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Based on record review, observation and staff interview the facility failed to provide correct signage on horizontal-sliding doors with a designed breakaway, (breakout) capability in 5 of 5 Emergency Operating Room Doors as required by NFPA 101 (2012), 19.2.2.2.10.2(2), and 7.2.1.9.1.4.

Findings included:

1. On 06/25/2019, observation during the interior tour from 10:00 a.m., to 3.00 p.m., accompanied by facility representatives, revealed on the 3rd floor of the E Wing Pavilion Building in the Emergency Operating Room Department, OR 4, emergency operating signage read, when standing in the corridor looking into OR 4, "In Emergency, Push to Open" with a red line below the 1" letters, with arrow tips pointing from both sides of the line toward the outer edges of the horizontal-sliding doors. Facility staff members were requested to activate the breakaway system on the doors and after repeated attempts were not able to activate the breakaway system. Staff interview revealed the facility staff members from Facility Services and operating room personnel were not familiar with the horizontal-sliding door breakaway system to be used during emergencies.

2. On 06/25/2019, staff interview of the Associate Vice President, the Director of Engineering and Assistant Director, in the Facility Department Conference Room, at approximately 3:30 p.m., revealed facility staff had discussed with the architect and the contractor responsible for installing and labeling the horizontal-sliding door that the 5 of 5 installed horizontal-sliding doors were not the typical sliding doors acquired by the facility and the signage placed on the glass, "In Emergency, Push to Open", on the entrance side, by the contractor, was not correct for placement and directions.

3. On 06/25/2019, record review of NFPA 101 (2012), states in 19.2.2.2.10.2 "Horizontal-sliding doors serving an occupant load of fewer than 10 shall be permitted, provided that all of the following criteria are met:..(2) The door is readily operable from either side without special knowledge or effort." Continuing record review revealed in 3.3.170, the definition of the Means of Egress is "A continuous and unobstructed way of travel from any point in a building or structure to a public way consisting of three separate and distinct parts: (1) the exit access, (2) the exit, and (3) the exit discharge, and in 3.3.82, the definition of Exit Access is "That portion of a means of egress that leads to an exit." Continuing record review of NFPA 101 (2012), states in 7.2.1.9.1.4. "...Sliding, power-operated door assemblies in an exit access serving an occupant load of fewer than 50 that manually open in the direction of door leaf travel, with forces not exceeding those required in 7.2.1.4.5, shall not be required to have the swing-out feature required by 7.2.1.9.1.2. The required sign shall be in letters not less than 1 in. (25 mm) high on a contrasting background and shall read as follows: IN EMERGENCY, SLIDE TO OPEN..."

4. On 06/26/2019, staff interview of Facility Services personnel at approximately 10:00 a.m., confirmed the issue of the signage being incorrect for placement, (entrance side rather than "Exit Access" side ) and statement of action (the Notice of "Push" rather than "Slide"). Continued staff interview confirmed the 5 Emergency Operating Room doors were different than these usually acquired by the facility and additional training for staff would be necessary.

NFPA 101 (2012), 19.2.2.2.10.2, 7.2.1.9.1.4

Based on observation and staff interview the facility failed to provide or provided confusing "Exit" and "Directional Exit signs with chevrons" in the means of egress as required by NFPA 101 (2012), 4.6.1.4, 4.6.1.4.1, 4.6.1.4.2 , 19.2.10, 19.2.10.1, 7.10.1.5.1, and 7.10.8.1.

Findings included:

1. On 06/25/2019, the second day of survey, observation during the interior tour from 9:30 a.m., to 3:15 p.m., accompanied by facility representatives revealed multiple locations in which Exit signs failed to provide correct direction to the nearest means of egress. Examples included on the 2nd floor of building "M", at the entrance to unit "C" in the first 45 feet of travel 7 Exit signs located in front of and after passage through cross corridor smoke barrier doors, with and without chevrons providing direction in multiple directions. Continuing observation revealed an Exit sign directly above a patient room double leaf door with no chevron, that in the event of fire could lead patients, or visitors to enter the patient room instead of preceding to the left and then making a right turn to enter a passage way to an Exit. Staff interview of the facility representatives confirmed the observations.

2. On 06/26/2019, record review of NFPA 101 (2012) 7.10.2, states "Directional Signs. 7.10.2.1* A sign complying with 7.10.3, with a directional indicator showing the direction of travel, shall be placed in every location where the direction of travel to reach the nearest exit is not apparent."

3. On 06/26/2019 record review of NFPA 101 (2012), 4.6.1.4 Technical Assistance. 4.6.1.4.1 The authority having jurisdiction shall be permitted to require a review by an approved independent third party with expertise in the matter to be reviewed at the submitter ' s
expense,...4.6.1.4.2 The independent reviewer shall provide an evaluation and recommend necessary changes of the proposed design, operation, process, or new technology to the authority having jurisdiction..."

