HospitalInspections.org

It was observed by inspectors 37696 & 36434 and maintenance that this requirement is not met due to no rated separation between the existing sprinklered hospital and the non-sprinklered Health Service Foundation business occupancy.

The two buildings are attached and exiting from the non-sprinklered building goes through the sprinklered hospital. The existing walls shown to be rated on the drawings provided were inspected and it was found the walls, as built, are not rated.

The walls are not continuous to the roof deck and have multiple penetration . Additionally, the doors in the reportedly rated walls were not rated and are not self-closing and some do not latch.

It was observed by inspectors 37696 & 36434 and maintenance that this requirement is not met due to:

1) no fire proofing on the structural steel in the floor/ceiling assembly over the entry section of the laundry.

2) the fireproofing in the Cardiac Rehab exercised area is the exposed ceiling and has been painted. Please provide documentation from the fire proofing supplier/installer on what type of paint would be allowed on the fire proofing used as well as what type of paint was applied in order to verify compliance.

Based on records review surveyor 35163 on 04/10/17, in the presence of the maintenance director the following was not met:

1. No documentation could be provided to indicate that doors were being inspected in accordance with 2012 NFPA 101-7.2.1.15

Based on observation of the surveyor 35163 on 04/10/17, in the presence of the maintenance director the following was not met:


1. Exit door- ambulatory/surgical area requires a code be entered on a pin pad in order to release the door locking mechanism and staff and maintenance director did not have/know the code to open the door.

It was observed by inspectors 37696 & 36434 and maintenance that this requirement is not met due to:

1) the balusters/protection in the guards/railings of the patio outside patient financial are made of rope and exceed allowable 4" spacing. This patio is 6' + above the ground. Per 7.2.2.4.5.3 Open guards, other than approved existing open guards, shall have intermediate rails or an ornamental pattern such that a sphere 4 in. (100 mm) in diameter is not able to pass through any opening up to a height of 34 in. Additionally the rope appears to be quite old and may be of questionable strength

2) The guard/railing in the stair at the 3rd floor by Rm 319 does not have the required balusters

It was observed by inspectors 37696 & 36434 and maintenance that this requirement is not met due to the deadend corridor past the gift shop towards the non-sprinklered portion of the building exceeds allowable 30'.

It was observed by inspectors 37696 & 36434 and maintenance that this requirement is not met due to

1) no directional signage marking the
2nd exit from x-ray back to the concourse
2nd exit from radiology past the mammogram area

2) the exit sign in the corridor outside surgery has a double chevron however the exit is only in 1 direction. Open chevron to be covered to correct exit path

3) exiting exit sign outside central stair by elevators on 2nd level to be double sided

It was observed by inspectors 37696 & 36434 and maintenance that this requirement is not met due to:

1) in the elevator penthouse, the drywall of the elevator shaft wall has holes in it either side of the metal steps that go to the top of the shaft. It appears that the metal steps punched through the drywall.

2) the light switch inside the elevator penthouse just inside the door, has holes either side of the double switch. This wall is the stairwell wall and is required to be rated with intact drywall. The holes are to be patched to the rating of the stairwell.

3) The stairwell door on the 3rd level is not latching. It appears that the striker plate needs to be adjusted to allow the door to latch.

4) Just inside the stairwell, from the Sleep Study area, in the wall, is an open electrical box. The electrical box is plastic and has no wires running to it. This empty plastic box creates and open penetration in the rated stairwell wall and is required to be infilled.

NOTE: the existing drawings of the lower level showing the rated separations do not match the construction of the walls nor does it appear that the separations shown on the drawings would be necessary based on the current uses in this area. Recommend an evaluation by a design professional of the lower level in order to determine the need of and and location of any rated wall assemblies. The following notes are based on the drawings provided.

