HospitalInspections.org

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

The inspector observed, while accompanied by the Maintenance Mechanic II and the Assistant Chief Executive Officer during the hours of the inspection from 1:00 pm to 5:45 pm on 5/21/2013 that there were smoke barrier penetrations in the following areas: 1) Cable Elevator Lobby, 2) Classroom #1, 3) West X-Ray door, 4) X-Ray S.W. door, 5) Scheduling, 6) Admissions, 7) 2nd floor at Oncology Wing, 8) Basement at Marketing Coordinator Office.

Based on observation the facility failed to provide adequate hazardous area separation.

The inspector observed, while accompanied by the Maintenance Mechanic II and the Assistant Chief Executive Officer during the hours of the inspection from 1:00 pm to 5:45 pm on 5/21/2013 that at the following locations the door did not latch properly: 1) Old 2nd Floor, Storage by Oncology, and 2) New 3rd Floor, Mechanical Room. The following locations did not have a 45 minute fire rated door: 1) New 3rd floor, Boiler Room, 2) 1st Floor, Soiled Utility in Cardiopulmonary, 3) 1st Floor, Equipment Room, 4) PACU Equipment Storage, and 5) PACU Clean Utility (2 doors). The following location did not have a closer or the closer was not working: 1) Future Cath Lab, 2) 1st Floor Equipment Room, 3) Storage in Endo, 4) Clean Utility at Nuclear Medicine.

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

The inspector observed, while accompanied by the Maintenance Mechanic II and the Assistant Chief Executive Officer during the hours of the inspection from 1:00 pm to 5:45 pm on 5/21/2013 that there was the following problem. The electrical room in the Cath Basement did not have a sprinkler head. This room contained the MSBC panel.

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

The inspector observed, while accompanied by the Maintenance Mechanic II and the Assistant Chief Executive Officer during the hours of the inspection from 1:00 pm to 5:45 pm on 5/21/2013 that there were the following issues. The medical gas room had a 20 minute door and it must be a 45 minute rated door. The medical gas room did not appear to be exhausted, please verify. Also, the medical gas bottles were not individually secured.

Doors in a 1 hour fire rated barrier shall be 45 minute rated fire door assemblies - NFPA 101, 2003: Table 8.3.4.2.

" 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 an adequate enclosure for the emergency generator.

The inspector observed, while accompanied by the Maintenance Mechanic II and the Assistant Chief Executive Officer during the hours of the inspection from 1:00 pm to 5:45 pm on 5/21/2013 that there was the following issue. The emergency generator ONAN did not have a complete 2 hour enclosure. This room must have a 90 minute fire door with a closer. All generators must have this configuration if inside the hospital building.

" The room shall have a minimum 2-hour fire rating or be located in an adequate enclosure located outside the building capable of resisting the entrance of snow or rain at a maximum wind velocity required by local codes. " - NFPA 110, 2002; 7.2.1.1.

Annual Fire Sprinkler Inspection

" A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed. " - NFPA 13, 1999, 12-1.

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

The inspector observed, while accompanied by the Maintenance Mechanic II and the Assistant Chief Executive Officer during the hours of the inspection from 1:00 pm to 5:45 pm on 5/21/2013 that there was the following issue with the annual inspection. The inspector stated the following: " Unable to do full main flow test. Floor drains can not handle water volume. " Complete tests must be performed.


Testing Intervals of Biomedical Equipment

All appliances used in patient care areas shall be tested in accordance with 7-5.1.3 or 7-5.2.2.1 before being put into service for the first time and after repair or modification. Patient-care-related electrical appliances shall be retested at intervals determined by their normal location or area of normal use, but not exceeding the intervals listed below:

General care areas - 12 months
Critical care areas - 6 months
Wet locations - 6 months

NFPA 99, 1999, 7-6.2.1.2.

Based on observation the facility failed to provide complete biomedical inspections with risk based on critical care areas.

