HospitalInspections.org

.

Based on observation, the facility failed to maintain a horizontal exit per the requirements of:

2012 NFPA 101, 19.2.2.5, 7.2.4.3.1, and 8.3.5.1

This deficiency affects 2 compartments.

Findings include:

During a tour of the facility, the surveyor observed an unsealed penetration of a 3/4" conduit used as a chase for two blue cables in the two hour fire barrier above the ceiling over the fire barrier cross corridor doors between the 1st Floor Main Elevator Lobby and the Rear Exit Corridor.

A member of the maintenance staff was present when this deficiency was identified.

.

.

Based on observation, the facility failed to maintain the clear unobstructed corridor width per the requirements of:

2012 NFPA 101, 19.2.3.4 (4) (a)

This deficiency affects the classroom in the basement.

Findings include:

During a tour of the facility, the surveyor observed six copy machines taking up space on both sides of the means of egress corridor for the basement classroom side exit. These items reduced the clear unobstructed corridor width to approximately 24 inches.

A member of the maintenance staff was present when this deficiency was identified.

.

.

Based on observation, the facility failed to provide continuous illumination of the exit signage per the requirements of:

2012 NFPA 101, 19.2.10.1, and 7.10.5.2.1

This deficiency affects 1 of 2 exit signs in the Admin Executive Suite corridor on the first floor.

Findings include:

During a tour of the facility, the surveyor observed the exit sign at the exit door from the Admin Executive Suite corridor near the Chief Financial Officers office was not illuminated.

A member of the maintenance staff was present when the deficiency was identified.

.

.

Based on observation, the facility failed to provide an approved method to ensure appliances that are protected under the hood, if they are moved, they are returned to the approved design location per the requirements of:

2012 NFPA 101, 19.3.2.5.1, and 9.2.3
2011 NFPA 96, 12.1.2.2, 12.1.2.3, and 12.1.2.3.1

This deficiency affects the Kitchen.

Findings include:

During a tour of the facility, the surveyor observed that the facility failed to provide an approved method to ensure appliances (two cooktops and two deep fryers) that are protected under the hood, if they are moved, they are returned to the approved design location.

A member of maintenance staff was present when this deficiency was identified.

.

.

Based on observation, the facility failed to store Alcohol-Based Hand-Rub (ABHR) solution per the requirements of:

2012 NFPA 101, 19.3.2.6 (7)

This deficiency affects the Basement Central Supply Room.

Findings include:

During a tour of the facility, the surveyor observed nine gallons of ABHR solution stored in the Basement Central Supply Room (one smoke compartment) and did not meet the requirements of NFPA 30 (Flammable and Combustible Liquids Code).

A member of maintenance staff was present when this deficiency was identified.

.

.

Based on observation and review of documentation, the facility failed to maintain the automatic sprinkler system per requirements of:

2012 NFPA 101, 19.3.5.1, and 9.7.5
2011 NFPA 25, 5.3.1.1.1.3

This deficiency affects all 1996 fast-response sprinklers located in Building 0102.

Findings include:

During a tour of the facility, the facility failed to provide documentation that the 1996 fast-response sprinklers found randomly throughout this building had been replaced or a representative sample tested within 20 years of installation

A member of the maintenance staff was present when this deficiency was identified.

.

.

Based on observation and review of documentation, the facility failed to maintain the automatic sprinkler system per requirements of:

2012 NFPA 101, 19.3.5.1, and 9.7.5
2011 NFPA 25, 5.3.1.1.1.3, and 13.7.1 (5)

This deficiency affects the automatic sprinkler system located in Building 0202.

Findings include:

During a tour of the facility, the surveyor observed the following:

1. The facility failed to provide documentation that the 1996 fast-response sprinklers found randomly throughout the building had been replaced or a representative sample tested within 20 years of installation

2. The Fire Department Connection (FDC) did not have an identification sign in place

A member of the maintenance staff was present when this deficiency was identified.

.

.

Based on observation, the facility failed to prohibit a portable space heating device per the requirements of:

2012 NFPA 101, 19.7.8

This deficiency affects 1 Basement IT Department Room.

Findings include:

During a tour of the facility, the surveyor observed a portable space heating device under a wood desk, next to stored cardboard boxes in the Basement IT Department. This was not located in a patient sleeping smoke compartment. The facility was unable to provide documentation that the heating element did not exceeding 212 degrees.

A member of the maintenance staff was present when this deficiency was identified.

.

.

Based on review of documentation, the facility failed to maintain the testing of both of the emergency generators per the requirements of:

2012 NFPA 99, 6.5.4.1.1.2, 6.5.4.1.3, 6.5.4.2, 6.4.4.1.1.3, and 6.4.4.1.3
2010 NFPA 110, 8.3.7.1

This deficiency affects 2 of 2 generators.

Findings include:

During a tour of the facility, the facility failed to provide documentation of performing monthly electrolyte specific gravity testing OR conductance testing on both of the facility's emergency generator's batteries for the past 12 months.

A member of the maintenance staff was present when this deficiency was identified.

.

.

Based on review of documentation, the facility failed to maintain the testing of both of the emergency generators per the requirements of:

2012 NFPA 99, 6.5.4.1.1.2, 6.5.4.1.3, 6.5.4.2, 6.4.4.1.1.3, and 6.4.4.1.3
2010 NFPA 110, 8.3.7.1

This deficiency affects 2 of 2 generators.

Findings include:

During a tour of the facility, the facility failed to provide documentation of performing monthly electrolyte specific gravity testing OR conductance testing on both of the facility's emergency generator's batteries for the past 12 months.

A member of the maintenance staff was present when this deficiency was identified.

.

Based on observation, the facility failed to maintain the oxygen cylinders per the requirements of:

2012 NFPA 99, 11.6.5.4 (1)

This deficiency affects both outside storage areas.

Findings include:

During a tour of the facility, the surveyor observed oxygen cylinders ( E-type and CYL250 ) setting directly on the ground in the following areas.

1. Outside of the fire pump room
2. Inside the fence of the liquid oxygen tank

A member of the maintenance staff was present when this deficiency was identified.