HospitalInspections.org

Based on observation during the survey walk-through while accompanied by facility representatives, not all exits are enclosed with construction having a fire resistance rating to comply with 19.3.1.1 and 8.2.5.2 and 7.1.3.2. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the building.

Findings include:

A. On 12/09/13 at 2:45 PM Wing C Stair E The distance between guardrails was observed to be in excess of 4" to comply with subpart (3) to 7.2.2.4.6 and 19.2.2.3. This condition was observed in multiple exit stairs. Example locations of Exit stair enclosures at which this condition was observed include:

1. Exit Stair C "Center Building"

2. Exit Stair B

3. Exit Stair K

Based on observation during the surveyor walk through while accompanied by the facility representatives, the facility failed to provide a fire alarm system with components, devices or equipment installed to comply with NFPA 72. This deficieint practice would affect patients, visitors and staff within A Wing and C Wing, from safely progressing to an adjacent fire compartment during a fire/smoke event.

Findings include:

A. Corrected 08/19/2014.

B. On 12/11/13 at 2:40PM Wing D, first floor Atrium, by direct observation from a single location more than two strobe annunciators are visible which are not synchronized to comply with NFPA 72 1999 Ed. 4-4.4.2.3.

A. Based on direct observation the afternoon of 12/10/13 while in the company of the manager of facilities operations, the safety officer, the chief engineer and the lead electrician the surveyors find the facility grease duct installation for the cafeteria grill is not installed in compliance with NFPA 96, 1998:

C Wing 2nd Floor:

1. The installation is provided with a damper as the duct leaves the shaft on the second floor as prohibited by NFPA 96, 6-1.

2. Access to the above damper is by way of a non-compliant access door. NFPA 96, 4-3.4.4.

3. The duct is constructed with bolted flanges and not seamless weld as required by NFPA 96, 4-5.2.1. there is evidence of leakage at these flanged joints.

4. A continuous shaft enclosure from the hood to the exterior is not provided. NFPA 96, 4-7.1 By direct observation the duct exits the shaft above the ceiling of Nourishment Room (2C184) across the room exposed through the corridor wall then up through the floor above what looks to be a shaft enclosure. The duct as it enters the shaft is not sealed at this point leaving the shaft open to second floor.



31586


B. Corrected 08/19/2014.
C. Corrected 08/19/2014.
D. Corrected 08/19/2014.

Based on observations during the survey walk- through, while accompanied by the facility representative, the facility failed to maintain the means of egress corridors free from obstructions to comply with 7.1.10. This condition could affect patients, visitors and staff from gaining access to an exit in a timely manner during a fire/smoke event.

Findings include:

A. During the morning and afternoon of 12/10/13, 12/11/13 and 12/12/13 means of egress corridors were observed to be used as storage for wheelchairs, computers-on wheels, IV stands, carts and chairs. The length of egress corridors were reduced to half their required width which does not comply with 19.2.1 and 7/1/10. Example locations observed:
1. Wing A second through fourth floors
2. Wing C second through fourth floors
3. Wing D corridor adjacent to the Operating Room suite.

B. 1. Corrected 08/19/2014.





31586


C. Corrected 08/19/2014.

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

A. Based on direct observation the morning of 12/10/13 while in the company of the manager of facilities operations, the chief engineer and the lead electrician the surveyor finds that the identified emergency electrical panels are not identified as life safety, critical or equipment and the they contain a mixture of circuits all three branches of the essential electrical system in non compliance with NFPA 70, 1999, 517-32, 33 & 34, NFPA 99, 1999, 3-4.2.2.2 & 4-4.2.2.3. This condition exists throughout the A Wing on all floors.


1. Wing A, 4th floor: