HospitalInspections.org

The inspector observed, while accompanied by the Safety Officer, Assistant Director, and Maintenance Project Lead, during the hours of the inspection from 9:30AM to 4:00 PM on 05/27/2015 and from 9:30AM to 6:00 PM on 5/28/2015 that there was the following issues:

A) Based on observation in the Schuster 1st floor west, sleep study area, exit door number 09 which is in means of egress was stuck and therefore did not operate properly.

" An exit enclosure shall not be used for any purpose that has the potential to interfere with its use as an exit and, if so designated, as an area of refuge. (See also 7.2.2.5.3.) " NFPA 101, 2003: 7.1.3.2.3

The inspector observed, while accompanied by the Safety Officer, Assistant Director, and Maintenance Project Lead, during the hours of the inspection from 9:30AM to 4:00 PM on 05/27/2015 and from 9:30AM to 6:00 PM on 5/28/2015 that there was the following issues:

A) In the Pump Room in the Young tower basement floor, the door into the Pump Room did not latch, there was no door closer, and the door was not fire rated.

" Doors to hazardous areas shall be self-closing or automatic-closing in accordance with 10.2.2.3. " -NFPA 101, 2003, 20.3.2.1.

" Doors in a 2 hour fire rated barrier shall be 90 minute rated fire door assemblies. " - NFPA 101, 2003: Table 8.3.4.2.

" Only labeled door frames shall be used in a rated fire door assembly. " - NFPA 80, 1999, 2-3.1.1.

The inspector observed, while accompanied by the Safety Officer, Assistant Director, and Maintenance Project Lead, during the hours of the inspection from 9:30AM to 4:00 PM on 05/27/2015 and from 9:30AM to 6:00 PM on 5/28/2015 that there was the following issues:

A) In the kitchen area in Schuster tower ground floor, one type K fire extinguisher had a broken built-in pressure gauge and therefore needed replacement.

" Class K fire extinguishers shall be provided for hazards where there is a potential for fires involving combustible cooking media (vegetable or animal oils and fats) " - NFPA 10, 2002: 5.7.1.

The inspector observed, while accompanied by the Safety Officer, Assistant Director, and Maintenance Project Lead, during the hours of the inspection from 9:30AM to 4:00 PM on 05/27/2015 and from 9:30AM to 6:00 PM on 5/28/2015 that there were the following issues:

A) Based on observation in the Schuster tower ground floor, room TG187, there were gas bottles stored in the same enclosed area as electrical devices such as Ethernet switches.
B) Based on observation in the Schuster tower ground floor, room TG187, there was a receptacle on the finished floor not wall mounted which could pose safety and tripping hazard for maintenance worker.
C) Based on observation in the Schuster tower ground floor, room TG187, verify that adequate ventilation is provided for indoor gas storage.


Level 1 Med Gas System: " Wherever the terms medical gas or vacuum occur, the provisions shall apply to all piped systems for oxygen, nitrous oxide, medical air, carbon dioxide, helium, nitrogen, medical surgical vacuum, waste anesthetic gas disposal, and mixtures thereof. Wherever the name of a specific gas or vacuum service occurs, the provision shall apply only to that gas. " - NFPA 99, 2002:5.1.1.2

" Locations for supply systems shall not be used for storage purposes other than for containers of nonflammable gases except that storage of full or empty containers shall be permitted. " -NFPA 99, 2002, 5.3.3.3.2.3

" Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft above the floor to avoid physical damage. " - NFPA 99, 1999: 4-3.1.1.2 (a) 11(d).

" Other nonflammable medical gas supply systems or storage locations shall be permitted to be in the same location with oxygen or nitrous oxide, or both, provided adequate ventilation to prevent the development of oxygen deficient atmospheres in the event of functioning of cylinder or manifold pressure relief devices is provided. " -NFPA 99, 2002, 5.3.3.2.4

The inspector observed, while accompanied by the Safety Officer, Assistant Director, and Maintenance Project Lead, during the hours of the inspection from 9:30AM to 4:00 PM on 05/27/2015 and from 9:30AM to 6:00 PM on 5/28/2015 that there was the following issues:

A) The battery for the battery powered lighting fixture was no longer charging and thus needed to be replaced at the Cogeneration Building location of the hospital.

