HospitalInspections.org

Based on direct observations, the facility failed to provide a proper 2-hour fire barrier. This deficient practice could affect patients, staff and visitors, if a fire was allowed to spread into the facility from the adjacent building.

Findings include:

A. On 10/5/2015 at 12:25 PM, while accompanied by the Director of Facilities it was determined by observations that on the 5th floor, north wing, 2-HR fire rated double doors only contained 1 latching point at the head of each door leaf. Bottom vertical rods were installed but were not functioning and the floor was not installed with a receiver. This does not comply with NFPA 101, Section 19.1.2.3 and NFPA 80, Section 3-4.3.2.

B. On 10/5/2015 at 2:25 PM, while accompanied by the Director of Facilities it was determined by observations that on the 2nd floor, adjacent to the surgery suite, north wing the 2-HR fire rated double doors only contained 1 latching point at the head of each door leaf. Bottom vertical rods were not installed. This does not comply with NFPA 101, Section 19.1.2.3 and NFPA 80, Section 3-4.3.2.

C. On 10/6/2015 at 10:44 AM, while accompanied by the Director of Facilities it was determined by observations that on the first floor, south ER public corridor the Bottom vertical rods were not installed. The doors were prepped for the installation of a thermal pin but it was not installed. This does not comply with NFPA 101, Section 19.1.2.3 and NFPA 80, Section 3-4.3.2.

D. On 10/6/2015 at 11:20 AM, while accompanied by the Director of Facilities it was determined by observations that on the first floor, elevator bank of 2 the 2-HR fire rated double doors only contained 1 latching point at the head of each door leaf. Bottom vertical rods were not installed. The doors were prepped for the installation of a thermal pin but it was not installed. This does not comply with NFPA 101, Section 19.1.2.3 and NFPA 80, Section 3-4.3.2.

E. On 10/6/2015 at 2:05 PM, while accompanied by the Director of Facilities it was determined by observations that on the ground floor, adjacent to room G34 the 2-HR fire rated double doors only contained 1 latching point at the head of each door leaf. Bottom vertical rods were not installed. This does not comply with NFPA 101, Section 19.1.2.3 and NFPA 80, Section 3-4.3.2.

Based on direct observations during the survey walk-through, staff interview and review of facility provided information; the construction type of the building does not comply with requirements. This deficient practice could affect patients, staff and visitors present if a lack of protection of the building structure from the effects of fire exposure can cause building collapse prior to evacuation.

Findings include:

On 10/5/2015 at 1:00PM, while accompanied by the Interim Facility Director and Maintenance staff, it was determined by an observation that on the 7th floor, Mechanical Room near Elevator #13, that spray on fire proofing was missing from portions of a structural steel beam. Lack of protection does not comply with the identified Type I (332) construction type in accordance with NFPA 10, Section 19.1.6.2 and NFPA 220, Section 3-1.

Based on direct observations of the placement of exit fixtures it was determined that the facility has not provided approved directional emergency illuminated exit signs readily visible from any direction of exit access where the nearest exit is not apparent. This deficient practice could affect patients, staff and visitors if an evacuation of the building was required and the exits were not properly marked.

A. On 10/5/2015 at 1:05PM, while accompanied by the Interim Facility Director and Maintenance staff, it was observed that in the North End Building, 7th floor Vestibule / Elevator Lobby, exit sign is missing to identify the required egress path to an exit stair. This does not comply with NFPA 101, section 19.2.10.1 and 7.10.1.2.

B. On 10/5/2015 at 1:15PM, while accompanied by the Interim Facility Director and Maintenance staff, an exit sign located above the double doors of the Vestibule / Elevator Lobby near the PICP Nurse Station 778 leads to an incorrect egress to exit. This does not comply with NFPA 101, Section 7.10.1.1.



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C. On 10/6/15 at 9:20 AM, while accompanied by the Director of Facilities it was determined by observations that on the ground floor, cafeteria lacked directional exit signs. The exit signs placed over the exit doors were obscured due to the location of existing structural columns. This does not comply with NFPA 101, Section 19.2.10.1, and section 7.10.

Based on direct observations, the surveyor determined that the required exit enclosures are not installed and maintained. This deficient practice could affect patients, staff and visitors, if fire was allowed to spread into the facility from the adjacent building.

Findings include:

On 10/6/2015, at 11:00AM, while accompanied by the Interim Facility Director and Maintenance Staff it was determined by an observation that on the First Floor, the designated exterior exit door near the MRI Area did not close to positively latch to comply with NFPA 101 2000, Section 19.2.2.2.6, 8.2.3.2.1 and NFPA 80 1999, 2-4.4.3.

