HospitalInspections.org

Based on observation the facility failed to provide 1-hour fire resistive separation for the vertical openings in accordance with the LSC section 19.3.1.1. This deficient practice could potentially affect 188 occupants of the facility. Findings include:

- On September 11, 2012 at approximately 12:45 PM, observed that the stairway door to the exit access stairway in the Lower Level Mechanical Room by the Electrical Room did not close to a positive latch and there was a 1/8 - inch gap between the door and the door frame. This deficiency would not prevent the spread of smoke and heat from entering the stairway and proceeding to the upper levels and is not in accordance with the 2000 Edition of the LSC 8.2.5.6. & 19.3.1.1.

This finding was observed and confirmed by the maintenance staff at the time of the inspection.

Based on observation the facility failed to provide smoke barriers that would provide at least a one half hour fire resistance rating in accordance with the LSC sections 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4. This deficient practice could potentially affect 188 occupants of the facility. Findings include:

- On September 11, 2012 at approximately 10:00 AM, observed that there are two open 1/2 - inch flex conduits that are protruding through the smoke barrier wall above the ceiling tile by the smoke barrier doors by room 834 that are not properly sealed with a fire resistant UL Listed material. This deficiency would not prevent the spread of smoke and heat from entering adjacent smoke zones and is not in accordance with the 2000 Edition of the LSC 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4.

- On September 11, 2012 at approximately 1:00 PM, observed that there is a 1/8 - inch wall through penetration around a pipe protruding through the smoke barrier wall above the ceiling tile above the smoke barrier doors by room # 182 that is not properly sealed with a UL Listed fire resistant material. This deficiency would not prevent the spread of smoke and heat from entering adjacent smoke zones and is not in accordance with the 2000 Edition of the LSC 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4.

- On September 12, 2012 at approximately 10:00 AM, observed that there is an open 1/2 - inch flex conduit that is protruding through the smoke barrier wall above the ceiling tile by the smoke barrier doors by room 3S37 that is not properly sealed with a fire resistant UL Listed material. This deficiency would not prevent the spread of smoke and heat from entering adjacent smoke zones and is not in accordance with the 2000 Edition of the LSC 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4.

- On September 12, 2012 at approximately 11:10 AM, observed that there are two 1/4 - inch wall through penetrations in the smoke barrier wall above the ceiling tile above the Emergency Room entrance smoke barrier doors that are not properly sealed with a UL Listed fire resistant material. This deficiency would not prevent the spread of smoke and heat from entering adjacent smoke zones and is not in accordance with the 2000 Edition of the LSC 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4.

These findings were observed and confirmed by the maintenance staff at the time of the inspection.

Based on observation the facility failed to provide for the smoke barrier doors to be self-closing or automatic closing in accordance with the LSC section 19.2.2.2.6. This deficient practice could potentially affect 188 occupants of the facility. Findings include:

- On September 11, 2012 at approximately 1:15 PM, observed that the Loading Dock smoke barrier doors did not close to prevent the spread of smoke and heat. There is a 1/8 - inch gap between the doors. This deficiency is not in accordance with the 2000 Edition of the LSC 19.3.7.5, 19.3.7.6, 19.3.7.7.

This finding was observed and confirmed by the maintenance staff at the time of the inspection.

Based on observation the facility failed to provide for the protection of hazardous areas in accordance with the LSC section 19.3.2.1. This deficient practice could potentially affect 188 occupants of the facility. Findings include:

- On September 11, 2012 at approximately 9:30 AM, observed that there is a 1/2 - inch open pipe protruding through the floor in the Calhalan Building Penthouse Elevator Room that is not properly sealed with a UL Listed fire resistant material. This deficiency would not prevent the spread of smoke and heat from entering the lower levels of the hospital and is not in accordance with the 2000 Edition of the LSC 8.4.1 and/or 19.3.5.4.

- On September 11, 2012 at approximately 11:15 AM, observed that the fire rated labels to the fire rated doors to the Storage Room numbered 3N93 were painted over and the fire rating of the door could not be determined. This deficiency is not in accordance with the 2000 Edition LSC 19.3.2.1.

- On September 11, 2012 at approximately 1:25 PM, observed that the fire rated door to the Cafeteria Coke Storage Room sticks to the tile floor and does not close to a positive latch. This deficiency is not in accordance with the 2000 Edition LSC 19.3.2.1.

These findings were observed and confirmed by the maintenance staff at the time of the inspection.