It was observed by inspectors 37696 & 36434 and maintenance that this requirement is not met due to

1) doors were not self-closing and positive latching in the following areas
a. door to electrical room in ambulance drive up area. It appears that the closing arm needs to be adjusted to pull the door closed completely so it can latch
b. The door to the soiled utility room in the ER is required to have latching hardware
c. the medical supply room off the ER treatment areas, on the treatment side
d. the flammables cabinet in the maintenance shop is required to be latching
e. The door to the storage room off out patient surgery
f. The janitor's closet near the Nurse Manager Office
g. The door to the janitor's closet in the main corridor just outside the lab
h. the janitors closet in the Positive Steps area
i. The acute care storage/breakroom door
j. door to the clean side of the laundry room to be latching
k. the rated wall to the laundry area on the lower level has a pair of double doors that do not latch
l. the double doors to the maintenance shop do not latch.


2) the following areas require to have ceiling and wall penetrations sealed to resist the passage of smoke or match the wall rating.
a. Acute care storage/breakroom gap between soffitt and aluminum window wall frame (interior wall) to be sealed to resist the passage of smoke
b. above the double doors to the laundry and sterilization area on the lower level are large holes in the wall above the double doors. Note that the existing drywall is 2 layers on each side of the wall and the drawings provided show that this is a 2 hour rated wall
c. according to the drawings provided, the maintenance shop area on the lower level is surrounded by a 1 hour rated wall however the floor/ceiling assembly in this space is not rated. There are multiple penetrations in both the wall and ceiling of this area.
d. The existing walls around the laundry area appear to be no less than 1 hour rated however the floor/ceiling assembly is not rated. Both wall and ceiling have multiple penetrations.
e. the door to the sleeping area on the lower level, according to the drawings provided, is in a 2 hour rated wall and therefore is required to be 90 minute rated with self-closing and positive latching hardware.
f. Mechanical room, pump 1 wall, penetrations over the door

It was observed by inspector 37696 and maintenance that this requirement is not met due to 100% of the wall between the upper and lower cabinets being covered in cork board which does not meet the allowable flame spread rating.

It was observed by inspectors 37696 & 36434 and maintenance that this requirement is not met due to the alarm pull by the exterior door in medical records was blocked by a cart

Based on observation of the surveyor 35163 on 04/10/17, in the presence of the maintenance director the following was not met:

1-Sprinkler escutcheon plate missing in room #212-ambulatory/surgical area

2-Sprinkler escutcheon plates missing in conference room-ambulatory/surgical area.


37696

It was observed by inspectors 37696 & 36434 and maintenance that this requirement is not met due to no sprinkler coverage in:
1. radiology coat closet
2. dirty linen storage room outside radiology in corridor
3. clean linen storage closet outside radiology in corridor
4. Room 9 E R sidewall sprinkler position in skylight
5. Cardiac Rehab Gym wiring attached to fire sprinkler piping
6. X-ray closet work area missing fire sprinkler coverage
7. X-ray Room 1 coverage questionable in entry
8. Elevator machine room medical building 3 no fire sprinkler coverage
9. Elevator stair access and machine room penthouse no fire sprinkler coverage
10. North wing top of stairs no fire sprinkler coverage
11. Non fire sprinkler piping supported by fire sprinkler piping central storage
12. Fire sprinkler head positioning central supply incorrect
13.Exit from maintenance shop no fire sprinkler coverage
14. Cooler and freezer in kitchen no fire sprinkler coverage
15. Closet in Foundation Office no fire sprinkler coverage

It was observed by inspectors 37696 & 36434 and maintenance that this requirement is not met due to:

1) following escutcheon rings missing or not seated in the ceiling/wall:
In the ER Radiology corridor
ER bathroom
Doctor's area
Respiratory therapy area etchussion ring missing on the far wall of the patient care area
Medical Records by back bathroom
In Social Services wing above Rm 368 there is a hole around the etchussion ring
Laundry, clean side, the etchussion ring is falling down from the ceiling
In Human Resources, small office, there is a hole around the side mounted sprinkler head etchussion ring
Director of Medical Affairs ring is missing
CEO the ring is out of the wall

2) items stacked less than allowable 18" from sprinkler heads in:
gift shop storage room
Admin Office storage room

3) Antifreeze solutions to be tested annually per section 5.2.4, last recorded test 10/2015

It was observed by inspectors 37696 & 36434 and maintenance that this requirement is not met due to

1) the ceiling tiles of the corridor in the ambulance delivery door were lifted out the ACT frame. Maintenance stated that when the doors open on windy days the change in pressure lifts them up.

