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Based on observations and confirmed by staff, the facility failed to ensure corridor walls are constructed as required.

THE FINDINGS INCLUDE:

During the morning hours of 10/6/15 while touring the Gastroenterology Unit (GI) located on the 2nd floor level, it was revealed that the unit which is divided into two areas by a 2 hour rated fire barrier is classified by the hospital as a healthcare occupancy for the GI procedure rooms and a business occupancy for the recovery area. It was stated by the GI unit staff that procedures are performed on both in-patients and out-patients during a normal business day.

According to the Survey & Certification/Survey & Certification Group memo identified as S&C-11-05-LSC revised on 2/18/11, units which care for patients which are mostly incapable of self-preservation are required to be classified as Healthcare or Ambulatory Healthcare. The S&C states a patient may be incapable of self-preservation due to many factors, including, but not limited to, age, physical or mental disability, medical or therapeutic interventions, medication reactions, etc. In addition, when determining the ability for self-preservation, consideration should be given to both the characteristics of current patients and the characteristics of patients the facility is likely to provide medical treatment or services to in the future, as evidenced by the provider's own advertisement and clientele to which the provider holds itself out to serve.
After speaking with the Executive Director and Charge Nurse of the GI unit, it was determined that the patients within the recovery area are not capable of self-preservation. It was stated that the patients are under the effects of anesthesia for at least 45-minutes following the completion of the procedure. In addition, a blank patient flow sheet with a "Modified Aldrete Score" was reviewed; the patient must achieve a score of 8 in order to be released from the recovery unit. One of the criteria in obtaining this score is the ability of the patients to regain full consciousness.

Since it has been determined that all areas of the GI unit are required to be surveyed under the Healthcare Occupancy chapter 19 of the LSC due to both in-patients and out-patients incapable of self-preservation, the recovery area was determined to be deficient. The recovery area consists of 12 bays. Ten of the recovery bays consist of separation by use of cubicle curtains; the other two bays have non-latching sliding doors. The recovery area is not provided with defined corridors or classified as a suite per healthcare requirements. Therefore, the hospital in not in compliance with 19.3.6.1 requiring corridor walls as a result of the lack of corridor separation due to the open recovery bays

Note: The unit was not surveyed as an Ambulatory Surgical Center (ASC) as the compartment is greater than 10,000 square feet and not provided with a smoke barrier as required.

This was acknowledged by the administrative staff team during the exit interview conference.

Based on observations the facility failed to ensure compliance with the 2000 edition of NFPA #101 "Life Safety Code". Chapter 19 section 19.3.6.3.1 requires doors protecting corridor openings in smoke compartments protected throughout by an approved, supervised automatic sprinkler system to be constructed to resist the passage of smoke in addition to being provided with a means suitable for keeping the door closed

THE FINDINGS INCLUDE:

1. While conducting the tour of the facility's Critical Care Center, located on the second floor of the #01-Main Building, observations revealed the Intensive Care Unit patient rooms located within the Critical Care Center are protected from the corridor by double leaf sliding glass doors units. Numerous door units (including but not limited to the units protecting rooms 2501, 2514, 2515 and 2516) exhibited a quarter (1/4") inch to a half (1/2") inch space running the full length of the meeting edge of the two glass door leafs when the door was in the latched position.

In addition, many of the units active (latching) leaf were found to be missing the top rail protective end cap resulting in an approximate half (1/2") inch by one and a half (1-1/2") inch space when the doors were in the closed and latched position.

2. While conducting the tour of the facility, the doors to the following patient rooms did not latch in their frames due to the latching hardware remaining in the retracted position: 3406, 3411, 3412, 3511, 3614, and 3310.

As a result of the findings the facility is found to be non-compliant with Section 19.3.6.3.1 of Chapter 19 of NFPA #101 "Life Safety Code".

This was acknowledged by the administrative staff team during the exit interview conference.

Based on observations, the facility failed to ensure that hazardous areas are enclosed as required. NFPA 101 "Life Safety Code" 2000 Edition Chapter 19 Section 19.3.2.1 "Hazardous Areas" requires doors protecting hazardous areas to be self-closing or automatic-closing.

Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.

THE FINDINGS INCLUDE:

Observations while touring the facility's basement on the morning of 10/06/15 revealed that the entrance door to the Food storage room, the entrance door to the Kitchen Paper storage room, and one of the pair of entrance doors to the Warehouse storage room are not equipped with self-closing devices. All of the rooms are greater than fifty square feet in size and house greater than normal quantities of combustible materials and must be protected by self or automatic closing doors.

As a result of the findings the facility is found to be non-compliant with Chapter 19 Section 19.3.2.1. of NFPA #101 "Life Safety Code".

This was acknowledged by the administrative staff team during the exit interview conference.

Based on observations and confirmed by staff, the facility failed to ensure that two approved exits are provided in each section of the building.

Section 19.2.4.1 states not less than two exits of the types described in 19.2.2.2 through 19.2.2.10, remotely located from each other, shall be provided for each floor or fire section of the building.

Section 19.2.6.2.1 states the travel distance between any room door required as an exit access and an exit shall not exceed 100 ft (30 m).
Exception: The maximum travel distance shall be permitted to be increased by 50 ft (15 m) in buildings protected throughout by an approved, supervised automatic sprinkler system.

Section 19.2.6.2.2 states the travel distance between any point in a room and an exit shall not exceed 150 ft (45 m).
Exception: The maximum travel distance shall be permitted to be increased by 50 ft (15 m) in buildings protected throughout by an approved, supervised automatic sprinkler system.

