HospitalInspections.org

Based upon observation and staff interview, facility failed to provide a building with an acceptable construction type. This deficient practice could affect patients, staff and visitors if a fire in the deficient area were to compromise the buildings structural integrity during a fire emergency.

Findings include:

A. On 09/28/2022 at 12:57pm while accompanied by the FM portions of the steel structure were observed that are not covered by fire proofing materials in accordance with the designated UL Design. Location observed: Bottom flange of steel beam near the east wall of Corridor #1599DR approximately the distance of 4 light fixtures north from a pair of cross corridor doors.


45373


B. On 09/27/2022, at 11:20 am while in the company of the SD & LE, it was observed that the 2nd floor corridor to Shared Storage above ICU floor contains a steel column which lacks fireproofing to compy with 19.1.6.1 and 2012 Edition of NFPA 220, Table 4.1.1.

Based on observation, document review, and staff interview the surveyor finds that portions of the Hospital are Type II (000) Construction, as defined by NFPA 220. The Hospital is a five-story building. This does not comply with the minimum construction type requirements of 19.1.6.2. Failure to install and maintain fire rated structural assemblies could result in a failure of the building structure during a fire.
Finding include:

On September 26, 2022, at 3:00pm during a discussion with FM and SC it was determined that portions of the Facility are of Type II (000) construction. This condition does not comply with Table 19.1.6.2.

Based on observation, not all stairs or smokeproof enclosures are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because their egress from the building could be impeded if the stairs and smokeproof enclosures are not properly constructed and maintained.

Findings include:

A. Stair arrangements were observed that continue more than one-half story below the level of exit discharge without a means to prevent travel past the level of exit discharge. This condition does not comply with 7.7.3.4.
Locations observed:
1. On 09/27/2022 at 3:15pm while accompanied by the F.M., First floor Stair. #6
2. On 09/28/2022 at 12:57pm while accompanied by the FM First floor Stair #5.

B. On 09/27/2022 while accompanied by the FM it was observed that there are five exit stairs ( #2, #4, #5, #6 and #7) serving the four floor levels plus the basement. It is noted that all stairs discharge to the interior of the building. The discharge for Stair #6 is indicated on the Life Safety floor plan to be an exit passageway. This condition does not comply with 7.7.2. The remainder of these stairs do not utilize designated exit passageways due to the following examples:

1. At 12:57pm First floor corridor #1599DP, #1599DQ and corridor #1599DR for Stair #5 and #4 leading to Vestibule #1599DS all contain piping, ductwork conduits etc which do not serve these corridors. This condition does not comply with 7.1.3.2.1(10), 7.1.3.2.2, 7.2.6.3.

2. At 12:46pm First floor corridor #1599DP, #1599DQ and corridor #1599DR for Stair #5 and #4 leading to Vestibule #1599DS all contain suspended acoustical tile or perforrated lay in ceilings which does not comply with 7.1.3.2.2 for a protected fire rated enclosure.

3. At 1:25pm First floor corridor #1699SK serving Stair #2 leading to corridor #16699SN contain piping, ductwork conduits etc which do not serve these corridors. This condition does not comply with 7.1.3.2.1(10), 7.1.3.2.2, 7.2.6.3.

4. At 1:36pm First floor corridor #1699SK serving Stair #2 leading to corridor #16699SN contains suspended acoustical tile lay in ceiling which does not comply with 7.1.3.2.2 for a protected fire rated enclosure.

C. On 09/27/2022 at 1:33pm while accompanied by the FM it was observed that a door which opens from an occupied area into the designated 2-hour rated enclosure for Stair #2 does not comply with NFPA 80 2010, 3.2.4, 4.2.1 for a listed fire rated door. Location observed: 1st floor Xray #4 room

Based on observation, exit signs are not provided to define access to at least two means of egress from a floor level to comply with Code requirements. Failure to define exits can prevent occupants from reaching an alternate exit when the primary exit access is compromised during an emergency event.

The findings include:

A. On 09/28/2022 at 1:35pm while in the company of the FM, the exit signage provided in the corridor located south of corridor #1099SH is not fully visible at all locations (including from Stair #7) due to a ceiling bulkhead. This condition does not comply with 7.10.1.8.


