HospitalInspections.org

Based on observation and interview, it was determined the facility failed to maintain a two-hour fire resistance rating to separate the healthcare occupancy from other occupancies in two instances, affecting the entire facility.

Findings include:

1. Observation on October 16, 2024, revealed the following two-hour occupancy separation deficiencies:
a) 9:13 a.m., observation above the occupancy separation doors, at occupational therapy on the fourth floor, revealed multiple unsealed data wires were passing through a conduit in the occupancy separation wall;
b) 10:06 a.m., observation above the occupancy separation doors, at Center for Life on the fifth floor, revealed multiple unsealed data wires were passing through a conduit in the occupancy separation wall.

Interview with the Maintenance Director and Maintenance Staff on October 17, 2024, at 1:30 p.m., confirmed the listed two-hour occupancy separation deficiencies.

Based on observation and interview, it was determined the facility failed to maintain exit access in one instance, affecting exiting in two of eleven smoke compartments.

Finding included:

1. Observation on October 15, 2024, at 11:17 a.m., revealed the second-floor stairwell by the Helipad was not in compliance with NFPA 101 section 7.7.3. The exit discharge for the stairway is located on the second floor and the stairs continue uninterrupted to the first floor.

Interview with the Maintenance Director and Maintenance Staff on October 17, 2024, at 1:30 p.m., confirmed the listed exit access deficiency.

Based on observation and interview, it was determined the facility failed to maintain self-closing doors in one instance, affecting one of eleven smoke compartments.

Findings include:

1. Observation on October 15, 2024, at 9:56 a.m., revealed the arm was removed from the self-closing device on the pharmacy door leaving the door unable to self-close when tested.


Interview with the Maintenance Director and Maintenance Staff on October 17, 2024, at 1:30 p.m., confirmed the listed self-closing door deficiency.

Based on observation and interview, it was determined the facility failed to maintain vertical opening enclosures in one instance, affecting two of eleven smoke compartments.

Findings include:

1. Observation on October 15, 2024, at 11:28 a.m. revealed the Wing Three stairwell, near the elevators on the second floor, had multiple unsealed pipe penetrations in the front wall above the door.


Interview with the Maintenance Director and Maintenance Staff on October 17, 2024, at 1:30 p.m., confirmed the vertical opening enclosure deficiency.

Based on observation and interview, it was determined the facility failed to maintain hazardous area enclosures in one instance, affecting one of eight smoke compartments.

Findings include:

1. Observation on October 16, 2024, at 9:29 a.m., revealed the facility failed to maintain the required one-hour fire rating in the elevator equipment room, in the locker room hallway, on the fourth floor. There was an unsealed pipe penetration in the wall behind the elevator hydraulic pump.

Interview with the Maintenance Director and Maintenance Staff on October 17, 2024, at 1:30 p.m., confirmed the listed hazardous area enclosure deficiency.

Based on documentation review and interview it was determined the facility failed to perform the required semi-annual visual fire alarm system inspection, affecting the entire facility.

Findings Include:

1. Review of documentation on October 17, 2024, at 9:30 a.m., revealed the facility failed to perform the required semi-annual visual fire alarm system inspection.


Interview with the Maintenance Director and Maintenance Staff on October 17, 2024, at 1:30 p.m., confirmed the listed fire alarm system inspection deficiency.

Based on documentation review and interview, it was determined the facility failed to maintain the automatic sprinkler system in two instances, affecting the entire facility. Testing shall be in accordance with NFPA 72...14.4.5. Number 15 L (1) and (M)

Findings include:

1. Review of documentation on October 17, 2024, at 9:30 a.m., revealed the facility failed to perform the following required semi-annual inspection/testing of the automatic sprinkler system:

a) valve supervisory switches/tamper switch (semi-annual) 14.4.5, initiating devices (1);
b) vane and pressure switch water-flow alarm devices (semi-annual) 14.4.5 initiating devices (m).


Interview with the Maintenance Director and Maintenance Staff on October 17, 2024, at 1:30 p.m., confirmed the listed valve supervisory switch and water flow alarm deficiencies.

Based on documentation review and interview, it was determined the facility failed to maintain the automatic sprinkler system inspection and testing requirements in three instances, affecting the entire facility.

