HospitalInspections.org

The facility did not ensure that stairways, elevator shafts, light and ventilation shafts, chutes and other vertical openings between floors were enclosed with construction having a fire resistance rating of at least one hour as required by the referenced LSC.

On 09/07/10 at 02:20 PM, the surveyor, while accompanied by the facility Fire Marshal observed that the newly-installed pneumatic tubing located through the ceiling in the Pharmacy contained voids & penetrations that were not protected with materials having a 30-minute fire resistance rating; i.e. blue, non metallic piping installed for delivery system & copper, insulated pipes routed up through concrete deck.

1. The facility did not ensure that smoke barriers were constructed to provide at least a one half hour fire resistance rating in accordance with 8.3 as required by the LSC and referenced facility provided fire protection plans.

a. On 09/07/10 - 09/09/10 at 09:30 AM and at times throughout the survey day, The surveyor along with the Facility Project Manager observed that the smoke barrier walls above the suspended ceiling assembly for the corridor smoke doors and adjacent smoke barriers walls in Buildings 300 and 400 had voids around penetrations used for the passage of wires, conduit, etc. that were not sealed with materials having at least a half hour fire resistance rating as required.

b. On 09/07/10 at 10:00 AM, the surveyor, while accompanied by the facility Fire Marshal observed that the smoke barrier that runs through the Operating Room suite had penetrations running through it that were not protected with materials having a 30-minute, fire resistance rating; i.e. voids and penetrations above ceiling around flexible, metal conduits running into recovery area, white & yellow cables running through wall above double doors in corridor.

c. On 09/07/10 - 09/09/10 at 09:30 AM and at times throughout the survey day, The surveyor along with the Facility Project Manager observed that the fire barrier above the suspended ceiling assembly for the building separation fire doors and adjacent fire barriers walls in Buildings 100, 400 and 500 had voids around penetrations used for the passage of wires, conduit, etc. that were not sealed with materials having at least a ? hour half hour fire resistance rating as required.

d. On 09/07/10 at 09:00 AM, the surveyor, while accompanied by the facility Fire Marshal observed that the area above the suspended ceiling, above the doors in the corridor that separates 3.4 & 3.3 (Operating Rooms) contained piping that ran through the fire barrier and not protected with materials having a ? -hour fire resistance rating; i.e. copper piping routed through for med gas.

The facility did not assure that the required automatic sprinkler system has valves supervised so that at least a local alarm will sound when the valves are closed as required by 19.3.5.1, 9.7.2.1, NFPA 72, & NFPA 25

On 09/07/10 at 11:35 AM, the surveyor, while accompanied by the facility Fire Marshal observed that the sprinkler heads that were installed within the walk-in refrigerator & freezer in the dietary department were equipped with control valves that are not electrically supervised; installer used ball-style valves that do not sound a local alarm when closed.

The facility did not ensure that the design, installation and use of its commercial cooking equipment was in accordance with NFPA 96: Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations as required by the referenced LSC.

On 09/07/10 at 11:55 AM, the surveyor, while accompanied by the facility Fire Marshal observed that the wheeled, natural-gas fired appliances located in the cooking line were not equipped with a system that would prevent damage to the flexible fuel lines; i.e. tether/cables installed but not being used on any of the gas equipment with wheels under the hood.

The facility did not ensure that Draperies, curtains, including cubicle curtains, and other loosely hanging fabrics and films serving as furnishings or decorations in health care occupancies are in accordance with provisions of 10.3.1 and NFPA 13, Standards for the Installation of Sprinkler Systems or NFPA 701.

On 09/07/10 at 01:45 PM the surveyor was not provided with documentation from the facility Fire Marshal, to indicate that any of curtains located throughout the patient care rooms & floors were constructed or treated to be flame resistant as required; i.e. No documentation & labels on curtains severely faded as not legible.

The facility did not ensure that solid linen or trash collection receptacles do not exceed 32 gallons in capacity and Mobile soiled linen or trash collection receptacles with capacities greater than 32 gallons are located in a room protected as a hazardous area when not attended as required by the referenced LSC.

On 09/07/10 at 10:45 PM, the surveyor, while accompanied by the facility Fire Marshal observed that 2, large, Rubbermaid brand collection containers had been left unattended and not in use in the exit-access corridor outside of the Operating Rooms in 3.000; i.e. containers not left within 1-hour enclosure.

The facility did not ensure that patient care electrical devices in-patient areas were being inspected as required in NFPA 99 " Health Care Facilities " .

On 08/09/10 at 11:50 AM, the surveyor while accompanied by the Behavioral Health Unit Director and the Interim, Director of Engineering observed that 7 (seven) of 16 (sixteen) electric, patient beds lacked current, preventive maintenance stickers and the facility failed to provide documentation that all electric, patient beds located throughout the Behavioral Health Unit (Pond 4) are inspected as required in NFPA 99, Section 7-5.1.3, 7-5.2.2.1 and 7-6.2.1.2 and as part of the facilities preventive maintenance program; i.e. maintenance labels either missing or expired on patient beds in unit.

The facility did not ensure that stairways, elevator shafts, light and ventilation shafts, chutes and other vertical openings between floors were enclosed with construction having a fire resistance rating of at least one hour as required by the referenced LSC.

On 09/07/10 at 02:20 PM, the surveyor, while accompanied by the facility Fire Marshal observed that the newly-installed pneumatic tubing located through the ceiling in the Pharmacy contained voids & penetrations that were not protected with materials having a 30-minute fire resistance rating; i.e. blue, non metallic piping installed for delivery system & copper, insulated pipes routed up through concrete deck.

1. The facility did not ensure that smoke barriers were constructed to provide at least a one half hour fire resistance rating in accordance with 8.3 as required by the LSC and referenced facility provided fire protection plans.

a. On 09/07/10 - 09/09/10 at 09:30 AM and at times throughout the survey day, The surveyor along with the Facility Project Manager observed that the smoke barrier walls above the suspended ceiling assembly for the corridor smoke doors and adjacent smoke barriers walls in Buildings 300 and 400 had voids around penetrations used for the passage of wires, conduit, etc. that were not sealed with materials having at least a half hour fire resistance rating as required.

b. On 09/07/10 at 10:00 AM, the surveyor, while accompanied by the facility Fire Marshal observed that the smoke barrier that runs through the Operating Room suite had penetrations running through it that were not protected with materials having a 30-minute, fire resistance rating; i.e. voids and penetrations above ceiling around flexible, metal conduits running into recovery area, white & yellow cables running through wall above double doors in corridor.

c. On 09/07/10 - 09/09/10 at 09:30 AM and at times throughout the survey day, The surveyor along with the Facility Project Manager observed that the fire barrier above the suspended ceiling assembly for the building separation fire doors and adjacent fire barriers walls in Buildings 100, 400 and 500 had voids around penetrations used for the passage of wires, conduit, etc. that were not sealed with materials having at least a ? hour half hour fire resistance rating as required.

d. On 09/07/10 at 09:00 AM, the surveyor, while accompanied by the facility Fire Marshal observed that the area above the suspended ceiling, above the doors in the corridor that separates 3.4 & 3.3 (Operating Rooms) contained piping that ran through the fire barrier and not protected with materials having a ? -hour fire resistance rating; i.e. copper piping routed through for med gas.

The facility did not assure that the required automatic sprinkler system has valves supervised so that at least a local alarm will sound when the valves are closed as required by 19.3.5.1, 9.7.2.1, NFPA 72, & NFPA 25

On 09/07/10 at 11:35 AM, the surveyor, while accompanied by the facility Fire Marshal observed that the sprinkler heads that were installed within the walk-in refrigerator & freezer in the dietary department were equipped with control valves that are not electrically supervised; installer used ball-style valves that do not sound a local alarm when closed.

The facility did not ensure that the design, installation and use of its commercial cooking equipment was in accordance with NFPA 96: Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations as required by the referenced LSC.

On 09/07/10 at 11:55 AM, the surveyor, while accompanied by the facility Fire Marshal observed that the wheeled, natural-gas fired appliances located in the cooking line were not equipped with a system that would prevent damage to the flexible fuel lines; i.e. tether/cables installed but not being used on any of the gas equipment with wheels under the hood.

The facility did not ensure that Draperies, curtains, including cubicle curtains, and other loosely hanging fabrics and films serving as furnishings or decorations in health care occupancies are in accordance with provisions of 10.3.1 and NFPA 13, Standards for the Installation of Sprinkler Systems or NFPA 701.

On 09/07/10 at 01:45 PM the surveyor was not provided with documentation from the facility Fire Marshal, to indicate that any of curtains located throughout the patient care rooms & floors were constructed or treated to be flame resistant as required; i.e. No documentation & labels on curtains severely faded as not legible.

The facility did not ensure that solid linen or trash collection receptacles do not exceed 32 gallons in capacity and Mobile soiled linen or trash collection receptacles with capacities greater than 32 gallons are located in a room protected as a hazardous area when not attended as required by the referenced LSC.

On 09/07/10 at 10:45 PM, the surveyor, while accompanied by the facility Fire Marshal observed that 2, large, Rubbermaid brand collection containers had been left unattended and not in use in the exit-access corridor outside of the Operating Rooms in 3.000; i.e. containers not left within 1-hour enclosure.

The facility did not ensure that patient care electrical devices in-patient areas were being inspected as required in NFPA 99 " Health Care Facilities " .

On 08/09/10 at 11:50 AM, the surveyor while accompanied by the Behavioral Health Unit Director and the Interim, Director of Engineering observed that 7 (seven) of 16 (sixteen) electric, patient beds lacked current, preventive maintenance stickers and the facility failed to provide documentation that all electric, patient beds located throughout the Behavioral Health Unit (Pond 4) are inspected as required in NFPA 99, Section 7-5.1.3, 7-5.2.2.1 and 7-6.2.1.2 and as part of the facilities preventive maintenance program; i.e. maintenance labels either missing or expired on patient beds in unit.