44908


B. On 09/27/22 at 1:17 PM while accompanied by LE and SD, it was observed on the lower level there was no exit signage towards the west end of corridor 339SB at the cross-corridor smoke doors. This does not comply with 7.10.2.1

Based on observations not all enclosures of hazardous areas are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building due to smoke and fire passing from the hazardous area through the remainder of the building.

Findings include:

A. On 09/27/22 at 9:12 AM while accompanied by LM, it was identified that on the 3rd floor, Clean Utility Room 356, door to the exit corridor did not latch to the frame when tested. This does not comply with 19.3.2.

B. On 0927/22 at 10:49 AM while accompanied by LM, it was identified that on the Lower Level, Blood Bank/Serology Room #B-09, door to the exit corridor did not latch to the frame when tested. This does not comply with 19.3.2.

C. On 09/27/22 at 12:57 PM while accompanied by LE and SD, it was identified that on the Lower Level, General Stores Room #B-134A door into storage room was propped opened with a floor wedge.

Based on observation a fume hood exhaust system is installed which does not provide the fire protection for Laboratories using chemicals. The lack of protection from hazardous materials or gases may affect the ability of staff to quickly exit the area during a fire emergency.

Findings include:

A. On 09/28/2022 at 2:50pm while in the company of the FM a duct run from a chemical fume hood was observed to extend horizontally more than 20 feet to the bottom of a shaft. The following was observed in the Basement Level Lab:

1. The horizontal length of the duct installation does not appear to comply with NFPA 45 2011, 8.4.12 due to
i. Due to the horizontal duct run a provision for the location of the fume hood discharge that prevents reentry exposures to personnel.
ii. Due to the fire wrap which forms a 90 degree angle of entry at the bottom of the shaft. This configuration is not known to be an Underwriters Laboratories Listed (U.L.) Design for this type of application.

2. The duct penetrates the shaft from the bottom. The construction of the shaft at the bottom is gypsum board of unknown fire rating. This configuration does not comply with the floor-ceiling or shaft requirements of 90A 2012, 5.3.2.1 or 5.3.4.1 or the authority having jurisdiction; for further requirements refer to figure A5.3. Should the duct fail the collapse of the duct will disturb the integrity of the shaft at the non structural gypsum board shaft floor.

Based on observation the facility failed to provide required smoke detection protection. This deficient practice can result in failure of the system to operate as intended and delay proper initiation when necessary.

Findings include:

On September 26, 2022, at 2:00pm, while in the company of the SC, it was observed in the G.I. Department electrical closet on the 5th floor that no complete and continuous physical separation from the room to the ceiling cavity above exists. The missing ceiling material would allow heat and products of combustion to bypass the installed smoke detector and therefore does not comply with NFPA 72-2010, 17.7.3.2.4.2.

Based on observation smoke detectors are not located as required for a compliant fire alarm system installation. Failure to locate devices accordingly may result in failure or delay of alarm initiation during an emergency. If devices do not function properly, then building occupants may not be alerted to an emergency in a timely manner.

Findings include:

It was observed at various locations that detectors are located where airflow may prevent normal operation of the device as written in NFPA 72-2012 17.7.4.1. Locations & conditions observed include the following:

1. On 09/27/22 at 1:50 PM, accompanied by the LE and SD, a smoke detector was observed within 3"-0" of an HVAC diffuser on Lower Level Decontamination Room #323P.

2. On 09/27/22 at 2:46 PM, accompanied by the LE and SD, a smoke detector was observed within 3"-0" of an HVAC diffuser on Lower Level Neuro EMG Offices TB063-65.


45373


3. On 09/27/2022, at 9:51 am while in the company of the SD & LE, a Smoke Detector is installed near supply/return register at the 2nd floor South Staff Lounge is not in compliance with 2010 Edition of NFPA 72, Section 17.7.4.1.

4. On 09/27/2022, at 9:55 am while in the company of the SD & LE, a Smoke Detector is installed near supply/return register at the 2nd floor South Utility Room is not in compliance with 2010 Edition of NFPA 72, Section 17.7.4.1.

Based on observation, the fire pull stations are not properly located. This could affect patients, staff and visitors if the fire alarm system does not operate properly during a fire emergency.

