HospitalInspections.org

Based on observation and interview, the facility did not maintain the Separation Barrier fire assemblies in accordance with NFPA 101 (2012 edition), 39.1.3.1.1, 6.1.14 and 39.1.3. This deficient practice had a potential to affect an undetermined number of outpatients, staff and visitors in the facility. The Business Occupancy (clinic facility) had a census of 80 outpatients on the day of survey.

Findings include:

1. On 10/24/2017 at 11:28 am, observation revealed in the Rehabilitation Clinic - Exercise Area 1917 that three metal pipes were penetrating the 2-hour fire barrier and were not properly fire protected. This deficient practice was confirmed by staff members G and GG at the time of discovery.

2. On 10/24/2017 at 11:46 am, observation revealed in the Clinic - Work Room 1804 the door in the 1-hour fire barrier assembly was not labeled and did not have an automatic closer. This deficient practice was confirmed by staff members G and GG at the time of discovery.

Based on observation and staff interview, the facility did not maintain the fire rated roof assembly and structural members in accordance with NFPA 101 (2012 edition), 19.1.6.1. This deficient practice could affect an undetermined number of patients, staff and visitors in the facility. The facility had a census of 8 on the day of survey.

Findings include:

1. On 10/24/2017 at 9:41 am, observation of a steel clamp attached to a structural beam above the ceiling in Housekeeping Room 2107 revealed a section of missing fire protection 5 inches by 3 inches. This deficient practice was confirmed by staff members D and GG at the time of discovery.

2. On 10/24/2017 at 10:03 am, observation of a steel clamp attached to a steel beam above the ceiling in Obstetrical Clean Supply Room 2402 revealed a section of missing fire protection 4 inches by 4 inches. This deficient practice was confirmed by staff members D & GG at the time of discovery.

3. On 10/24/2017 at 10:28 am, observation of 9 steel clamps attached to numerous steel beams above the ceiling in the Cancer Center Waiting Room 2802 revealed multiple sections of missing fire protection in various sizes from 3 inches to 6 inches by 2 inches to 8 inches. These deficient practices were confirmed by staff members D & GG at the time of discovery.

4. On 10/24/2017 at 10:36 am, observation of a steel clamp attached to steel beam above ceiling in Exam Room 2814 revealed a section of missing fire protection 3 inches by 3 inches. This deficient practice was confirmed by staff members D & GG at the time of discovery.

5. On 10/24/2017 at 10:39 am, observation of 2 steel clamps attached to steel beam above ceiling in the Exam Room 2815 revealed two sections of missing fire protection 4 inches by 3 inches. These deficient practices were confirmed by staff members D & GG at the time of discovery.

6. On 10/24/2017 at 10:51 am, observation of 2 steel clamps attached to steel beam above ceiling in the Soiled Utility Room 2709 revealed two sections of missing fire protection 3 inches by 4 inches. These deficient practices were confirmed by staff members D & GG at the time of discovery.

7. On 10/24/2017 at 11:56 am, observation of numerous steel clamps attached to numerous steel beams above ceiling in the Outpatient Rehab Clinic Waiting Room 1801 B revealed several sections of missing fire protection 4 inches by 4 inches. This deficient practice was confirmed by staff members G & GG at the time of discovery.

8. On 10/24/2017 at 1:20 pm, observation of several steel clamps attached to steel beams revealed missing fire protection located in the Boiler Room and Loading Dock Room. These deficient practices were confirmed by staff members G, E & GG at the time of discovery.

9. On 10/24/2017 at 2:00 pm, observation of several steel clamps attached to the steel beams above ceiling in the Dietary Staff Locker Alcove and Kitchen Production Area 1510 revealed multiple sections of missing fire protection 4 inches by 4 inches. These deficient practices were confirmed by staff members G, E & GG at the time of discovery.

10. On 10/24/2017 at 3:45 pm, observation of 2 steel clamps attached to steel beams above ceiling in the Admitting Suite Area by the Main Entrance Lobby revealed two sections of missing fire protection 3 inches by 4 inches. These deficient practices were confirmed by staff members D, E & GG at the time of discovery.

