HospitalInspections.org

Based on observation and interview, the facility failed to maintain a 2 hour fire barrier as required.
Findings include:

On 5/23/2011 at 11:15 PM a 90 minute door in the 2 hour fire resistance rated barrier between the hospital and the materials management area was found to have the closer disabled. Doors in the barrier are required to have automatic closers.

On 5/23/2011 at 4:45pm, a door in a 2 hour fire resistive construction between the hospital and the Z wing was found to have a door latch with a push bar that had been modified by the facility with a screw holding the latch in the retracted position. Doors in 2 hour fire resistive rated wall are required to conform to NFPA 80 which requires door hardware to be labeled. Modification of the hardware invalidates the label. The biomedical engineer reports that the latch was defeated so that an automatic opener would operate.

In addition, the cashier ' s office in the Z wing had a window opening through the 2 hour fire resistive barrier that was not protected with a fire resistant rated opening protective. There was a roll down metal shutter that was not automatic closing and was without a label indicating the fire resistive rating. The construction under the window appeared to be less than 2 hour construction. The wall must meet 2 hour fire resistive construction and the opening protected with 90 minute rated doors.

In addition a door in the 2 hour fire resistive wall had a door to an electrical room that could not be opened to determine the rating. There was storage against the door on the z wing side. Electrical equipment was installed on the hospital side that blocked the door from opening. Storage is not permitted in front of doors and the rating of the door must be verifiable.

The facility Biomedical Engineer and/ or the Hospital Facilities Manager acknowledged the finding when the deficiency was identified.
Failure to maintain doors in fire resistant barriers and to maintain the integrity of the barriers increases the risk of death or injury due to fire.
The deficiency affected 2 of 24 smoke compartments.

Ref: 2000 NFPA 101 Section 19.1.2.1, 19.1.2.3, 19.1.1.4.2, 8.2.3.2.1, 8.2.3.2.3.1, 1999 NFPA 80 3-4.3.1

Based on observation and interview, the facility failed to maintain corridor doors as required.

Findings include:

On 5/23/2011 at 11:15 am a hazardous storage room containing soiled linen and garbage in the materials management/ operating Room corridor latch did not function. Corridor doors are required to have a device to keep the door closed and resist a force of 5 lbs applied at the latch edge of the door.

On 5/23/2011 at 3:30 the main entrance to the special services unit corridor door was found to not latch.

On 5/23/2011 at 3:30 Corridor door # A103 was found remain unlatched when closed.

On 5/23/2011 at 3:30pm the 1st floor mechanical room door was found to remain unlatched when closed.

On 5/24/2011 at 1:30pm, two doors to storage room B244 were found to remain unlatched when closed.

The facility Biomedical Engineer and/ or the Hospital Facilities Manager acknowledged the finding when the deficiency was identified.
Failure to provide corridor doors with latches increases the risk of death or injury due to fire.
The deficiency affected 3 of 24 smoke compartments.
Ref: 2000 NFPA 101 Section 19.3.6.3.2

On 5/23/2011 at 3:30 pm wedges were found in use on corridor doors A109 and A106 to hold them open.

Hold open devices are permitted when they release when the doors are pushed or pulled. Door wedges are not permitted.

The facility Biomedical Engineer and/ or the Hospital Facilities Manager acknowledged the finding when the deficiency was identified.

Failure to permit doors to be operated with permitted hold open devices increase the risk of death or injury due to fire.
The deficiency affected 1 of 24 smoke compartments.
Ref: 2000 NFPA 101 Section 19.3.6.3.3

Based on observation and interview, the facility failed to maintain smoke barrier doors as required.
Findings include:

On 5/24/2011 at 4:45, smoke barrier door pair A468 was tested. One of the doors had an astragal that prevented the doors from closing fully when relying on the door closers. The doors were not self closing or automatic closing.

Smoke barrier doors are required to be self closing or automatic closing.

The facility Biomedical Engineer and/ or the Hospital Facilities Manager acknowledged the finding when the deficiency was identified.

Failure to increases the risk of death or injury due to fire.

The deficiency affected 2 of 24 smoke compartments.

Ref: 2000 NFPA 101 Section 19.3.7.6

Based on observation and interview, the facility failed to maintain hazardous areas as required.

Findings include:

On 5/23/2011 at 2:15pm, the door to a housekeeping storage area having an area of approximately 256 sf scraped the floor allowing the door to be held in the open position preventing automatic closing.

On 5/24/2011 at 1:00pm, storage room door #B201 estimated at 144 square feet was found without a closer on the door.

On 5/24/2011 at 1:15pm, storage room B219 estimated at 100 square feet was found without a closer on the door.

On 2/24/2011 at 1:15 pm, soiled utility room # B222 was found blocked open preventing the door from automatically closing.

On 2/24/2011 at 1:30pm, two doors on storage room B244 were found to have non functioning closers.

Doors to hazardous area that open to a corridor are required to be automatic closing.

On 5/24/2011 at 1:15pm, storage room B216 in respiratory therapy was found without a door.

Storage areas greater than 50 sf are considered hazardous areas and are required to be enclosed in a construction that resists the passage of smoke.

On 5/23/2011 at 4:15pm, the door in the soiled linen in the hemodialysis unit, room # D140 was found to lack a closing device and found not to close into the door frame.

On 5/24/2011 at 2:00pm, telemetry storage room door B320 would not self close with the closer.

On 5/24/2011 at 1:30pm, clean utility room door C284 did not have a closer. The room was estimated to be 64 square feet in size and be being used for storage of combustible materials rendering it a hazardous area.

Doors to hazardous areas are required to be self closing and latching.

The facility Biomedical Engineer and/ or the Hospital Facilities Manager acknowledged the finding when the deficiency was identified.

Failure to maintain doors to hazardous areas increases the risk of death or injury due to fire.

The deficiency affected 5 of 24 smoke compartments.

Ref: 2000 NFPA 101 Section 19.3.2.1, 19.3.6.3.2


On 5/27/2011 at 9:00am, the wall separating the dining room/ kitchen area from the corridor had an automatic teller machine installed facing the corridor through an opening in wall. The machine was surrounded by walls, but open at the top.

Cooking facilities/kitchens are considered hazardous areas. The cooking facility is open to the dining area via the opening to the dirty dish tray conveyor rendering the dining area a hazardous area.

The facility Biomedical Engineer and/ or the Hospital Facilities Manager acknowledged the finding when the deficiency was identified.

Failure to maintain hazardous area enclosures increases the risk of death or injury due to fire.
The deficiency affected 2 of 24 smoke compartments.
Ref: 2000 NFPA 101 Section 19.3.2.1, 19.3.6.1(a)

Based on observation and interview the facility failed to protect exit components as required.

