HospitalInspections.org

This STANDARD is not met as evidenced by:

Observations revealed that there were several fire barriers located throughout the facility that did not meet the rated requirements for two hour fire separation and are not in accordance with NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 19.1.1.4.3,. These deficient practices could allow the products of combustion to travel from one building to another, which could negatively impact all the patients, staff and visitors of the facility.

Findings include:

On facility tour between 2:00 PM on 08/01/2011 to 12:30 PM on 08/03/2011, observation revealed, that the following deficient conditions were identified:

1. The 2-hour rated building separation wall on the 1st floor between the hospital and on-site clinic is not equipped with the required 90 minute doors, separating 2 out of 2 building separation openings. This was based on life safety drawing provided by the facility.

2. The 2-hour rated building separation wall on the 1st floor between the hospital (I-occupancy) and the emergency room's garage (S- Occupancy) was not equipped with the required 90 minute doors nor did the existing doors positively latch when closed,

3. In Stairwell B (B-075) on the C-Level, the door going from stairwell to construction area was not equipped with the required 90 minute fire rated door and a 90 minute fire rated glass.

4. In Stairwell B (B-075) on the C-Level an open penetration from an open end conduit was identified on the construction side of the stairwell.

5. The 1 hour rated construction wall separating the existing building from the new construction located next to fire alarm room B063 has multiple penetrations above the ceiling tile.

6. The 2 hour occupancy separation wall near rooms 1030/1075 was equipped with a fire door that had only a 20 minute fire rating and not the required 90-minute fire rated door.

7. The 2 hour fire separation wall separating the garage from the emergency room is equipped with only a 45-minute fire rated door and not the required 90-minute fire door.


These deficient practices were confirmed by the Director of Maintenance (AA) and Director, Facility Management (DL)at the time of discovery.

This STANDARD is not met as evidenced by:

Based on observations, the facility has failed to provide proper protection for several hazardous areas located throughout the facility in accordance with NFPA Life Safety Code 101 (2000 edition) section 19.3.2.1. The following deficient practices could affect all patients, staff and visitors as smoke and fire in this rooms could enter the corridor making it untenable.

Findings include:

On facility tour between 2:00 PM on 08/01/2011 to 12:30 PM on 08/03/2011, observation revealed, that the following deficient conditions were identified:

1. 5th floor - Room # 5107, soiled utility room, north door will not fully close and positively latch,

2. Storage room # 5118 (over 50 square feet), will not fully close and positively latch,

3. 6th floor - clean utility room (over 50 square feet), open penetration above ceiling on east wall,

4. The storage room door in the Med Unit 1, was blocked,

5. The soiled receiving door did not positively latch,

6. Accordion doors to the gurney storage room, and the roof access corridors are not self-closing and smoke resistive,

7. The Soiled Linen room door, 4005, will not fully close and positively latch,

8. The accordion doors on the Southwest side of the TCAB Unit are not self-closing and smoke resistant.



These deficient practices were confirmed by the Director of Maintenance (AA) and the Project Manager, Facility Development (GT) at the time of discovery.

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to maintain a fire resistance rating of at least two hour in the exit component accordance with the following requirements of 2000 NFPA 101, Section 19.3.1.2, 8.2.5.2 and 7.1.3.2.1 (e). These deficient practices could allow the products of combustion to travel from the affected building and into the exiting component making it untenable, which could negatively impact all the patients, staff and visitors of the facility.


Findings include:

On facility tour between 2:00 PM on 08/01/2011 to 12:30 PM on 08/03/2011, observation revealed, that the following deficient conditions were identified:

1. Stairwell D - 6th floor had a radio unit mounted with-in stairwell,

2. Stairwell E - 6th floor had an open penetration,

3. In Stairwell F - 7th floor there was a 3 foot long cracks in block wall that went all the way through the blocks.

4. In Stairwell R - 5th floor the fire-stopping is coming out from around the steam line,

5. In Stairwell B - 5th floor there is a crack from the top to the bottom on the hinge side of the door (barcode 2776)


These deficient practices were confirmed by the Director of Maintenance (AA) at the time of discovery.

This STANDARD is not met as evidenced by:

Based on review of reports, records and interview, it was determined that the facility failed to vary the times on numerous fire drills in the last 12-month period. This deficient practice could affect how staff react in the event of a fire. Improper reaction by staff would affect the safety of all residents, visitors and staff.

Findings include:

On facility tour between 2:00 PM 8/1/11 and 12:30 PM on 8/3/11, during a documentation review of the available fire drill reports and interview with the Facility Safety and Security Director (BB), it was revealed that the facility failed to vary the times of the fire drills as follows,

1. 2 Day Shift fire drills were held in the 11am hour,
2. 3 Afternoon Shift fire drills held in the 3pm hour,
3. All 5 of the Overnight Shift fire drills were held in the 6am hour.