THE FINDINGS INCLUDE:

During the morning and afternoon hours of 10/5/15 and 10/6/15 while touring the facility, it was noted that two approved exits are not provided from each section of the facility. The travel distances on both the 3rd and 2nd floor levels are excessive in numerous locations. Upon measuring the actual distances with a measuring wheel, the following locations were noted as being deficient:

1) Third Floor: There are numerous patient rooms located within smoke zones 3-2, 3-3, 3-6 and 3-8 which have travel distances far exceeding 200' to the required second means of egress stairwell and/or horizontal exit.

2) Second Floor: There are numerous patient rooms located within smoke zones 2-2, 2-3 and 2-7 which have travel distances far exceeding 200' to the required second means of egress stairwell and/or horizontal exit.

This was acknowledged by the administrative staff team during the exit interview conference.

NOTE: This item does not meet NFPA 101 Life Safety Code, 2000 edition; however it would meet an alternative compliance with the Code (Fire Safety Evaluation System - FSES) under equivalency concepts of NFPA 101A, Guide on Alternative Approaches to Life Safety, 2001 edition where such equivalency is requested and approved.

Based on record review and confirmed by staff, the facility failed to test and maintain records of the fire alarm system in accordance with NFPA 72. Section 7.3.2 and Table 7.3.2 require systems with sealed batteries to have the battery charger tested annually, replace the battery every 4 years, to conduct a 30 minute battery discharge test annually, and to conduct a load voltage test semi-annually.

THE FINDINGS INCLUDE:

After reviewing the inspection/test form dated 11/4/15 it was noted that the facility is not conducting the required testing in accordance with NFPA 72. Documenation provided failed to substantiate that the semi-annual load voltage test is conducted twice a year. Record review reveals the vendor conducted the load voltage test once on 11/4/15. (Note: The batteries were installed in April 2014.)

This was acknowledged by the administrative staff team during the exit interview conference.

Based on observation, the facility was not in compliance with NFPA 90A.

Section 3-3.1.1 states approved fire dampers shall be provided where air ducts penetrate or terminate at openings in walls or partitions required to have a fire resistance rating of 2 hours or more.

Section 3-3.2 Floors Required to Have a Fire Resistance Rating states where air ducts extend through only one floor and serve only two adjacent stories, the air ducts shall be enclosed(see 3-3.4.1 or fire dampers shall be installed at each point where the floor is penetrated.
Exception: Air ducts serving air-conditioning terminal devices on the floor above, provided a fire test conducted in accordance with NFPA 251, Standard Methods of Tests of Fire Endurance of Building Construction and Materials, determines that the fire resistance rating of the floor is maintained.

Section 3-3.3 Floor- or Roof-Ceiling Assemblies Having a Fire Resistance Rating states where air ducts and openings for air ducts are used in a floor- or roof-ceiling assembly that is required to have a fire resistance rating, all the materials and the construction of the assembly, including the air duct materials and the size and protection of the openings, shall conform with the design of the fire-resistive assembly, as tested in accordance with NFPA 251, Standard Methods of Tests of Fire Endurance of Building Construction and Materials. (Where dampers are required, see 3-4.4.)

Section 3-3.4.1 states air ducts that pass through the floors of buildings that require the protection of vertical openings shall be enclosed with partitions or walls constructed of materials as permitted by the building code of the authority having jurisdiction. The enclosure shall have a minimum fire resistance rating (based on possible fire exposure from either side of the partition or wall) of 1 hour where such air ducts are located in a building less than four stories in height and a minimum rating of 2 hours where such air ducts are located in a building four stories or more in height.
Exception: Where an air duct penetrates only one floor, or one floor and an air-handling equipment penthouse floor, and the air duct contains a fire damper located where the duct penetrates the floor, an air duct enclosure shall not be required.

Section 3-4.1 states fire dampers used for the protection of openings in walls, partitions, or floors with fire resistance ratings of less than 3 hours shall have a 1 1/2-hour fire protection rating in accordance with UL 555, Standard for Safety Fire Dampers.

Section 2-3.4.1 states service opening shall be provided in air ducts adjacent to each fire damper, smoke damper, and smoke detector. The opening shall be large enough to permit maintenance and resetting of the device.

Section 2-3.4.2 states service openings shall be identified with letters having a minimum height of 1/2 in. (1.27 cm) to indicate the location of the fire protection device(s) within.

THE FINDINGS INCLUDE:

Based on observations during the survey, it was observed that there are three ducts, sized 42" x 72", 36" x 60", and 16" x 16", which penetrate the the roof/ceiling assembly (roof to 3rd floor )and the floor/ceiling assembly (3rd floor to 2nd floor) on Level 3 in the previously occupied retail pharmacy location. These three ducts are not provided with fire dampers where they penetrate the floor/ceiling assembly(3rd floor to 2nd floor) nor are they provided with a one hour rated enclosure as required by NFPA 90A.

This was acknowledged by the administrative staff team during the exit interview conference.

Based on observations, the facility failed to ensure that utilities comply with the provisions of Section 9.1. Section 9.1.2 requires electrical wiring and equipment to be installed in accordance with NFPA 70.

NFPA 70, Article 384-18. Enclosure states panelboards shall be mounted in cabinets, cutout boxes, or enclosures designed for the purpose and shall be dead front.
Exception: Panelboards other than of the dead-front externally operable type shall be permitted where accessible only to qualified persons.

THE FINDINGS INCLUDE:

Observations while touring the facility on 10/6/15 revealed wiring in the Same Day Surgery, Level 3, is not installed in accordance with NFPA 70. A computer is directly wired into the electric panelboard identified as NE308. In addition, the front cover plate of the panelboard has been removed exposing the live wiring.

This was confirmed by the Director of Maintenance and reviewed with the Administrator at the exit conference.