11. On 10/24/2017 at 3:59 pm, observation of a steel clamp attached to steel beam above ceiling in the Surgery Pre & Post-Op Recovery - Soiled Utility Room 1116 revealed a section of missing fire protection 4 inches by 3 inches. This deficient practice was confirmed by staff members D, E & GG at the time of discovery.

12. On 10/24/2017 at 4:02 pm, observation of a steel clamp attached to steel beam above ceiling in the Surgery Pre & Post-Op Recovery - Clean Supply Room 1114 revealed a section of missing fire protection 3 inches by 4 inches. This deficient practice was confirmed by staff members D, E & GG at the time of discovery.

Based on record review and staff interview, the facility did not have the proper completed record documents from monthly and annual testing of emergency lighting system in accordance with NFPA 101 (2012 edition), sections 19.2.9.1 and 7.9. This deficient practice had a potential to affect an undetermined number of patients, staff and visitors in the facility. The facility had a census of 8 on the day of survey.

Findings include:

On 10/23/2017 at 3:31 pm, record review revealed the reviewer signature and date were missing from the Monthly and Annual testing records. This deficient practice was confirmed by staff members E & GG at the time of discovery.

Based on observation and staff interview, the facility did not provide adequate exit and directional signage to the exit or exit discharge per NFPA 101 (2012 edition), section 19.2.10.1 and 7.10. This deficient practice had a potential to affect an undetermined number of patients, staff and visitors in the facility. The facility had a census of 8 on the day of survey.

Findings include:

1. On 10/24/2017 at 1:22 pm, observation revealed a missing exit sign while egressing from Boiler Room into Loading Dock Area. This deficient practice was confirmed by staff members D, E and GG at the time of discovery.

2. On 10/24/2017 at 3:05 pm, observation revealed a missing exit sign in the Exit Passageway on the 1st Floor between the Radiology and Emergency Departments, coming down out of Exit Stairs from 2nd Floor, serving Medical and Surgical Inpatient Units. The exit sign was pointing towards Radiology and Emergency Departments but could not be seen from the Exit Stairs. This deficient practice was confirmed by staff members D, E and GG at the time of discovery.

Based on observation and staff interview, the facility did not maintain the hazardous areas with proper smoke resistant partitions and doors per NFPA 101 (2012 edition), section 8.4, or 1-hour fire resistance rated wall assembly enclosures or 3/4-hour fire rated door assemblies in accordance with 19.3.2.1 for areas in the chart (a-g). This deficient practice had a potential to affect an undetermined number of patients, staff and visitors in the facility. The facility had a census of 8 on the day of survey.

Findings include:

1. On 10/24/2017 at 9:00 am, observation revealed a 1-hour fire rated wall assembly in Shell Space 2380 not built correctly. The bottom sill of the wall was missing fire sealant and the drywall screws at the bottom of wall were not fully mudded over. This deficient practice was confirmed by staff members D and GG at the time of discovery.

2. On 10/24/2017 at 9:02 am, observation revealed a 1-hour fire rated wall assembly in Shell Space 2380 had a vertical opening greater than 8'-0" by 1/2" with exposed insulation and an unfinished vertical corner edge near door greater than 10'-0" in length. This deficient practice was confirmed by staff members D and GG at the time of discovery.

3. On 10/24/2017 at 9:05 am, observation revealed a 1-hour fire rated wall above the ceiling in Corridor 2412 outside the Shell Space had a 1-1/2 inch diameter pipe penetration that was not properly fire rated. This deficient practice was confirmed by staff members D and GG at the time of discovery.

4. On 10/24/2017 at 10:54 am, observation revealed in the Clean Supply Room 2707 a 1-hour fire rated wall assembly had two 2 inch diameter holes that were not properly fire rated. This deficient practice was confirmed by staff members D and GG at the time of discovery.

5. On 10/24/2017 at 12:01 pm, observation revealed in the Clinics Waiting Area 1801 B a 1-hour fire rated wall assembly was penetrated by a diagonal 8" x 8" steel beam that was not properly fire rated. This deficient practice was confirmed by staff members G and GG at the time of discovery.