This deficient practice was verified by the Director of Safety and Security (BB) at the time of the discovery.

This STANDARD is not met as evidenced by:

Based on review of reports, records and interview, it was determined that the facility failed to vary the times on numerous fire drills in the last 12-month period. This deficient practice could affect how staff react in the event of a fire. Improper reaction by staff would affect the safety of all residents, visitors and staff.

Findings include:

On facility tour between 2:00 PM 8/1/11 and 12:30 PM on 8/3/11, during a documentation review of the available fire drill reports and interview with the Facility Safety and Security Director (BB), it was revealed that the facility failed to vary the times of the fire drills as follows,

1. 2 Day Shift fire drills were held in the 11am hour,
2. 3 Afternoon Shift fire drills were held in the 3pm hour,
3. all 5 Overnight Shift fire drills were held in the 6am hour.


This deficient practice was verified by the Director of Safety and Security (BB) at the time of the discovery.

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to install and maintain the fire alarm system in accordance with the requirements of 2000 NFPA 101, Sections 19.3.4.1 and 9.6, as well as 1999 NFPA 72, Sections 2-3.4.5.1.2, 2-3.5.1. These deficient practices could adversely affect the functioning of the fire alarm system that could delay the timely notification and emergency actions for the facility thus negatively affecting all patients, staff, and visitors of the facility.


Findings include:


On facility tour between 2:00 PM on 08/01/2011 to 12:30 PM on 08/03/2011, observation revealed, that the following deficient conditions were identified:

1. On the 6th floor the smoke detectors did not cover all points within 21 feet of the corner in the 6.7 corridor area,

2. On the 6th floor in 6002, there is an area open to corridor that does not have automatic smoke detection,

3. On the 6th floor, smoke detector N4-L6-D78 is located within 3 feet of an air supply diffuser,

4. On the 5th floor Helipad corridor, smoke detector L6-D84 is located within 3 feet of an air supply diffuser,

5. On the 1st. floor in waiting area #1086 which is open to the corridor, the smoke detection does not cover all points within 21 feet of corner,

6. On the 1st floor in waiting area # S1025 an area which is open to corridor, there is no automatic smoke detection.


These deficient practices were confirmed by the Director of Maintenance (AA) at the time of discovery.

This STANDARD is not met as evidenced by:

Based on observation and interview, the facility used portable space heaters in non-resident care areas and failed to follow the policy on the use of portable space heaters in the facility that meets the requirements of NFPA 101-2000 edition, Section 19.7.8. This deficient practice could affect patients, visitors and staff.

Findings include:

On facility tour between 2 PM 8/01/2011 and 12:30 PM on 8/03/11, it was observed that there were portable space heaters located and being used in the facility which are in violation of the facility policy which prohibits the use of space heaters. The portable space heating devices were located in office areas 1334, 1381, and 1368.1.

These deficient practices were confirmed by the Director of Maintenance (AA) and Director, Facility Management (DL)at the time of discovery.

This STANDARD is not met as evidenced by:

Based on observations and interview, the facility has oxygen gas cylinders stored in rooms that are not properly marked as per the requirements of 1999 NFPA 99, Sections 8-3.1.11.3 . This deficient practice could create confusion and delay in an emergency situation when oxygen is needed in a hurry.

Findings include:

On facility tour between 2:00 PM on 08/01/2011 to 12:30 PM on 08/03/2011, observation revealed, that the following deficient conditions:

1. On the 6th floor in room #6087 there are (3) E size oxygen cylinders stored in this room and the entrance door is not properly signed as an O2 storage area.

2. On the 5th floor in room # 5086 there are (6) E size oxygen cylinders stored in this room and both the north and south doors are not properly signed as an O2 storage area.


These deficient practices were confirmed by the Director of Maintenance (AA) at the time of discovery.

This STANDARD is not met as evidenced by:
Based on observation and a staff interview, the facility failed to provide battery-powered emergency light units in accordance with NFPA 99 Health Care Facilities (1999 edition). The deficient practice could negatively affect all patients and staff by delaying the egress from these locations in the event of a power outage.


Findings include:

On facility tour between 2:00 PM on 08/01/2011 to 12:30 PM on 08/03/2011, observation revealed, that both Operating Rooms in the Birthing Center on 3rd floor were not equipped with battery backup emergency lighting.


These deficient practices were confirmed by the Project Manager, Facility Development (GT) at the time of discovery.

