HospitalInspections.org

Based on observation and facility tour on the days of survey January 31,2011 through February 4, 2011, it was determined the facility was not in compliance with the requirements of NFPA-101-Life Safety Code and NFPA-80- Care and Maintenance of Doors.
There shall be no impediment to properly closing the doors to prevent the spread of fire and the passage of smoke.
Every item of equipment or fire door required by code shall be continuously maintained in proper operating condition.
Doors shall be operable at all times.
Door hardware shall be examined frequently and properly maintained.
Doors shall be securely attached to the door frames and door frames securely attached to the wall structure.
The disconnection of the automatic door closer devices prevents the fire door from closing in the event of a fire.

The findings include:

Doors are damaged, out of alignment with the door frames, door latches do not engage properly, door knob devices are removed, and do not close for a smoke tight fit for the following:

1. At the 2nd floor room # 20225, the door holding magnetic device is not secured properly to the wall.
2. At the 2nd floor room #20640, the door does not close properly.
3. At the 1st floor Lab area, the flammable locker has a broken latch.
4. At the 1st floor elevator lobby area, room #10139 does not latch properly.
5. At the 1st floor radiology room #1, the door does not latch properly.
6. At the 1st floor, the transportation room door is damaged and does not close properly.
7. At the 1st floor , Brenda office area, the door is prevented from closing by a cabinet.
8. At room # B-0040, a chair is used to prop the door in the open position.
9. At the Pavilion 5th floor, the Fire doors at exit 880 do not latch properly for a smoke tight fit.
10. At the 5th floor soiled utility room at exit sign # 883, the door does not latch properly.
11. At the 4th floor Pavilion, the southeast janitor closet door, the automatic door closer
device has been disconnected.


NFPA-101-2000-LSC--19.3.6.1, 19.3.6.3.2, 7.2.1, 7.2., 7.2.9.2, 4.6.12.1
NFPA--80--15.1.2, 15.2.1.1, 15.2.4.1, 15.2.3.3
FAC--69 A-3.012
FAC--59 A-4.130(1)

.

Based on observation and tour with facility staff on the days of survey, the facility was not in compliance with the requirements of NFPA- 101-2000 -Life Safety Code and NFPA-13 the Installation of Automatic Fire Sprinkler Systems.

Buildings containing Healthcare Facilities shall be protected throughout by an approved, supervised automatic fire sprinkler system.
Each required automatic fire sprinkler system for Healthcare Facilities shall be in accordance with NFPA-13-Standard for Automatic Fire Sprinkler Systems.

The findings include:

Observations revealed that there are no automatic fire sprinklers installed as required at the following areas:

1. At the Clinical Center-the Healthy Start Storage room, 3rd floor.
2. The electrical closets at room #B 3036, 3rd floor.
3. The Nursing Conference Room-Lawson office areas, 3rd floor.
4. The 5th floor room #50097.
5. The 2nd floor Anesthesia Department storage closet room.
6. The Radiology pediatric side office area.
7. The radiology area, Dr. Catillo's office.
8. The Peds. Radiology room #20158.
9. The Dictation office 2nd floor room #10124.
10. The 2nd floor ultrasound storage closet #2.
11. The housekeeping closet #1-164.
12. The storage closet across from room #1-116 at administration.
13. The 1st floor staff elevator lobby area, the trauma alcove.
14. The electrical closet at room #10129.
15. the 5th floor 5N office storage area.
16. The 3rd floor Rainbow Clinic area.
17. The 5th floor elevator lobby office room #50097.
18. The 4th floor Orthopedic Trauma Research office area.
19. The 2nd floor sterilization room #2-126.

There are missing sprinkler ceiling cover plates at the following areas:

1. The 6th floor rooms # 603, and #628.
2, The 6th floor staff elevator area.
3 The 4th floor Old Rehab area.
4. The 3rd floor Rehab office.
5. The 3rd floor Pediatrician Hearing area.
6. The 3rd floor NICU area.
7. The 8th floor elevator lobby area.
8. The 8th floor office #80105 area.
9. The 6th floor 6N area at Fire Door.
10. The 5th floor at room #50100.
11. The 4th floor electrical closet area.
12. The 2nd floor O.R. ROOM #14
13. The 2nd floor Exam room #4.
14. The Dietary area above the freezer.