Findings include:

On 5/23/2011 at 2:30pm the 1 hour rated exit door to a stairwell leading from the morgue was blocked open with a soiled utility bin. The stairwell led to a ground level exit one story up. Exit enclosure doors are required to be self closing or held open by automatic devices that release the door when required.

In addition cardboard, two chairs and a pallet were found in the stairwell. Storage is not permitted in exit stairwells.

The facility Biomedical Engineer and/ or the Hospital Facilities Manager acknowledged the finding when the deficiency was identified.

Failure to protect exit components as required increases the risk of death or injury due to fire.

The deficiency affected 1 of 24 smoke compartments.

Ref: 2000 NFPA 101 Section 19.2.2.3, 7.2.2.5.1, 7.1.3.2.1(c), 7.2.1.8, 7.1.3.2.3

On 5/23/2011 at 4:30, stair #4 was found to be open to the first floor, have unrated construction at the 2nd floor evidenced by glass adjacent to the door (#218B) entering the 2nd floor corridor, wall material adjacent the lab that did not meet 1 hour fire resistive rating, and an unrated door to the lab (D227A) from the stair. In addition there was an enclosed storage area underneath the stairs without separating the stairs from the storage with the same fire resistive rating as the enclosure. Stairs serving as an exit or exit enclosure are required to be enclosed with a one hour fire resistive rating when serving 3 stories or less. Storage under stairs is not permitted unless provided with the same fire resistive rating as the enclosure and the access to the storage is not from within the enclosure.

The facility Biomedical Engineer and/ or the Hospital Facilities Manager acknowledged the finding when the deficiency was identified.

Failure to protect exit components as required increases the risk of death or injury due to fire.

The deficiency affected 2 of 24 smoke compartments.

Ref: 2000 NFPA 101 Section 19.2.2.3, 7.2.2.5.1, 7.1.3.2.1(a,c), 7.1.3.2.3, 7.2.2.5.3

Based on observation and interview, the facility failed to maintain the means of egress as required.

Findings include:

On 5/23/2011 at 2:15pm 8 laundry carts, 5 distribution carts and 3 gurneys were stored in the 1st floor B wing corridor that reduced the corridor usable width to 4 feet.

On 5/24/2011 at 11:00am, crates were in the radiology corridor A267 reducing the required 8 foot corridor width to 4 feet.

Means of egress are required to be maintained free of obstructions to full and instant use in case of fire.

The facility Biomedical Engineer and/ or the Hospital Facilities Manager acknowledged the finding when the deficiency was identified.

Failure to maintain the means of egress as required increases the risk of death or injury due to fire.

The deficiency affected 2 of 24 smoke compartments.

Ref: 2000 NFPA 101 Section 19.2.1, 7.1.10.1


On 5/23/2011 at 4:00pm in the means of egress from medical records, a cipher lock was installed on a door in addition to and separate from the door knob requiring two latching devices be operated to egress the area.

On 5/23/2011 at 4:00pm in the corridor door from the hemo dialysis unit, a cipher lock was installed on the door in addition to and separate from the door knob requiring two latching devices be operated to egress the area.

On 5/24/2011 at 11:00am a cipher lock was installed in the means of egress on door A219 in addition to and separate from the door knob requiring two latching devices be operated to egress the area.

On 5/24/2011 at 2:15pm a cipher lock was installed in the means of egress on door B215 in addition to and separate from the door knob requiring two latching devices be operated to egress the area.

On 5/24/2011 at 3:00, two door knobs were found on doors A322.

On 5/24/2011 at 3:00, a door knob and a barrel bolt were found on doors A323.

On 5/24/2011 at 4:15pm, two door knobs were found on education area doors A457, A471, and A440.

Doors shall be operable with not more than one releasing operation. Locks if provided shall not require the use of a key, tool, or special knowledge of effort for operation from the egress side.


The facility Biomedical Engineer and/ or the Hospital Facilities Manager acknowledged the finding when the deficiency was identified.

Failure to be able to egress the building readily increase the risk of death or injury due to fire.

The deficiency affected 5 of 24 smoke compartments.

Ref: 2000 NFPA 101 Section 19.2.2.2.1, 7.2.1.5.4


On 5/23/2011 a sliding door on an isolation area in hemo dialysis was missing its handle. The handle was reported to have been removed so that the door could be opened further than with the handle in place. Without the handle, the method to open the door was not obvious.

On 5/23/2011 at 3:00pm, the pharmacy storage area had a sliding gate on a secure are locked by a pad lock.

On 5/24/2011 at 11:30am, a pad lock was used to secure a gate in the stairwell # 2 between the fourth floor and the roof. The padlock did not permit ready egress.

On 5/24/2011 at 3:10pm, a magnetic lock was found engaged on door B401 in pediatrics that prevented egress without a proximity card or release from a control at nurse ' s station. Clinical need for the lock was not present. The biomedical engineer cited the accrediting agency requiring this for security of the area.

On 5/24/2011 at 1:45pm, a magnetic lock was found engaged on door C200 that prevented egress from the obstetrics unit without the use of a proximity card. Clinical need for the lock was not present. The biomedical engineer cited the accrediting agency requiring this for security of the area.

On 5/24/2011 at 1:30pm, a magnetic lock was found engaged on door C248 that prevented egress from the labor and deliver unit without the use of a proximity card or release from a control at nurse ' s station. Clinical need for the lock was not present. The biomedical engineer cited the accrediting agency requiring this for security of the area.

On 5/24/2011 at 1:30pm, a magnetic lock was found engaged on door C286 that prevented egress from the nursery unit without the use of a proximity card. Clinical need for the lock was not present. The biomedical engineer cited the accrediting agency requiring this for security of the area.

On 5/24/2011 at 2:30pm a bathroom door in room A319 was missing its door knob while still having its latch. The door latch could not be operated even with the effort of a tool at the time of observation.

Doors in the means of egress are required to open readily from the egress side.

The facility Biomedical Engineer and/ or the Hospital Facilities Manager acknowledged the finding when the deficiency was identified.

Failure to be able to egress the facility readily increases the risk of death or injury due to fire.

The deficiency affected 7 of 24 smoke compartments.

Ref: 2000 NFPA 101 Section 19.2.2.2.1, 7.2.1.5.1


On 5/24/2011, at 1:00pm a thumb bolt was found on door C294 at a height of 60 inches above the floor.

On 5/24/2011 at 1:15 pm a thumb bolt was found on delivery room # 1 and #2 at a height of 60 inches above the floor.

On 5/24/2011 at 2:30pm a thumb latch was found on nourishment from A 351 at a height of 60inches above the floor.

On 5/24/2011 at 2:45pm a cipher lock was found on door A357 at a height of 60 inches above the floor.