This STANDARD is not met as evidenced by:

Observations revealed that there were several fire barriers located throughout the facility that did not meet the rated requirements for two hour fire separation and are not in accordance with NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 19.1.1.4.3,. These deficient practices could allow the products of combustion to travel from one building to another, which could negatively impact all the patients, staff and visitors of the facility.

Findings include:

On facility tour between 2:00 PM on 08/01/2011 to 12:30 PM on 08/03/2011, observation revealed, that the following deficient conditions were identified:

1. The 2-hour rated building separation wall on the 1st floor between the hospital and on-site clinic is not equipped with the required 90 minute doors, separating 2 out of 2 building separation openings. This was based on life safety drawing provided by the facility.

2. The 2-hour rated building separation wall on the 1st floor between the hospital (I-occupancy) and the emergency room's garage (S- Occupancy) was not equipped with the required 90 minute doors nor did the existing doors positively latch when closed,

3. In Stairwell B (B-075) on the C-Level, the door going from stairwell to construction area was not equipped with the required 90 minute fire rated door and a 90 minute fire rated glass.

4. In Stairwell B (B-075) on the C-Level an open penetration from an open end conduit was identified on the construction side of the stairwell.

5. The 1 hour rated construction wall separating the existing building from the new construction located next to fire alarm room B063 has multiple penetrations above the ceiling tile.

6. The 2 hour occupancy separation wall near rooms 1030/1075 was equipped with a fire door that had only a 20 minute fire rating and not the required 90-minute fire rated door.

7. The 2 hour fire separation wall separating the garage from the emergency room is equipped with only a 45-minute fire rated door and not the required 90-minute fire door.


These deficient practices were confirmed by the Director of Maintenance (AA) and Director, Facility Management (DL)at the time of discovery.

This STANDARD is not met as evidenced by:

Based on observations, the facility has failed to provide proper protection for several hazardous areas located throughout the facility in accordance with NFPA Life Safety Code 101 (2000 edition) section 19.3.2.1. The following deficient practices could affect all patients, staff and visitors as smoke and fire in this rooms could enter the corridor making it untenable.

Findings include:

On facility tour between 2:00 PM on 08/01/2011 to 12:30 PM on 08/03/2011, observation revealed, that the following deficient conditions were identified:

1. 5th floor - Room # 5107, soiled utility room, north door will not fully close and positively latch,

2. Storage room # 5118 (over 50 square feet), will not fully close and positively latch,

3. 6th floor - clean utility room (over 50 square feet), open penetration above ceiling on east wall,

4. The storage room door in the Med Unit 1, was blocked,

5. The soiled receiving door did not positively latch,

6. Accordion doors to the gurney storage room, and the roof access corridors are not self-closing and smoke resistive,

7. The Soiled Linen room door, 4005, will not fully close and positively latch,

8. The accordion doors on the Southwest side of the TCAB Unit are not self-closing and smoke resistant.



These deficient practices were confirmed by the Director of Maintenance (AA) and the Project Manager, Facility Development (GT) at the time of discovery.

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to maintain a fire resistance rating of at least two hour in the exit component accordance with the following requirements of 2000 NFPA 101, Section 19.3.1.2, 8.2.5.2 and 7.1.3.2.1 (e). These deficient practices could allow the products of combustion to travel from the affected building and into the exiting component making it untenable, which could negatively impact all the patients, staff and visitors of the facility.


Findings include:

On facility tour between 2:00 PM on 08/01/2011 to 12:30 PM on 08/03/2011, observation revealed, that the following deficient conditions were identified:

1. Stairwell D - 6th floor had a radio unit mounted with-in stairwell,

2. Stairwell E - 6th floor had an open penetration,

3. In Stairwell F - 7th floor there was a 3 foot long cracks in block wall that went all the way through the blocks.

4. In Stairwell R - 5th floor the fire-stopping is coming out from around the steam line,

5. In Stairwell B - 5th floor there is a crack from the top to the bottom on the hinge side of the door (barcode 2776)


These deficient practices were confirmed by the Director of Maintenance (AA) at the time of discovery.

This STANDARD is not met as evidenced by:

Based on review of reports, records and interview, it was determined that the facility failed to vary the times on numerous fire drills in the last 12-month period. This deficient practice could affect how staff react in the event of a fire. Improper reaction by staff would affect the safety of all residents, visitors and staff.

Findings include:

On facility tour between 2:00 PM 8/1/11 and 12:30 PM on 8/3/11, during a documentation review of the available fire drill reports and interview with the Facility Safety and Security Director (BB), it was revealed that the facility failed to vary the times of the fire drills as follows,

1. 2 Day Shift fire drills were held in the 11am hour,
2. 3 Afternoon Shift fire drills held in the 3pm hour,
3. All 5 of the Overnight Shift fire drills were held in the 6am hour.