The inspector observed, while accompanied by the Maintenance Mechanic II and the Assistant Chief Executive Officer during the hours of the inspection from 1:00 pm to 5:45 pm on 5/21/2013 that the criteria for testing equipment did not include testing critical care areas every 6 months. This was discovered by interviewing staff responsible for the testing.


Fuel and Water Preferred Customer Status

" Continuity of Essential Building Systems. When designated by the emergency preparedness management plan to provide continuous service in a disaster or emergency, health care facilities shall establish contingency plans for the continuity of essential building systems, as applicable: (a) Electricity, (b) Water, (c) Ventilation, (d) Fire protection systems, (e) Fuel sources, (f) Medical gas and vacuum systems (if applicable), (g) Communications systems. " - NFPA 99, 1999, 11-5.3.2

Based on observation the facility failed to provide letters from vendors for emergency fuel and water.

The inspector observed, while accompanied by the Maintenance Mechanic II and the Assistant Chief Executive Officer during the hours of the inspection from 1:00 pm to 5:45 pm on 5/21/2013 that there were no letters indicating that they have a preferred customer status in the event of an emergency for water and fuel.

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

The inspector observed, while accompanied by the Maintenance Mechanic II and the Assistant Chief Executive Officer during the hours of the inspection from 1:00 pm to 5:45 pm on 5/21/2013 that there were the following issues. They were: 1) in the Disconnect Room the ATSs were not labeled according to the branch they support, 2) in the Cath Basement the ATSs were also not labeled according to the branch they support, 3) in the Endo Proceedure Rooms the critical outlets did not have permanent labels (all critical areas require permanent labels), and 4) the PACU isolation room did not have permanent labels on the critical outlets.

" All boxes and enclosures (including transfer switches, generators, and power panels) for emergency circuits shall be permanently marked so they will be readily identified as a component of an emergency circuit or system. " - NFPA 70, 2002: 700-9(a). They shall be labeled "LIFE SAFETY", "CRITICAL", or "EQUIPMENT" as applicable.

" In critical care areas, emergency system receptacles must be identified, indicating the panel board and circuit number supplying them in accordance with NFPA 70, 2002: 517-19(a).

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

The inspector observed, while accompanied by the Maintenance Mechanic II and the Assistant Chief Executive Officer during the hours of the inspection from 1:00 pm to 5:45 pm on 5/21/2013 that there were smoke barrier penetrations in the following areas: 1) Cable Elevator Lobby, 2) Classroom #1, 3) West X-Ray door, 4) X-Ray S.W. door, 5) Scheduling, 6) Admissions, 7) 2nd floor at Oncology Wing, 8) Basement at Marketing Coordinator Office.

Based on observation the facility failed to provide adequate hazardous area separation.

The inspector observed, while accompanied by the Maintenance Mechanic II and the Assistant Chief Executive Officer during the hours of the inspection from 1:00 pm to 5:45 pm on 5/21/2013 that at the following locations the door did not latch properly: 1) Old 2nd Floor, Storage by Oncology, and 2) New 3rd Floor, Mechanical Room. The following locations did not have a 45 minute fire rated door: 1) New 3rd floor, Boiler Room, 2) 1st Floor, Soiled Utility in Cardiopulmonary, 3) 1st Floor, Equipment Room, 4) PACU Equipment Storage, and 5) PACU Clean Utility (2 doors). The following location did not have a closer or the closer was not working: 1) Future Cath Lab, 2) 1st Floor Equipment Room, 3) Storage in Endo, 4) Clean Utility at Nuclear Medicine.

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

The inspector observed, while accompanied by the Maintenance Mechanic II and the Assistant Chief Executive Officer during the hours of the inspection from 1:00 pm to 5:45 pm on 5/21/2013 that there was the following problem. The electrical room in the Cath Basement did not have a sprinkler head. This room contained the MSBC panel.

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

The inspector observed, while accompanied by the Maintenance Mechanic II and the Assistant Chief Executive Officer during the hours of the inspection from 1:00 pm to 5:45 pm on 5/21/2013 that there were the following issues. The medical gas room had a 20 minute door and it must be a 45 minute rated door. The medical gas room did not appear to be exhausted, please verify. Also, the medical gas bottles were not individually secured.

