aware of the requirement of annual testing of the Line Isolation Monitors nor was any evidence presented that demonstrated that the required testing had been performed.