On 5/24/2011 at 2:45pm a cipher lock was found on door clean utility room A369 at a height of 60 inches above the floor.

On 5/24/2011 at 2:45pm a cipher lock was found on door A367 at a height of 60 inches above the floor.

On 5/24/2011 at 3:15pm a thumb latch was found on nourishment center door A443 at a height of 60 inches above the floor.

On 5/24/2011 at 4:45pm a cipher lock was found on surgical unit women ' s locker room door A447 at a height of 60 inches above the floor.

On 5/24/2011 at 5:00pm a cipher lock was found on surgical ward door A445 at a height of 60 inches above the floor.

The releasing mechanism for a lock or latch in the means of egress is required to be located between 34 and 48 inches above the floor.


The facility Biomedical Engineer and/ or the Hospital Facilities Manager acknowledged the finding when the deficiency was identified.

Failure to install locks at the appropriate height increases the risk of death or injury due to fire.

The deficiency affected 4 of 24 smoke compartments.

Ref: 2000 NFPA 101 Section 19.2.2.2.1, 7.2.1.5.4

On 5/23/2011
Information technology section door missing sensor, 1 each
Pharmacy: doors only had push to exit, missing sensor. 2 each
Central Sterile Receiving clean and dirty egress doors: no push to exit button, 2 each
Pharmacy storage: doors only had push to exit, missing sensor. 3 each
E102: door only had push to exit, missing sensor.

On 5/24/2011
Laboratory, door D223: missing push to exit button
Radiology door A240: missing push to exit button
Radio fluoroscopy #1, door A259: missing push to exit
Radio fluoroscopy #2, door A253: missing push to exit
Door A260: missing push to exit
Door A271: missing push to exit
Emergency Room, door A214, A228, A235: doors missing push to exit
Respiratory med room, Door B209: no sensor
Door B236: sensor disabled
Recovery room doors B241A, B241: no push to exit
Operating Room door B244, no push to exit
Door B243, B283, B279: no push to exit
Door C294: no push to exit
Nursery door C286: no sensor
Med telemetry door B301: no push to exit
Medical Surgery door A350: no push to exit
Door A352: no sensor
Surgical ward door A442 missing push to exit

On 5/25/2011 at 9:00 am, the fire alarm was activated via a pull station. The following doors did not release the magnetic locking mechanism:
A350
A352
A301B
E213
A214A
C248

The facility biomedical engineer and/ or the hospital facilities manager acknowledged the finding when the deficiency was identified.

Failure to provide access controlled egress doors as permitted increases the risk of death or injury due to fire.

The deficiency affected 12 of 24 smoke compartments.

Ref: 2000 NFPA 101 section 19.2.2.2.4, 7.2.1.6.2

Based on observation and interview, the facility failed to install sprinklers throughout the facility.
Findings include:

On 5/23/2011 at 4:30pm, a storage space under stair #4 was found to be unsprinkled.

On 5/24/2011 at 11:00am elevator machine rooms #1 and #2 were found to be unsprinkled.

Although by construction type, the facility is not required to be sprinkled, the facility takes advantage of exceptions to requirements for a sprinkled facility and as such is required to be fully sprinkled.

The facility electrician acknowledged the finding when the deficiency was identified.

Failure to fully sprinkle increases the risk of death or injury due to fire.

The deficiency affected 3 of 24 smoke compartments.

Ref: 2000 NFPA 101 Section 19.3.5.1, 9.7.1.1, (19.3.2.1 exception for sprinkled facilities); 1999 NFPA 13 Section 5-13.6.2, 5-13.3.2

Based on observation and interview, the facility failed to maintain the sprinkler system as required.

Findings include:

On 5/23/2011 at 2:30pm, file boxes were found to be stacked to 16 inches under the sprinkler heads in the biomedical shop.
On 5/23/2011 at 3:00pm materials were stored less than 18 inches of three sprinkler heads in pharmacy storage.
On 5/23/2011 room at 3:30 pm, room A104 contained storage within 18 " of the sprinkler head.
On 5/23/2011 at 3:45pm, a shelf was found to be within 10 inches from a sprinkler head in medical records.

The facility Biomedical Engineer and/ or the Hospital Facilities Manager acknowledged the finding when the deficiency was identified.

Failure to maintain the required distance from sprinkler heads increases the risk of death or injury due to fire.

The deficiency affected 4 of 24 smoke compartments.

Ref: 2000 NFPA 101 Section 19.3.5.1, 9.7.1; NFPA 13 Section 5-5.5.2.1

On 5/23/2011 at 3:30pm Room A104 lay in drop ceiling was missing a ceiling tile.
On 5/23/2011 at 4:30pm 4 drop ceiling tiles were missing in electrical room Z102
On 5/23/2011 at 4:30 pm drop ceiling tiles were missing above stairway #4.
On 5/24/2011 at 10:30am, openings in the ceiling were found around conduits where they penetrated the ceiling.
On 5/24/2011 at 11:00am, the ceiling access hatch was open in electrical room A212.
On 5/24/2011 at 1:30pm, a drop ceiling tile was out in storage room B244.
On 5/24/2011 at 2:30pm, 50% of the drop ceiling tiles were missing in room A319.
On 5/24/2011 at 4:45 pm, a drop ceiling tile was missing in chapel office room A461.
On 5/24/2011 at 4:45pm, the ceiling access hatch was open in electrical room A408.
On 5/24/2011 at 5:00pm, a drop ceiling tile was missing in surgical ward room A445.
On 5/24/2011 at 2:00pm, the drop ceiling tiles in electrical closet C254 had holes in them.

The facility Biomedical Engineer and/ or the Hospital Facilities Manager acknowledged the finding when the deficiency was identified.

Failure to maintain the ceiling where sprinkler heads are installed increases the risk of death or injury due to fire due to delaying activation.

The deficiency affected 4 of 24 smoke compartments.

Ref: 2000 NFPA 101 Section 19.3.5.1, 9.7.1; 1999 NFPA 13 5-6.4.1.1


On 5/23/2011 at 3:30pm, the sprinkler escutcheon ring was missing from a sprinkler in special services room E109.
On 5/23/2011 at 3:30pm, the sprinkler escutcheon ring was missing from a sprinkler in A109.
On 5/24/2011 at 4:45 pm, the sprinkler escutcheon ring was missing from a sprinkler in A461.
On 5/24/2011 at 2:30pm a sprinkler escutcheon ring had fallen out of place in room E304.
On 5/24/2011 at 2:00pm, a sprinkler was found missing its execution ring in obstetrics room C208.

The facility Biomedical Engineer and/ or the Hospital Facilities Manager acknowledged the finding when the deficiency was identified.

Failure to maintain sprinkler heads increases the risk of death or injury due to fire.

