HospitalInspections.org

Based on observation of the surveyors 35163 and 20980 on 8/11/15, while accompanied by the facility general maintenance worker, the following was identified:


1. Fire doors/frames in several areas of the facility were found to have missing or painted rating identification tags which made them no longer legible; therefore we could not determine that they met the required standard.

2. Unprotected penetrations in fire walls/ceiling assemblies above suspended ceilings were found in several areas of the facility, which would not prevent the passage of smoke/ fire.

Based on observation of the surveyors 35163 and 20980 on 8/11/15, while accompanied by the facility general maintenance worker, the following was identified:


1. Unprotected penetrations in smoke walls above suspended ceilings, were found in several locations within the facility, which would not prevent the passage of smoke/fire

Based on observation of the surveyors 35163 and 20980 on 8/11/15, while accompanied by the facility general maintenance worker, the following was identified:


1. Smoke barrier doors/frames in several areas of the facility were found to have missing or painted rating identification tags which made them no longer legible; therefore we could not determine that they met the required standard.

This tag not met as observed by surveyors 20980 & 35163 and a facility general maintenance worker. It was observed that north exit enclosure had conduit piping entering into and going out of the enclosure breaching the fire rated assembly. It was also observed that data communications equipment was located and operating in the same exit enclosure and compromising the integrity of the enclosure. Nothing will be located/stored in the exit enclosure unless it is part of the fire alarm or sprinkler system or it is directly associated with the stair enclosure.

Based on observation of the surveyors 35163 and 20980 on 8/11/15, while accompanied by the facility general maintenance worker, the following was identified:

1. When exiting the hospital physical therapy area (towards the exit next to the MRI trailer) the exit sign is not visible and therefore could cause individuals to use an exit that exceeds the acceptable travel distance.

Based on observation of the surveyors 35163 and 20980 on 8/11/15, while accompanied by the facility general maintenance worker, the following was identified:


1. Unprotected penetrations in smoke walls above suspended ceilings, were found in several areas of the facility, which would not prevent the passage of smoke/ fire

Based on observation of the surveyors 35163 and 20980 on 8/11/15, while accompanied by the facility general maintenance worker, the following was identified:


1. Fire doors/frames in sevearal locations of the facility were found to have missing or painted rating identification tags which made them no longer legible; therefore we could not determine that they met the required standard.

This tag not met as observed by surveyors 20980 & 35163 and a facility general maintenance worker. It was observed that the exit door leading into the north exit stair enclosure at the second level is not equipped with a panic hardware device as required. It was also observed that the 1. The exit leading off of the main entrance area that is connected to the basement stairs is required to have a means of identifying that the stairs leading to the basement is not a means of exit. It is also required that a one way gate be installed to prevent people that are exiting that main floor area and going down the stairs to the basement area. The gate will also note prevent people from exiting the basement area. Ref NFPA Life Safety Code 101, chapter 7, section 7.7.3.2 The exit discharge shall be arranged and marked to make clear the direction of egress to a public way. Stairs shall be arranged so as to make clear the direction of egress to a public way. Stairs that continue more than one-half story beyond the level of exit discharge shall be interrupted at the level of exit discharge by partitions, doors, or other effective means. Also it is required that appropriate signage be posted to reflect that the stairs leading to the basement is not part of the exit discharge. 7.10.8.3.1 Any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads as follows:
NO
EXIT

7.10.8.3.2 The NO EXIT sign shall have the word NO in letters 2 in. (51 mm) high, with a stroke width of in. (9.5 mm), and the word EXIT in letters 1 in. (25 mm) high, with the word EXIT below the word NO, unless such sign is an approved existing sign.

Based on observation of the surveyors 35163 and 20980 on 8/11/15, while accompanied by the facility general maintenance worker, the following was identified:

1. There was a metal bench and signage in front of the main entrance/exit horizontal sliding doors, which obstructs the opening of the doors during emergency operations of the doors and therefore would impede egress.


1. Triage exit and main entrance/exit did not have proper signage-"push to open in emergency."

This tag not met as observed by surveyors 20980 & 35163 and a facility general maintenance worker. It was observed that the fire alarm test records show that during the 1/5/2015 and 7/20/2015 the audio/visual alarms for the fire alarm system were not tested as required. It was also observed that documentation did not show that smoke detectors were sensitivity tested in the last two years.