The finding is:

On 09/27/2022 at 1:50pm while in the company of the FM, manual pull stations are not located within 5 feet of the designated exit door to comply with 19.3.4.2.1, 9.6.2.3.(2), NFPA 72, 2010, 17.14.5 and 17.14.6.

Locations observed:

1. 1st floor 2-hour designated fire compartment separation at the pair of cross corridor doors leading to DRS. Pavilion from corridor South of Corr #1099SH.

2. 1st floor Corr #1099SH serving Stair #7 contains a manual pull station which is greater than 5 feet from the stair discharge door.

3. 1st floor Corr located South of Corr#1099SE containing an exit discharge door leading directly outside lacks a manual pull station 5 feet from the discharge door. This exterior discharge would serve the Administration Office area and Stair #7.

Based on observation the facility lacks complete sprinkler protection. Failure to install and maintain this installation could result in delayed response and fire suppression. This deficient practice could affect patients, staff and visitors during a fire event.

Findings include:

On September 26, 2022, at 3:00pm while in the company of SC, it was observed in Clean Utility 4119 that the facility did not maintain 18-inch clearance from the bottom of sprinkler heads to obstructions. This does not comply with NFPA 13-2010 8.5.6.1.

Based on observation the facility lacks complete sprinkler protection. Failure to install and maintain this installation could result in delayed response and fire suppression. This deficient practice could affect patients, staff and visitors during a fire event.

Findings include:

A. On 09/27/22 at 10:04 AM accompanied by LM, sprinkler heads are not installed at Basement landing for Exit Stair #7. This condition does not comply with NFPA 13, 2010, 8.10.6, 8.15.

B. On 09/27/22 at 2:53 PM accompanied by SD and LE, a sprinkler head was wrapped in a towel preventing proper coverage in Neuro EMG Office Storage Room/Mechanical Room TB055. This condition does not comply with NFPA 13, 2010, 8.6.

C. While accompanied by the SD and LE, missing or damaged ceiling tiles were observed. This condition can delay activation of a sprinkler head by allowing heat and combustive materials to bypass the sprinkler. This condition does not comply with NFPA 13-2010, 8.6.4.1. Example locations observed:
1. On 09/27/22 at 2:09 PM located in Lower Level, Elevator Equipment Room #B-130.
2. On 09/27/22 at 2:32 PM located in Lower Level, Telecommunications Room #B-109.
3. On 09/27/22 at 2:49 PM located in Lower Level, EMG Exam Room #TB077.
4. On 09/28/22 at 9:10 AM located in Lower Level, Data Center 034.

D. On 09/27/22, while in the company of the SD and LE, the surveyor observed a missing escutcheon around the annular opening for a concealed sprinkler in the ceiling. This does not comply with NFPA 13, 2010 6.2.7.1. Example location:
1. At 2:46 PM, in the Lower Level, Neuro EMG Offices TB063-65

E. On 09/27/22, while in the company of SD and LE, the surveyor observed the facility did not maintain 18-inch clearance from the bottom of sprinkler heads to obstructions. This does not comply with NFPA 13, 2010 8.5.6.1. Example locations include:
1. At 12:54 PM located in Lower Level, Central Storage, Room #B-134D.
2. At 2:15 PM located in Lower Level Storage Room #B-213
3. At 2:26 PM located in Lower Level, Neuro EMG Offices Room #TB065.


45373


F. On 09/27/2022, at 10:40 am while in the company of the SD & LE, it was observed that sprinkler head at the 2nd floor North Janitor Closet near Room # 215 is missing escutcheon ring and/or cover plate. This installation does not comply with 2010 Edition of NFPA 13, Section 6.2.7.2.

G. On 09/27/2022, at 10:50 am while in the company of the SD & LE, it was observed at the 2nd floor South Storage Room near Room # 236, clearance between sprinkler heads and storage/storage shelf is not provided 18" or more in accordance with 2010 Edition of NFPA 13, Section 8.5.6.1.

Based on observation, the facility failed to conduct required maintenance and testing necessary to maintain the sprinkler system. This deficient practice could affect patients, staff and visitors, if a sprinkler system failed to function as designed due to the lack of required maintenance and testing.