The deficiency affected 4 of 24 smoke compartments.

Ref: 2000 NFPA 101 Section 19.3.5.1, 9.7.1; 1999 NFPA 13 3-2.7.2


On 5/24/2011, at 9:10am, a quick response sprinkler was found installed in the kitchen where all the other heads appeared to be normal response sprinklers. Where quick response sprinklers are used, all the sprinklers in the compartment must be quick response type.

The facility Biomedical Engineer and/ or the Hospital Facilities Manager acknowledged the finding when the deficiency was identified.
Failure to maintain sprinklers as required increases the risk of death or injury due to fire.

The deficiency affected 1 of 24 smoke compartments.

Ref: 2000 NFPA 101 section 19.1.6.2, 19.3.5.1, 9.7.1.1; 1999 NFPA 13 section 7-2.3.2.4(3)


On 5/24/2011 at 9:10am, 10 upright sprinkler heads in the kitchen were installed in the pendant position.

On 5/24/2011 outside the C wing on the second floor pendant sprinkler heads were found to be installed in the upright position.

Upright sprinklers are required to be installed in upright position and pendant head sprinklers are required to be installed in the pendant position.

The Hospital Facilities Manager acknowledged the finding when the deficiency was identified.

Failure to install sprinklers in the proper orientation increases the risk of death or injury due to fire.

The deficiency affected 1 of 24 smoke compartments.

Ref: 2000 NFPA 101 Section 19.3.5.1, 9.7.5; 1998 NFPA 25

On 5/27/2011 records review and interview indicated that a new fire alarm system was activated on August 2010. As such sprinkler flow switch and tamper switch testing were not available for the past year with the exception of a flow switch test for February 2011. The Hospital Facilities Manager had implemented a contract for testing but did not have results indicating testing requirements would be met.

The Hospital Facilities Manager acknowledged the finding when the deficiency was identified.

Failure to test sprinkler systems as required increases the risk of death or injury due to fire.

The deficiency affected 24 of 24 smoke compartments.

Ref: 2000 NFPA 101 Section 19.3.5.1, 9.7.5; 1998 NFPA 25 2-3.3, 9-3.4.3

Based on observation and interview and records review, the facility failed to provide ventilating and air-conditioning system as required.

Findings include:

On 5/27/2011 at 9:30am, the facility indicated that the dampers protecting the stair enclosure #2 and #3 were protected with fire dampers. Records and staff interview indicated that the dampers were smoke activated only. The staff indicated that they were not aware of a fusible link or other approved heat actuated device that would close the dampers.

Stairs serving 4 or more stores are required to be protected with 2 hour fire resistant construction. Appropriate damper for duct penetrations are required.

The facility Biomedical Engineer and the Hospital Facilities Manager acknowledged the finding when the deficiency was identified.

Failure to protect stair enclosures as required increases the risk of death or injury due to fire.

The deficiency affected 18 of 24 smoke compartments.

Ref: 2000 NFPA 101 Section 19.2.2.3, 7.2.2.5.1, 7.1.3.2.1 exception 1, 8.2.3.2.4.1, 9.2.1; 1999 NFPA 90A Section 3-3.1.13-4.5.1

Based on records review and interview, the facility failed to maintain cooking facilities as required.

Findings include:

On 5/27/2011 at 9am, documentation for hood cleaning was for the past 12 months was not available. The facilities manager indicated that duct cleaning had not been completed due to a contract error.

Hood inspection is required semi- annually on moderate volume cooking facilities and cleaned when inspection indicates need.

The facility Hospital Facilities Manager acknowledged the finding when the deficiency was identified.

Failure to clean cooking facility hoods as required increases the risk of death or injury due to fire.

The deficiency 1 affected of 24 smoke compartments.

Ref: 2000 NFPA 101 Section 19.3.2.6, NFPA 96 Section 8-3.1

Based on observation and interview, the facility failed to store medical gases as required.
Findings include:

On 5/23/2011 at 2:15 pm, a room storing 19 H size oxygen cylinders (5,700 cf) and other gas cylinders was found to be unvented. Venting to the outside by a dedicated mechanical venting system or by natural ventilation is required when storing greater than 3,000 cf of gasses.
The facility Biomedical Engineer and/ or the Hospital Facilities Manager acknowledged the finding when the deficiency was identified.

Failure to store medical gasses as required increase the risk of death or injury due to fire.

The deficiency affected 1 of 24 smoke compartments.

Ref: 2000 NFPA 101 Section 19.3.2.4; 1999 NFPA 99 Section 4-3.1.1.2(b)

Based on observation and interview, the facility failed to maintain medical gas facilities as required.

Findings include:
On 5/23/2011, the source valve for the medical oxygen system was labeled with a number tag. This valve is required to be labeled " SOURCE VALVE FOR THE (SOURCE NAME) "

The facility Biomedical Engineer and/ or the Hospital Facilities Manager acknowledged the finding when the deficiency was identified.

Failure to label valves as required increases the risk of death or injury due to fire.

The deficiency affected all smoke compartments.

Ref: 2000 NFPA 101 Section 19.3.2.3; 1999 NFPA 99, Section 12-3.4.1, 4-3.1.2.3

On 5/24/2011 at 2:00pm the charge nurse in the progressive care unit stated that there was the potential and they had in the past had patients that patients in the unit were on life support and in the unit could expect to receive patients that require life support equipment. No medical gas area alarm was present.

On 5/24/2011 at 2:30pm, the nursing supervisor in the medical surgical unit stated that there was the potential and they had in the past had patients that patients in the unit were on life support and in the unit could expect to receive patients that require life support equipment. No medical gas area alarm was present.

On 5/24/2011 at 3:10 pm, the nursing supervisor in the surgical ward stated that there was the potential and they had in the past had patients that patients in the unit were on life support and in the unit could expect to receive patients that require life support equipment. No medical gas area alarm was present.

On 5/24/2011 at 2:00pm in the CCU (Critical Care Unit) the area medical gas alarm was not functional. The biomedical engineer stated that the area alarm had not been hooked up yet.

Area medical gas alarms are required in areas that provide vital life support.

The facility Biomedical Engineer and/ or the Hospital Facilities Manager acknowledged the finding when the deficiency was identified.

Failure to provide area alarms increase the risk of death or injury due to fire.

The deficiency affected 4 of 24 smoke compartments.

Ref: 2000 NFPA 101 Section 19.3.2.3; 1999 NFPA 99, Section 12-3.4.1, 4-3.1.2.2(c)

Based on observation and interview, the facility failed to install ABHRs as permitted.

Findings include:
On 5/24/2011 at 3:10 pm an ABHR was found to be mounted on the wall directly over an electrical outlet in med room B420.