This tag not met as observed by surveyors 20980 & 35163 and a facility general maintenance worker. It was observed that the sprinkler system riser has a grounding wire attached to it. In accordance with NFPA. 10.6.8* In no case shall the underground piping be used as a grounding electrode for electrical systems. This does not preclude the bonding of the underground piping to the lightning protection grounding system as required by NFPA 780 in those cases where lightning protection is provided for the structure. [24:10.6.8]

This tag not met as observed by surveyors 20980 & 35163 and a facility general maintenance worker. It was observed that; 1) The window curtains in patient rooms did not have tags indicating that they were flame resistant. 2) Some of the patient room privacy curtains were not labeled to be flame resistant. 3) Patient room furniture located in areas that are not sprinkler protected did not meet the requirement of this tag.

Based on observation of the surveyors 35163 and 20980 on 8/11/15, while accompanied by the facility general maintenance worker, the following was identified:

1. Label for area served in the medical gas area alarm panel, located in the operating room hallway near MH1028B was not visible.

2. Medical gas lines/valves in basement were not properly labeled and improper piping used (soft drawn copper w/compression fittings.)

3. The Emergency low pressure oxygen inlet box was not secured and therefore could allow for unauthorized access or tampering.

This tag not met as observed by surveyors 20980 & 35163 and a facility general maintenance worker. It was observed that the fire proofing of the ceiling structural support beams located in the basement, 1st and 2nd floors had been chipped away or missing therefore compromising the required fire rating of the structure.

The following additional deficiency was observed by surveyors 20980 & 35163 and a facility general maintenance worker. Through interviewing of laundry personnel it was found that the facility laundry dryers are being used to dry mops heads and rags. The newer dryer had labeling that cautioned the drying of mop heads and oily rags and the older two dryers maintenance manual had a warning that stated mop heads and oily rags are not to be dried in the units.

This tag not met as observed by surveyors 20980 & 35163 and a facility general maintenance worker. It was observed that in the flammable storage locker located in the generator room was an accumulation of oily and dirty rags. Store rags in proper containers.

Based on observation of the surveyors 35163 and 20980 on 8/11/15, while accompanied by the facility general maintenance worker, the following was identified:


1. Fire doors/frames in several areas of the facility were found to have missing or painted rating identification tags which made them no longer legible; therefore we could not determine that they met the required standard.

2. Unprotected penetrations in fire walls/ceiling assemblies above suspended ceilings were found in several areas of the facility, which would not prevent the passage of smoke/ fire.

Based on observation of the surveyors 35163 and 20980 on 8/11/15, while accompanied by the facility general maintenance worker, the following was identified:


1. Unprotected penetrations in smoke walls above suspended ceilings, were found in several locations within the facility, which would not prevent the passage of smoke/fire

Based on observation of the surveyors 35163 and 20980 on 8/11/15, while accompanied by the facility general maintenance worker, the following was identified:


1. Smoke barrier doors/frames in several areas of the facility were found to have missing or painted rating identification tags which made them no longer legible; therefore we could not determine that they met the required standard.

This tag not met as observed by surveyors 20980 & 35163 and a facility general maintenance worker. It was observed that north exit enclosure had conduit piping entering into and going out of the enclosure breaching the fire rated assembly. It was also observed that data communications equipment was located and operating in the same exit enclosure and compromising the integrity of the enclosure. Nothing will be located/stored in the exit enclosure unless it is part of the fire alarm or sprinkler system or it is directly associated with the stair enclosure.

Based on observation of the surveyors 35163 and 20980 on 8/11/15, while accompanied by the facility general maintenance worker, the following was identified:

1. When exiting the hospital physical therapy area (towards the exit next to the MRI trailer) the exit sign is not visible and therefore could cause individuals to use an exit that exceeds the acceptable travel distance.

Based on observation of the surveyors 35163 and 20980 on 8/11/15, while accompanied by the facility general maintenance worker, the following was identified:


1. Unprotected penetrations in smoke walls above suspended ceilings, were found in several areas of the facility, which would not prevent the passage of smoke/ fire

Based on observation of the surveyors 35163 and 20980 on 8/11/15, while accompanied by the facility general maintenance worker, the following was identified:


1. Fire doors/frames in sevearal locations of the facility were found to have missing or painted rating identification tags which made them no longer legible; therefore we could not determine that they met the required standard.

