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Based on random observation during the survey walk-through and staff interview, not all portions of the building are of fire resistive construction in accordance with 19.1.6.2. These deficiencies could affect any patients, staff, or visitors in the building by permitting the building structure to be compromised during fire conditions.

Findings include:

A. During an interview held in the Conference Room at 10:45 AM on February 18, 2014, the provider's Architectural Consultant stated that the building (including the Hospital and the X-Ray Addition) is of Type II (000) construction; the building is not fully covered by an automatic sprinkler system as required by Table 19.1.6.2.

B. At 2:20 PM on February 18, 2014, portions of the exterior wall of the Laundry Room were observed to be constructed with plywood as prohibited by NFPA 220 1999 Table 3-1.

Based on random observation during the survey walk-through, not all wall finishes in rooms or spaces could be verified as carrying a flame spread rating of Class A or B or less in accordance with 19.3.3.1. This deficiency could affect any patients, staff, or visitors in the immediate area by permitting smoke to develop in occupied portions of the building.

Findings include:

A. Two 4'-0" by 8'-0" plywood panels were observed covering the inside face of the exterior windows in the Temporary Pharmacist's Office. The panels do not carry a Class A or B flame spread rating as required by 19.3.3.2.(1).

Based on random observation during the survey walk-through, not all doors in exit access corridors are in compliance with 19.3.6.3. These deficiencies could affect any patients, staff, or visitors in the building by allowing smoke or fire to enter the egress corridor.

Findings include:

A. At 2:38 PM on February 18, 2014, the following deficiencies were observed at the Dutch door serving the Temporary Pharmacy:

1. The upper leaf of the Dutch door was observed to latch into the door frame and not into the lower leaf; thus two operations could be required to open the door as prohibited by 7.2.1.5.1.

2. The Dutch Door assembly was observed to lack an astragal, rabbet, or bevel at the leading edge of the upper and lower leafs as required by 19.3.6.3.6.

Based on random observation during the survey walk-through, not all doors in smoke barrier walls are resistant to the passage of smoke in accordance with 19.3.7.5., 19.3.7.6., and 19.3.7.7. This deficiency could affect any patients, staff, or visitors in the building by allowing smoke to pass between smoke compartments.

Findings include:

A. During a test of the building fire alarm system conducted at 1:39 PM on February 18, 2014, the north leaf of the pair of cross-corridor doors in the smoke barrier wall immediately south of the new Pharmacy was observed to not come to a fully closed position as required by 19.3.7.6.

Based on random observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1. This deficiency could affect any patients, staff, or visitors in the Radiology Department by preventing them from reaching an exit under fire conditions.

Findings include:

A. At 9:46 AM on February 19, 2014, the sidewalk serving the exterior exit door from the X-Ray Addition was observed to be covered with snow as prohibited by 7.1.10.1.

Based on staff interview, fire drills are not held at varying times and varying conditions in accordance with 19.7.1.2. This deficiency could affect any patients, staff, or visitors in the building because the fire alarm system may not function properly under fire conditions.

Findings include:

A. During an interview held in the Conference Room 8:59 AM on February 19, 2014, the provider's Maintenance Manager confirmed that Third Shift fire drills do not include the transmission of a fire alarm signal as required by 19.7.1.2.

Based on random observation during the survey walk-through and staff interview, not all portions of the building fire alarm system are installed in accordance with 19.3.4. These deficiencies could affect any patients, staff, or visitors in the building because the fire alarm system could fail to operate under fire conditions.

Findings include:

A. During a test of the building fire alarm system conducted on the afternoon of February 18, 2014, alarm initiating devices in Fire Alarm Area 8 were observed to not activate the building fire alarm system as required by 19.3.4.2. and 9.6.2.1, as evidenced by the unsuccessful, attempted activation of the following devices:

1. 1:49 PM: The smoke detector on the east side of the pair of cross-corridor doors in the smoke barrier wall immediately south of the PACU.

2. 1:51 PM: A smoke detector in the Corridor immediately outside of the Laboratory.
3. 1:52 PM: A smoke detector in the Corridor immediately outside of the Radiology Department.

4. 1:54 PM: A manual fire alarm pull station at the north exterior exit door adjacent to the Emergency Department.

B. During an interview held in the Vestibule serving the Nursing Home Connector at 2:07 PM on February 18, 2014, the provider's Maintenance Manager stated that a series of fire alarm devices in the Vestibule (which is located in the Hospital and not in the Nursing Home Connector) close the pair of fire rated doors between the Hospital and the Nursing Home Connector and activate the fire alarm system in the Nursing Home Connector and the Nursing Home, but not in the Hospital as required by 19.3.4.2. and 9.6.2.1. Devices identified as functioning in this manner include:
1. A smoke detector.

