HospitalInspections.org

Based on observations as referenced in the Life Safety report of survey completed August 10, 2016, the hospital failed to have an effective governing body ensuring a safe environment for patients.

The findings include:

The hospital failed to develop and maintain the facilities in a manner to ensure the safety of patients.

~ cross refer 482.41 Physical Environment - Tag A0700

Based on observations as referenced in the Life Safety report of survey completed August 10, 2016, the hospital failed to develop and maintain the facilities in a manner to ensure the safety of patients.

The findings include:

The hospital failed to ensure the safety and well-being of patients by failing to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association.

~Cross-refer to 482.41(b)(1)(2)(3) Physical Environment Standard Tag A-0710.

Based on observations as referenced in the Life Safety Report of survey completed August 10, 2016, the hospital failed to ensure the safety and well-being of patients by failing to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association.

The findings include:

1) Based on observations, on August 9, 2016 at approximately 10:30 AM onward, the following deficiencies were noted:

A. The travel distance to smoke barrier on the fourth floor exceeds 100 feet of travel from the most remote exit access door - the facility is not equipped with a complete automatic sprinkler system throughout the facility. The facility architectural drawings were completed in 1968 and referenced area was reviewed and approved under Life Safety Codes required at that time - Life Safety Codes adopted by CMS from 1967 - 1985 Editions did not permit a travel distance exceeding 150 feet in health care facilities not equipped with a complete automatic sprinkler systems. The travel distance of reference is measured from the exit access door allowing a maximum of 50 feet travel from any point within a room for a total of 150 feet. Referenced area contains cross corridor smoke barrier door frames with missing doors and hardware - doors, if provided, would meet travel distance requirement for facilities without a complete automatic sprinkler system.

NFPA 101, 19.3.7.1, 4.6.12

This deficiency affected one of two smoke compartments.

~ Cross refer to Life Safety Code Standard - NFPA 101, Tag K 0024.

2) Based on observations, on August 9, 2016 at approximately 10:30 AM onward, the following deficiencies were noted:

A. Vision panels in cross corridor smoke barrier doors are covered with posters and other paper products - located on fourth floor near elevator #1.

B. Cross corridor smoke barrier doors are not equipped with vision panels in outpatient surgery center - referenced area is located on the first floor and constructed under NFPA 101, 2000 New Life Safety Code.

NFPA 101, 19.3.7.3, 19.3.7.5, 18.3.7.3, 18.3.7.5

This deficiency affected two of two smoke compartments.

~ Cross refer to Life Safety Code Standard - NFPA 101, Tag K 0025.

3) Based on observations, on August 9, 2016 at approximately 10:30 AM onward, the following deficiencies were noted:

A. There is bulk storage items stored under the canopy of loading dock area - the area is not equipped with automatic sprinklers.

B. Large pantries in the main kitchen are not enclosed with one hour fire resistive construction or equipped with sprinklers and smoke resistive enclosures.

C. The corridor door to the clean linen room across from room 203 was not self-closing.

D. The storage room #314 was greater than 100 square feet and was not provided with sprinkler coverage or 1 hr. fire rated construction.

E. The soiled linen room located next to the nurse station on third floor has a duct penetrating the wall above the ceiling above the door that was not sealed in order to maintain the required rating of the wall.

NFPA 101, 19.3.2.1, NFPA 13

This deficiency affected four smoke compartments.

~ Cross refer to Life Safety Code Standard - NFPA 101, Tag K 0029.

4) Based on observations, on August 9, 2016 at approximately 10:30 AM onward, the following deficiencies were noted:

A. Exit access door from enclosed courtyard is equipped with non-passage type hardware from inside courtyard. Hardware depends upon magnetic swipe for release of electromagnetic lock. The lock did not release with activation of fire alarm system, loss of power to the device, and the facility is not equipped with a complete automatic sprinkler system. Area of reference is located on the first floor near linear accelerator room.

Note: Hardware was deactivated and removed by hospital staff at time of observation.

B. Delayed egress lock at labor/delivery unit exit access door is not equipped with signage as required by Section 7-2.1.6 of NFPA 101, 2000 Edition.