" The emergency generator location shall have task illumination, battery charger for emergency battery powered lighting unit(s), and selected receptacles at the generator set location " - NFPA 99, 1999: 3-4.2.2.2.(b)5.

The inspector observed, while accompanied by the Safety Officer, Assistant Director, and Maintenance Project Lead, during the hours of the inspection from 9:30AM to 4:00 PM on 05/27/2015 and from 9:30AM to 6:00 PM on 5/28/2015 that there was the following issues:

A) Based on observation of the emergency generator log, maintained by the facility, there existed gaps in the weekly inspection of generator and batteries per NFPA 110:3.5.1.2.3(b) and NFPA 99:3-4.4.1.3 for the year 2014-2015.

Generators are inspected weekly and exercised under load for 30 minutes per month in accordance with NFPA 99, 3.4.4.1, and NFPA 110, 6-4.2.

The inspector observed, while accompanied by the Safety Officer, Assistant Director, and Maintenance Project Lead, during the hours of the inspection from 9:30AM to 4:00 PM on 05/27/2015 and from 9:30AM to 6:00 PM on 5/28/2015 that there was the following issues:

A) Based on observation of the entire facility (Schuster tower, Young tower, and Hilton tower), Emergency System receptacles in critical care areas were either not labeled or had removable labels that were in the process of aging and displayed obvious sign of peeling.

" Critical Care Areas: Patient Bed Location Branch Circuits. Each patient bed location shall be supplied by at least two branch circuits, one or more from the emergency system and one or more circuits from the normal system. At least one branch circuit from the emergency system shall supply an outlet(s) only at that bed location. All branch circuits from the normal system shall be from a single panel board. Emergency System receptacles shall be identified and shall also indicate the panelboard and circuit number supplying them. " NFPA 70, 2002, 517.19(A).

The inspector observed, while accompanied by the Safety Officer, Assistant Director, and Maintenance Project Lead, during the hours of the inspection from 9:30AM to 4:00 PM on 05/27/2015 and from 9:30AM to 6:00 PM on 5/28/2015 that there was the following issues:

A) Based on observation in the Schuster 1st floor west, sleep study area, exit door number 09 which is in means of egress was stuck and therefore did not operate properly.

" An exit enclosure shall not be used for any purpose that has the potential to interfere with its use as an exit and, if so designated, as an area of refuge. (See also 7.2.2.5.3.) " NFPA 101, 2003: 7.1.3.2.3

The inspector observed, while accompanied by the Safety Officer, Assistant Director, and Maintenance Project Lead, during the hours of the inspection from 9:30AM to 4:00 PM on 05/27/2015 and from 9:30AM to 6:00 PM on 5/28/2015 that there was the following issues:

A) In the Pump Room in the Young tower basement floor, the door into the Pump Room did not latch, there was no door closer, and the door was not fire rated.

" Doors to hazardous areas shall be self-closing or automatic-closing in accordance with 10.2.2.3. " -NFPA 101, 2003, 20.3.2.1.

" Doors in a 2 hour fire rated barrier shall be 90 minute rated fire door assemblies. " - NFPA 101, 2003: Table 8.3.4.2.

" Only labeled door frames shall be used in a rated fire door assembly. " - NFPA 80, 1999, 2-3.1.1.

The inspector observed, while accompanied by the Safety Officer, Assistant Director, and Maintenance Project Lead, during the hours of the inspection from 9:30AM to 4:00 PM on 05/27/2015 and from 9:30AM to 6:00 PM on 5/28/2015 that there was the following issues:

A) In the kitchen area in Schuster tower ground floor, one type K fire extinguisher had a broken built-in pressure gauge and therefore needed replacement.

" Class K fire extinguishers shall be provided for hazards where there is a potential for fires involving combustible cooking media (vegetable or animal oils and fats) " - NFPA 10, 2002: 5.7.1.