The finding is:

On 09/28/2022 at 2:12 PM, accompanied by the FM, observation determined that the facility had failed to maintain sprinkler heads free of foreign materials. A sprinkler head was covered with plastic which does not comply with NFPA 25 2011 Edition, Section 5.2.1.1. Location observed First floor Linen chute

Based on observation, not all corridor doors are installed and maintained to remain in the closed position. This deficient practice could affect patients, staff, and visitors in the building because smoke and fire could pass into corridors if the corridor doors are not installed in a compliant manner.

The finding is:

On 09/27/2022 at 1:38pm while accompanied by the FM corridor doors do not latch to a closed position which does not comply with 19.3.6.3.
Example locations observed:

1. Pair of corridor doors from ED suite to Corridor #1799EB (part of waiting area).
2. Pair of corridor doors from ED suite to Corridor #1799EP (adjacent to EVS/sprinkler rm)
3. Pair of corridor doors from ED suite (corr #1799EX) to Corridor #1799EN (adjacent to Triage A)
4. Pair of door to Storage 1311P from Corridor #1399PC are slow auto closing that do not latch.

Based on observation, the facility failed to maintain the smoke barrier doors. This deficient practice could affect the safety of patients, staff, and visitors if smoke from a fire was allowed to pass from one smoke compartment to an adjacent smoke zone.

The finding is:

On 09/27/22 at 10:36 AM, while accompanied by LM, an observation revealed that the cross-corridor smoke barrier doors between Corridor TB100 and Corridor TB010 did not close to a smoke tight condition in accordance with NFPA 101, 2012 Edition, Section 19.3.7.8.

Based on observation, the facility failed to provide access to fire protection appliances within the ventilation duct system. This deficient practice could affect patients, staff and visitors during a fire event if failure to install and maintain this installation would result in the passage of fire and products of combustion from one fire compartment to another.

The finding is:

A. On 09/27/2022 at 1:22am while accompanied by the FM it was identified that a damper acess panel on the side of a duct which is positioned in a manner that does not allow for the complete opening of the duct access panel or observation of the damper for inspection. This duct penetrates a designated 2-hour fire rated barrier wall. The inability to access dampers for inspection and maintenance does not comply with NFPA 80-2010, 19.2.3.
Location observed:
1st floor above pair of cross corridor doors south wall of corridor 1699SK (corridor serves Stair #2) NFPA 90A 2012 4.3.5.1.1

Based on observation the facility failed to provide hazardous duct assemblies in a manner which meets the manufacturer's requirements along with codes and industry standards. The failure to provide adequate ventilation systems for hazardous equipment due to a chimney effect could affect the staff, patients and visitors throughout the facility during a fire event.

Findings include:

B. On 09/26/2022 at 2:03pm while accompanied by the FM observation of a kitchen grease hood exhaust duct was observed within the same enclosure as supply/return ducts, piping and wiring serving other areas of the facility. This condition does not comply NFPA 96. 2008 7.1.3.1 and 7.7.2.1.2 for a minimum 2-hour fire rated enclosure of the grease duct itself. Location observed, large shaft within the Mechanical penthouse

C. On 09/26/2022 at 2:20pm while accompanied by the FM observation of the kitchen grease hood exhaust fan assemblies installed in the mechanical penthouse adjacent to the shaft contains flexible connections which does not comply with NFPA 96, 2008 8.1.3.5.

D. On 09/26/2022 at 2:06pm while accompanied by the FM observation of the kitchen grease hood exhaust fan installed in the mechanical penthouse did not appear to contain a drain directly to a visible grease receptacle to comply with NFPA 96, 2008 8.1.3.6.

E. On 09/26/2022 at 2:28pm while accompanied by the FM observation of the horizontal grease duct installation showed no access panels to comply with NFPA 96, 2008 7.3.1 for change in direction, and 7.4.1 regarding any accessible openings for access and cleaning. Location observed mechanical penthouse

Based on observation elevator hoistways are constructed to maintain a fire rated enclosure which does not allow smoke and fire to enter the elevator car. The facility failed to provide an enclosure which maintains the fire safety of patients, visitors and staff.

