HospitalInspections.org

Based on observation, emergency lighting is not installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because their egress under emergency conditions could be impeded if emergency ligting is not properly installed and maintained.

Findings include:

On 6/01/2022 at 3:15pm while accompanied by the AD and FM in suite 202 on the 2nd floor it was observed that two battery powered emergency lights were not functional when the test buttons are pressed. Therefore, the lights are not in compliance with 39.2.9.1, 7.9.

Based on observation, not all exit signs are installed as required. This deficient practice could affect patients, staff, and visitors in the building because their egress under emergency conditions could be impeded if exit signs are not properly installed and maintained.

Findings include:

A. On 6/01/2022 at 1:25pm while accompanied by the AD and FM in the 2nd floor East wing it was observed that exit signage is not provided in the mechanical room. This is not in compliance with 7.10.3.1.

B. On 6/01/2022 at 1:35pm while accompanied by the AD and FM in the 2nd floor West wing it was observed that exit signage is not provided in the mechanical room/interstital space. This is not in compliance with 7.10.3.1.

Based on observation not all exit doors are installed or maintained to provide protection of the exit enclosure. This deficiency could affect patients, staff and visitors if the exit access door did not provide the proper protection during a fire emergency.

Findings include:

On 6/01/2022 at 12:35pm while in the company of the AD and FM on the 6th floor Penthouse it was observed that the double door serving the stair failed to self-close and self-latch due to a missing astragal coordinator. This does not comply with the requirements of Table 8.3.4.2 and NFPA 80-2010, 6.4.1.1.

Based on observation the facility failed to provide the required smoke detection protection. This deficient practice could result in the untimely notification of fire which may affect patients, staff and visitors.

Findings include:

It was observed that detectors are located where airflow may prevent normal operation of the device as stated in NFPA 72-2010, 17.7.4.1. Locations & conditions observed include the following:

A. On 6/01/2022 at 12:47pm, while in the company of AD and FM on the 4th floor of the East Wing it was observed that 2 smoke detectors were within 3"-0" of an HVAC diffuser near the physical therapy room.

B. On 6/01/2022 at 1:00pm, while in the company of AD and FM on the 3rd floor of the East Wing it was observed that a smoke detector was within 3"-0" of an HVAC diffuser near the Clean Utility Room.

C. On 6/01/2022 at 1:06pm, while in the company of AD and FM on the 2nd floor of the East Wing it was observed that a smoke detector was within 3"-0" of an HVAC diffuser near the Room E213.

D. On 6/01/2022 at 1:07pm, while in the company of AD and FM on the 2nd floor of the East Wing it was observed that a smoke detector was within 3"-0" of an HVAC diffuser in the mechanical/electrical room into which elevator 12 opens.

E. On 6/01/2022 at 1:10pm, while in the company of AD and FM on the 2nd floor of the East Wing it was observed that a smoke detector was within 3"-0" of an HVAC diffuser near the Room E204.

F. On 6/01/2022 at 1:15pm, while in the company of AD and FM on the 2nd floor of the East Wing it was observed that a smoke detector was within 3"-0" of an HVAC diffuser near the Nurse's Station.

G. On 6/01/2022 at 1:40pm, while in the company of AD and FM on the 2nd floor of the West Wing it was observed that a smoke detector was within 3"-0" of an HVAC diffuser near the Room W2108 EVS.

Based on observation the facility failed to maintain the sprinkler system as required. Failure to maintain the system could result in delayed response and fire suppression. This deficient practice could affect patients, staff, and visitors during a fire event.

Findings include:

A. On 6/01/2022 at 11:15am while in the company of the AD and FM, it was determined during document review that there is no evidence to indicate weekly sprinkler system control valve inspections are performed. This does not comply with NFPA 25-2011, 13.3.2.1.

B. On 6/01/2022 at 11:20am while in the company of the AD and FM, it was determined during document review that there is no evidence to indicate monthly sprinkler system pressure gauges inspections are performed. This does not comply with NFPA 25-2011, 13.3.7.1.

C. On 6/01/2022 at 11:30am while in the company of the AD and FM, it was determined during document review that there is no evidence to indicate weekly fire pump visual inspections are performed. This does not comply with NFPA 25-2011, TBL 8.1.1.2, 8.2.2

Based on observation, portable fire extinguishers are not maintained as required. This deficient practice could affect patients, staff, and visitors in the building because portable fire extinguishers which are not maintained properly may fail to operate under fire conditions.

Findings include:

On 6/01/2022 at 3:35pm while accompanied by the AD and FM evidence was not provided demonstrating monthly visual inspections as required. Therefore, the extinguishers are not in compliance with 39.3.5, 9.7.4.1, NFPA 10-2010, 7.2.1.2.