The facility is required to engage a qualified vendor/contractor or qualified employee to evaluate the location and information provided by existing Exit directional signage and submit a report with recommendations for correction/reduction/addition and appropriate placement of Exit signage throughout the facility as part of the facility's Plan of Correction.

NFPA 101 (2012), 4.6.1.4, 4.6.1.4.1, 4.6.1.4.2 , 19.2.10, 19.2.10.1, 7.10.1.5.1, and 7.10.8.1

Based on record review and staff interview the facility failed to provide documentation of the required annual duct detector pressure differential as required by NFPA 101 (2012), 19.3.4.1, 9.6.1.3, NFPA 72 (2010), 14.2.1, 14.2.1.1, 14.2.1.1.1, 14.2.1.1.2, 14.6.2.4, Figure 14.6.2.4(16-17), 14.4.2.2, Table 14.4.2.2(g)(1), and Table 14.4.2.2(g)(6)

Findings included:

1. On 06/24/2019, record review from 9:15 a.m., to 3:30 p.m., revealed the facility failed to provide documentation of the required annual duct detector pressure differential testing. Staff interview of the Assistant Director confirmed the required annual duct detector pressure differential testing had not been done in the last 12 months.

2. On 06/26/2019, record review of NFPA 72 (2010), 14.2.1 Performance, states in 14.2.1.1 Performance Verification, that the purpose of smoke and duct detector testing is "To ensure operational integrity.." through "...inspection, testing, and maintenance program," and in 14.2.1.1.1 the "Inspection, testing, and maintenance programs shall satisfy the requirements of this Code and conform to the equipment manufacturer's published instructions" and in 14.2.1.1.2 "Inspection, testing, and maintenance programs shall verify correct operation of the system." Continuing record review states in NFPA 72 (2010), 14.6.2.4* "A record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 14.6.2.4, including, "...(16) Other tests as required by the equipment manufacturer's published instructions" and "(17) Other tests as required by the authority having jurisdiction."

NFPA 101 (2012), 19.3.4.1, 9.6.1.3
NFPA 72 (2010), 14.2.1, 14.2.1.1, 14.2.1.1.1, 14.2.1.1.2, 14.6.2.4, Figure 14.6.2.4(16-17), 14.4.2.2, Table 14.4.2.2(g)(1), Table 14.4.2.2(g)(6)

Based on observation and staff interview the facility failed to maintain water closet, (bathroom), ventilation as required by NFPA 101 (2012), 19.5.2.1, 9.2.1, 4.5.8, and NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems.

Findings included:

1. On 06/25/2019, observation during the interior tour from 10:00 a.m., to 3:00 p.m., accompanied by facility representatives, revealed installed water closet, (bathroom), ventilation units in buildings B, C, and M, failed to operate in 4 of 4 randomly selected patient bathrooms. Testing was accomplished by the Assistant Director applying a piece of tissue paper to the face of the bathroom ventilation return resulting in the tissue falling from the return indicating no suction by the ventilation unit. Staff interview of the Assistant Director concurrent with tour confirmed that patient bathrooms did not have functional ventilation as required.

2. On 06/24/2019, observation during the interior tour from 9:30 a.m., to 3:30 p.m., of buildings E, revealed all patient bathroom ventilation units not functioning on the 7th floor, and the 5th floor. Staff interview of the Assistant Director concurrent with the tour confirmed that patient bathrooms did not have functional ventilation as required.

NFPA 101 (2012), 19.5.2.1, 9.2.1, 4.5.8
NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems

Based on record review, staff interview and observation, the facility failed to periodically instruct staff for emergencies or evacuation, the operation of horizontal sliding doors with "breakout" or "breakaway" features required by NFPA 101 (2012), 19.7.2, and 19.7.3.2.

Findings included:

1. On 06/25/2019, observation during the interior tour from 10:00 a.m., to 3.00 p.m., accompanied by facility representatives, revealed on the 3rd floor of the E Wing Pavilion Building in the Emergency Operating Room Department, OR 4, emergency operating signage read, when standing in the corridor looking into OR 4, "In Emergency, Push to Open" with a red line below the 1" letters, with arrow tips pointing from both sides of the line toward the outer edges of the horizontal-sliding doors. Facility staff members were requested to activate the breakaway system on the doors and after repeated attempts were not able to activate the breakaway system. Staff interview revealed the facility staff members from Facility Services and operating room personnel were not familiar with the horizontal-sliding door breakaway system to be used during emergencies.