The finding is:

On 09/26/2022 at 2:40pm while accompanied by the FM elevator shafts were observed which contain vertical metal ducts at the top of each hoistway. Location observed: A minimum of four elevator shafts within the Mechanical Penthouse. The ductwork appears to be part of a smoke control system for elevator pressurization and zoned smoke control. This installation does not comply with NFPA 92 2012 4.3.1, 4.7, 8.4.6.7.3 and NFPA 101 8.6 fire rated vertical openings due to the following:

1. The elevator hoistway shafts contains a large hole cut into the concrete top of shaft/floor of penthouse which does not comply with 8.6.4 for the requirments of a shaft that does not extend through the top of the building.

2. The shafts do not comply with 8.6.4.2 due to the termination of the shaft within a mechanical penthouse which is not of the same fire resistant construction as the shafts and further contains equipment not related to the elevator hoistways.

3. The elevator hoistways do not comply with 8.3.4.2 for a continuous 2-hour fire rating due to the connection of a non fire rated sheet metal duct at the top of the shafts. In one location the metal ducts are attached to a sheet metal "curb" surrounding the top of the elevator hoistway. In other locations the ducts tie directly to the top of the shafts with horizontal duct runs to the exterior walls of the penthouse.

4. The ducts which extend vertically from the sheet metal curb through the mechanical penthouse, contain horizontal damper installations which are located between the metal curb and the metal ducts. This condition does not comply with 8.6.4.3.

Based on observation, soiled linen chutes are not protected. Failure to protect these areas during a fire/smoke event, permits fire/smoke to migrate from one room or area to other floor levels rather than being contained.

The finding is:

On 09/28/2022, at 9:55am while in the company of the FM, it was observed that the first floor linen chute door does not self close to a latched position to comply with 19.5.4. and 8.3.3.3.

Based on observation and staff interview during the building tour the facility lacks complete protection of the medical gas piping system. Failure to install and maintain this installation could result in failure of the piping system. This deficient practice could affect patients, staff, and visitors.

Findings include:

A. On September 26, 2022, at 3:15pm while in the company of the SC, it was observed above the Northwest wing 4th floor ceiling that medical gas system piping is supported by a dissimilar metal not in accordance with NFPA 99-2012, 5.1.10.11.4.2. and not otherwise properly insulated to comply with NFPA 99-2012, 5.1.10.11.4.4.

B. On September 28, 2022, at 11:00am while in the company of the FM and SC, it could not be confirmed through direct observation upon conclusion of the walk-through portion of the survey that electrical bonding of the facility's medical gas piping system has been completed. This is not in compliance with NFPA 70-2011, 250.104 (B).

Based on observation and staff interview, the facility lacks complete electrical bonding of the medical gas piping system. Failure to install and maintain this installation could potentially result in the piping system becoming electrically energized. This deficient practice could affect patients, staff and visitors.

Findings include:

On 09/28/2022, at 10:05 am while in the company of the SD & LE, it could not be confirmed through direct observation that electrical bonding of the facility's medical gas piping system has been completed. This is not in compliance with 2011 Edition of NFPA 70, Section 250.104 (B).

Based on observation, portions of the facility lack identification of the medical gas piping systems. Failure to label this installation could result in misuse or disruption of medical gas services. This deficient practice could affect patients and staff if services were unexpectantly disrupted.

Findings include:

A. On September 26, 2022, while in the company of the SC, it was observed that medical gas system piping is not labeled in accordance with NFPA 99-2012, 5.3.11.1.1.

Locations include:

1. At 2:15pm above the 5th floor G.I. Department ceiling

2. At 3:15pm above the Northwest wing 4th floor ceiling

Based upon observation, electrical systems are not installed and maintained in accordance with Code requirements. This deficient practice could affect patients, staff and visitors if failure to install and maintain the building's electrical systems could result in electrical shock hazards or loss of essential power for life support or means of egress lighting

Findings include:

A. On 09/27/2022 at 1:52 PM, while accompanied by the FM, observation determined that, the electrical panel within the ICU is not provided with accurate panel directory to comply with NFPA 70 2011 408-4(A). Location observed electrical closet adjacent to ICU room #5 panel PLN

B. On 09/27/2022 at 1:54 PM, while accompanied by the FM, observation determined that electrical panels example location - panel PLN contain mixed electrical loads supplying both Life Safety, Critical and Normal Branch. This does not comply with NFPA 99-2012, 6.4.2.2.3 and NFPA 70 2011 517-32.