C. Delayed Egress lock did not release with activation of fire alarm system by smoke detection system - located on second floor Labor/Delivery Unit exit access door.

D. Delayed egress lock on tower stair is not equipped with signage as required by Section 7-2.1.6 of NFPA 101. Located on second floor near Labor and Delivery Unit.

Note: Delayed egress lock referenced in items(1) and (2) did release with application of press to release device as required by Section 7-2.1.6 of NFPA 101. The locks are not permitted due to lack of complete automatic sprinkler system or complete smoke detection system throughout facility.

E. There are no guardrails designed to prevent passage of six inch sphere and complete throughout egress path at loading dock exit discharges - located on first floor.

F. Exit access door hardware is impeded by plastic wrapper on latch release mechanism - located in walk-in freezer of main kitchen area.

G. On 2nd and 3rd floor there are multiple doors that are equipped with dead bolts that require two motions of the hand to exit the room in case of emergency.

NFPA 101, 19.2.1, 7.1

This deficiency affected one of two smoke compartments.

~ Cross refer to Life Safety Code Standard - NFPA 101, Tag K 0038.

5) Based on observations, on August 9, 2016 at approximately 10:30 AM onward, the following deficiencies were noted:

There is no exit sign above exit access door from interior courtyard - located on first floor near linear accelerator room. Area of reference is located in new addition of hospital.

NFPA 101, 19.2.10.1, 18.2.10.1

This deficiency affected one of two smoke compartments.

~ Cross refer to Life Safety Code Standard - NFPA 101, Tag K 0047.

6) Based on observations, on August 9, 2016 at approximately 10:30 AM onward, the following deficiencies were noted:

A. The mobile MRI unit located outside next to the hospital was not connected to the hospital fire alarm system.

NFPA 70 and 72. NFPA 101: 9.6.1.4, 9.6.1.7,

~ Cross refer to Life Safety Code Standard - NFPA 101, Tag K 0052.

7) Based on observations, on August 9, 2016 at approximately 10:30 AM onward, the following deficiencies were noted:

Audible signals for supervision of sprinkler control valves can be silenced at main fire alarm control panel. Signal shall sound when valve(s) are closed.

NFPA 101, 9.7.2.1

This deficiency affected one of two smoke compartments.

~ Cross refer to Life Safety Code Standard - NFPA 101, Tag K 0061.

8) Based on observations, on August 9, 2016 at approximately 10:30 AM onward, the following deficiencies were noted:

There is lint and debris covering heat sensitive element of pendent sprinkler - located in nourishment room across from resident room 401.

NFPA 101, 19.7.6, 9.7.5, 4.6.12, NFPA 25, NFPA 13

This deficiency affected one of two smoke compartments.

~ Cross refer to Life Safety Code Standard - NFPA 101, Tag K 0062.

9) Based on observations, on August 9, 2016 at approximately 10:30 AM onward, the following deficiencies were noted:

A. Staff when questioned in the labor and delivery area did not know how to shut the HVAC system with the emergency shut down switch located at the nurse station.

NFPA 101: 19.1.1.3 Total Concept.

All health care facilities shall be designed, constructed, maintained, and operated to minimize the possibility of a fire emergency requiring the evacuation of occupants. Because the safety of health care occupants cannot be ensured adequately by dependence on evacuation of the
building, their protection from fire shall be provided by appropriate arrangement of facilities,
adequate staffing, and development of operating and maintenance procedures composed of the following:
(1) Design, construction, and compartmentation
(2) Provision for detection, alarm, and extinguishment
(3) Fire prevention and the planning, training, and drilling programs for the isolation of fire,
transfer of occupants to areas of refuge, or evacuation of the building

B. An access door for the smoke dampers # 1-17 and 1-16 on 1st floor in order to clean inspect and maintain the device.

NFPA 90A, 2-3.4.1

This deficiency affected one smoke compartments.

~ Cross refer to Life Safety Code Standard - NFPA 101, Tag K 0067.

