HospitalInspections.org

Based on surveyor observation during the Life Safety Tour with the Director of Engineering, it was determined that the facility failed to ensure that exit signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system.

Findings are as follows:

NFPA 101 SECTION 19.10.2.1 states, "Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system".

Surveyor observation of the 90 Plain Street facility on 8/16/11 at 1:55PM, accompanied by the Director of Engineering, revealed a suite on the fourth floor (#453) containing 5 examination rooms and a restroom. The exit discharge from the suite did not display an exit sign with continuous illumination.

Surveyor observation during the life safety code tour of the first floor of the 79 Plain Street facility on 8/16/11 at 2:00PM, accompanied by the Director of Engineering, revealed a closet with solid slider doors containing several coats and multiple packages of linen; and a closet with solid slider doors containing medical supplies. Both closets were not equipped with sprinkler protection.

In addition, surveyor observation of the basement level at approximately 2:15PM revealed a conference room closet containing a florescent light recessed aproximately 3 inches from the ceiling and obstructing a sprinkler deflector.

Based on surveyor observation it was determined that the facility failed to provide protection throughout by an approved, supervised automatic sprinkler system in accordance with NFPA 101 Section 13.5-5.6.

Findings are as follows:

NFPA 101 Section 13.5-5.6 requires clearance between the sprinkler deflector and the top of the storage to be a minimum of 18 inches.

Surveyor observation during the life safety code tour of the South Pavillion section of the Main Building on 8/16/11 at 10:30AM, accompanied by the Vice President of Property Infrastructure Support Services, revealed a storage closet (#1416) with a large chafing dish on the top shelf approximately 2 inches from a sprinkler deflector. Additional observation of the same storage area on 8/17/11 at 11:00AM revealed a serving bowl and cardboard box on the top shelf approximately 2 inches from the sprinkler deflector.

Surveyor observation during the life safety code tour of the South Pavillion section of the Main Building on 8/17/11 at approximately 11:00AM, accompanied by the Vice President of Property Infrastructure Support Services, revealed a Childbirth Class Storage Closet (#1421) with 4 cardboard boxes of paper brochures stacked on the top shelf approximately 6 inches from the sprinkler deflector.

Based on surveyor observation, it was determined that the facility failed to comply with NFPA 99 standards regarding storage requirements for oxygen tanks.

Findings are as follows:

NFPA 99 Section 4-5.1.1.2 (7)states: "Combustible materials, such as paper, cardboard, plastics and fabrics shall not be stored or kept near supply system cylinders or manifolds containing oxygen or nitrous oxide".

Surveyor observation of the Operating Unit on the 2nd floor of the Main Building on 8/15/11 at 1:30PM during the life safety code tour, accompanied by the Director of Engineering, revealed 9 oxygen tanks in 2 racks on the floor in an area next to a 7 foot rack containing combustible materials including medical gowns, caps, shoe coverings, masks and multiple cardboard boxes.

Based on surveyor observation during the Life Safety Tour with the Director of Engineering, it was determined that the facility failed to ensure that exit signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system.

Findings are as follows:

NFPA 101 SECTION 19.10.2.1 states, "Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system".

Surveyor observation of the 90 Plain Street facility on 8/16/11 at 1:55PM, accompanied by the Director of Engineering, revealed a suite on the fourth floor (#453) containing 5 examination rooms and a restroom. The exit discharge from the suite did not display an exit sign with continuous illumination.

Surveyor observation during the life safety code tour of the first floor of the 79 Plain Street facility on 8/16/11 at 2:00PM, accompanied by the Director of Engineering, revealed a closet with solid slider doors containing several coats and multiple packages of linen; and a closet with solid slider doors containing medical supplies. Both closets were not equipped with sprinkler protection.

In addition, surveyor observation of the basement level at approximately 2:15PM revealed a conference room closet containing a florescent light recessed aproximately 3 inches from the ceiling and obstructing a sprinkler deflector.

Based on surveyor observation it was determined that the facility failed to provide protection throughout by an approved, supervised automatic sprinkler system in accordance with NFPA 101 Section 13.5-5.6.

Findings are as follows:

NFPA 101 Section 13.5-5.6 requires clearance between the sprinkler deflector and the top of the storage to be a minimum of 18 inches.

Surveyor observation during the life safety code tour of the South Pavillion section of the Main Building on 8/16/11 at 10:30AM, accompanied by the Vice President of Property Infrastructure Support Services, revealed a storage closet (#1416) with a large chafing dish on the top shelf approximately 2 inches from a sprinkler deflector. Additional observation of the same storage area on 8/17/11 at 11:00AM revealed a serving bowl and cardboard box on the top shelf approximately 2 inches from the sprinkler deflector.

Surveyor observation during the life safety code tour of the South Pavillion section of the Main Building on 8/17/11 at approximately 11:00AM, accompanied by the Vice President of Property Infrastructure Support Services, revealed a Childbirth Class Storage Closet (#1421) with 4 cardboard boxes of paper brochures stacked on the top shelf approximately 6 inches from the sprinkler deflector.

Based on surveyor observation, it was determined that the facility failed to comply with NFPA 99 standards regarding storage requirements for oxygen tanks.

Findings are as follows:

NFPA 99 Section 4-5.1.1.2 (7)states: "Combustible materials, such as paper, cardboard, plastics and fabrics shall not be stored or kept near supply system cylinders or manifolds containing oxygen or nitrous oxide".

Surveyor observation of the Operating Unit on the 2nd floor of the Main Building on 8/15/11 at 1:30PM during the life safety code tour, accompanied by the Director of Engineering, revealed 9 oxygen tanks in 2 racks on the floor in an area next to a 7 foot rack containing combustible materials including medical gowns, caps, shoe coverings, masks and multiple cardboard boxes.