This deficient practice was verified by the Director of Safety and Security (BB) at the time of the discovery.

This STANDARD is not met as evidenced by:

Based on review of reports, records and interview, it was determined that the facility failed to vary the times on numerous fire drills in the last 12-month period. This deficient practice could affect how staff react in the event of a fire. Improper reaction by staff would affect the safety of all residents, visitors and staff.

Findings include:

On facility tour between 2:00 PM 8/1/11 and 12:30 PM on 8/3/11, during a documentation review of the available fire drill reports and interview with the Facility Safety and Security Director (BB), it was revealed that the facility failed to vary the times of the fire drills as follows,

1. 2 Day Shift fire drills were held in the 11am hour,
2. 3 Afternoon Shift fire drills were held in the 3pm hour,
3. all 5 Overnight Shift fire drills were held in the 6am hour.


This deficient practice was verified by the Director of Safety and Security (BB) at the time of the discovery.

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to install and maintain the fire alarm system in accordance with the requirements of 2000 NFPA 101, Sections 19.3.4.1 and 9.6, as well as 1999 NFPA 72, Sections 2-3.4.5.1.2, 2-3.5.1. These deficient practices could adversely affect the functioning of the fire alarm system that could delay the timely notification and emergency actions for the facility thus negatively affecting all patients, staff, and visitors of the facility.


Findings include:


On facility tour between 2:00 PM on 08/01/2011 to 12:30 PM on 08/03/2011, observation revealed, that the following deficient conditions were identified:

1. On the 6th floor the smoke detectors did not cover all points within 21 feet of the corner in the 6.7 corridor area,

2. On the 6th floor in 6002, there is an area open to corridor that does not have automatic smoke detection,

3. On the 6th floor, smoke detector N4-L6-D78 is located within 3 feet of an air supply diffuser,

4. On the 5th floor Helipad corridor, smoke detector L6-D84 is located within 3 feet of an air supply diffuser,

5. On the 1st. floor in waiting area #1086 which is open to the corridor, the smoke detection does not cover all points within 21 feet of corner,

6. On the 1st floor in waiting area # S1025 an area which is open to corridor, there is no automatic smoke detection.


These deficient practices were confirmed by the Director of Maintenance (AA) at the time of discovery.

This STANDARD is not met as evidenced by:

Based on observation and interview, the facility used portable space heaters in non-resident care areas and failed to follow the policy on the use of portable space heaters in the facility that meets the requirements of NFPA 101-2000 edition, Section 19.7.8. This deficient practice could affect patients, visitors and staff.

Findings include:

On facility tour between 2 PM 8/01/2011 and 12:30 PM on 8/03/11, it was observed that there were portable space heaters located and being used in the facility which are in violation of the facility policy which prohibits the use of space heaters. The portable space heating devices were located in office areas 1334, 1381, and 1368.1.

These deficient practices were confirmed by the Director of Maintenance (AA) and Director, Facility Management (DL)at the time of discovery.

This STANDARD is not met as evidenced by:

Based on observations and interview, the facility has oxygen gas cylinders stored in rooms that are not properly marked as per the requirements of 1999 NFPA 99, Sections 8-3.1.11.3 . This deficient practice could create confusion and delay in an emergency situation when oxygen is needed in a hurry.

Findings include:

On facility tour between 2:00 PM on 08/01/2011 to 12:30 PM on 08/03/2011, observation revealed, that the following deficient conditions:

1. On the 6th floor in room #6087 there are (3) E size oxygen cylinders stored in this room and the entrance door is not properly signed as an O2 storage area.

2. On the 5th floor in room # 5086 there are (6) E size oxygen cylinders stored in this room and both the north and south doors are not properly signed as an O2 storage area.


These deficient practices were confirmed by the Director of Maintenance (AA) at the time of discovery.

This STANDARD is not met as evidenced by:
Based on observation and a staff interview, the facility failed to provide battery-powered emergency light units in accordance with NFPA 99 Health Care Facilities (1999 edition). The deficient practice could negatively affect all patients and staff by delaying the egress from these locations in the event of a power outage.


Findings include:

On facility tour between 2:00 PM on 08/01/2011 to 12:30 PM on 08/03/2011, observation revealed, that both Operating Rooms in the Birthing Center on 3rd floor were not equipped with battery backup emergency lighting.


These deficient practices were confirmed by the Project Manager, Facility Development (GT) at the time of discovery.