Based on observation the facility failed to provide approved exit access in accordance with the LSC section 19.2.1. This deficient practice could potentially affect the staff occupants of the facility. Findings include:

- On September 11, 2012 at approximately 2:00 PM, observed that the exit door to the outside in the Mechanical Room by the Medical Gas Storage Room in the Emergency Room Wing next to room GA 301 required an unreasonable amount of force to open. This deficiency is not in accordance with the 2000 Edition LSC section 7.1. 19.2.1.

- On September 12, 2012 at approximately 11:00 AM, observed that the exit access vestibule by room GA106 to the exit door to the outside is being utilized as storage for medical equipment. This deficiency is not in accordance with the 2000 Edition LSC section 7.1. 19.2.1.

These findings were observed and confirmed by the maintenance staff at the time of the inspection.

Based on observation and/or review of records the facility failed to provide and/or maintain smoke detection devices in accordance with the LSC section 9.6.1.3. This deficient practice could potentially affect 188 occupants of the facility. Findings include:

- On September 12, 2012 at approximately 9:55 AM, observed that the smoke detector located in the Surgical Wing in front of the smoke barrier doors by O.R. Room # 6 is not securely attached to the ceiling. This deficiency is not in accordance with the LSC 2000 Edition 9.6.1.3.

This finding was observed and confirmed by the maintenance staff at the time of the inspection.

Based on observation and/or review of records the facility failed to provide documentation that the automatic sprinkler system is maintained and/or tested in accordance with the LSC sections 19.7.6, 4.6.12, 9.7.5. This deficient practice could potentially affect 188 occupants of the facility. Findings include:

- On September 12, 2012 at approximately 10:40 AM, observed that a pendent type sprinkler head is being improperly used as a sidewall sprinkler head in room MB362. This deficiency is not in accordance with the 2000 Edition LSC 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5.

This finding was observed and confirmed by the maintenance staff at the time of the inspection.

Based on observation the facility failed to provide unobstructed egress in accordance with the LSC section 7.1.10. This deficient practice could potentially affect 188 occupants of the facility. Findings include:

- On September 11, 2012 at approximately 10:15 AM, observed that the corridor wall medical chart cabinet, which was unattended, was not in the fully closed position and extended in to the corridor by patient room # 754-1. This deficiency is not in accordance with the 2000 Edition of the LSC 7.1.10.

- On September 11, 2012 at approximately 10:20 AM, observed that the corridor wall medical chart cabinet, which was unattended, was not in the fully closed position and extended in to the corridor by patient room # 702-1. This deficiency is not in accordance with the 2000 Edition of the LSC 7.1.10.

- On September 11, 2012 at approximately 10:20 AM, observed that the corridor wall medical chart cabinet, which was unattended, was not in the fully closed position and extended in to the corridor by patient room # 704-2. This deficiency is not in accordance with the 2000 Edition of the LSC 7.1.10.

These findings were observed and confirmed by the maintenance staff at the time of the inspection.

Based on observation the facility failed to provide protection of medical gasses in accordance with NFPA 99. This deficient practice could potentially affect 188 occupants of the facility. Findings include:

- On September 11, 2012 at approximately 10:35 AM, observed that Oxygen Storage Room # 635 was not identified as an Oxygen Storage Room. This deficiency is not in accordance with NFPA 99, Standards for Health Care Facilities.

- On September 11, 2012 at approximately 10:55 AM, observed that Oxygen Storage Room # 535 was not identified as an Oxygen Storage Room. This deficiency is not in accordance with NFPA 99, Standards for Health Care Facilities.

- On September 11, 2012 at approximately 11:45 AM, observed that Oxygen Storage Room # 435 was not identified as an Oxygen Storage Room. This deficiency is not in accordance with NFPA 99, Standards for Health Care Facilities.

- On September 11, 2012 at approximately 11:15 AM observed that Oxygen Storage Room # 3S25 was not identified as an Oxygen Storage Room. This deficiency is not in accordance with NFPA 99, Standards for Health Care Facilities.

- On September 11, 2012 at approximately 1:40 PM, observed that 9 E-Type Oxygen Cylinders are stored to close to combustible materials in the room identified as the Sorting Room. This deficiency is not in accordance with NFPA 99, Standards for Health Care Facilities.