The facility Biomedical Engineer and/ or the Hospital Facilities Manager acknowledged the finding when the deficiency was identified.

Failure to install ABHRs as required increases the risk of death or injury due to fire.

The deficiency affected 1 of 24 smoke compartments.

Based on observation and interview, the facility failed to maintain a 2 hour fire barrier as required.
Findings include:

On 5/23/2011 at 11:15 PM a 90 minute door in the 2 hour fire resistance rated barrier between the hospital and the materials management area was found to have the closer disabled. Doors in the barrier are required to have automatic closers.

On 5/23/2011 at 4:45pm, a door in a 2 hour fire resistive construction between the hospital and the Z wing was found to have a door latch with a push bar that had been modified by the facility with a screw holding the latch in the retracted position. Doors in 2 hour fire resistive rated wall are required to conform to NFPA 80 which requires door hardware to be labeled. Modification of the hardware invalidates the label. The biomedical engineer reports that the latch was defeated so that an automatic opener would operate.

In addition, the cashier ' s office in the Z wing had a window opening through the 2 hour fire resistive barrier that was not protected with a fire resistant rated opening protective. There was a roll down metal shutter that was not automatic closing and was without a label indicating the fire resistive rating. The construction under the window appeared to be less than 2 hour construction. The wall must meet 2 hour fire resistive construction and the opening protected with 90 minute rated doors.

In addition a door in the 2 hour fire resistive wall had a door to an electrical room that could not be opened to determine the rating. There was storage against the door on the z wing side. Electrical equipment was installed on the hospital side that blocked the door from opening. Storage is not permitted in front of doors and the rating of the door must be verifiable.

The facility Biomedical Engineer and/ or the Hospital Facilities Manager acknowledged the finding when the deficiency was identified.
Failure to maintain doors in fire resistant barriers and to maintain the integrity of the barriers increases the risk of death or injury due to fire.
The deficiency affected 2 of 24 smoke compartments.

Ref: 2000 NFPA 101 Section 19.1.2.1, 19.1.2.3, 19.1.1.4.2, 8.2.3.2.1, 8.2.3.2.3.1, 1999 NFPA 80 3-4.3.1

Based on observation and interview, the facility failed to maintain corridor doors as required.

Findings include:

On 5/23/2011 at 11:15 am a hazardous storage room containing soiled linen and garbage in the materials management/ operating Room corridor latch did not function. Corridor doors are required to have a device to keep the door closed and resist a force of 5 lbs applied at the latch edge of the door.

On 5/23/2011 at 3:30 the main entrance to the special services unit corridor door was found to not latch.

On 5/23/2011 at 3:30 Corridor door # A103 was found remain unlatched when closed.

On 5/23/2011 at 3:30pm the 1st floor mechanical room door was found to remain unlatched when closed.

On 5/24/2011 at 1:30pm, two doors to storage room B244 were found to remain unlatched when closed.

The facility Biomedical Engineer and/ or the Hospital Facilities Manager acknowledged the finding when the deficiency was identified.
Failure to provide corridor doors with latches increases the risk of death or injury due to fire.
The deficiency affected 3 of 24 smoke compartments.
Ref: 2000 NFPA 101 Section 19.3.6.3.2

On 5/23/2011 at 3:30 pm wedges were found in use on corridor doors A109 and A106 to hold them open.

Hold open devices are permitted when they release when the doors are pushed or pulled. Door wedges are not permitted.

The facility Biomedical Engineer and/ or the Hospital Facilities Manager acknowledged the finding when the deficiency was identified.

Failure to permit doors to be operated with permitted hold open devices increase the risk of death or injury due to fire.
The deficiency affected 1 of 24 smoke compartments.
Ref: 2000 NFPA 101 Section 19.3.6.3.3

Based on observation and interview, the facility failed to maintain smoke barrier doors as required.
Findings include:

On 5/24/2011 at 4:45, smoke barrier door pair A468 was tested. One of the doors had an astragal that prevented the doors from closing fully when relying on the door closers. The doors were not self closing or automatic closing.

Smoke barrier doors are required to be self closing or automatic closing.

The facility Biomedical Engineer and/ or the Hospital Facilities Manager acknowledged the finding when the deficiency was identified.

Failure to increases the risk of death or injury due to fire.

The deficiency affected 2 of 24 smoke compartments.

Ref: 2000 NFPA 101 Section 19.3.7.6

Based on observation and interview, the facility failed to maintain hazardous areas as required.

Findings include:

On 5/23/2011 at 2:15pm, the door to a housekeeping storage area having an area of approximately 256 sf scraped the floor allowing the door to be held in the open position preventing automatic closing.

On 5/24/2011 at 1:00pm, storage room door #B201 estimated at 144 square feet was found without a closer on the door.

On 5/24/2011 at 1:15pm, storage room B219 estimated at 100 square feet was found without a closer on the door.

On 2/24/2011 at 1:15 pm, soiled utility room # B222 was found blocked open preventing the door from automatically closing.

On 2/24/2011 at 1:30pm, two doors on storage room B244 were found to have non functioning closers.

Doors to hazardous area that open to a corridor are required to be automatic closing.

On 5/24/2011 at 1:15pm, storage room B216 in respiratory therapy was found without a door.

Storage areas greater than 50 sf are considered hazardous areas and are required to be enclosed in a construction that resists the passage of smoke.

On 5/23/2011 at 4:15pm, the door in the soiled linen in the hemodialysis unit, room # D140 was found to lack a closing device and found not to close into the door frame.

On 5/24/2011 at 2:00pm, telemetry storage room door B320 would not self close with the closer.

On 5/24/2011 at 1:30pm, clean utility room door C284 did not have a closer. The room was estimated to be 64 square feet in size and be being used for storage of combustible materials rendering it a hazardous area.

Doors to hazardous areas are required to be self closing and latching.

The facility Biomedical Engineer and/ or the Hospital Facilities Manager acknowledged the finding when the deficiency was identified.

Failure to maintain doors to hazardous areas increases the risk of death or injury due to fire.

The deficiency affected 5 of 24 smoke compartments.

Ref: 2000 NFPA 101 Section 19.3.2.1, 19.3.6.3.2


On 5/27/2011 at 9:00am, the wall separating the dining room/ kitchen area from the corridor had an automatic teller machine installed facing the corridor through an opening in wall. The machine was surrounded by walls, but open at the top.

Cooking facilities/kitchens are considered hazardous areas. The cooking facility is open to the dining area via the opening to the dirty dish tray conveyor rendering the dining area a hazardous area.

The facility Biomedical Engineer and/ or the Hospital Facilities Manager acknowledged the finding when the deficiency was identified.

