HospitalInspections.org

K211
Based on observation and interview, the facility did not ensure the path of egress had a safe path to a public way. This observed situation was not compliant with NFPA 101 (2012 edition), 7.7.1.1. 39.2.1.1 and 7.2.1.5.1.

FINDINGS INCLUDE:

1) On 01/31/2017 at 8:15 AM, observation revealed in the mechanical room, that the path of travel out of the exit was across snow, grass and dirt on the way to the public way. This was not a safe path to a public way. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Director of Environmental Services).
2) On 01/31.2017 at 8:45 AM, observation revealed in the mechanical room that the door to the exit required 2 motions to open the door. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Director of Environmental Services).


K321
Based on observation and interview, the facility did not provide a fire rated enclosure around a hazardous area or a sprinkler(s) in the room. This observed situation was not compliant with NFPA 101 (2012 edition), 39.3.2.1.

FINDINGS INCLUDE:

1. On 01/31/2017 at 8:30 AM, observation revealed on the 1st floor in mechanical room that contained fuel fired furnaces and water heaters, that there were no sprinklers and the space was not surrounded by a 3/4 hour fire rated door and door frame. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Director of Environmental Services).

Based on observation and interview, the facility did not have the proper construction type. The beams for the floor were missing the fireproofing. This is not in compliance with NFPA 101 (2012 edition) Table 19.1.6.1.

FINDING INCLUDE:

1. On 01/31/2017 at 1:10 PM, observation revealed on the 2nd floor, room 2179, that the fireproofing was missing on the structural beams. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Director).
2. On 01/31/2017 at 1:22 PM observation revealed on the 2nd floor storage room (near room 2179), that the fireproofing was missing on the structural beams. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Director).
3. On 2/1/2017 at 1:00 PM observation revealed that the Biohazard storage room in the 1956 building had a section of the ceiling made out of combustible (wood) material. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Director).

Based on observation and interview, the facility did have two rooms that were not normally occupied rooms that exited into the stair enclosure. This observed situation was not compliant with NFPA 101 (2012 edition), 7.1.3.2.1(9).

FINDINGS INCLUDE:

1. On 01/31/2017 at 4 PM, observation revealed on the 1st floor, at the bottom of stair C, that two rooms, a belt storage room and an old boiler room, are unoccupied and the exit doors open up onto stairs C. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W, (Facilities Director).

Based on observation and interview, the facility did not install a fire door that released with the fire alarm or local smoke detectors. This observed situation was not compliant with NFPA 101 (2012 ed.), 7.2.1.8.2.

FINDINGS INCLUDE:

1. On 01/31/2017 at 11:30 AM, observation revealed on the 1st floor that the fire shutter between the hospital and the medical office building (Dean Clinic) did not activate on the fire alarm and did not have local smoke detectors to activate the fire alarm or close the fire shutter. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W, (Facilities Director).

2. On 2/1/2017 at 11:05 AM, observation revealed on the 1st floor, that the smoke barrier doors into the food servery were held open by magnetic hold opens and was connected to the fire alarm, did not have local smoke detectors near the doors, and the adjacent spaces were not fully smoke detected. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W, (Facilities Director).

Based on observation and interview, the facility did not maintain the minimum width required for exit access. This observed situation was not compliant with NFPA 101 (2012 ed.), 19.2.3.4

FINDINGS INCLUDE:

1. On 01/30/2017 at 1:20 PM, observation revealed on the 3rd floor in room 336, that the exit access between the refrigerators and the column was 21 inches wide and is required to be 44 inches wide. This narrow passage is used to access a work area beyond the passage. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W, (Facilities Director).

Based on observation and interview, the facility did not have 2 remote exits from the 4th floor penthouse. The penthouse was used as a storage room and thereby creating a 4th floor story. This observed situation was not compliant with NFPA 101 (2012 edition), 19.2.4.1-19.2.4.3.