2. A manual fire alarm pull station located at the south exterior exit door.

C. At 1:55 PM on February 18, 2014, the pair of cross-corridor doors in the smoke barrier wall immediately east of the Conference Room was observed to be provided with heat detectors on either side of the doors, and not smoke detectors as required by NFPA 72 1999 2-10.6.5.1.

D. At 2:36 PM on February 18, 2014, a smoke detector in the Nursing Unit Clean Supply Room was observed to be located within 3'-0" of a supply air diffuser as prohibited by NFPA 72 1999 2-3.5.1.

Based on document review, the facility's fire alarm system is not inspected, tested, and maintained in accordance with 9.6. This deficiency could affect any patients, staff, or visitors in the building because the fire alarm system could fail to operate under fire conditions.

Findings include:

A. During the document review process at 8:54 AM on February 19, 2013, it was determined that not all fire alarm system components are tested annually, as required by NFPA 72 1999 Table 7-3.2., as evidenced by the following:

1. A report from the provider's fire alarm testing vendor, dated May 23, 2013, states that "Heat detectors, electrically test water flow, tamper switches, sprinkler bells, and panic switches to be tested in November."

2. A report from that sane vendor, dated November 14, 2013, states that no devices were tested on that date.

Based on random observation during the survey walk-through and document review, not all portions of the facility's commercial cooking equipment is installed and maintained in accordance with NFPA 96. These deficiencies could affect any patients, staff, or visitors in the building because fires could develop in the Kitchen and building occupants may not be notified of the fire condition.

Findings include:

A. During the document review process conducted at 9:03 AM on February 19, 2014, reports from the provider's kitchen hood suppression system testing vendor, dated July 17, 2013 and February 7, 2014, stated that the activation of the kitchen hood suppression system does not activate the building fire alarm system as required by NFPA 96 1998 7-6.2. At 11:00 AM that date, the activation of the microswitch within the suppression system controller was observed to shut off the fuel sources for the gas-fired kitchen equipment, but did not activate the building fire alarm system as required.

B. Also during the test of the microswitch described in Item A. above, no audible alarm was activated as required by NFPA 96 1998 7-6.1.

C. During the document review process conducted at 9:03 AM on February 19, 2014, the report from the provider's kitchen hood suppression system testing vendor dated February 7, 2014 stated that the kitchen hood suppression system is not compliant with UL 300 as required by NFPA 96 1998 7-7.2.

D. At 2:17 PM on February 18, 2014, the Kitchen deep fat fryer was observed to be less than 16" from adjacent open flame cooking equipment as prohibited by NFPA 96 1998 9-1.2.3.

Based on random observation during the survey walk-through, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency in accordance with 19.2.3.3. These deficiencies could affect any patients, staff, or visitors in the areas cited because they could be prevented from reaching exits.

Findings include:

A. Carts, furnishings, and equipment were observed in exit access corridors that obstruct egress as prohibited by 19.2.3.3. and 7.1.10.2.1. Locations and items observed include:

1. 2:22 PM February 18, 2014: South Nursing unit Corridor, a desk (part of the Temporary Nurses' Station) and 2 cabinets.

2. 9:45 AM February 19, 2014, Corridor adjacent to Emergency Department, several wheelchairs.

3. 10:00 AM February 19, 2014: Vestibule in egress path immediately south of the Dialysis unit, sprinkler piping, drywall, and other construction materials.

Based on random observation during the survey walk-through, not all soiled linen or trash receptacles are stored in accordance with 19.7.5.5. This deficiency could affect any patients, staff, or visitors in the immediate area by contributing smoke to the exit access corridor.

Findings include:

A. At 2:05 PM on February 18, 2014, 2 trash or recycling receptacles with capacities in excess of 32 gallons in were observed that are stored in the Vestibule serving the Nursing Home Connector, and not in a room protected as a hazardous area as required by 19.7.5.5.

Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

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

Based on document review and staff interview, the emergency generator is not inspected and tested in accordance with NFPA 99. These deficiencies could affect any patients, staff, or visitors in the building because the emergency generator could fail to operate under power outage conditions.