C. On 09/27/2022 at 1:45pm while accompanied by the FM surveyor's observation determined that critical care patient beds lack electrical receptacles served by normal power to comply with NFPA 70 2011 517-19(A).
Example locations :
1. Intensive Care Unit
2. Same Day Recovery

D. On 09 27/2022 at 1:50pm while accompanied by the FM critical care patient beds are served by emergency outlets with power distribution from the same transfer switch which does not comply with NFPA 70 2011 517-19(B).
Example locations:
1. Intensive Care Unit
2. Same Day Recovery

E. On 09/27/2022 at 2:25pm while accompanied by the FM observation determined that, general patient care areas contain electrical outlets (emergency and normal power) which are on both of the electrical panels 1LNL, 1LCL These panel directories are not accurate to comply with NFPA 70 2011 408-4(A). Further, both electrical panels are served by the same ATS (automatic transfer switch) which does not comply with NFPA 70 2011, 517-18(A), 700-5. Example location: Emergency department exam rooms


44908


Based on the observation the facility failed to properly install electrical wiring. Improper electrical wiring could cause electrocution or an electrical fire. This deficient practice could affect the safety of patients, staff, and visitors.

The finding is:

F. On 09/27/22 at 10:52 AM accompanied by LM, it was observed in the Lower Level, Glass Washing Room #B24 that a cover plate was observed missing on an electrical junction box which does not comply with NFPA 70-2011, 314.28C

Based on observation, ground fault circuit interruption (GFCI) is not provided in accordance with Code requirements. If GFCI protection is not provided, the circuit remains an electrical shock hazard to occupants. This deficient practice could affect the safety of patients, staff, and visitors.

Findings include:

A. On 09/27/22 at 10:52 AM accompanied by LM, it was observed in the Lower Level, Glass Washing Room #B24 that a strip of power receptacles which are less than 6'-0" from a sink are not provided with GFCI protection to comply with NFPA 70-2011, 210.8(B)(5).


45373


B. On 09/27/2022, at 10:15 am while in the company of the SD & LE, it was observed that electrical receptacle at the 2nd floor East Medication Room's Restroom near Room # 257 is within 6'-0" of sink and is not provided with GFCI protection to prevent shock injuries and electrical burns in accordance with 2011 Edition of NFPA 70, Section 210.8(B)(5).

C. On 09/27/2022, at 10:25 am while in the company of the SD & LE, it was observed that electrical receptacle at the 2nd floor Restroom near East Conference Room is within 6'-0" of sink and is not provided with GFCI protection to prevent shock injuries and electrical burns in accordance with 2011 Edition of NFPA 70, Section 210.8(B)(5).

Based upon observation and staff interview, not all patient bed locations are provided with electrical power in accordance with Code requirements. Failure to provide electrical power at patient bed locations can disrupt use of bedside equipment used by patients.

Findings include:

On September 27, 2022, at 10:00am while in the company of the SC it was observed that the 2nd floor Cysto. Procedure Room lacked both normal power and emergency power to comply with NFPA 70-2011, 517.19(A)

Based on direct observation and staff interview it appears that emergency power is not properly divided into three branches. The facility failed to provide identification of emergency transfer switches and distribution panels. An emergency electrical system which is not readily identified as an emergency system by operating personnel could effect all occupants of the building if the emergency power failed to operate properly upon loss of normal power.

The findings include:

A. On 09/28/2022 at 9:45am while accompanied by the FM the surveyor requested a one line electrical diagram for the building. The one line diagram did not indicate which branch of the EES was served by each transfer switch (NFPA 70-700-5, 700-7, 700-10. Transfer switches which are not labeled per the branch served, provide no information which confirms anything other than one branch of the EES is solely being tested. Therefore it cannot be confirmed that the monthly test of a transfer switch concludes the transfer from standard to alternate power for critical vs life safety vs equipment to comply with NFPA 110, 2010 8.4.6.1.

B. On 09/28/2022 at 9:55am while accompanied by the FM and FD during on site discussion facility staff indicated that the 68' and 76' wings emergency electrical system is not separated into Life Safety branch, Critical branch & Equipment branch. This condition does not comply with NFPA 99-2012, 6.3.2.2.10.1 as a Type 1 EES