HospitalInspections.org

Based on observation, on October 21, 2009 at approximately 8:09am onward, there is an unprotected roof/ceiling assembly and structure throughout the following areas:

a. solarium

b. dining room

c. pharmacy

d. general storage and medical records areas - near materials management office

Based on observation, on October 21, 2009 at approximately 8:09am onward, there is no positive latching hardware and astragal for exit access doors from dining room area.

A. Based on observation, on October 21, 2009 at approximately 9:10am onward, the fire alarm system did not sound with activation of the sprinkler system serving hazardous areas in the first floor medical records area.

B. Based on observation, on October 21, 2009 at approximately 9:10am onward, doors and enclosures to the following severe hazardous areas were not listed and constructed to maintain a minimum one hour enclosures:

a. medical records area with open files - area is much greater than 100 square feet.

b. supply room - near medical records - much greater than 100 square feet.

A. Based on observation, on October 20, 2009 at approximately 11:12am onward, the facility utilizes special locking arrangements that did not release with activation of the fire alarm system in the following areas:

1. cross corridor egress doors from and through OB area.(first floor).

2. med/surg area near central nurse's station.(first floor)

B. Based on observation, on October 20, 2009 at approximately 11:12am onward, the exit discharge serving the cardiac rehabilitation area is incomplete across the outside roof surface. Guardrails are not provided along egress path and near edges of roof.(second floor)

C. Based on observation, on October 20, 2009 at approximately 11:12am onward, the exit discharge path serving the second floor administrator's wing is obstructed by an open storm water drain - grate was removed at the time of survey.

D. Based on observation, on October 20, 2009 at approximately 11:12am onward, the facility utilizes special locking arrangements and is not equipped with a complete sprinkler system or complete detection system for all spaces.

Based on observation, on October 21, 2009 at approximately 12:30pm onward, there are no smoke detectors located in elevator equipment rooms located in the following areas:

a. equipment room located above central elevator

b. south wing - exterior near operating rooms

Based on observation, on October 20, 2009 at approximately 11:12am onward, there are no service access openings for all duct-mounted smoke detectors serving the medical records office.(located in mechanical room near first floor medical records area)

Based on observation, on October 21, 2009 at approximately 2:30pm onward, the kitchen mechanical systems are noncompliant due to the following:

a. there is no makeup air unit for the range hood exhaust system located in the kitchen.

b. range hood inspection report, dated July 16, 2008, cites holes and rusty ductwork during inspection - there are no documents to demonstrate corrective action for the referenced comments.

Based on observation, on October 20, 2009 at approximately 11:12am onward, the essential electrical system is noncompliant due to the following:

a. generator annunciator panel is located in an unsupervised security room near the ED.

b. devices wired to the life safety branch panelboard that are permitted by Article 517 of the National Electrical Code. Motorized doors and nurse computers are not permitted on the life safety branch panelboard in the ED area.

Based on observation, on October 20, 2009 at approximately 11:12am onward, the essential electrical system is noncompliant due to the following:

a. generator annunciator panel visual signals did not function with activation of test switch and test of the emergency power system.

b. emergency power system supplying load indicator, located on the generator annunciator panel, did not function during loss of power to the automatic transfer switch serving the life safety branch of the essential electrical system.

c. lack task lighting at the outdoor switchgear.

d. lack of proper supports for generator fuel storage tank - supports are sunk into asphalt pavement on one side.

e. devices wired to the life safety branch panelboards that are not permitted by Article 517 of the National Electrical Code.

f. lack of knockout covers for missing circuit breakers in life safety branch panelboard located on corridor wall near special procedures room.(main corridor near laboratory entrance)

g. nomenclature for emergency panelboards and devices served are inconsistent - panelboards utilize black labels, and devices served utilize red identification labels or red devices.

Based on observation, on October 21, 2009 at approximately 8:09am onward, there is an unprotected roof/ceiling assembly and structure throughout the following areas:

a. solarium

b. dining room

c. pharmacy

d. general storage and medical records areas - near materials management office

Based on observation, on October 21, 2009 at approximately 8:09am onward, there is no positive latching hardware and astragal for exit access doors from dining room area.

A. Based on observation, on October 20, 2009 at approximately 11:12am onward, the facility utilizes special locking arrangements that did not release with activation of the fire alarm system in the following areas:

1. cross corridor egress doors from and through OB area.(first floor).

2. med/surg area near central nurse's station.(first floor)

B. Based on observation, on October 20, 2009 at approximately 11:12am onward, the exit discharge serving the cardiac rehabilitation area is incomplete across the outside roof surface. Guardrails are not provided along egress path and near edges of roof.(second floor)

C. Based on observation, on October 20, 2009 at approximately 11:12am onward, the exit discharge path serving the second floor administrator's wing is obstructed by an open storm water drain - grate was removed at the time of survey.

D. Based on observation, on October 20, 2009 at approximately 11:12am onward, the facility utilizes special locking arrangements and is not equipped with a complete sprinkler system or complete detection system for all spaces.

Based on observation, on October 21, 2009 at approximately 12:30pm onward, there are no smoke detectors located in elevator equipment rooms located in the following areas:

a. equipment room located above central elevator

b. south wing - exterior near operating rooms

Based on observation, on October 21, 2009 at approximately 2:30pm onward, the kitchen mechanical systems are noncompliant due to the following:

a. there is no makeup air unit for the range hood exhaust system located in the kitchen.

b. range hood inspection report, dated July 16, 2008, cites holes and rusty ductwork during inspection - there are no documents to demonstrate corrective action for the referenced comments.

Based on observation, on October 20, 2009 at approximately 11:12am onward, the essential electrical system is noncompliant due to the following:

a. generator annunciator panel is located in an unsupervised security room near the ED.

b. devices wired to the life safety branch panelboard that are permitted by Article 517 of the National Electrical Code. Motorized doors and nurse computers are not permitted on the life safety branch panelboard in the ED area.

Based on observation, on October 20, 2009 at approximately 11:12am onward, the essential electrical system is noncompliant due to the following:

a. generator annunciator panel visual signals did not function with activation of test switch and test of the emergency power system.

b. emergency power system supplying load indicator, located on the generator annunciator panel, did not function during loss of power to the automatic transfer switch serving the life safety branch of the essential electrical system.

c. lack task lighting at the outdoor switchgear.

d. lack of proper supports for generator fuel storage tank - supports are sunk into asphalt pavement on one side.

e. devices wired to the life safety branch panelboards that are not permitted by Article 517 of the National Electrical Code.

f. lack of knockout covers for missing circuit breakers in life safety branch panelboard located on corridor wall near special procedures room.(main corridor near laboratory entrance)

g. nomenclature for emergency panelboards and devices served are inconsistent - panelboards utilize black labels, and devices served utilize red identification labels or red devices.