Findings include:

A. During an interview held in the Conference Room at 8:47 AM on February 19, 2014, the provider's Maintenance Manager stated that no records were available that demonstrate that:

1. The emergency generator is visually inspected on a weekly basis, as required by NFPA 110 1999 6-4.1.

2. The emergency generator storage batteries are visually inspected on a weekly basis, as required by NFPA 99 1999 3-4.4.1.3. and NFPA 110 1999 6-3.6.

3. The emergency generator is tested under load for 30 minutes each month, as required by NFPA 99 1999 3-4.4.1.1. and NFPA 110 6-4.2.

4. The transfer switches are subjected to a periodic maintenance program, as required by NFPA 110 1999 6-3.5.

Based on staff interview, the facility's electrical system is not divided into the critical branch, life safety branch, and the emergency system as required by NFPA 99. These deficiencies could affect any patients, staff, or visitors in the building because the emergency electrical system (EES) could become compromised.

Findings include:

A. During an interview held in the Nursing Unit Clean Supply Room (which houses several electrical panels) held at 2:34 PM on February 18, 2014, the provider's Maintenance Manager stated that the building does not have a Type 1 Emergency Electrical System as required by NFPA 70 1999 Article 517 and NFPA 99 199 3-4.2.2.2.

Based on random observation during the survey walk-through and staff interview, not all portions of the building electrical system are installed in accordance with NFPA 70 1999. These deficiencies could affect any patients being treated in the cited areas because emergency power may not be available under certain conditions, or may affect any patients, staff, or visitors in the building because the fire alarm system could become compromised.

Findings include:

A. At 2:24 PM on February 18, 2014, each bed in Patient Sleeping Room 306 was observed to not be provided with at least one duplex electrical receptacle which is served by the building's emergency electrical system, as required by NFPA 70 1999 517-18(a), because only a single duplex receptacle on emergency power is present. During an interview conducted in that location at that time, the provider's Maintenance Manager stated that this configuration is typical for all Patient Sleeping Rooms in the building.

B. Patient bed locations were observed at which at least one duplex outlet served by the building's normal power system is not provided as required by NFPA 70 1999 517-19(a). locations observed include:

1. 2:29 PM February 18, 2014: 2 Stage I Recovery Bays in Surgical Department PACU.

2. 9:50 AM February 19, 2014: 2 Treatment Rooms in Emergency Department.

3. 9:52 AM February 19, 2014: 2 Treatment Bays in Emergency Department Trauma Room.

Based on random observation during the survey walk-through and staff interview, not all portions of the building are of fire resistive construction in accordance with 19.1.6.2. These deficiencies could affect any patients, staff, or visitors in the building by permitting the building structure to be compromised during fire conditions.

Findings include:

A. During an interview held in the Conference Room at 10:45 AM on February 18, 2014, the provider's Architectural Consultant stated that the building (including the Hospital and the X-Ray Addition) is of Type II (000) construction; the building is not fully covered by an automatic sprinkler system as required by Table 19.1.6.2.

B. At 2:20 PM on February 18, 2014, portions of the exterior wall of the Laundry Room were observed to be constructed with plywood as prohibited by NFPA 220 1999 Table 3-1.

Based on random observation during the survey walk-through, not all wall finishes in rooms or spaces could be verified as carrying a flame spread rating of Class A or B or less in accordance with 19.3.3.1. This deficiency could affect any patients, staff, or visitors in the immediate area by permitting smoke to develop in occupied portions of the building.

Findings include:

A. Two 4'-0" by 8'-0" plywood panels were observed covering the inside face of the exterior windows in the Temporary Pharmacist's Office. The panels do not carry a Class A or B flame spread rating as required by 19.3.3.2.(1).

Based on random observation during the survey walk-through, not all doors in exit access corridors are in compliance with 19.3.6.3. These deficiencies could affect any patients, staff, or visitors in the building by allowing smoke or fire to enter the egress corridor.

Findings include:

A. At 2:38 PM on February 18, 2014, the following deficiencies were observed at the Dutch door serving the Temporary Pharmacy:

1. The upper leaf of the Dutch door was observed to latch into the door frame and not into the lower leaf; thus two operations could be required to open the door as prohibited by 7.2.1.5.1.

2. The Dutch Door assembly was observed to lack an astragal, rabbet, or bevel at the leading edge of the upper and lower leafs as required by 19.3.6.3.6.

Based on random observation during the survey walk-through, not all doors in smoke barrier walls are resistant to the passage of smoke in accordance with 19.3.7.5., 19.3.7.6., and 19.3.7.7. This deficiency could affect any patients, staff, or visitors in the building by allowing smoke to pass between smoke compartments.