Findings include:

1. Review of documentation on October 17, 2024, at 9:30 a.m., revealed the following automatic sprinkler system inspection and testing deficiencies:

a) the facility failed to perform the required annual and semi-annual sprinkler system inspections in the past twelve months;
b) the facility failed to provide documentation for the required five-year internal inspection and the replacement or recalibration of gages for the automatic sprinkler system;
c) the facility failed to perform the required annual fire pump inspection within the past twelve months.

Interview with the Maintenance Director and Maintenance Staff on October 17, 2024, at 1:30 p.m., confirmed the listed automatic sprinkler system inspection and testing deficiencies.

Based on documentation review, observation, and interview, it was determined the facility failed to maintain the automatic sprinkler system in eight instances, affecting the entire facility.

Findings include:

1. Observation on October 15, 2024, revealed the following automatic sprinkler system deficiencies:

The facility failed to maintain a heat/smoke resistive ceiling for the proper activation/operation of the automatic sprinkler system in the following locations:

a) 10:06 a.m., there were multiple unsealed wire and pipe penetrations in the ceiling of the old security office;
b) 10:09 a.m., there were multiple unsealed pipe penetrations in the ceiling of the utility closet by the pharmacy window;
c) 10:19 a.m., there were multiple unsealed pipe penetrations in the ceiling of the transformer room by the ED;
d) 11:01 a.m., there were multiple unsealed wire penetrations in the ceiling of the Cath Lab electrical closet located on the second floor;
e) 11:11 a.m., there were multiple wires on the sprinkler branch line, above the ceiling, by the Wing Three equipment room on the second floor.

Interview with the Maintenance Director and Maintenance Staff on October 17, 2024, at 1:30 p.m., confirmed the listed automatic sprinkler system deficiencies.


2. Review of documentation on October 17, 2024, at 9:30 a.m., revealed the following automatic sprinkler system inspection and testing deficiencies:

a) the facility failed to perform the required annual and semi-annual sprinkler system inspections in the past twelve months;
b) the facility failed to provide documentation for the required five-year internal inspection and the replacement or recalibration of gages for the automatic sprinkler system;
c) the facility failed to perform the required annual fire pump inspection within the past twelve months.


Interview with the Maintenance Director and Maintenance Staff on October 17, 2024, at 1:30 p.m., confirmed the listed automatic sprinkler system deficiencies.

Based on documentation review and interview, it was determined the facility failed to maintain portable fire extinguisher inspections in two instances, affecting the entire facility. In accordance with NFPA 10, 7.1.2.1.

Findings include:

1. Review of documentation on October 17, 2024, at 9:30 a.m., revealed the following portable fire extinguisher inspection deficiencies:

a) the facility failed to provide an annual portable fire extinguisher inspection report;
b) the facility is unable to confirm if the person/persons who performed the annual portable fire extinguisher inspection are certified to inspect portable fire extinguishers.


Interview with the Maintenance Director and Maintenance Staff on October 17, 2024, at 1:30 p.m., confirmed the listed portable fire extinguisher inspection deficiencies.

Based on observation, documentation review, and interview, it was determined the facility failed to maintain portable fire extinguishers in three instances, affecting the entire facility. In accordance with NFPA 10, 7.1.2.1.

Findings include:

1. Observation on October 15, 2024, at 11:45 a.m., revealed the portable fire extinguisher in the boiler room hallway was sitting on the floor unsecured.

Interview with the Maintenance Director and Maintenance Staff on October 17, 2024, at 1:30 p.m., confirmed the portable fire extinguisher was on the floor and unsecured.


2. Review of documentation on October 17, 2024, at 9:30 a.m., revealed the following portable fire extinguisher inspection deficiencies:

a) the facility failed to provide an annual portable fire extinguisher report;
b) the facility is unable to confirm if the person/persons who performed the annual portable fire extinguisher inspection are certified to inspect portable fire extinguishers.


Interview with the Maintenance Director and Maintenance Staff on October 17, 2024, at 1:30 p.m., confirmed the listed portable fire extinguisher maintenance and inspection deficiencies.

Based on observation and interview, it was determined the facility failed to maintain smoke barrier walls in one instance, affecting two of eight smoke compartments.

Findings include:

1. Observation on October 16, 2024, at 9:45 a.m., revealed there were unsealed MC cables in the smoke barrier wall inside OBGYN exam room 6, above the door.
Interview with the Maintenance Director and Maintenance Staff on October 17, 2024, at 1:30 p.m., confirmed the listed smoke barrier wall deficiency.