2. On 06/25/2019, staff interview of the Associate Vice President, the Director of Engineering and Assistant Director, in the Facility Department Conference Room, at approximately 3:30 p.m., revealed facility staff had discussed with the architect and the contractor responsible for installing and labeling the horizontal-sliding door that the 5 of 5 installed horizontal-sliding doors were not the typical sliding doors acquired by the facility and the signage placed on the glass, "In Emergency, Push to Open", on the entrance side, by the contractor, was not correct for placement and directions.

3. On 06/25/2019, record review of NFPA 101 (2012), states in 19.2.2.2.10.2 "Horizontal-sliding doors serving an occupant load of fewer than 10 shall be permitted, provided that all of the following criteria are met:..(2) The door is readily operable from either side without special knowledge or effort." Continuing record review revealed in 3.3.170, the definition of the Means of Egress is "A continuous and unobstructed way of travel from any point in a building or structure to a public way consisting of three separate and distinct parts: (1) the exit access, (2) the exit, and (3) the exit discharge, and in 3.3.82, the definition of Exit Access is "That portion of a means of egress that leads to an exit." Continuing record review of NFPA 101 (2012), states in 7.2.1.9.1.4. "...Sliding, power-operated door assemblies in an exit access serving an occupant load of fewer than 50 that manually open in the direction of door leaf travel, with forces not exceeding those required in 7.2.1.4.5, shall not be required to have the swing-out feature required by 7.2.1.9.1.2. The required sign shall be in letters not less than 1 in. (25 mm) high on a contrasting background and shall read as follows: IN EMERGENCY, SLIDE TO OPEN..."

4. On 06/26/2019, staff interview of Facility Services personnel at approximately 10:00 a.m., confirmed the issue of the signage being incorrect for placement, (entrance side rather than "Exit Access" side ) and statement of action (the Notice of "Push" rather than "Slide"). Continued staff interview confirmed the 5 Emergency Operating Room doors were different than those usually acquired by the facility and additional training for staff would be necessary.

NFPA 101 (2012), 19.7.2, 19.7.3.2.

Based on record review and staff interview, the facility failed to maintain fire door assemblies and failed to document the individual fire doors inspected, and tested as required by NFPA 101 (2012 Edition) 19.7.6, 4.6.12, 8.3.3.1, NFPA 1 (2012 Edition) 12.4.6, 12.4.6.3,12.4.6.6, 12.4.6.8, NFPA 80 (2010 Edition) 5.2, 5.2.3, 5.2.4, 5.2.4.1, 5.2.4.2, and 6.4.1.4.

Findings included:

1. On 06/24/2019, observation during the facility tour from 9:30 a.m., to 3:30 a.m., accompanied by facility representatives, revealed on the 7th floor, Exit Door E7F728, Stairway P, failed to fully close and latch and the first floor Stairway P, Exit Door self-closing device failed to fully close and latch the Exit Door.

2. On 06/24/2019, record review from 9:15 a.m., to 3:30 p.m., when asking for documentation of the required annual fire door inspection and functional testing a consolidated report was provided that did not list the individual door number or location and did not identify the outcome of the 11 point visual inspection for each door. Staff interview of the Assistant Director, concurrent with record review, confirmed that inspection and testing of fire doors did not identify the location and outcome for each of the doors.

NFPA 101 (2012 Edition) 19.7.6, 4.6.12, 8.3.3.1
NFPA 1 (2012 Edition) 12.4.6, 12.4.6.3,12.4.6.6, 12.4.6.8
NFPA 80 (2010 Edition) 5.2, 5.2.3, 5.2.4, 5.2.4.1, 5.2.4.2, 6.4.1.4

Based on record review and staff interview the facility failed to provide documentation, on the day of survey, of the testing of the Essential Electrical System prime movers, (7, 750 KW diesel powered emergency generators), lead acid batteries in accordance with NFPA 99 (2012) 6.4.1.1.13, and NFPA 110 (2010) 8.3.7.1.

Finding included:

1. On 06/24/2019, record review from 9:15 a.m., to 3:30 p.m., of the Essential Electrical System prime mover records revealed no documentation of the required monthly testing and recording of electrolyte specific gravity of the generator battery. Staff interview of the Assistant Director confirmed the recording of the specific gravity of Essential Electrical System prime movers, 7 batteries had not been recorded.

2. On 06/26/2019, record review of NFPA 110 (2010), revealed in, 8.3.7.1, "Maintenance of lead-acid batteries shall include the
monthly testing and recording of electrolyte specific gravity. Battery conductance testing shall be permitted in lieu of the testing
of specific gravity when applicable or warranted."

NFPA 99 (2012 Edition) 6.4.1.1.13
NFPA 110 (2010 Edition) 8.3.7.1