10) Based on observations, on August 9, 2016 at approximately 10:30 AM onward, the following deficiencies were noted:

There is an exposed element, high temperature, portable space heater under desk in main kitchen office. The heating elements exceed 212 degrees Fahrenheit.

NFPA 101, 2000 ed, Chapter 19.7.8

This deficiency affected one of two smoke compartments.

~ Cross refer to Life Safety Code Standard - NFPA 101, Tag K 0070.

11) Based on observations, on August 9, 2016 at approximately 10:30 AM onward, the following deficiencies were noted:

A. The "Enovate" wall-mounted clerical pad did not self-close when opened and released by staff - the pad protrudes greater than six inches into required corridor egress path in the open position. The station is located on corridor wall beside room 426.

B. Furniture, wall-mounted television, wing chairs, and other impediments are stored in means of egress corridor near fourth floor elevator and clinical shift manager's office.

C. The corridor on 2nd and 3rd floor on the east end have storage in the corridor consisting of tables, chairs and other furniture that was obstructing the means of egress.

NFPA 101, 7.1.10
NFPA 101, 19.2.1, 7.1.10

This deficiency affected six of six smoke compartments.

~ Cross refer to Life Safety Code Standard - NFPA 101, Tag K 0072.

12) Based on observations, on August 9, 2016 at approximately 10:30 AM onward, the following deficiencies were noted:

A. There is oxygen cylinders stored less than twenty feet from combustible storage supplies - located in storage room across hall from resident room 400. The floor is not equipped with complete sprinkler system.

B. There is oxygen cylinders stored less than five feet from combustible storage supplies - located in PACU on the first floor, area of reference is fully sprinklered and constructed after NFPA 101, 1985 New Life Safety Code.

Note: In fully sprinklered facilities, oxygen is permitted to be stored not less than five feet from combustible storage.

C. The oxygen manifold system is not protected from extremes of weather - cylinders are exposed to blowing rain, sleet, snow, free-standing on concrete path in standing water, and direct sun exposure. Located near pain management entrance.

NFPA 101, 19.3.2.4, NFPA 99, 4-3.1.1.2

This deficiency affected one of two smoke compartments.

~ Cross refer to Life Safety Code Standard - NFPA 101, Tag K 0076.

13) Based on observations, on August 9, 2016 at approximately 10:30 AM onward, the following deficiencies were noted:

A. Duct penetration in smoke barrier is not equipped with smoke damper assembly with service access opening - item was observed above ceiling in "Team Member Lounge" on the fourth floor.

NFPA 101, 19.3.7.3, 8.3.5

This deficiency affected two of two smoke compartments.

~ Cross refer to Life Safety Code Standard - NFPA 101, Tag K 0104.

14) Based on observations, on August 9, 2016 at approximately 10:30 AM onward, the following deficiencies were noted:

A. The facility could not verify operation of low fuel level indicator signals at generator annunciator panel.

B. There is no remote emergency stop switch located outside of generator enclosures.

C. There is no weekly inspection documents for generator batteries - there were no documents to show specific gravity readings and electrolyte levels in accordance with manufacturer's specifications.

NFPA 101, 9.1.2, NFPA 110, Chapter 6, NFPA 99

This deficiency potentially affects all smoke compartments.

~ Cross refer to Life Safety Code Standard - NFPA 101, Tag K 0144.

15) Based on observations, on August 9, 2016 at approximately 10:30 AM onward, the following deficiencies were noted:

A. The knockout cover is missing from circuit breaker in distribution cubicle D1 - located in electrical room near emergency generators.

B. Lights at pain management means of egress is wired to the Critical Branch and not the Life Safety Branch of the Essential Electrical System.

C. Flexible metal conduit is not secured to fitting connection at junction box - located under warmer in serving area of first floor main kitchen.

D. There is no ground-fault protection of receptacles in dishwash area of main kitchen - the area contained wet floors at time of survey.

This deficiency affected one of two smoke compartments in areas containing smoke barriers.

~ Cross refer to Life Safety Code Standard - NFPA 101, Tag K 0147.