Findings include:

A. During a test of the building fire alarm system conducted at 1:39 PM on February 18, 2014, the north leaf of the pair of cross-corridor doors in the smoke barrier wall immediately south of the new Pharmacy was observed to not come to a fully closed position as required by 19.3.7.6.

Based on random observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1. This deficiency could affect any patients, staff, or visitors in the Radiology Department by preventing them from reaching an exit under fire conditions.

Findings include:

A. At 9:46 AM on February 19, 2014, the sidewalk serving the exterior exit door from the X-Ray Addition was observed to be covered with snow as prohibited by 7.1.10.1.

Based on staff interview, fire drills are not held at varying times and varying conditions in accordance with 19.7.1.2. This deficiency could affect any patients, staff, or visitors in the building because the fire alarm system may not function properly under fire conditions.

Findings include:

A. During an interview held in the Conference Room 8:59 AM on February 19, 2014, the provider's Maintenance Manager confirmed that Third Shift fire drills do not include the transmission of a fire alarm signal as required by 19.7.1.2.

Based on random observation during the survey walk-through and staff interview, not all portions of the building fire alarm system are installed in accordance with 19.3.4. These deficiencies could affect any patients, staff, or visitors in the building because the fire alarm system could fail to operate under fire conditions.

Findings include:

A. During a test of the building fire alarm system conducted on the afternoon of February 18, 2014, alarm initiating devices in Fire Alarm Area 8 were observed to not activate the building fire alarm system as required by 19.3.4.2. and 9.6.2.1, as evidenced by the unsuccessful, attempted activation of the following devices:

1. 1:49 PM: The smoke detector on the east side of the pair of cross-corridor doors in the smoke barrier wall immediately south of the PACU.

2. 1:51 PM: A smoke detector in the Corridor immediately outside of the Laboratory.
3. 1:52 PM: A smoke detector in the Corridor immediately outside of the Radiology Department.

4. 1:54 PM: A manual fire alarm pull station at the north exterior exit door adjacent to the Emergency Department.

B. During an interview held in the Vestibule serving the Nursing Home Connector at 2:07 PM on February 18, 2014, the provider's Maintenance Manager stated that a series of fire alarm devices in the Vestibule (which is located in the Hospital and not in the Nursing Home Connector) close the pair of fire rated doors between the Hospital and the Nursing Home Connector and activate the fire alarm system in the Nursing Home Connector and the Nursing Home, but not in the Hospital as required by 19.3.4.2. and 9.6.2.1. Devices identified as functioning in this manner include:
1. A smoke detector.

2. A manual fire alarm pull station located at the south exterior exit door.

C. At 1:55 PM on February 18, 2014, the pair of cross-corridor doors in the smoke barrier wall immediately east of the Conference Room was observed to be provided with heat detectors on either side of the doors, and not smoke detectors as required by NFPA 72 1999 2-10.6.5.1.

D. At 2:36 PM on February 18, 2014, a smoke detector in the Nursing Unit Clean Supply Room was observed to be located within 3'-0" of a supply air diffuser as prohibited by NFPA 72 1999 2-3.5.1.

Based on document review, the facility's fire alarm system is not inspected, tested, and maintained in accordance with 9.6. This deficiency could affect any patients, staff, or visitors in the building because the fire alarm system could fail to operate under fire conditions.

Findings include:

A. During the document review process at 8:54 AM on February 19, 2013, it was determined that not all fire alarm system components are tested annually, as required by NFPA 72 1999 Table 7-3.2., as evidenced by the following:

1. A report from the provider's fire alarm testing vendor, dated May 23, 2013, states that "Heat detectors, electrically test water flow, tamper switches, sprinkler bells, and panic switches to be tested in November."

2. A report from that sane vendor, dated November 14, 2013, states that no devices were tested on that date.

Based on random observation during the survey walk-through and document review, not all portions of the facility's commercial cooking equipment is installed and maintained in accordance with NFPA 96. These deficiencies could affect any patients, staff, or visitors in the building because fires could develop in the Kitchen and building occupants may not be notified of the fire condition.

Findings include:

A. During the document review process conducted at 9:03 AM on February 19, 2014, reports from the provider's kitchen hood suppression system testing vendor, dated July 17, 2013 and February 7, 2014, stated that the activation of the kitchen hood suppression system does not activate the building fire alarm system as required by NFPA 96 1998 7-6.2. At 11:00 AM that date, the activation of the microswitch within the suppression system controller was observed to shut off the fuel sources for the gas-fired kitchen equipment, but did not activate the building fire alarm system as required.