Failure to maintain hazardous area enclosures increases the risk of death or injury due to fire.
The deficiency affected 2 of 24 smoke compartments.
Ref: 2000 NFPA 101 Section 19.3.2.1, 19.3.6.1(a)

Based on observation and interview the facility failed to protect exit components as required.

Findings include:

On 5/23/2011 at 2:30pm the 1 hour rated exit door to a stairwell leading from the morgue was blocked open with a soiled utility bin. The stairwell led to a ground level exit one story up. Exit enclosure doors are required to be self closing or held open by automatic devices that release the door when required.

In addition cardboard, two chairs and a pallet were found in the stairwell. Storage is not permitted in exit stairwells.

The facility Biomedical Engineer and/ or the Hospital Facilities Manager acknowledged the finding when the deficiency was identified.

Failure to protect exit components as required increases the risk of death or injury due to fire.

The deficiency affected 1 of 24 smoke compartments.

Ref: 2000 NFPA 101 Section 19.2.2.3, 7.2.2.5.1, 7.1.3.2.1(c), 7.2.1.8, 7.1.3.2.3

On 5/23/2011 at 4:30, stair #4 was found to be open to the first floor, have unrated construction at the 2nd floor evidenced by glass adjacent to the door (#218B) entering the 2nd floor corridor, wall material adjacent the lab that did not meet 1 hour fire resistive rating, and an unrated door to the lab (D227A) from the stair. In addition there was an enclosed storage area underneath the stairs without separating the stairs from the storage with the same fire resistive rating as the enclosure. Stairs serving as an exit or exit enclosure are required to be enclosed with a one hour fire resistive rating when serving 3 stories or less. Storage under stairs is not permitted unless provided with the same fire resistive rating as the enclosure and the access to the storage is not from within the enclosure.

The facility Biomedical Engineer and/ or the Hospital Facilities Manager acknowledged the finding when the deficiency was identified.

Failure to protect exit components as required increases the risk of death or injury due to fire.

The deficiency affected 2 of 24 smoke compartments.

Ref: 2000 NFPA 101 Section 19.2.2.3, 7.2.2.5.1, 7.1.3.2.1(a,c), 7.1.3.2.3, 7.2.2.5.3

Based on observation and interview, the facility failed to maintain the means of egress as required.

Findings include:

On 5/23/2011 at 2:15pm 8 laundry carts, 5 distribution carts and 3 gurneys were stored in the 1st floor B wing corridor that reduced the corridor usable width to 4 feet.

On 5/24/2011 at 11:00am, crates were in the radiology corridor A267 reducing the required 8 foot corridor width to 4 feet.

Means of egress are required to be maintained free of obstructions to full and instant use in case of fire.

The facility Biomedical Engineer and/ or the Hospital Facilities Manager acknowledged the finding when the deficiency was identified.

Failure to maintain the means of egress as required increases the risk of death or injury due to fire.

The deficiency affected 2 of 24 smoke compartments.

Ref: 2000 NFPA 101 Section 19.2.1, 7.1.10.1


On 5/23/2011 at 4:00pm in the means of egress from medical records, a cipher lock was installed on a door in addition to and separate from the door knob requiring two latching devices be operated to egress the area.

On 5/23/2011 at 4:00pm in the corridor door from the hemo dialysis unit, a cipher lock was installed on the door in addition to and separate from the door knob requiring two latching devices be operated to egress the area.

On 5/24/2011 at 11:00am a cipher lock was installed in the means of egress on door A219 in addition to and separate from the door knob requiring two latching devices be operated to egress the area.

On 5/24/2011 at 2:15pm a cipher lock was installed in the means of egress on door B215 in addition to and separate from the door knob requiring two latching devices be operated to egress the area.

On 5/24/2011 at 3:00, two door knobs were found on doors A322.

On 5/24/2011 at 3:00, a door knob and a barrel bolt were found on doors A323.

On 5/24/2011 at 4:15pm, two door knobs were found on education area doors A457, A471, and A440.

Doors shall be operable with not more than one releasing operation. Locks if provided shall not require the use of a key, tool, or special knowledge of effort for operation from the egress side.


The facility Biomedical Engineer and/ or the Hospital Facilities Manager acknowledged the finding when the deficiency was identified.

Failure to be able to egress the building readily increase the risk of death or injury due to fire.

The deficiency affected 5 of 24 smoke compartments.

Ref: 2000 NFPA 101 Section 19.2.2.2.1, 7.2.1.5.4


On 5/23/2011 a sliding door on an isolation area in hemo dialysis was missing its handle. The handle was reported to have been removed so that the door could be opened further than with the handle in place. Without the handle, the method to open the door was not obvious.

On 5/23/2011 at 3:00pm, the pharmacy storage area had a sliding gate on a secure are locked by a pad lock.

On 5/24/2011 at 11:30am, a pad lock was used to secure a gate in the stairwell # 2 between the fourth floor and the roof. The padlock did not permit ready egress.

On 5/24/2011 at 3:10pm, a magnetic lock was found engaged on door B401 in pediatrics that prevented egress without a proximity card or release from a control at nurse ' s station. Clinical need for the lock was not present. The biomedical engineer cited the accrediting agency requiring this for security of the area.

On 5/24/2011 at 1:45pm, a magnetic lock was found engaged on door C200 that prevented egress from the obstetrics unit without the use of a proximity card. Clinical need for the lock was not present. The biomedical engineer cited the accrediting agency requiring this for security of the area.

On 5/24/2011 at 1:30pm, a magnetic lock was found engaged on door C248 that prevented egress from the labor and deliver unit without the use of a proximity card or release from a control at nurse ' s station. Clinical need for the lock was not present. The biomedical engineer cited the accrediting agency requiring this for security of the area.

On 5/24/2011 at 1:30pm, a magnetic lock was found engaged on door C286 that prevented egress from the nursery unit without the use of a proximity card. Clinical need for the lock was not present. The biomedical engineer cited the accrediting agency requiring this for security of the area.

On 5/24/2011 at 2:30pm a bathroom door in room A319 was missing its door knob while still having its latch. The door latch could not be operated even with the effort of a tool at the time of observation.

Doors in the means of egress are required to open readily from the egress side.

The facility Biomedical Engineer and/ or the Hospital Facilities Manager acknowledged the finding when the deficiency was identified.

Failure to be able to egress the facility readily increases the risk of death or injury due to fire.

The deficiency affected 7 of 24 smoke compartments.

Ref: 2000 NFPA 101 Section 19.2.2.2.1, 7.2.1.5.1


On 5/24/2011, at 1:00pm a thumb bolt was found on door C294 at a height of 60 inches above the floor.

On 5/24/2011 at 1:15 pm a thumb bolt was found on delivery room # 1 and #2 at a height of 60 inches above the floor.