Based on direct observations during the survey walk-through, not all exit access doors are arranged so that exits are readily accessible at all times. This deficient practice could affect patients, staff and visitors if the path to an exit is blocked by a locked door.

Findings include:

On 10/5/2015 at 10:00AM, while accompanied by the Interim Facility Director and Maintenance staff, on the 6th Floor, Vestibule / Elevator Lobby, egress double doors were observed that are equipped with magnetic locking devices that required a card reader to open which does not comply with 19.2.2.2.4. The building is not protected throughout by a sprinkler system or fire detection system, so the presence of delayed egress locks or magnetic locking devices are not in compliance with the general requirements of NFPA 101, Section 7.2.1.5.1.

Based on direct observations, the facility failed to provide required illumination that can prevent patients, staff and visitors from safely negotiating the means of egress during failure of normal power.

Findings include:

On October 6, 2015 at 2:30PM, while accompanied by the Interim Facility Director and Maintenance Staff, it was determined through staff interview the required battery powered emergency lighting testing and maintenance is not documented monthly and annually to comply with NFPA 101, Section 7.9.3.

1. Battery powered emergency lighting systems could not be confirmed to be tested every 30 days for duration of 30 seconds to comply with NFPA 110, Section 5-3.2.

2. Battery powered emergency lighting systems could not be confirmed to be tested annually for duration of 90 minutes to comply with NFPA 110, Section 5-3.2.

Based on direct observations during the survey walk through the facility failed to maintain a properly functioning fire alarm system. The installation did not meet all of the code requirements. This could affect patients, staff and visitor if the fire alarm system does not operate properly during a fire emergency.

Findings include:

A. On 10/6/2015, at 10:55AM, , while accompanied by the Interim Facility Director and Maintenance Staff, the surveyor observed a smoke detector, on the First Floor of MRI Waiting Area, which is located too close to a supply air diffuser. This does not comply with NFPA 72 1999 2-3.5.1.

B. On 10/06/15 at 10:00AM, while accompanied by the Interim Facility Director and Maintenance Staff, the surveyor observed on the 6th Floor the double doors to the Vestibule / Elevator Lobby which are equipped with magnetic locking devices, which did not drop out when the fire alarm was activated. This does not comply with NFPA 101 Section 19.2.2.2.4 and 7.2.1.5.1.



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C. On 10/5/15 at 1:45 PM, while accompanied by the Director of Facilities it was determined by observations that on the 3rd floor, LDR suite, men's and women's locker rooms contained 2 sleeping rooms each. The 4 rooms were not installed with fire alarm strobe lights. This does not comply with NFPA 101, Section 19.3.4.1, Section 9.6 and NFPA 72, Section 4-4.4.3.

Based on direct observations, the facility failed to provide proper installation of electrical wiring and devices. This deficient practice could affect patients, staff and visitors if proper illumination of critical building areas were not maintained during an emergency.

Findings include:

On 10/6/15 at 10:15 AM, while accompanied by the Maintenance Mechanic, the surveyor observed that the fire pump location was not equipped with a battery light in accordance with NFPA-20, Section 2-7.4.

Based on direct observations and staff interviews during the survey walk-through, October 5-6, 2015, and based on document review, and staff interview, the surveyors find the facility is not in compliance with the life safety code and other code requirements that are documented under the K-tags of this survey.

Findings include:

Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

Based on direct observations, the facility failed to install electrical wiring in accordance with the National Electrical Code. This deficient practice could affect patients, staff and visitors if improper wiring or labeling of circuits prevented shutoff of devices during or after patient procedures.

Findings include:

A. On 10/5/15 at 1:15 PM, while accompanied by the Maintenance Mechanic, the surveyor observed the recovery area on the second floor was not equipped with a normal receptacle or a critical receptacle from a second transfer switch to meet the requirements of NFPA-70, Section 517-19 and NFPA-99, Section 3-3.2.1.2(a)1.

B. On 10/5/15 at 1:30 PM, while accompanied by the Maintenance Mechanic, the surveyor observed on the 2nd floor, the operating rooms were not equipped with a normal power receptacle or a critical receptacle from a second transfer switch to meet the requirements of NFPA-70, Section 517-19 and NFPA-99, Section 3-3.2.1.2(a)1.

C. On 10/5/15 at 2:20 PM, while accompanied by the Maintenance Mechanic, the surveyor observed on the first floor, the trauma room in the ER, was not equipped with a normal power receptacle or a critical receptacle from a second transfer switch to meet the requirements of NFPA-70, Section 517-19 and NFPA-99, Section 3-3.2.1.2(a)1.