The inspector observed, while accompanied by the Safety Officer, Assistant Director, and Maintenance Project Lead, during the hours of the inspection from 9:30AM to 4:00 PM on 05/27/2015 and from 9:30AM to 6:00 PM on 5/28/2015 that there were the following issues:

A) Based on observation in the Schuster tower ground floor, room TG187, there were gas bottles stored in the same enclosed area as electrical devices such as Ethernet switches.
B) Based on observation in the Schuster tower ground floor, room TG187, there was a receptacle on the finished floor not wall mounted which could pose safety and tripping hazard for maintenance worker.
C) Based on observation in the Schuster tower ground floor, room TG187, verify that adequate ventilation is provided for indoor gas storage.


Level 1 Med Gas System: " Wherever the terms medical gas or vacuum occur, the provisions shall apply to all piped systems for oxygen, nitrous oxide, medical air, carbon dioxide, helium, nitrogen, medical surgical vacuum, waste anesthetic gas disposal, and mixtures thereof. Wherever the name of a specific gas or vacuum service occurs, the provision shall apply only to that gas. " - NFPA 99, 2002:5.1.1.2

" Locations for supply systems shall not be used for storage purposes other than for containers of nonflammable gases except that storage of full or empty containers shall be permitted. " -NFPA 99, 2002, 5.3.3.3.2.3

" Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft above the floor to avoid physical damage. " - NFPA 99, 1999: 4-3.1.1.2 (a) 11(d).

" Other nonflammable medical gas supply systems or storage locations shall be permitted to be in the same location with oxygen or nitrous oxide, or both, provided adequate ventilation to prevent the development of oxygen deficient atmospheres in the event of functioning of cylinder or manifold pressure relief devices is provided. " -NFPA 99, 2002, 5.3.3.2.4

The inspector observed, while accompanied by the Safety Officer, Assistant Director, and Maintenance Project Lead, during the hours of the inspection from 9:30AM to 4:00 PM on 05/27/2015 and from 9:30AM to 6:00 PM on 5/28/2015 that there was the following issues:

A) The battery for the battery powered lighting fixture was no longer charging and thus needed to be replaced at the Cogeneration Building location of the hospital.

" The emergency generator location shall have task illumination, battery charger for emergency battery powered lighting unit(s), and selected receptacles at the generator set location " - NFPA 99, 1999: 3-4.2.2.2.(b)5.

The inspector observed, while accompanied by the Safety Officer, Assistant Director, and Maintenance Project Lead, during the hours of the inspection from 9:30AM to 4:00 PM on 05/27/2015 and from 9:30AM to 6:00 PM on 5/28/2015 that there was the following issues:

A) Based on observation of the emergency generator log, maintained by the facility, there existed gaps in the weekly inspection of generator and batteries per NFPA 110:3.5.1.2.3(b) and NFPA 99:3-4.4.1.3 for the year 2014-2015.

Generators are inspected weekly and exercised under load for 30 minutes per month in accordance with NFPA 99, 3.4.4.1, and NFPA 110, 6-4.2.

The inspector observed, while accompanied by the Safety Officer, Assistant Director, and Maintenance Project Lead, during the hours of the inspection from 9:30AM to 4:00 PM on 05/27/2015 and from 9:30AM to 6:00 PM on 5/28/2015 that there was the following issues:

A) Based on observation of the entire facility (Schuster tower, Young tower, and Hilton tower), Emergency System receptacles in critical care areas were either not labeled or had removable labels that were in the process of aging and displayed obvious sign of peeling.

" Critical Care Areas: Patient Bed Location Branch Circuits. Each patient bed location shall be supplied by at least two branch circuits, one or more from the emergency system and one or more circuits from the normal system. At least one branch circuit from the emergency system shall supply an outlet(s) only at that bed location. All branch circuits from the normal system shall be from a single panel board. Emergency System receptacles shall be identified and shall also indicate the panelboard and circuit number supplying them. " NFPA 70, 2002, 517.19(A).