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Based on observation the facility failed to provide components of a building's designated construction type. This condition could affect individuals on the floor of fire incident from safely traveling the means of egress to the nearest exit stair and to a discharge on another floor.
Finding include:

On 02/22/2016 at 10:00 am, 3rd floor Center stair, the surveyor observed while accompanied by the facility F.D. and C.E.O., portions of the hospital which contain unprotected structural steel beams. This does not comply with the minimum construction type requirements of 19.1.6.2 and NFPA 220, 1999 Edition.

Based on observations the facility failed to maintain properly rated shaft enclosures. This deficient practice could affect patients, staff and visitor if smoke and fire were allowed to expand from other areas of the facility through deficient shaft enclosures.

Findings include:

On 02/22/2016 at 10:15am, the surveyor, while accompanied by the C.E.O. and F.D. observed an access panel located in a 2-hour fire rated shaft. The framed-in opening did not contain a fire resistant rating. This condition does not comply with 18.3.1 and 8.2.5.2 for a continuous fire rated protected enclosure of the shaft wall.

Location observed: 3rd floor surgery waiting room closet.

By direct observation/staff interview the surveyor finds the facility failed to install a means to automatically close the fire shutter separating the kitchen from the corridor. This deficient practice could result in the failure / response during a fire event, which may affect patients, staff and visitors.
On 2/22/16 at 2:30PM in the company of the Chief Executive Officer, the surveyor finds that the fire shutter was being held open by a fusible link only and would not released to close by manual fire alarm operation or local smoke detection to comply with NFPA 72 1999 edition 2-10.6.

Based on observation the facility failed to provide complete separation between hazardous areas and the remainder of the building. These deficiencies could affect all patients within the smoke compartment, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into the exit access in the event of a fire condition.

Findings include:

A. On 02/22/2016 at 1:15 pm, 2nd floor, while accompanied by the F.D. and C.E.O, the surveyor observed a storage room (formerly patient room which is located across from the nurse station) which contains equipment and combustible materials that does not comply with 19.3.2.1 (7) and 8.4.1.3 for an adequate separation provided by a fire resistant self closing door and frame. The room lacks a 1-hour fire resistant enclosure to be shown on the facility life safety floor plans.

B. On 02/22/2016 at 2:30 pm,Basement, while accompanied by the F.D. and C.E.O., the surveyor observed clean storage, material management, laundry room all connected with ceiling areas open to each other.


C. On 02/22/2016 at 2:00 pm, 1st floor Emergency Department, while accompanied by the F.D. and the C.E.O., the surveyor observed equipment and linens stored in a corridor alcove. The amount of combustibles deems it a hazardous area which is not separated from a means of egress corridor.

D. On 02/22/2016 at 2:10am, 1st floor Pharmacy room, while accompanied by the F.D. and the C.E.O., the surveyor observed a designated hazardous area (due to the amount of storage) which is sprinkler protected located adjacent to an office space, the office space does not comply with 8.4.1.3 due to the following:

1. The room did not appear to be sprinkler protected.

2. The room did not appear to have a fire rated separation from the pharmacy due to the lack of a fire rated door and frame.

Based on observation the facility failed to provide exit stairs constructed to provide a safe means of egress to a discharge. These deficiencies could affect any patients, staff, or visitors in the stair during a building or floor evacuation.

Findings include:

On 02/22/2016 at 10:00 am while accompanied by the F.D. and C.E.O., the surveyor observed stair landings which lack a continuous toe plate which are to prevent a person from tripping over the edge of a stair landing during vertical egress. The current condition does not comply with subpart (3) to 7.2.2.4.6.

Example location observed, the "center" stair leading to the mechanical penthouse.

Based on document review the facility does not maintain proper records of required testing. This could effect anybody having surgery if the battery lights did not work upon loss of power.

Findings include:

On 2/22/16 at 2:45 pm, the surveyor observed during document review, while accompanied by the CEO and the FD, that records were not available showing that battery lights were tested for 30 seconds each month and for 90 minutes annually in accordance with the 2000 Edition of NFPA-101, Section 7.9.3.

Based on observation the facility failed to provide exit signs that are fully visible, or incorrectly identify paths of egress. This deficiency may affect all patients within the areas of the facility, as well as any staff and visitors present, by preventing those occupants from readily utilizing an available exit during a fire or smoke event.

Findings include:

On 2/22/2016 at 2:45 pm, surveyor observed, while accompanied by the facility F.D. and C.E.O., basement level exit signs are not provided to identify the 2nd means of egress to comply with 19.2.5.9. 19.2.5.10 and 7.10.

Locations noted include the following:

1. Meeting room exit signage not clearly visible.

2. Exit path leading to Center stair not clearly visible.

Based on observation, the fire alarm panels are not properly labeled. This could effect facility maintenance staff if power is lost to the system.