- On September 12, 2012 at approximately 10:50 AM observed that an E-Type Oxygen Cylinder was unsecured and not properly stored in room GB 262. This deficiency is not in accordance with NFPA 99, Standards for Health Care Facilities.

- On September 12, 2012 at approximately 12:10 PM, observed that E-Type Oxygen Cylinders are being stored in the rear exit access corridor obstructing the rear exit door in the Healthcare Store located in the Main Lobby. This deficiency is not in accordance with NFPA 99, Standards for Health Care Facilities.

These findings were observed and confirmed by the maintenance staff at the time of the inspection.

The facility failed to maintain the emergency generator in accordance with NFPA 110.

NFPA 110 SEC. 6.4.1 AND 6.4.2, LEVEL 1 AND LEVEL 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load monthly for a minimum of 30 minutes. This deficient practice could potentially affect 188 occupants of the facility. Findings include:

- On September 11, 2012 at approximately 1:20 PM, observed that the Generator Fuel Senor Light Indicator Panel located in room 172 was beeping and the lamp was illuminated in the red indicating that Sensor # 1 was out. This deficiency is not in accordance with NFPA 99 3.4.4.1.

This finding was observed and confirmed by the maintenance staff at the time of the inspection.

Based on observation the facility failed to provide the electrical system in accordance with the LSC section 9.1.2. This deficient practice could potentially affect 188 occupants of the facility. Findings include:

- On September 11, 2012 at approximately 10:30 AM, observed that there are exposed electrical wires before the plug for a piece of medical equipment identified as a Data Scope Accutor that was charging by the Nursing Station across from room 705. This deficiency is not in accordance with NFPA 70, National Electrical Code. 9.1.2.

- On September 11, 2012 at approximately 11:30 AM, observed that there are two unsecured electrical junction boxes located above the ceiling tile, above the smoke barrier doors by room 3S14. This deficiency is not in accordance with NFPA 70, National Electrical Code. 9.1.2.

- On September 12, 2012 at approximately 9:50 AM, observed that there is an electrical power strip attached to the rear corridor wall that is charging medical equipment in the Surgical Wing across from O. R. Room # 7 that is connected to another power strip. This deficiency is not in accordance with NFPA 70, National Electrical Code. 9.1.2.

These findings were observed and confirmed by the maintenance staff at the time of the inspection.

Based on observation the facility failed to provide 1-hour fire resistive separation for the vertical openings in accordance with the LSC section 19.3.1.1. This deficient practice could potentially affect 188 occupants of the facility. Findings include:

- On September 11, 2012 at approximately 12:45 PM, observed that the stairway door to the exit access stairway in the Lower Level Mechanical Room by the Electrical Room did not close to a positive latch and there was a 1/8 - inch gap between the door and the door frame. This deficiency would not prevent the spread of smoke and heat from entering the stairway and proceeding to the upper levels and is not in accordance with the 2000 Edition of the LSC 8.2.5.6. & 19.3.1.1.

This finding was observed and confirmed by the maintenance staff at the time of the inspection.

Based on observation the facility failed to provide smoke barriers that would provide at least a one half hour fire resistance rating in accordance with the LSC sections 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4. This deficient practice could potentially affect 188 occupants of the facility. Findings include:

- On September 11, 2012 at approximately 10:00 AM, observed that there are two open 1/2 - inch flex conduits that are protruding through the smoke barrier wall above the ceiling tile by the smoke barrier doors by room 834 that are not properly sealed with a fire resistant UL Listed material. This deficiency would not prevent the spread of smoke and heat from entering adjacent smoke zones and is not in accordance with the 2000 Edition of the LSC 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4.

- On September 11, 2012 at approximately 1:00 PM, observed that there is a 1/8 - inch wall through penetration around a pipe protruding through the smoke barrier wall above the ceiling tile above the smoke barrier doors by room # 182 that is not properly sealed with a UL Listed fire resistant material. This deficiency would not prevent the spread of smoke and heat from entering adjacent smoke zones and is not in accordance with the 2000 Edition of the LSC 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4.

- On September 12, 2012 at approximately 10:00 AM, observed that there is an open 1/2 - inch flex conduit that is protruding through the smoke barrier wall above the ceiling tile by the smoke barrier doors by room 3S37 that is not properly sealed with a fire resistant UL Listed material. This deficiency would not prevent the spread of smoke and heat from entering adjacent smoke zones and is not in accordance with the 2000 Edition of the LSC 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4.