FINDINGS INCLUDE:

1. On 01/31/2017 at 1:45 PM, observation revealed on the 4th floor (Penthouse) that the entire floor was a large storage room. There is only one exit out of the space. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Director).

Based on observation and interview, the facility did not maintain the minimum exit signage indicating the correct path of egress. This observed situation was not compliant with NFPA 101 (2012 ed.), 7.10.2.

FINDINGS INCLUDE:

1. On 02/1/2017 at 1:17 PM, observation revealed on the 1st floor near elevator lobby B, that the exit sign did not point in the direction of egress. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W, (Facilities Director).
2. On 02/1/2017 at 1:57 PM, observation revealed in the corridor by room 1180A, that the exit sign was missing. An exit sign is required to provide direction to the exit, This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W, (Facilities Director).

Based on observation and interview, the facility did not maintain 2 hour fire rated walls as shown on the life safety plan. This observed situation was not compliant with NFPA 101 (2012 ed.), 19.3.1

FINDINGS INCLUDE:

1. On 01/30/2017 at 12:05 PM, observation revealed on the 3rd floor that the 2 hour rated smoke barrier wall was not properly constructed. A layer of drywall was missing where an old window was in room 345. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W, (Facilities Director).

Based on observation and interview, the facility did not enclose vertical openings between floors with a 1 hour fire-rated assembly. This observed situation was not compliant with NFPA 101 (2012 edition), 19.3.1

FINDINGS INCLUDE:

1. On 01/31/2017 at 1:27 PM, observation revealed on the 2nd floor shaft, that one layer of dry wall was missing near the flange of the duct (fire damper) going into the shaft approximately 2' X 3'. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Director).

Based on observation and interview, the facility did not enclose hazardous rooms with a smoke-tight room enclosure in a sprinkled smoke zone and door closers were missing. This observed situation was not compliant with NFPA 101 (2012 ed.), 19.3.2.1

FINDINGS INCLUDE:

1. On 01/30/2017 at 11:50 AM, observation revealed on the 3rd floor that the med room supply unit had become a hazardous storage area, with 3 shelving units of combustible supplies. The room did not have 1 hour rated walls, the door was not fire rated, and there was no closer on the door. The room was considered hazardous because it exceeded 100 sq ft and contained a quantity of stored combustible materials considered hazardous. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W, (Facilities Director).
2. On 1/30/2017 at 2:01 PM, observation revealed on the 2nd floor that room 214 was a 92 square foot room and contained a quantity of stored combustible materials considered hazardous. The door did not have a door closer on it. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W, (Facilities Director).
3. On 1/31/2017 at 10:20 AM, observation revealed on the 2nd floor that room 2146, OR equipment storage room, contained a quantity of stored combustible materials considered hazardous. The 1 hour wall enclosing the room as indicated on their life safety plan, had a vertical cast iron pipe running the length of the pipe, instead of penetrating the wall. This is not a 1 hour rated assembly. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W, (Facilities Director).
4. On 1/31/2017 at 2:28 PM, observation revealed on the 3rd floor, pharmacy,which contained stored combustible materials in quantities considered hazardous, and the life safety plan indicates a 1 hour wall around the pharmacy, the door was not 3/4 hour fire rated and did hot have a closer on it. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W, (Facilities Director).

Based on observation and interview the facility failed to install the fire alarm system in accordance with NFPA 101 (2012 edition) Sections 19.3.4.3.1 and 9.6, and NFPA 72 (2011 edition) Sections 18.4.

FINDING INCLUDE:

1. On 1/30/2017 at 10:36 AM, observation revealed that conference room 2346 did not have a strobe notification appliance for the fire alarm system. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W, (Facilities Director).
2. On 1/30/2017 at 2:25 PM, observation revealed that cardiac rehab room did not have full strobe coverage. The one strobe in the room could not be seen everywhere in the room. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W, (Facilities Director).
3. On 1/31/2017 at 2:00 PM, the US Cellar room (control room for cell phones) in the penthouse, had a fire alarm and a fire suppression system. It could not be verified if the fire alarm system was interconnected to the hospital fire alarm system. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W, (Facilities Director).