6. On 10/24/2017 at 1:24 pm, observation revealed in the Maintenance Room 1714 a 1-hour fire rated wall assembly was penetrated by three 3/4 inch sleeves that were not properly fire rated. This deficient practice was confirmed by staff members E, G and GG at the time of discovery.

7. On 10/24/2017 at 1:50 pm, observation revealed in Clinical Laboratory Room 1602 a 1-hour fire rated enclosure contained a door and frame assembly that was not labeled. This deficient practice was confirmed by staff members E, G and GG at the time of discovery.

8. On 10/24/2017 at 1:56 pm, observation revealed in Kitchen Room 1506 that the door in the 1-hour fire rated wall assembly was not labeled. This deficient practice was confirmed by staff members E, G and GG at the time of discovery.

9. On 10/24/2017 at 2:08 pm, observation revealed in the Food Service - Housekeeping Closet 1507 that the door in the 1-hour fire rated wall assembly was not labeled. This deficient practice was confirmed by staff members E, G and GG at the time of discovery.

10. On 10/24/2017 at 2:14 pm, observation revealed in the Food Service Office 1521 that the 1-hour fire rated wall assembly above the ceiling was not continuous to the deck above and did not have the screws taped and mudded. This deficient practice was confirmed by staff members E, G and GG at the time of discovery.

11. On 10/24/2017 at 4:08 pm, observation revealed in the Surgery - Soiled Utility Room a 1-hour fire rated wall assembly had a 1/2 inch diameter metal conduit penetration that was not properly fire rated. This deficient practice was confirmed by staff members D, E and GG at the time of discovery.

Based on observation and staff interview, the facility did not have a properly placed fire detector at the ceiling within the hazardous space per NFPA 72 (2010 edition), National Fire Alarm Code, section 17.6.3.1.3.1 and NFPA 101 (2012 edition) 19.3.4.1 and 9.6. This deficient practice had a potential to affect an undetermined number of patients, staff and visitors in the facility. The facility had a census of 8 on the day of survey.

Findings include:

On 10/24/2017 at 9:01 am, observation revealed a smoke detector had a 4'-0" vertical distance from the detector to the top of the ceiling. This deficient practice was confirmed by staff members D and GG at the time of discovery.

Based on record review and interview, the facility failed to inspect the automatic fire alarm system per NFPA 101 (2012 edition), Sections 19.3.4.1, 9.6 as well as NFPA 72 (2010 edition) Figure 14.6.2.4, Table 14.3.1 (3)(d), and Table 14.4.5 (6)(a)(2-4). This deficient practice had a potential to affect an undetermined number of patients, staff and visitors in the facility. The facility had a census of 8 on the day of survey.

FINDINGS INCLUDE:

1. On 10/23/2017 at 12:30 pm, record review revealed the Fire Alarm System, inspection records did not record Semi-Annual inspections for the Sealed lead-acid batteries, Supervising station transmitters and receivers, and Testing Frequencies for lead-acid batteries. This deficient practice was confirmed by staff members E and GG at the time of discovery.

2. On 10/23/2017 at 12:45 pm, record review revealed the Fire Alarm System inspection records did not contain the annual recordings of the supervisory power source. This deficient practice was confirmed by staff members E and GG at the time of discovery.

Based on record review and interview, the facility failed to inspect the automatic fire alarm system per NFPA 101 (2012 edition), Sections 39.3.4.1, 9.6 as well as NFPA 72 (2010 edition) Figure 14.6.2.4, Table 14.3.1 (3)(d), and Table 14.4.5 (6)(a)(2-4). This deficient practice had a potential to affect an undetermined number of patients, staff and visitors in the facility. The facility had a census of 90 outpatients on the day of survey.

FINDINGS INCLUDE:

1. On 10/23/2017 at 12:30 pm, record review revealed the Fire Alarm System, inspection records did not record Semi-Annual inspections for the Sealed lead-acid batteries, Supervising station transmitters and receivers, and Testing Frequencies for lead-acid batteries. This deficient practice was confirmed by staff members E and GG at the time of discovery.