All sprinkler locations shall be inspected for missing ceiling plates and replaced.

NFPA-101-2000-LSC---19.3.5.1, 9.7.2.1.1, 9.7.2., 4.6.12.1
NFPA-13
NFPA- 25
Fire Marshall Rules 69 A-3.012, 69 A-53
F.A.C. 59A-4.130(1)

Based on observation and tour with facility staff on the days of survey, the facility was not in compliance with the requirements of NFPA-101-Life Safety Code, NFPA-90-A, and NFPA-91, Requirements for ventilating and air exhaust systems.

Observations revealed that the air exhaust system air moving devices were not functioning properly and were not conveying odors, dust materials, maintaining proper negative air pressure, and exhausting for proper indoor quality air at the following locations.

The findings include:

1. At the 8th floor janitor closet
2. At the 8th floor soiled utility room.
3. At room #834
4. At the 7th floor respiratory supply room.
5. At the 5th floor 5S AREA.
6. At the Medical Education Dept. office room #50096.
7. At the 3rd floor area 3N bathroom area.
8. At the 3rd floor area 3S bathroom area.
9. At the 2nd floor special procedures soiled utility room.
10. At the 2nd floor housekeeping closet.
11. At the 2nd floor radiology dressing room.
12. At the 2nd floor women's restroom
13. At the 1st floor Oxygen storage room #10128.
14. At the 1st floor restroom across from room #2.
15. At the 1st floor Ed. Admin-J-closet room.
16. At Brenda's office area, room #B 056 janitor closet .


NFPA-101-LSC-- 19.5.2.1, 19.5.2.2, 4.6.12.1, 4.6.12.3, 9.2.1, 9.2.2
NFPA- 90 A
NFPA-91-- 7.1, 7.3, 7.4, 7.5
F.A.C. 59 A-4.130(!), Table I -item #42 General Standards

Based on observation and facility tour on the days of survey January 31,2011 through February 4, 2011, it was determined the facility was not in compliance with the requirements of NFPA-101-Life Safety Code and NFPA-80- Care and Maintenance of Doors.
There shall be no impediment to properly closing the doors to prevent the spread of fire and the passage of smoke.
Every item of equipment or fire door required by code shall be continuously maintained in proper operating condition.
Doors shall be operable at all times.
Door hardware shall be examined frequently and properly maintained.
Doors shall be securely attached to the door frames and door frames securely attached to the wall structure.
The disconnection of the automatic door closer devices prevents the fire door from closing in the event of a fire.

The findings include:

Doors are damaged, out of alignment with the door frames, door latches do not engage properly, door knob devices are removed, and do not close for a smoke tight fit for the following:

1. At the 2nd floor room # 20225, the door holding magnetic device is not secured properly to the wall.
2. At the 2nd floor room #20640, the door does not close properly.
3. At the 1st floor Lab area, the flammable locker has a broken latch.
4. At the 1st floor elevator lobby area, room #10139 does not latch properly.
5. At the 1st floor radiology room #1, the door does not latch properly.
6. At the 1st floor, the transportation room door is damaged and does not close properly.
7. At the 1st floor , Brenda office area, the door is prevented from closing by a cabinet.
8. At room # B-0040, a chair is used to prop the door in the open position.
9. At the Pavilion 5th floor, the Fire doors at exit 880 do not latch properly for a smoke tight fit.
10. At the 5th floor soiled utility room at exit sign # 883, the door does not latch properly.
11. At the 4th floor Pavilion, the southeast janitor closet door, the automatic door closer
device has been disconnected.


NFPA-101-2000-LSC--19.3.6.1, 19.3.6.3.2, 7.2.1, 7.2., 7.2.9.2, 4.6.12.1
NFPA--80--15.1.2, 15.2.1.1, 15.2.4.1, 15.2.3.3
FAC--69 A-3.012
FAC--59 A-4.130(1)

.