Based on observation and interview, it was determined the facility failed to maintain self-closing smoke barrier doors with a coordinating device, in two instances, affecting two of eight smoke compartments. In accordance with NFPA 80, 2010 Edition, 6.4.1.2 and 6.4.1.2.1.

Findings include:

1. Observation on October 16, 2024, revealed the following smoke doors were equipped with an astragal, preventing the inactive door from closing and latching before the active door closes and latches, suggesting coordinating devices shall be used.

a) 10:10 a.m., the smoke barrier doors located in PT by Center for Life;
b) 10:27 a.m., the smoke barrier doors located in PT by Hospice.


Interview with the Maintenance Director and Maintenance Staff on October 17, 2024, at 1:30 p.m., confirmed the listed smoke barrier door deficiencies.

Based on documentation review and interview, it was determined the facility failed to ensure smoke dampers were inspected within the required six-year period, affecting eight of eight smoke compartments in the facility. In accordance with NFPA 105, Standard for the Installation of Smoke Door Assemblies and Other Opening Protectives.

Findings include:

1. Review of documentation on October 17, 2024, at 9:30 a.m., revealed the facility lacked documentation to indicate that smoke dampers were inspected every six years. There is no documentation available to confirm smoke damper inspection was performed within the required six-year period.


Interview with the Maintenance Director and Maintenance Staff on October 17, 2024, at 1:30 p.m., confirmed the listed smoke damper deficiency.

Based on documentation review and interview, it was determined the facility failed to ensure smoke dampers were inspected within the required six-year period, affecting eleven of eleven smoke compartments in the facility. In accordance with NFPA 105, Standard for the Installation of Smoke Door Assemblies and Other Opening Protectives.

Findings include:

1. Review of documentation and interview on October 17, 2024, at 9:30 a.m., revealed the facility lacked documentation to indicate that smoke dampers were inspected every six years. There is no documentation available to confirm smoke damper inspection was performed within the required six-year period.


Interview with the Maintenance Director and Maintenance Staff on October 17, 2024, at 1:30 p.m., confirmed the listed smoke damper deficiency.

Based on documentation review and interview, it was determined the facility failed to perform four of 12 required fire drills.

Findings include:

1. Review of documentation on October 17, 2024, at 9:30 a.m., revealed the facility failed to perform the following required fire drills:

a) third shift in the first quarter of the year;
b) second shift in the second quarter of the year;
c) second shift in the fourth quarter of the year;
d) third shift in the fourth quarter of the year.


Interview with the Maintenance Director and Maintenance Staff on October 17, 2024, at 1:30 p.m., confirmed the listed fire drill deficiencies.

Based on observation and interview, it was determined the facility failed to maintain electrical receptacles in two instances, affecting two of eleven smoke compartments.

Findings include:

1. Observation on October 15, 2024, revealed the following electrical receptacles, within six feet of a sink, were not GFCI-protected:

a) 9:53 a.m., in the Pharmacy;
b) 10:31 a.m., in the staff lounge located in the Lab.

Interview with the Maintenance Director and Maintenance Staff on October 17, 2024, at 1:30 p.m., confirmed the above-listed electrical receptacle deficiency.

Based on documentation review and interview, it was determined the facility failed to maintain the automatic transfer switch, in one instance, affecting the entire facility. Testing shall be in accordance with NFPA 110, 8.4.6. and NFPA 101 7.9.1.3.

Findings include:

1. Review of documentation on October 17, 2024, at 9:30 a.m., revealed the facility failed to perform and document the required monthly testing/function of the automatic transfer switch, to confirm a delay of not more than ten seconds is permitted to switch to emergency power.


Interview with the Maintenance Director and Maintenance Staff on October 17, 2024, at 1:30 p.m., confirmed the listed automatic transfer switch testing/function deficiency.

Based on observation and interview, it was determined the facility failed to maintain electrical wiring systems and equipment in one instance, affecting one of eleven smoke compartments.

Findings include:

1. Observation on October 15, 2024, at 9:58 a.m., revealed a microwave plugged into a power strip in patient registration room one.

Interview with the Maintenance Director and Maintenance Staff on October 17, 2024, at 1:30 p.m., confirmed the listed electrical wiring systems deficiency.