2. On 10/23/2017 at 12:45 pm, record review revealed the Fire Alarm System inspection records did not contain the annual recordings of the supervisory power source. This deficient practice was confirmed by staff members E and GG at the time of discovery.

Based on observation, record review and interview, the facility did not maintain the sprinkler system in accordance with NFPA 25 (2011 edn) NFPA 101 LSC (2012 edition), sections 19.3.5.3 and 9.7. This deficient practice had the potential to affect an undetermined number of patients, staff and visitors in the facility. The facility had a census of 8 on the day of survey.

Findings include:

1. On 10/24/2017 at 3:31 pm, observation revealed multiple sprinklers and escutcheon rings in the Ambulance Garage were rusted. This deficient practice was confirmed by staff members D, E and GG at the time of discovery.

2. On 10/24/2017 at 3:33 pm, observation revealed multiple ceiling openings of 24 inches by 2 inches where the over-head garage doors were supported by steel angle supports were within close proximity of the sprinklers. This deficient practice was confirmed by staff members D, E and GG at the time of discovery.

3. On 10/23/2017 at 11:30 am, during record review of Life Safety Management Plan Documents, within Procedure: (B) Fire Pump, on Page 1 of 3. This facility doesnot have a fire pump, therefore this Policy and Procedure statement should not be in this document. This deficient practice was confirmed by staff members E and GG at the time of discovery.

Based on observation, record review and interview, the facility did not maintain the sprinkler system in accordance with NFPA 25 (2011 edn) NFPA 101 LSC (2012 edition), sections 39.1.3.1.1, 6.1.14 and 9.7.1.1(1) for medical clinics within business occupancies. This deficient practice had the potential to affect an undetermined number of patients, staff and visitors in the facility. The facility had a census of 8 on the day of survey.

Findings include:

On 10/23/2017 at 11:30 am, during record review of Life Safety Management Plan Documents, within Procedure: (B) Fire Pump, on Page 1 of 3. This facility does not have a fire pump, therefore this Policy and Procedure statement should not be in this document. This deficient practice was confirmed by staff members E and GG at the time of discovery.

Based on observation and interview, the facility did not maintain the smoke barriers to the required 1/2-hour fire resistance with proper fire/smoke resisting partitions and doors per NFPA 101 (2012 edition), sections 19.3.7.3, 8.5, 8.6.7.1(1). This deficient practice had a potential to affect an undetermined number of patients, staff and visitors in the facility. The facility had a census of 8 on the day of survey.

Findings include:

1. On 10/24/2017 at 9:29 am, observation revealed in the corridor outside of office 2338 a 1/2 inch diameter data pipe penetration through the smoke barrier wall was not properly fire rated. This deficient practice was confirmed by staff members D and GG at the time of discovery.

2. On 10/24/2017 at 2:25 pm, observation revealed in the Food Service Serving Area 1503 a 6" x 8" hole above ceiling in the 1/2-hour fire rated smoke barrier wall. This deficient practice was confirmed by staff members E, G and GG at the time of discovery.

Based on observation and interview, the facility did not maintain the Electrical Systems requirements for electrical panels by having properly identified, labeled breaker switches and properly positioned in accordance with NFPA 99 (2012 edition), Chapter 6. This deficient practice had a potential to affect an undetermined number of patients, staff and visitors in the facility. The facility had a census of 8 on the day of survey.

Findings include:

1. On 10/24/2017 at 1:15 pm, observation revealed in the Main Electrical Vault Room of the Central Utility Plant that breaker #16 was in an 'ON' position when the ID label revealed it was a spare. This deficient practice was confirmed by staff members D, E and GG at the time of discovery.

2. On 10/24/2017 at 1:18 pm, observation revealed in the Main Electrical Room of the Central Utility Plant in electrical panels HLSH/DP1A, HCH/DP1A and HLSL/DP1A that several breakers were in the ON position when the ID labels revealed they were spares. This deficient practice was confirmed by staff members D, E and GG at the time of discovery.