- On September 12, 2012 at approximately 11:10 AM, observed that there are two 1/4 - inch wall through penetrations in the smoke barrier wall above the ceiling tile above the Emergency Room entrance smoke barrier doors that are not properly sealed with a UL Listed fire resistant material. This deficiency would not prevent the spread of smoke and heat from entering adjacent smoke zones and is not in accordance with the 2000 Edition of the LSC 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4.

These findings were observed and confirmed by the maintenance staff at the time of the inspection.

Based on observation the facility failed to provide for the smoke barrier doors to be self-closing or automatic closing in accordance with the LSC section 19.2.2.2.6. This deficient practice could potentially affect 188 occupants of the facility. Findings include:

- On September 11, 2012 at approximately 1:15 PM, observed that the Loading Dock smoke barrier doors did not close to prevent the spread of smoke and heat. There is a 1/8 - inch gap between the doors. This deficiency is not in accordance with the 2000 Edition of the LSC 19.3.7.5, 19.3.7.6, 19.3.7.7.

This finding was observed and confirmed by the maintenance staff at the time of the inspection.

Based on observation the facility failed to provide for the protection of hazardous areas in accordance with the LSC section 19.3.2.1. This deficient practice could potentially affect 188 occupants of the facility. Findings include:

- On September 11, 2012 at approximately 9:30 AM, observed that there is a 1/2 - inch open pipe protruding through the floor in the Calhalan Building Penthouse Elevator Room that is not properly sealed with a UL Listed fire resistant material. This deficiency would not prevent the spread of smoke and heat from entering the lower levels of the hospital and is not in accordance with the 2000 Edition of the LSC 8.4.1 and/or 19.3.5.4.

- On September 11, 2012 at approximately 11:15 AM, observed that the fire rated labels to the fire rated doors to the Storage Room numbered 3N93 were painted over and the fire rating of the door could not be determined. This deficiency is not in accordance with the 2000 Edition LSC 19.3.2.1.

- On September 11, 2012 at approximately 1:25 PM, observed that the fire rated door to the Cafeteria Coke Storage Room sticks to the tile floor and does not close to a positive latch. This deficiency is not in accordance with the 2000 Edition LSC 19.3.2.1.

These findings were observed and confirmed by the maintenance staff at the time of the inspection.

Based on observation the facility failed to provide approved exit access in accordance with the LSC section 19.2.1. This deficient practice could potentially affect the staff occupants of the facility. Findings include:

- On September 11, 2012 at approximately 2:00 PM, observed that the exit door to the outside in the Mechanical Room by the Medical Gas Storage Room in the Emergency Room Wing next to room GA 301 required an unreasonable amount of force to open. This deficiency is not in accordance with the 2000 Edition LSC section 7.1. 19.2.1.

- On September 12, 2012 at approximately 11:00 AM, observed that the exit access vestibule by room GA106 to the exit door to the outside is being utilized as storage for medical equipment. This deficiency is not in accordance with the 2000 Edition LSC section 7.1. 19.2.1.

These findings were observed and confirmed by the maintenance staff at the time of the inspection.

Based on observation and/or review of records the facility failed to provide and/or maintain smoke detection devices in accordance with the LSC section 9.6.1.3. This deficient practice could potentially affect 188 occupants of the facility. Findings include:

- On September 12, 2012 at approximately 9:55 AM, observed that the smoke detector located in the Surgical Wing in front of the smoke barrier doors by O.R. Room # 6 is not securely attached to the ceiling. This deficiency is not in accordance with the LSC 2000 Edition 9.6.1.3.

This finding was observed and confirmed by the maintenance staff at the time of the inspection.

Based on observation and/or review of records the facility failed to provide documentation that the automatic sprinkler system is maintained and/or tested in accordance with the LSC sections 19.7.6, 4.6.12, 9.7.5. This deficient practice could potentially affect 188 occupants of the facility. Findings include:

- On September 12, 2012 at approximately 10:40 AM, observed that a pendent type sprinkler head is being improperly used as a sidewall sprinkler head in room MB362. This deficiency is not in accordance with the 2000 Edition LSC 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5.

This finding was observed and confirmed by the maintenance staff at the time of the inspection.

Based on observation the facility failed to provide unobstructed egress in accordance with the LSC section 7.1.10. This deficient practice could potentially affect 188 occupants of the facility. Findings include:

- On September 11, 2012 at approximately 10:15 AM, observed that the corridor wall medical chart cabinet, which was unattended, was not in the fully closed position and extended in to the corridor by patient room # 754-1. This deficiency is not in accordance with the 2000 Edition of the LSC 7.1.10.