Based on observation and tour with facility staff on the days of survey, the facility was not in compliance with the requirements of NFPA- 101-2000 -Life Safety Code and NFPA-13 the Installation of Automatic Fire Sprinkler Systems.

Buildings containing Healthcare Facilities shall be protected throughout by an approved, supervised automatic fire sprinkler system.
Each required automatic fire sprinkler system for Healthcare Facilities shall be in accordance with NFPA-13-Standard for Automatic Fire Sprinkler Systems.

The findings include:

Observations revealed that there are no automatic fire sprinklers installed as required at the following areas:

1. At the Clinical Center-the Healthy Start Storage room, 3rd floor.
2. The electrical closets at room #B 3036, 3rd floor.
3. The Nursing Conference Room-Lawson office areas, 3rd floor.
4. The 5th floor room #50097.
5. The 2nd floor Anesthesia Department storage closet room.
6. The Radiology pediatric side office area.
7. The radiology area, Dr. Catillo's office.
8. The Peds. Radiology room #20158.
9. The Dictation office 2nd floor room #10124.
10. The 2nd floor ultrasound storage closet #2.
11. The housekeeping closet #1-164.
12. The storage closet across from room #1-116 at administration.
13. The 1st floor staff elevator lobby area, the trauma alcove.
14. The electrical closet at room #10129.
15. the 5th floor 5N office storage area.
16. The 3rd floor Rainbow Clinic area.
17. The 5th floor elevator lobby office room #50097.
18. The 4th floor Orthopedic Trauma Research office area.
19. The 2nd floor sterilization room #2-126.

There are missing sprinkler ceiling cover plates at the following areas:

1. The 6th floor rooms # 603, and #628.
2, The 6th floor staff elevator area.
3 The 4th floor Old Rehab area.
4. The 3rd floor Rehab office.
5. The 3rd floor Pediatrician Hearing area.
6. The 3rd floor NICU area.
7. The 8th floor elevator lobby area.
8. The 8th floor office #80105 area.
9. The 6th floor 6N area at Fire Door.
10. The 5th floor at room #50100.
11. The 4th floor electrical closet area.
12. The 2nd floor O.R. ROOM #14
13. The 2nd floor Exam room #4.
14. The Dietary area above the freezer.

All sprinkler locations shall be inspected for missing ceiling plates and replaced.

NFPA-101-2000-LSC---19.3.5.1, 9.7.2.1.1, 9.7.2., 4.6.12.1
NFPA-13
NFPA- 25
Fire Marshall Rules 69 A-3.012, 69 A-53
F.A.C. 59A-4.130(1)

Based on observation and tour with facility staff on the days of survey, the facility was not in compliance with the requirements of NFPA-101-Life Safety Code, NFPA-90-A, and NFPA-91, Requirements for ventilating and air exhaust systems.

Observations revealed that the air exhaust system air moving devices were not functioning properly and were not conveying odors, dust materials, maintaining proper negative air pressure, and exhausting for proper indoor quality air at the following locations.

The findings include:

1. At the 8th floor janitor closet
2. At the 8th floor soiled utility room.
3. At room #834
4. At the 7th floor respiratory supply room.
5. At the 5th floor 5S AREA.
6. At the Medical Education Dept. office room #50096.
7. At the 3rd floor area 3N bathroom area.
8. At the 3rd floor area 3S bathroom area.
9. At the 2nd floor special procedures soiled utility room.
10. At the 2nd floor housekeeping closet.
11. At the 2nd floor radiology dressing room.
12. At the 2nd floor women's restroom
13. At the 1st floor Oxygen storage room #10128.
14. At the 1st floor restroom across from room #2.
15. At the 1st floor Ed. Admin-J-closet room.
16. At Brenda's office area, room #B 056 janitor closet .


NFPA-101-LSC-- 19.5.2.1, 19.5.2.2, 4.6.12.1, 4.6.12.3, 9.2.1, 9.2.2
NFPA- 90 A
NFPA-91-- 7.1, 7.3, 7.4, 7.5
F.A.C. 59 A-4.130(!), Table I -item #42 General Standards