Based on direct observations, the facility failed to provide a proper 2-hour fire barrier. This deficient practice could affect patients, staff and visitors, if a fire was allowed to spread into the facility from the adjacent building.

Findings include:

A. On 10/5/2015 at 12:25 PM, while accompanied by the Director of Facilities it was determined by observations that on the 5th floor, north wing, 2-HR fire rated double doors only contained 1 latching point at the head of each door leaf. Bottom vertical rods were installed but were not functioning and the floor was not installed with a receiver. This does not comply with NFPA 101, Section 19.1.2.3 and NFPA 80, Section 3-4.3.2.

B. On 10/5/2015 at 2:25 PM, while accompanied by the Director of Facilities it was determined by observations that on the 2nd floor, adjacent to the surgery suite, north wing the 2-HR fire rated double doors only contained 1 latching point at the head of each door leaf. Bottom vertical rods were not installed. This does not comply with NFPA 101, Section 19.1.2.3 and NFPA 80, Section 3-4.3.2.

C. On 10/6/2015 at 10:44 AM, while accompanied by the Director of Facilities it was determined by observations that on the first floor, south ER public corridor the Bottom vertical rods were not installed. The doors were prepped for the installation of a thermal pin but it was not installed. This does not comply with NFPA 101, Section 19.1.2.3 and NFPA 80, Section 3-4.3.2.

D. On 10/6/2015 at 11:20 AM, while accompanied by the Director of Facilities it was determined by observations that on the first floor, elevator bank of 2 the 2-HR fire rated double doors only contained 1 latching point at the head of each door leaf. Bottom vertical rods were not installed. The doors were prepped for the installation of a thermal pin but it was not installed. This does not comply with NFPA 101, Section 19.1.2.3 and NFPA 80, Section 3-4.3.2.

E. On 10/6/2015 at 2:05 PM, while accompanied by the Director of Facilities it was determined by observations that on the ground floor, adjacent to room G34 the 2-HR fire rated double doors only contained 1 latching point at the head of each door leaf. Bottom vertical rods were not installed. This does not comply with NFPA 101, Section 19.1.2.3 and NFPA 80, Section 3-4.3.2.

Based on direct observations during the survey walk-through, staff interview and review of facility provided information; the construction type of the building does not comply with requirements. This deficient practice could affect patients, staff and visitors present if a lack of protection of the building structure from the effects of fire exposure can cause building collapse prior to evacuation.

Findings include:

On 10/5/2015 at 1:00PM, while accompanied by the Interim Facility Director and Maintenance staff, it was determined by an observation that on the 7th floor, Mechanical Room near Elevator #13, that spray on fire proofing was missing from portions of a structural steel beam. Lack of protection does not comply with the identified Type I (332) construction type in accordance with NFPA 10, Section 19.1.6.2 and NFPA 220, Section 3-1.

Based on direct observations of the placement of exit fixtures it was determined that the facility has not provided approved directional emergency illuminated exit signs readily visible from any direction of exit access where the nearest exit is not apparent. This deficient practice could affect patients, staff and visitors if an evacuation of the building was required and the exits were not properly marked.

A. On 10/5/2015 at 1:05PM, while accompanied by the Interim Facility Director and Maintenance staff, it was observed that in the North End Building, 7th floor Vestibule / Elevator Lobby, exit sign is missing to identify the required egress path to an exit stair. This does not comply with NFPA 101, section 19.2.10.1 and 7.10.1.2.

B. On 10/5/2015 at 1:15PM, while accompanied by the Interim Facility Director and Maintenance staff, an exit sign located above the double doors of the Vestibule / Elevator Lobby near the PICP Nurse Station 778 leads to an incorrect egress to exit. This does not comply with NFPA 101, Section 7.10.1.1.



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C. On 10/6/15 at 9:20 AM, while accompanied by the Director of Facilities it was determined by observations that on the ground floor, cafeteria lacked directional exit signs. The exit signs placed over the exit doors were obscured due to the location of existing structural columns. This does not comply with NFPA 101, Section 19.2.10.1, and section 7.10.

Based on direct observations, the surveyor determined that the required exit enclosures are not installed and maintained. This deficient practice could affect patients, staff and visitors, if fire was allowed to spread into the facility from the adjacent building.

Findings include:

On 10/6/2015, at 11:00AM, while accompanied by the Interim Facility Director and Maintenance Staff it was determined by an observation that on the First Floor, the designated exterior exit door near the MRI Area did not close to positively latch to comply with NFPA 101 2000, Section 19.2.2.2.6, 8.2.3.2.1 and NFPA 80 1999, 2-4.4.3.