Findings include:

On 2/22/16 at 9:30 am, while accompanied by the CEO and the FD, the surveyor observed the fire alarm panels located in the lower level conference room and the elevator lobby were not labeled with the life safety panel and circuit serving them in accordance with the 1999 Edition of NFPA-72, Section 1-5.2.5.2.

Based on observation, the facility failed to provide a completely enclosed ventilation system. This deficient practice could result in the failure / response during a fire event, which may affect patients, staff and visitors.
Finding includes:

On 02/22/2016 at 10:30am, 2nd floor, while accompanied by the facility F.D. and C.E.O., the surveyor observed a duct penetration through the fire rated smoke barrier which was not installed as required by the duct/damper manufacturer. Location observed above the ceiling at the pair of cross corridor doors leading into surgery. This installation does not comply with 19.3.7.3 exception no. 2 and NFPA 90A .

By direct observation, the facility failed to correctly install / maintain the piped medical gas system. This deficient practice could result in the response during a fire event, which may affect patients, staff and visitors.
A. On 2/22/16 at 11:00AM in the company of the Chief Executive Officer, the surveyor finds the medical gas zone valves serving the 1913 second floor patient room rooms are installed behind a normally open cross corridor door hidden from plain view in noncompliance with NFPA 99, 1999 4-3.1.2.3 (i).
B. On 2/22/16 at 10:00AM in the company of the Chief Executive Officer, the surveyor finds the facility medical gas zone valves identification serving the 2nd and 3rd floor rooms outlets/inlets have not been updated to reflect renovation changes and the abandonment of outlets/inlets. NFPA 99, 1999, 4-3.1.2.14 (b) 3

Based on observation, the facility failed to to maintain a proper emergency power system. If the generator fails to operate upon the loss of normal power, this could effect all occupants of the building.

Findings Include:

A. On 2/22/16 at 11:00 am, while accompanied by the CEO and the FD, the surveyor observed that the generator annunciators were either missing or deficient.

1. The Onan generator was not equipped with a remote annunciator.

2. The Detroit generator annunciator did not meet the requirements of the 1999 Edition of NFPA-99, Section 3-4.1.1.15, and the 1999 Edition of NFPA-110, Table 3-5.5.2(d).

B. On 2/22/16 at 2:00 pm, while accompanied by the CEO and the FD, the surveyor observed the batteries serving the generators were in unheated enclosures and were not equipped with battery heaters to meet the requirements of the 1999 Edition of NFPA-110, Section 3-3.1.

C. On 2/22/16 at 2:00 pm, while accompanied by the CEO and the FD, the surveyor observed the battery charger for the batteries of the Onan generator was not connected in accordance with the requirements of the 1999 Edition of NFPA-110, Section 5-12.6.

A. Due to the number, variety, and severity of the life safety code 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.

B. On 02/22/2016 at 12:45 pm, 1st floor negative pressure patient room ante room, the surveyor observed while accompanied by the F.D. and C.E.O., a faucet mounted temperature pressure regulator installed over a sink which does not comply with ANSI Z358.1-1998.

Based on observation, the emergency power was not properly divided into three branches. This could effect all occupants of the building if the emergency power failed to operate properly upon loss of normal power.

Findings include:

On 2/22/16 at 10:45 am, while accompanied by the CEO and the FD, the surveyor observed that all panels serving the second floor were served from one of the two emergency generators and all panels were serving a mix of life safety, critical and equipment loads. This was not in compliance with the 1999 Edition of NFPA-70, Sections 517-30 through 517-35.

Examples:

1. Panel EM2A serves a mix of critical and equipment loads.
2. Panel L3A serves a mix of critical and equipment loads.
3. Panel marked as Onan generator serves a mix of all branches of emergency power.

Based on observation, the facility failed to provide a proper electrical system. This could effect any patient if a transfer switch failed.

Findings include:

A. On 2/22/16 at 10:00 am, while accompanied by the CEO and the FD, the surveyor observed the following areas were not equipped with normal power receptacles or receptacles served from two separate critical transfer switches as required by the 1999 Edition of NFPA-99, Section 3-3.2.1.2(a)1.

1. The operating rooms
2. The stage 1 recovery rooms
3. All patient rooms

B. On 2/22/16 at 1;30 pm, while accompanied by the CEO and the FD, the surveyor observed that the elevator equipment room was not equipped with a lighting disconnect served from the life safety branch of emergency power in accordance with the 1999 Edition of NFPA-70, Section 620-22, and Section 517-32.

Based on observation, the facility failed to provide an elevator recall system. This could effect anybody using the elevator during a fire.

Findings include:

On 2/22/16 at 2:30 pm, while accompanied by the CEO and the FD, the surveyor observed that the elevators were not equipped with a recall system to meet the requirements of ANSI/ASME A 17.1.