- On September 11, 2012 at approximately 10:20 AM, observed that the corridor wall medical chart cabinet, which was unattended, was not in the fully closed position and extended in to the corridor by patient room # 702-1. This deficiency is not in accordance with the 2000 Edition of the LSC 7.1.10.

- On September 11, 2012 at approximately 10:20 AM, observed that the corridor wall medical chart cabinet, which was unattended, was not in the fully closed position and extended in to the corridor by patient room # 704-2. This deficiency is not in accordance with the 2000 Edition of the LSC 7.1.10.

These findings were observed and confirmed by the maintenance staff at the time of the inspection.

Based on observation the facility failed to provide protection of medical gasses in accordance with NFPA 99. This deficient practice could potentially affect 188 occupants of the facility. Findings include:

- On September 11, 2012 at approximately 10:35 AM, observed that Oxygen Storage Room # 635 was not identified as an Oxygen Storage Room. This deficiency is not in accordance with NFPA 99, Standards for Health Care Facilities.

- On September 11, 2012 at approximately 10:55 AM, observed that Oxygen Storage Room # 535 was not identified as an Oxygen Storage Room. This deficiency is not in accordance with NFPA 99, Standards for Health Care Facilities.

- On September 11, 2012 at approximately 11:45 AM, observed that Oxygen Storage Room # 435 was not identified as an Oxygen Storage Room. This deficiency is not in accordance with NFPA 99, Standards for Health Care Facilities.

- On September 11, 2012 at approximately 11:15 AM observed that Oxygen Storage Room # 3S25 was not identified as an Oxygen Storage Room. This deficiency is not in accordance with NFPA 99, Standards for Health Care Facilities.

- On September 11, 2012 at approximately 1:40 PM, observed that 9 E-Type Oxygen Cylinders are stored to close to combustible materials in the room identified as the Sorting Room. This deficiency is not in accordance with NFPA 99, Standards for Health Care Facilities.

- On September 12, 2012 at approximately 10:50 AM observed that an E-Type Oxygen Cylinder was unsecured and not properly stored in room GB 262. This deficiency is not in accordance with NFPA 99, Standards for Health Care Facilities.

- On September 12, 2012 at approximately 12:10 PM, observed that E-Type Oxygen Cylinders are being stored in the rear exit access corridor obstructing the rear exit door in the Healthcare Store located in the Main Lobby. This deficiency is not in accordance with NFPA 99, Standards for Health Care Facilities.

These findings were observed and confirmed by the maintenance staff at the time of the inspection.

The facility failed to maintain the emergency generator in accordance with NFPA 110.

NFPA 110 SEC. 6.4.1 AND 6.4.2, LEVEL 1 AND LEVEL 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load monthly for a minimum of 30 minutes. This deficient practice could potentially affect 188 occupants of the facility. Findings include:

- On September 11, 2012 at approximately 1:20 PM, observed that the Generator Fuel Senor Light Indicator Panel located in room 172 was beeping and the lamp was illuminated in the red indicating that Sensor # 1 was out. This deficiency is not in accordance with NFPA 99 3.4.4.1.

This finding was observed and confirmed by the maintenance staff at the time of the inspection.

Based on observation the facility failed to provide the electrical system in accordance with the LSC section 9.1.2. This deficient practice could potentially affect 188 occupants of the facility. Findings include:

- On September 11, 2012 at approximately 10:30 AM, observed that there are exposed electrical wires before the plug for a piece of medical equipment identified as a Data Scope Accutor that was charging by the Nursing Station across from room 705. This deficiency is not in accordance with NFPA 70, National Electrical Code. 9.1.2.

- On September 11, 2012 at approximately 11:30 AM, observed that there are two unsecured electrical junction boxes located above the ceiling tile, above the smoke barrier doors by room 3S14. This deficiency is not in accordance with NFPA 70, National Electrical Code. 9.1.2.

- On September 12, 2012 at approximately 9:50 AM, observed that there is an electrical power strip attached to the rear corridor wall that is charging medical equipment in the Surgical Wing across from O. R. Room # 7 that is connected to another power strip. This deficiency is not in accordance with NFPA 70, National Electrical Code. 9.1.2.

These findings were observed and confirmed by the maintenance staff at the time of the inspection.