On 5/24/2011 at 2:30pm a thumb latch was found on nourishment from A 351 at a height of 60inches above the floor.

On 5/24/2011 at 2:45pm a cipher lock was found on door A357 at a height of 60 inches above the floor.

On 5/24/2011 at 2:45pm a cipher lock was found on door clean utility room A369 at a height of 60 inches above the floor.

On 5/24/2011 at 2:45pm a cipher lock was found on door A367 at a height of 60 inches above the floor.

On 5/24/2011 at 3:15pm a thumb latch was found on nourishment center door A443 at a height of 60 inches above the floor.

On 5/24/2011 at 4:45pm a cipher lock was found on surgical unit women ' s locker room door A447 at a height of 60 inches above the floor.

On 5/24/2011 at 5:00pm a cipher lock was found on surgical ward door A445 at a height of 60 inches above the floor.

The releasing mechanism for a lock or latch in the means of egress is required to be located between 34 and 48 inches above the floor.


The facility Biomedical Engineer and/ or the Hospital Facilities Manager acknowledged the finding when the deficiency was identified.

Failure to install locks at the appropriate height increases the risk of death or injury due to fire.

The deficiency affected 4 of 24 smoke compartments.

Ref: 2000 NFPA 101 Section 19.2.2.2.1, 7.2.1.5.4

On 5/23/2011
Information technology section door missing sensor, 1 each
Pharmacy: doors only had push to exit, missing sensor. 2 each
Central Sterile Receiving clean and dirty egress doors: no push to exit button, 2 each
Pharmacy storage: doors only had push to exit, missing sensor. 3 each
E102: door only had push to exit, missing sensor.

On 5/24/2011
Laboratory, door D223: missing push to exit button
Radiology door A240: missing push to exit button
Radio fluoroscopy #1, door A259: missing push to exit
Radio fluoroscopy #2, door A253: missing push to exit
Door A260: missing push to exit
Door A271: missing push to exit
Emergency Room, door A214, A228, A235: doors missing push to exit
Respiratory med room, Door B209: no sensor
Door B236: sensor disabled
Recovery room doors B241A, B241: no push to exit
Operating Room door B244, no push to exit
Door B243, B283, B279: no push to exit
Door C294: no push to exit
Nursery door C286: no sensor
Med telemetry door B301: no push to exit
Medical Surgery door A350: no push to exit
Door A352: no sensor
Surgical ward door A442 missing push to exit

On 5/25/2011 at 9:00 am, the fire alarm was activated via a pull station. The following doors did not release the magnetic locking mechanism:
A350
A352
A301B
E213
A214A
C248

The facility biomedical engineer and/ or the hospital facilities manager acknowledged the finding when the deficiency was identified.

Failure to provide access controlled egress doors as permitted increases the risk of death or injury due to fire.

The deficiency affected 12 of 24 smoke compartments.

Ref: 2000 NFPA 101 section 19.2.2.2.4, 7.2.1.6.2

Based on observation and interview, the facility failed to install sprinklers throughout the facility.
Findings include:

On 5/23/2011 at 4:30pm, a storage space under stair #4 was found to be unsprinkled.

On 5/24/2011 at 11:00am elevator machine rooms #1 and #2 were found to be unsprinkled.

Although by construction type, the facility is not required to be sprinkled, the facility takes advantage of exceptions to requirements for a sprinkled facility and as such is required to be fully sprinkled.

The facility electrician acknowledged the finding when the deficiency was identified.

Failure to fully sprinkle increases the risk of death or injury due to fire.

The deficiency affected 3 of 24 smoke compartments.

Ref: 2000 NFPA 101 Section 19.3.5.1, 9.7.1.1, (19.3.2.1 exception for sprinkled facilities); 1999 NFPA 13 Section 5-13.6.2, 5-13.3.2

Based on observation and interview, the facility failed to maintain the sprinkler system as required.

Findings include:

On 5/23/2011 at 2:30pm, file boxes were found to be stacked to 16 inches under the sprinkler heads in the biomedical shop.
On 5/23/2011 at 3:00pm materials were stored less than 18 inches of three sprinkler heads in pharmacy storage.
On 5/23/2011 room at 3:30 pm, room A104 contained storage within 18 " of the sprinkler head.
On 5/23/2011 at 3:45pm, a shelf was found to be within 10 inches from a sprinkler head in medical records.

The facility Biomedical Engineer and/ or the Hospital Facilities Manager acknowledged the finding when the deficiency was identified.

Failure to maintain the required distance from sprinkler heads increases the risk of death or injury due to fire.

The deficiency affected 4 of 24 smoke compartments.

Ref: 2000 NFPA 101 Section 19.3.5.1, 9.7.1; NFPA 13 Section 5-5.5.2.1

On 5/23/2011 at 3:30pm Room A104 lay in drop ceiling was missing a ceiling tile.
On 5/23/2011 at 4:30pm 4 drop ceiling tiles were missing in electrical room Z102
On 5/23/2011 at 4:30 pm drop ceiling tiles were missing above stairway #4.
On 5/24/2011 at 10:30am, openings in the ceiling were found around conduits where they penetrated the ceiling.
On 5/24/2011 at 11:00am, the ceiling access hatch was open in electrical room A212.
On 5/24/2011 at 1:30pm, a drop ceiling tile was out in storage room B244.
On 5/24/2011 at 2:30pm, 50% of the drop ceiling tiles were missing in room A319.
On 5/24/2011 at 4:45 pm, a drop ceiling tile was missing in chapel office room A461.
On 5/24/2011 at 4:45pm, the ceiling access hatch was open in electrical room A408.
On 5/24/2011 at 5:00pm, a drop ceiling tile was missing in surgical ward room A445.
On 5/24/2011 at 2:00pm, the drop ceiling tiles in electrical closet C254 had holes in them.

The facility Biomedical Engineer and/ or the Hospital Facilities Manager acknowledged the finding when the deficiency was identified.

Failure to maintain the ceiling where sprinkler heads are installed increases the risk of death or injury due to fire due to delaying activation.

The deficiency affected 4 of 24 smoke compartments.

Ref: 2000 NFPA 101 Section 19.3.5.1, 9.7.1; 1999 NFPA 13 5-6.4.1.1


On 5/23/2011 at 3:30pm, the sprinkler escutcheon ring was missing from a sprinkler in special services room E109.
On 5/23/2011 at 3:30pm, the sprinkler escutcheon ring was missing from a sprinkler in A109.
On 5/24/2011 at 4:45 pm, the sprinkler escutcheon ring was missing from a sprinkler in A461.
On 5/24/2011 at 2:30pm a sprinkler escutcheon ring had fallen out of place in room E304.
On 5/24/2011 at 2:00pm, a sprinkler was found missing its execution ring in obstetrics room C208.