Based on observation the facility failed to provide components of a building's designated construction type. This condition could affect individuals on the floor of fire incident from safely traveling the means of egress to the nearest exit stair and to a discharge on another floor.
Finding include:

On 02/22/2016 at 10:00 am, 3rd floor Center stair, the surveyor observed while accompanied by the facility F.D. and C.E.O., portions of the hospital which contain unprotected structural steel beams. This does not comply with the minimum construction type requirements of 19.1.6.2 and NFPA 220, 1999 Edition.

Based on observations the facility failed to maintain properly rated shaft enclosures. This deficient practice could affect patients, staff and visitor if smoke and fire were allowed to expand from other areas of the facility through deficient shaft enclosures.

Findings include:

On 02/22/2016 at 10:15am, the surveyor, while accompanied by the C.E.O. and F.D. observed an access panel located in a 2-hour fire rated shaft. The framed-in opening did not contain a fire resistant rating. This condition does not comply with 18.3.1 and 8.2.5.2 for a continuous fire rated protected enclosure of the shaft wall.

Location observed: 3rd floor surgery waiting room closet.

By direct observation/staff interview the surveyor finds the facility failed to install a means to automatically close the fire shutter separating the kitchen from the corridor. This deficient practice could result in the failure / response during a fire event, which may affect patients, staff and visitors.
On 2/22/16 at 2:30PM in the company of the Chief Executive Officer, the surveyor finds that the fire shutter was being held open by a fusible link only and would not released to close by manual fire alarm operation or local smoke detection to comply with NFPA 72 1999 edition 2-10.6.

Based on observation the facility failed to provide complete separation between hazardous areas and the remainder of the building. These deficiencies could affect all patients within the smoke compartment, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into the exit access in the event of a fire condition.

Findings include:

A. On 02/22/2016 at 1:15 pm, 2nd floor, while accompanied by the F.D. and C.E.O, the surveyor observed a storage room (formerly patient room which is located across from the nurse station) which contains equipment and combustible materials that does not comply with 19.3.2.1 (7) and 8.4.1.3 for an adequate separation provided by a fire resistant self closing door and frame. The room lacks a 1-hour fire resistant enclosure to be shown on the facility life safety floor plans.

B. On 02/22/2016 at 2:30 pm,Basement, while accompanied by the F.D. and C.E.O., the surveyor observed clean storage, material management, laundry room all connected with ceiling areas open to each other.


C. On 02/22/2016 at 2:00 pm, 1st floor Emergency Department, while accompanied by the F.D. and the C.E.O., the surveyor observed equipment and linens stored in a corridor alcove. The amount of combustibles deems it a hazardous area which is not separated from a means of egress corridor.

D. On 02/22/2016 at 2:10am, 1st floor Pharmacy room, while accompanied by the F.D. and the C.E.O., the surveyor observed a designated hazardous area (due to the amount of storage) which is sprinkler protected located adjacent to an office space, the office space does not comply with 8.4.1.3 due to the following:

1. The room did not appear to be sprinkler protected.

2. The room did not appear to have a fire rated separation from the pharmacy due to the lack of a fire rated door and frame.

Based on observation the facility failed to provide exit stairs constructed to provide a safe means of egress to a discharge. These deficiencies could affect any patients, staff, or visitors in the stair during a building or floor evacuation.

Findings include:

On 02/22/2016 at 10:00 am while accompanied by the F.D. and C.E.O., the surveyor observed stair landings which lack a continuous toe plate which are to prevent a person from tripping over the edge of a stair landing during vertical egress. The current condition does not comply with subpart (3) to 7.2.2.4.6.

Example location observed, the "center" stair leading to the mechanical penthouse.

Based on document review the facility does not maintain proper records of required testing. This could effect anybody having surgery if the battery lights did not work upon loss of power.

Findings include:

On 2/22/16 at 2:45 pm, the surveyor observed during document review, while accompanied by the CEO and the FD, that records were not available showing that battery lights were tested for 30 seconds each month and for 90 minutes annually in accordance with the 2000 Edition of NFPA-101, Section 7.9.3.

Based on observation the facility failed to provide exit signs that are fully visible, or incorrectly identify paths of egress. This deficiency may affect all patients within the areas of the facility, as well as any staff and visitors present, by preventing those occupants from readily utilizing an available exit during a fire or smoke event.

Findings include:

On 2/22/2016 at 2:45 pm, surveyor observed, while accompanied by the facility F.D. and C.E.O., basement level exit signs are not provided to identify the 2nd means of egress to comply with 19.2.5.9. 19.2.5.10 and 7.10.

Locations noted include the following:

1. Meeting room exit signage not clearly visible.

2. Exit path leading to Center stair not clearly visible.

Based on observation, the fire alarm panels are not properly labeled. This could effect facility maintenance staff if power is lost to the system.

