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Based on observation and interview, the facility did not provide a common separation wall with rated wall construction. This deficient practice could affect all patients, staff, and visitors in 8 of the 8 smoke compartments.

FINDINGS INCLUDE:

1. On July 10, 2013 at 8:30 am and on August 28, 2013, observation revealed on the 1st floor in the passage into the surgery area from the main hospital corridor, that the 2 hour separation wall and rated doors were not present at this location. In addition, all doors into the surgery building are not 1-1/2 hour rated doors. The surgery addition, built in 1993, is a Type II (0,0,0) building and is separated from the Type II(1,1,1) building. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.1.1.4.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff K (Director of Facilities).
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Based on observation and interview, the facility did not provide and maintain the required building construction type with a compliant type of construction and sealed floor penetrations. This deficient practice could affect all patients, staff, and visitors in 8 of the 8 smoke compartments.

FINDINGS INCLUDE:

1. On July 10, 2013 at 8:00 am and August 28, 2013, observation revealed that the building's construction type was not compliant because the lower level is not a basement because more than 50% of the level is exposed for the building perimeter. Therefore the building is a three (3) story building. The facility produced a life safety plan indicating that the building is a Type II (1,1,1) construction type building. A Type II (1,1,1) three story building is permitted only if the building is fully sprinkled. The build is not fully sprinklered protected. This observed situation was not compliant with NFPA 101 (2000 ed.), Table 19.1.6.2.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff K (Director of Facilities).
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Based on observation and interview, the facility did provide stairways that did open to unoccupied rooms. This deficient practice could affect all patients, staff, and visitors in 5 of the 8 smoke compartments.

FINDINGS INCLUDE:

1) On 07/09/2013 at 11 am and on August 28, 2013, observation revealed that the storage / air handle room in the lower lever, which is an unoccupied room, opens into an exit stairway. This observed situation was not compliant with NFPA 101, (2000 edition) 7.1.3.2.1.

2) On 07/09/2013 at 8:50 am and on August 28, 2013, observation revealed that the stairs to the penthouse, which is an unoccupied room, opens onto the exit stairway. This observed situation was not compliant with NFPA 101, (2000 edition) 7.1.3.2.1.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff K (Director of Facilities).

Based upon observation and interview, the facility failed to provide exit access that is arranged so that exits are readily accessible at all times. This deficient practice could affect all patients, staff, and visitors in 4 of the 8 smoke compartments.

FINDINGS INCLUDE:

5. On 07/10/2013 at 11:05 am and on August 28, 2013, observation revealed that the across corridor door to the OR from the ER was locked. This created a dead end corridor greater than 30 feet.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff K (Director of Facilities).

Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, with sprinklers free of obstructions near the ceiling, all rooms sprinkled when the code required full sprinkler protection, and unobstructed water distribution. This deficient practice could affect all patients, staff, and visitors in 1 of the 8 smoke compartments.

FINDINGS INCLUDE:

1. On July 9, 2013 at 2:54 PM and on August 28, 2012, observation revealed on the 1st floor in the Middle office, of Print Patient Accounts, that items were placed near the ceiling within 18" of the sprinkler deflector. These items obstructed the discharge of sprinkler water from reaching the intended coverage for the room or space. The obstruction included 3 double cabinet files which were 6 and 8 inches from the bottom of the sprinkler deflector. This obstruction would interfere with the development of the water spray pattern and may reduce the amount of water that the code requires to reach all portions of the protected floor space. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff K (Director of Facilities).
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Based on observation and interview, the facility did not provide a ventilation system in accordance with manufacturer specifications and NFPA 90A with neutral airflow between the corridor and rooms, and ventilation systems that comply with NFPA 90A. This deficient practice could affect all patients, staff, and visitors in 3 of the 8 smoke compartments.

FINDINGS INCLUDE:

1. On 07-10-2013 at 11:10 am and on August 28, 2013, observation revealed on the patient floors, that airflow between the corridor and the room was not neutral. Some rooms are using the corridor as a supply air plenum and other rooms are using the corridor as a return air plenum. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.5.2.1 9.2 and NFPA 90A, 2-3.11.1.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff K (Director of Facilities).

Item #1
NFPA 110 Standard for Emergency and Standby Power Systems (1985 edition (the generator was install under))

5-2.1 "For Level 1 installations, energy converters shall be located in separate service room dedicated to the EPS, separated from the remainder of the building by fire separations having a minimum two-hour fire rating, or shall be located in an adequate enclosure outside the building capable of preventing the entrance of snow or rain. Rooms for Level 1 shall not be shared with other equipment or electrical service equipment not a part of the EPSS."

Based on observation and interview, the facility failed to properly isolate the emergency generator (EPS) in its own rated room. This deficient practice could affect all patients, staff, and visitors in 1 of the 8 smoke compartments.

FINDINGS INCLUDE:

1. On 07/10/2013 at 7:30 am and on August 28, 2013, observation revealed that the emergency generator room shared a common room with a refrigeration system. The generator is required to be located in a room without other mechanical systems.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff K (Director of Facilities).

Item # 2

NFPA 101 LIFE SAFETY CODE STANDARD

7.1.5 Headroom Means of egress shall be designed and maintained to provide headroom as provided in their sections of this Code and shall be not less than 7 feet 6 inches with projections from the ceiling not less than 6 feet 8 inches nominal height above the finished floor.

Based on observation and interview, the facility failed to properly maintain the proper head room in the means of egress. This deficient practice could affect all patients, staff, and visitors in 1 of the 8 smoke compartments.

FINDINGS INCLUDE:

1. On 07/10/2013 at 7:50 am and on Auagust 28, 2013 observation revealed that the ceiling height in the corridor from the ground floor west entrance is less than 7'-0". The 38 foot long corridor has a height of 86" (7'-2") at one end and slopes to 80" (6'-8") at the other. This observed situation was not compliant with NFPA 101 (2000 edition) section 7.1.3.2.1(d).

This condition was confirmed at the time of discovery in an interview with staff K (Director of Facilities).

Based on observation and interview the facility did not monitor derangement signals at a continuously monitored location and did not provide a remote stop switch for the generator. This deficient practice could affect all patients, staff, and visitors in 8 of the 8 smoke compartments.

FINDINGS INCLUDE:

1. On 07/08/2013 at 3:50 pm and on August 28, 2013 observation revealed on the lower level floor in the maintenance shop, that audible and visual derangement signals were not located in a continuously monitored location. A generator annunciation panel was located in the main entrance (ER area). The observed situation was not compliant with NFPA 110 (1999 edition), 3-5.5.2(d) & NFPA 99 (1999 edition), 3-4.1.1.15(b).

2. On 07/08/2013 at 4:00 pm and on August 28, 2013, observation revealed on the outside floor in the generator room, that the emergency generator was not provided with a remote stop switch. The stop shall be located outside of the generator room. This observed situation was not compliant with NFPA 110 (1999 ed.), 3-5.5.6.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff K (Director of Facilities).

Based on observation and interview, the facility did not provide a Type I essential electrical system that was properly divided. This deficient practice could affect all patients, staff, and visitors in 1 of the 8 smoke compartments.

FINDINGS INCLUDE:

1. On 07/10/2013 at 11:15 am and on august 28, 2013 observation revealed that the Type 1 emergency electrical system did not have normal power outlets in the recovery and OR areas. Both critical outlet and normal outlets are required or the critical care outlets are permitted if they are on two different transfer switches. This observed situation was not compliant with NFPA 99 (1999 edition) 3-4.2.2.2.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff K (Director of Facilities).