Based on direct observations during the survey walk-through, not all exit access doors are arranged so that exits are readily accessible at all times. This deficient practice could affect patients, staff and visitors if the path to an exit is blocked by a locked door.

Findings include:

On 10/5/2015 at 10:00AM, while accompanied by the Interim Facility Director and Maintenance staff, on the 6th Floor, Vestibule / Elevator Lobby, egress double doors were observed that are equipped with magnetic locking devices that required a card reader to open which does not comply with 19.2.2.2.4. The building is not protected throughout by a sprinkler system or fire detection system, so the presence of delayed egress locks or magnetic locking devices are not in compliance with the general requirements of NFPA 101, Section 7.2.1.5.1.

Based on direct observations, the facility failed to provide required illumination that can prevent patients, staff and visitors from safely negotiating the means of egress during failure of normal power.

Findings include:

On October 6, 2015 at 2:30PM, while accompanied by the Interim Facility Director and Maintenance Staff, it was determined through staff interview the required battery powered emergency lighting testing and maintenance is not documented monthly and annually to comply with NFPA 101, Section 7.9.3.

1. Battery powered emergency lighting systems could not be confirmed to be tested every 30 days for duration of 30 seconds to comply with NFPA 110, Section 5-3.2.

2. Battery powered emergency lighting systems could not be confirmed to be tested annually for duration of 90 minutes to comply with NFPA 110, Section 5-3.2.

Based on direct observations during the survey walk through the facility failed to maintain a properly functioning fire alarm system. The installation did not meet all of the code requirements. This could affect patients, staff and visitor if the fire alarm system does not operate properly during a fire emergency.

Findings include:

A. On 10/6/2015, at 10:55AM, , while accompanied by the Interim Facility Director and Maintenance Staff, the surveyor observed a smoke detector, on the First Floor of MRI Waiting Area, which is located too close to a supply air diffuser. This does not comply with NFPA 72 1999 2-3.5.1.

B. On 10/06/15 at 10:00AM, while accompanied by the Interim Facility Director and Maintenance Staff, the surveyor observed on the 6th Floor the double doors to the Vestibule / Elevator Lobby which are equipped with magnetic locking devices, which did not drop out when the fire alarm was activated. This does not comply with NFPA 101 Section 19.2.2.2.4 and 7.2.1.5.1.



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C. On 10/5/15 at 1:45 PM, while accompanied by the Director of Facilities it was determined by observations that on the 3rd floor, LDR suite, men's and women's locker rooms contained 2 sleeping rooms each. The 4 rooms were not installed with fire alarm strobe lights. This does not comply with NFPA 101, Section 19.3.4.1, Section 9.6 and NFPA 72, Section 4-4.4.3.

Based on direct observations, the facility failed to provide proper installation of electrical wiring and devices. This deficient practice could affect patients, staff and visitors if proper illumination of critical building areas were not maintained during an emergency.

Findings include:

On 10/6/15 at 10:15 AM, while accompanied by the Maintenance Mechanic, the surveyor observed that the fire pump location was not equipped with a battery light in accordance with NFPA-20, Section 2-7.4.

Based on direct observations and staff interviews during the survey walk-through, October 5-6, 2015, and based on document review, and staff interview, the surveyors find the facility is not in compliance with the life safety code and other code requirements that are documented under the K-tags of this survey.

Findings include:

Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

Based on direct observations, the facility failed to install electrical wiring in accordance with the National Electrical Code. This deficient practice could affect patients, staff and visitors if improper wiring or labeling of circuits prevented shutoff of devices during or after patient procedures.

Findings include:

A. On 10/5/15 at 1:15 PM, while accompanied by the Maintenance Mechanic, the surveyor observed the recovery area on the second floor was not equipped with a normal receptacle or a critical receptacle from a second transfer switch to meet the requirements of NFPA-70, Section 517-19 and NFPA-99, Section 3-3.2.1.2(a)1.

B. On 10/5/15 at 1:30 PM, while accompanied by the Maintenance Mechanic, the surveyor observed on the 2nd floor, the operating rooms were not equipped with a normal power receptacle or a critical receptacle from a second transfer switch to meet the requirements of NFPA-70, Section 517-19 and NFPA-99, Section 3-3.2.1.2(a)1.

C. On 10/5/15 at 2:20 PM, while accompanied by the Maintenance Mechanic, the surveyor observed on the first floor, the trauma room in the ER, was not equipped with a normal power receptacle or a critical receptacle from a second transfer switch to meet the requirements of NFPA-70, Section 517-19 and NFPA-99, Section 3-3.2.1.2(a)1.