Findings include:

On 2/22/16 at 9:30 am, while accompanied by the CEO and the FD, the surveyor observed the fire alarm panels located in the lower level conference room and the elevator lobby were not labeled with the life safety panel and circuit serving them in accordance with the 1999 Edition of NFPA-72, Section 1-5.2.5.2.

Based on observation, the facility failed to provide a completely enclosed ventilation system. This deficient practice could result in the failure / response during a fire event, which may affect patients, staff and visitors.
Finding includes:

On 02/22/2016 at 10:30am, 2nd floor, while accompanied by the facility F.D. and C.E.O., the surveyor observed a duct penetration through the fire rated smoke barrier which was not installed as required by the duct/damper manufacturer. Location observed above the ceiling at the pair of cross corridor doors leading into surgery. This installation does not comply with 19.3.7.3 exception no. 2 and NFPA 90A .

By direct observation, the facility failed to correctly install / maintain the piped medical gas system. This deficient practice could result in the response during a fire event, which may affect patients, staff and visitors.
A. On 2/22/16 at 11:00AM in the company of the Chief Executive Officer, the surveyor finds the medical gas zone valves serving the 1913 second floor patient room rooms are installed behind a normally open cross corridor door hidden from plain view in noncompliance with NFPA 99, 1999 4-3.1.2.3 (i).
B. On 2/22/16 at 10:00AM in the company of the Chief Executive Officer, the surveyor finds the facility medical gas zone valves identification serving the 2nd and 3rd floor rooms outlets/inlets have not been updated to reflect renovation changes and the abandonment of outlets/inlets. NFPA 99, 1999, 4-3.1.2.14 (b) 3

Based on observation, the facility failed to to maintain a proper emergency power system. If the generator fails to operate upon the loss of normal power, this could effect all occupants of the building.

Findings Include:

A. On 2/22/16 at 11:00 am, while accompanied by the CEO and the FD, the surveyor observed that the generator annunciators were either missing or deficient.

1. The Onan generator was not equipped with a remote annunciator.

2. The Detroit generator annunciator did not meet the requirements of the 1999 Edition of NFPA-99, Section 3-4.1.1.15, and the 1999 Edition of NFPA-110, Table 3-5.5.2(d).

B. On 2/22/16 at 2:00 pm, while accompanied by the CEO and the FD, the surveyor observed the batteries serving the generators were in unheated enclosures and were not equipped with battery heaters to meet the requirements of the 1999 Edition of NFPA-110, Section 3-3.1.

C. On 2/22/16 at 2:00 pm, while accompanied by the CEO and the FD, the surveyor observed the battery charger for the batteries of the Onan generator was not connected in accordance with the requirements of the 1999 Edition of NFPA-110, Section 5-12.6.

A. Due to the number, variety, and severity of the life safety code 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.

B. On 02/22/2016 at 12:45 pm, 1st floor negative pressure patient room ante room, the surveyor observed while accompanied by the F.D. and C.E.O., a faucet mounted temperature pressure regulator installed over a sink which does not comply with ANSI Z358.1-1998.

Based on observation, the emergency power was not properly divided into three branches. This could effect all occupants of the building if the emergency power failed to operate properly upon loss of normal power.

Findings include:

On 2/22/16 at 10:45 am, while accompanied by the CEO and the FD, the surveyor observed that all panels serving the second floor were served from one of the two emergency generators and all panels were serving a mix of life safety, critical and equipment loads. This was not in compliance with the 1999 Edition of NFPA-70, Sections 517-30 through 517-35.

Examples:

1. Panel EM2A serves a mix of critical and equipment loads.
2. Panel L3A serves a mix of critical and equipment loads.
3. Panel marked as Onan generator serves a mix of all branches of emergency power.

Based on observation, the facility failed to provide a proper electrical system. This could effect any patient if a transfer switch failed.

Findings include:

A. On 2/22/16 at 10:00 am, while accompanied by the CEO and the FD, the surveyor observed the following areas were not equipped with normal power receptacles or receptacles served from two separate critical transfer switches as required by the 1999 Edition of NFPA-99, Section 3-3.2.1.2(a)1.

1. The operating rooms
2. The stage 1 recovery rooms
3. All patient rooms

B. On 2/22/16 at 1;30 pm, while accompanied by the CEO and the FD, the surveyor observed that the elevator equipment room was not equipped with a lighting disconnect served from the life safety branch of emergency power in accordance with the 1999 Edition of NFPA-70, Section 620-22, and Section 517-32.

Based on observation, the facility failed to provide an elevator recall system. This could effect anybody using the elevator during a fire.

Findings include:

On 2/22/16 at 2:30 pm, while accompanied by the CEO and the FD, the surveyor observed that the elevators were not equipped with a recall system to meet the requirements of ANSI/ASME A 17.1.