This tag not met as observed by surveyors 20980 & 35163 and a facility general maintenance worker. It was observed that the exit door leading into the north exit stair enclosure at the second level is not equipped with a panic hardware device as required. It was also observed that the 1. The exit leading off of the main entrance area that is connected to the basement stairs is required to have a means of identifying that the stairs leading to the basement is not a means of exit. It is also required that a one way gate be installed to prevent people that are exiting that main floor area and going down the stairs to the basement area. The gate will also note prevent people from exiting the basement area. Ref NFPA Life Safety Code 101, chapter 7, section 7.7.3.2 The exit discharge shall be arranged and marked to make clear the direction of egress to a public way. Stairs shall be arranged so as to make clear the direction of egress to a public way. Stairs that continue more than one-half story beyond the level of exit discharge shall be interrupted at the level of exit discharge by partitions, doors, or other effective means. Also it is required that appropriate signage be posted to reflect that the stairs leading to the basement is not part of the exit discharge. 7.10.8.3.1 Any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads as follows:
NO
EXIT

7.10.8.3.2 The NO EXIT sign shall have the word NO in letters 2 in. (51 mm) high, with a stroke width of in. (9.5 mm), and the word EXIT in letters 1 in. (25 mm) high, with the word EXIT below the word NO, unless such sign is an approved existing sign.

Based on observation of the surveyors 35163 and 20980 on 8/11/15, while accompanied by the facility general maintenance worker, the following was identified:

1. There was a metal bench and signage in front of the main entrance/exit horizontal sliding doors, which obstructs the opening of the doors during emergency operations of the doors and therefore would impede egress.


1. Triage exit and main entrance/exit did not have proper signage-"push to open in emergency."

This tag not met as observed by surveyors 20980 & 35163 and a facility general maintenance worker. It was observed that the fire alarm test records show that during the 1/5/2015 and 7/20/2015 the audio/visual alarms for the fire alarm system were not tested as required. It was also observed that documentation did not show that smoke detectors were sensitivity tested in the last two years.

This tag not met as observed by surveyors 20980 & 35163 and a facility general maintenance worker. It was observed that the sprinkler system riser has a grounding wire attached to it. In accordance with NFPA. 10.6.8* In no case shall the underground piping be used as a grounding electrode for electrical systems. This does not preclude the bonding of the underground piping to the lightning protection grounding system as required by NFPA 780 in those cases where lightning protection is provided for the structure. [24:10.6.8]

This tag not met as observed by surveyors 20980 & 35163 and a facility general maintenance worker. It was observed that; 1) The window curtains in patient rooms did not have tags indicating that they were flame resistant. 2) Some of the patient room privacy curtains were not labeled to be flame resistant. 3) Patient room furniture located in areas that are not sprinkler protected did not meet the requirement of this tag.

Based on observation of the surveyors 35163 and 20980 on 8/11/15, while accompanied by the facility general maintenance worker, the following was identified:

1. Label for area served in the medical gas area alarm panel, located in the operating room hallway near MH1028B was not visible.

2. Medical gas lines/valves in basement were not properly labeled and improper piping used (soft drawn copper w/compression fittings.)

3. The Emergency low pressure oxygen inlet box was not secured and therefore could allow for unauthorized access or tampering.

This tag not met as observed by surveyors 20980 & 35163 and a facility general maintenance worker. It was observed that the fire proofing of the ceiling structural support beams located in the basement, 1st and 2nd floors had been chipped away or missing therefore compromising the required fire rating of the structure.

The following additional deficiency was observed by surveyors 20980 & 35163 and a facility general maintenance worker. Through interviewing of laundry personnel it was found that the facility laundry dryers are being used to dry mops heads and rags. The newer dryer had labeling that cautioned the drying of mop heads and oily rags and the older two dryers maintenance manual had a warning that stated mop heads and oily rags are not to be dried in the units.

This tag not met as observed by surveyors 20980 & 35163 and a facility general maintenance worker. It was observed that in the flammable storage locker located in the generator room was an accumulation of oily and dirty rags. Store rags in proper containers.