B. Also during the test of the microswitch described in Item A. above, no audible alarm was activated as required by NFPA 96 1998 7-6.1.

C. During the document review process conducted at 9:03 AM on February 19, 2014, the report from the provider's kitchen hood suppression system testing vendor dated February 7, 2014 stated that the kitchen hood suppression system is not compliant with UL 300 as required by NFPA 96 1998 7-7.2.

D. At 2:17 PM on February 18, 2014, the Kitchen deep fat fryer was observed to be less than 16" from adjacent open flame cooking equipment as prohibited by NFPA 96 1998 9-1.2.3.

Based on random observation during the survey walk-through, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency in accordance with 19.2.3.3. These deficiencies could affect any patients, staff, or visitors in the areas cited because they could be prevented from reaching exits.

Findings include:

A. Carts, furnishings, and equipment were observed in exit access corridors that obstruct egress as prohibited by 19.2.3.3. and 7.1.10.2.1. Locations and items observed include:

1. 2:22 PM February 18, 2014: South Nursing unit Corridor, a desk (part of the Temporary Nurses' Station) and 2 cabinets.

2. 9:45 AM February 19, 2014, Corridor adjacent to Emergency Department, several wheelchairs.

3. 10:00 AM February 19, 2014: Vestibule in egress path immediately south of the Dialysis unit, sprinkler piping, drywall, and other construction materials.

Based on random observation during the survey walk-through, not all soiled linen or trash receptacles are stored in accordance with 19.7.5.5. This deficiency could affect any patients, staff, or visitors in the immediate area by contributing smoke to the exit access corridor.

Findings include:

A. At 2:05 PM on February 18, 2014, 2 trash or recycling receptacles with capacities in excess of 32 gallons in were observed that are stored in the Vestibule serving the Nursing Home Connector, and not in a room protected as a hazardous area as required by 19.7.5.5.

Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

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

Based on document review and staff interview, the emergency generator is not inspected and tested in accordance with NFPA 99. These deficiencies could affect any patients, staff, or visitors in the building because the emergency generator could fail to operate under power outage conditions.

Findings include:

A. During an interview held in the Conference Room at 8:47 AM on February 19, 2014, the provider's Maintenance Manager stated that no records were available that demonstrate that:

1. The emergency generator is visually inspected on a weekly basis, as required by NFPA 110 1999 6-4.1.

2. The emergency generator storage batteries are visually inspected on a weekly basis, as required by NFPA 99 1999 3-4.4.1.3. and NFPA 110 1999 6-3.6.

3. The emergency generator is tested under load for 30 minutes each month, as required by NFPA 99 1999 3-4.4.1.1. and NFPA 110 6-4.2.

4. The transfer switches are subjected to a periodic maintenance program, as required by NFPA 110 1999 6-3.5.

Based on staff interview, the facility's electrical system is not divided into the critical branch, life safety branch, and the emergency system as required by NFPA 99. These deficiencies could affect any patients, staff, or visitors in the building because the emergency electrical system (EES) could become compromised.

Findings include:

A. During an interview held in the Nursing Unit Clean Supply Room (which houses several electrical panels) held at 2:34 PM on February 18, 2014, the provider's Maintenance Manager stated that the building does not have a Type 1 Emergency Electrical System as required by NFPA 70 1999 Article 517 and NFPA 99 199 3-4.2.2.2.

Based on random observation during the survey walk-through and staff interview, not all portions of the building electrical system are installed in accordance with NFPA 70 1999. These deficiencies could affect any patients being treated in the cited areas because emergency power may not be available under certain conditions, or may affect any patients, staff, or visitors in the building because the fire alarm system could become compromised.

Findings include:

A. At 2:24 PM on February 18, 2014, each bed in Patient Sleeping Room 306 was observed to not be provided with at least one duplex electrical receptacle which is served by the building's emergency electrical system, as required by NFPA 70 1999 517-18(a), because only a single duplex receptacle on emergency power is present. During an interview conducted in that location at that time, the provider's Maintenance Manager stated that this configuration is typical for all Patient Sleeping Rooms in the building.

B. Patient bed locations were observed at which at least one duplex outlet served by the building's normal power system is not provided as required by NFPA 70 1999 517-19(a). locations observed include:

1. 2:29 PM February 18, 2014: 2 Stage I Recovery Bays in Surgical Department PACU.

2. 9:50 AM February 19, 2014: 2 Treatment Rooms in Emergency Department.

3. 9:52 AM February 19, 2014: 2 Treatment Bays in Emergency Department Trauma Room.