The facility Biomedical Engineer and/ or the Hospital Facilities Manager acknowledged the finding when the deficiency was identified.

Failure to maintain sprinkler heads increases the risk of death or injury due to fire.

The deficiency affected 4 of 24 smoke compartments.

Ref: 2000 NFPA 101 Section 19.3.5.1, 9.7.1; 1999 NFPA 13 3-2.7.2


On 5/24/2011, at 9:10am, a quick response sprinkler was found installed in the kitchen where all the other heads appeared to be normal response sprinklers. Where quick response sprinklers are used, all the sprinklers in the compartment must be quick response type.

The facility Biomedical Engineer and/ or the Hospital Facilities Manager acknowledged the finding when the deficiency was identified.
Failure to maintain sprinklers as required increases the risk of death or injury due to fire.

The deficiency affected 1 of 24 smoke compartments.

Ref: 2000 NFPA 101 section 19.1.6.2, 19.3.5.1, 9.7.1.1; 1999 NFPA 13 section 7-2.3.2.4(3)


On 5/24/2011 at 9:10am, 10 upright sprinkler heads in the kitchen were installed in the pendant position.

On 5/24/2011 outside the C wing on the second floor pendant sprinkler heads were found to be installed in the upright position.

Upright sprinklers are required to be installed in upright position and pendant head sprinklers are required to be installed in the pendant position.

The Hospital Facilities Manager acknowledged the finding when the deficiency was identified.

Failure to install sprinklers in the proper orientation increases the risk of death or injury due to fire.

The deficiency affected 1 of 24 smoke compartments.

Ref: 2000 NFPA 101 Section 19.3.5.1, 9.7.5; 1998 NFPA 25

On 5/27/2011 records review and interview indicated that a new fire alarm system was activated on August 2010. As such sprinkler flow switch and tamper switch testing were not available for the past year with the exception of a flow switch test for February 2011. The Hospital Facilities Manager had implemented a contract for testing but did not have results indicating testing requirements would be met.

The Hospital Facilities Manager acknowledged the finding when the deficiency was identified.

Failure to test sprinkler systems as required increases the risk of death or injury due to fire.

The deficiency affected 24 of 24 smoke compartments.

Ref: 2000 NFPA 101 Section 19.3.5.1, 9.7.5; 1998 NFPA 25 2-3.3, 9-3.4.3

Based on observation and interview and records review, the facility failed to provide ventilating and air-conditioning system as required.

Findings include:

On 5/27/2011 at 9:30am, the facility indicated that the dampers protecting the stair enclosure #2 and #3 were protected with fire dampers. Records and staff interview indicated that the dampers were smoke activated only. The staff indicated that they were not aware of a fusible link or other approved heat actuated device that would close the dampers.

Stairs serving 4 or more stores are required to be protected with 2 hour fire resistant construction. Appropriate damper for duct penetrations are required.

The facility Biomedical Engineer and the Hospital Facilities Manager acknowledged the finding when the deficiency was identified.

Failure to protect stair enclosures as required increases the risk of death or injury due to fire.

The deficiency affected 18 of 24 smoke compartments.

Ref: 2000 NFPA 101 Section 19.2.2.3, 7.2.2.5.1, 7.1.3.2.1 exception 1, 8.2.3.2.4.1, 9.2.1; 1999 NFPA 90A Section 3-3.1.13-4.5.1

Based on records review and interview, the facility failed to maintain cooking facilities as required.

Findings include:

On 5/27/2011 at 9am, documentation for hood cleaning was for the past 12 months was not available. The facilities manager indicated that duct cleaning had not been completed due to a contract error.

Hood inspection is required semi- annually on moderate volume cooking facilities and cleaned when inspection indicates need.

The facility Hospital Facilities Manager acknowledged the finding when the deficiency was identified.

Failure to clean cooking facility hoods as required increases the risk of death or injury due to fire.

The deficiency 1 affected of 24 smoke compartments.

Ref: 2000 NFPA 101 Section 19.3.2.6, NFPA 96 Section 8-3.1

Based on observation and interview, the facility failed to store medical gases as required.
Findings include:

On 5/23/2011 at 2:15 pm, a room storing 19 H size oxygen cylinders (5,700 cf) and other gas cylinders was found to be unvented. Venting to the outside by a dedicated mechanical venting system or by natural ventilation is required when storing greater than 3,000 cf of gasses.
The facility Biomedical Engineer and/ or the Hospital Facilities Manager acknowledged the finding when the deficiency was identified.

Failure to store medical gasses as required increase the risk of death or injury due to fire.

The deficiency affected 1 of 24 smoke compartments.

Ref: 2000 NFPA 101 Section 19.3.2.4; 1999 NFPA 99 Section 4-3.1.1.2(b)

Based on observation and interview, the facility failed to maintain medical gas facilities as required.

Findings include:
On 5/23/2011, the source valve for the medical oxygen system was labeled with a number tag. This valve is required to be labeled " SOURCE VALVE FOR THE (SOURCE NAME) "

The facility Biomedical Engineer and/ or the Hospital Facilities Manager acknowledged the finding when the deficiency was identified.

Failure to label valves as required increases the risk of death or injury due to fire.

The deficiency affected all smoke compartments.

Ref: 2000 NFPA 101 Section 19.3.2.3; 1999 NFPA 99, Section 12-3.4.1, 4-3.1.2.3

On 5/24/2011 at 2:00pm the charge nurse in the progressive care unit stated that there was the potential and they had in the past had patients that patients in the unit were on life support and in the unit could expect to receive patients that require life support equipment. No medical gas area alarm was present.

On 5/24/2011 at 2:30pm, the nursing supervisor in the medical surgical unit stated that there was the potential and they had in the past had patients that patients in the unit were on life support and in the unit could expect to receive patients that require life support equipment. No medical gas area alarm was present.

On 5/24/2011 at 3:10 pm, the nursing supervisor in the surgical ward stated that there was the potential and they had in the past had patients that patients in the unit were on life support and in the unit could expect to receive patients that require life support equipment. No medical gas area alarm was present.

On 5/24/2011 at 2:00pm in the CCU (Critical Care Unit) the area medical gas alarm was not functional. The biomedical engineer stated that the area alarm had not been hooked up yet.

Area medical gas alarms are required in areas that provide vital life support.

The facility Biomedical Engineer and/ or the Hospital Facilities Manager acknowledged the finding when the deficiency was identified.

Failure to provide area alarms increase the risk of death or injury due to fire.

The deficiency affected 4 of 24 smoke compartments.

Ref: 2000 NFPA 101 Section 19.3.2.3; 1999 NFPA 99, Section 12-3.4.1, 4-3.1.2.2(c)