Based on observation of the surveyor 35163 on 04/10/17, in the presence of the maintenance director the following was not met:

1. Conference room door - ambulatory/surgical area, had gap larger than ½" between the door and frame and would not prevent the passage of smoke.

2. Procedure room A- ambulatory/surgical suite????? was converted to a storage room (over 100 sq/ft) and did not have a self- closing device on the door

3. OR-1 was converted to a storage room (over 100 sq/ft) and did not have a self- closing device on the door and would not properly close/latch-appears to be hitting on the frame.

4. Picking room storage room (over 100 sq/ft)door did not have a self- closing device

5. Supply 2 storage room-surgical area (over 100 sq/ft)door did not have a self- closing device

6. Anesthesia supply room door had a self-closing device that when placed in the fully open position kept the door open and did not self-close(propped door in the open position)

7. Break room in surgical area adjacent to the exit corridor did not have a self-closing device

8. Door next to nursing desk had a flip down door hold open device on the door



37696

It was observed by inspectors 37696 & 36434 and maintenance that this requirement is not met due to:

1) the gap between the door leafs of the double doors from ER to the main corridor exceeds allowable 1/8"

2) The cardiac trauma room in the ER the side panel hardware does not allow for the main door to latch. Maintenance commented that the hardware should be replaced

3) the CR room door was propped open with a "wet floor" sign

4) gap between the door leaf and the frame of the Nurses Manager Office is greater than 1/2" and exceeds allowable

It was observed by inspectors 37696 & 36434 and maintenance that this requirement is not met due to

1) open penetrations in smoke barrier walls in the following locations
over double doors to cardio pulmonary service
over double doors into positive steps

It was observed by inspectors 37696 & 36434 and maintenance that this requirement is not met due to the staff on duty was able to locate the disaster plan however was unable to find the fire emergency plan in the book. The staff member questioned has been on staff for 22 years.

Based on records review surveyor 35163 on 04/10/17, in the presence of the maintenance director the following was not met:


1. No documentation could be provided to indicate a drill was conducted on the 7pm - 0700 shift for the first quarter of 2016

Based on records review surveyor 35163 on 04/10/17, in the presence of the maintenance director the following was not met:

1. Deficiencies were identified in the last medical gas inspection report and no documentation could be provided to indicate they had been corrected.

- Valves located in ACU/LDRP are considered service valves and they did not have secured access.

-The outlets in respiratory therapy are not supplied through a zone valve

-The oxygen system has threaded check valves on the piping where it enters the building

It was observed by inspectors 37696 & 36434 and maintenance that this requirement is not met due to in the elevator penthouse is an electrical junction box without a cover and a switch on the exterior wall without a cover.

It was observed by inspectors 37696 & 36434 and maintenance that this requirement is not met due to the lab having clear packing tape securing wires to wall mounted electrical outlet strips.

It was observed by inspectors 37696 & 36434 and maintenance that this requirement is not met due to a light switch in Rm 204 that does not work any lights. It was unknown at the time of survey if there was power to this switch.

Based on observation of the surveyor 35163 on 04/10/17, in the presence of the maintenance director the following was not met:

1. Ambulatory/surgical area- medication room had a multi outlet device that was being use to power permanent equipment.


37696

It was observed by inspectors 37696 & 36434 and maintenance that this requirement is not met due to the microwave in the staff breakroom in the radiology area was plugged into a power strip

It was observed by inspectors 37696 & 36434 and maintenance that this requirement is not met due to no O2 storage signs on storage room housing O2 canisters. In the Respiratory Storage room there are (5) tanks being stored without signage.