Doors in a 1 hour fire rated barrier shall be 45 minute rated fire door assemblies - NFPA 101, 2003: Table 8.3.4.2.

" 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 an adequate enclosure for the emergency generator.

The inspector observed, while accompanied by the Maintenance Mechanic II and the Assistant Chief Executive Officer during the hours of the inspection from 1:00 pm to 5:45 pm on 5/21/2013 that there was the following issue. The emergency generator ONAN did not have a complete 2 hour enclosure. This room must have a 90 minute fire door with a closer. All generators must have this configuration if inside the hospital building.

" The room shall have a minimum 2-hour fire rating or be located in an adequate enclosure located outside the building capable of resisting the entrance of snow or rain at a maximum wind velocity required by local codes. " - NFPA 110, 2002; 7.2.1.1.

Annual Fire Sprinkler Inspection

" A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed. " - NFPA 13, 1999, 12-1.

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

The inspector observed, while accompanied by the Maintenance Mechanic II and the Assistant Chief Executive Officer during the hours of the inspection from 1:00 pm to 5:45 pm on 5/21/2013 that there was the following issue with the annual inspection. The inspector stated the following: " Unable to do full main flow test. Floor drains can not handle water volume. " Complete tests must be performed.


Testing Intervals of Biomedical Equipment

All appliances used in patient care areas shall be tested in accordance with 7-5.1.3 or 7-5.2.2.1 before being put into service for the first time and after repair or modification. Patient-care-related electrical appliances shall be retested at intervals determined by their normal location or area of normal use, but not exceeding the intervals listed below:

General care areas - 12 months
Critical care areas - 6 months
Wet locations - 6 months

NFPA 99, 1999, 7-6.2.1.2.

Based on observation the facility failed to provide complete biomedical inspections with risk based on critical care areas.

The inspector observed, while accompanied by the Maintenance Mechanic II and the Assistant Chief Executive Officer during the hours of the inspection from 1:00 pm to 5:45 pm on 5/21/2013 that the criteria for testing equipment did not include testing critical care areas every 6 months. This was discovered by interviewing staff responsible for the testing.


Fuel and Water Preferred Customer Status

" Continuity of Essential Building Systems. When designated by the emergency preparedness management plan to provide continuous service in a disaster or emergency, health care facilities shall establish contingency plans for the continuity of essential building systems, as applicable: (a) Electricity, (b) Water, (c) Ventilation, (d) Fire protection systems, (e) Fuel sources, (f) Medical gas and vacuum systems (if applicable), (g) Communications systems. " - NFPA 99, 1999, 11-5.3.2

Based on observation the facility failed to provide letters from vendors for emergency fuel and water.

The inspector observed, while accompanied by the Maintenance Mechanic II and the Assistant Chief Executive Officer during the hours of the inspection from 1:00 pm to 5:45 pm on 5/21/2013 that there were no letters indicating that they have a preferred customer status in the event of an emergency for water and fuel.

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

The inspector observed, while accompanied by the Maintenance Mechanic II and the Assistant Chief Executive Officer during the hours of the inspection from 1:00 pm to 5:45 pm on 5/21/2013 that there were the following issues. They were: 1) in the Disconnect Room the ATSs were not labeled according to the branch they support, 2) in the Cath Basement the ATSs were also not labeled according to the branch they support, 3) in the Endo Proceedure Rooms the critical outlets did not have permanent labels (all critical areas require permanent labels), and 4) the PACU isolation room did not have permanent labels on the critical outlets.

" All boxes and enclosures (including transfer switches, generators, and power panels) for emergency circuits shall be permanently marked so they will be readily identified as a component of an emergency circuit or system. " - NFPA 70, 2002: 700-9(a). They shall be labeled "LIFE SAFETY", "CRITICAL", or "EQUIPMENT" as applicable.

" In critical care areas, emergency system receptacles must be identified, indicating the panel board and circuit number supplying them in accordance with NFPA 70, 2002: 517-19(a).