Based on observation and interviews, the facility did not provide the correct installation of the sprinkler system per NFPA 13 (2010 edition) and per NFPA 101 (2012 edition), 19.3.5.3.

FINDING INCLUDE:

1. On 01/30/2017 at 2:22 PM observation revealed on the 2nd floor in the Pulmonary Function Lab, that some of the ceiling tile was missing which slows the response time of the sprinklers. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W, (Facilities Director).
2. On 01/30/2017 at 2:45 PM observation revealed on the 2nd floor in room 2215, that the storage on the carts was 12 inches below the bottom of the sprinklers and not the 18 inches that is required. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W, (Facilities Director).
3. On 02/01/2017 at 9 AM, observation revealed that in stair D, at the bottom of the stairs, there was not full sprinkler coverage. One sprinkler was blocked by a bulkhead that was 24 inches down and 56 inches away from the sprinkler. The other sprinkler was 12.5 inches away and the obstruction was down 3.75 inches from the sprinkler. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W, (Facilities Director).
4. On 02/02/2017 at 11:30 AM, observation revealed that in Data room L215 on the lower level, there were ceiling tiles missing in the ceiling grid. This would cause delay in the activation of the sprinkler system. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W, (Facilities Director).
5. On 02/01/2017 at 1:15 PM, observation revealed that in room 1303, there was a sprinkler one inch away from the wall. The minimum distance away from the wall is 4 inches. This would cause delay in the activation of the sprinkler system. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W, (Facilities Director).
6. On 02/01/2017 at 2:30 PM, observation revealed that in room 1209, on the 1st floor, the sprinklers were closer than 6 feet apart. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W, (Facilities Director).

Based on observation and interview, the facility did not maintain corridor doors that latched. This observed situation was not compliant with NFPA 101 (2012 ed.), 19.3.6.3.5

FINDINGS INCLUDE:

1. On 01/30/2017 at 2:34 PM, observation revealed on the 2nd floor that the doors into the OR suite, from the corridor by Men's Locker room (Hallway 2213), did not latch. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W, (Facilities Director).

Based on observation and interview, the facility did not have smoke barrier walls constructed to 1/2 hour fire resistance rating. This observed situation was not compliant with NFPA 101 (2012 edition), 19.3.7.3

FINDINGS INCLUDE:

1. On 01/31/2017 at 9:30 AM, observation revealed on the 1st floor at the smoke barrier's corridor doors, corridor 1217, that the wall above the ceiling corridor was not constructed to meet the required fire rating assembly. There were gaps in the dry wall assembly, penetrations that were not fire rated and holes in the drywall. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Director).
2. On 2/1/2017 at 11:15 am observation revealed on the 1st floor, that the entire smoke barrier wall along the corridor/food servery wall had cracks and penetrations that were not properly sealed to maintain the 1 hour fire rating as shown on the life safety plan. Penetrations included 1/2 electrical conduits and two 2" pipes. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W, (Facilites Director).

Based on observation and interview, the facility did maintain the corridor as a supply or return air system. This observed situation was not compliant with NFPA 101 (2012 ed.), 9.2.1 and NFPA 90A.

FINDINGS INCLUDE:

1. On 01/30/2017 at 4 PM, observation revealed on the 2nd floor in the Day Surgery Waiting room 336, that the exhaust air from the construction zone was discharged into the corridor. Corridors can not be supply or return air plenum systems. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W, (Facilities Director).

Based on observation and staff interview, the facility exceed the 32 gallons capacity of trash or soiled linen containers within a 64 square foot area. This does not conform to NFPA 101 (2012 edition), 19.7.5.7.(2)

FINDINGS INCLUDE:

1. On 01/30/2017 at 3:14 PM, observation revealed on the 2nd floor in Operating Room #2, that two 18 gallon soiled linen containers and a 10 gallon trash container were next to each other and together they exceeded 32 gallons in a 64 square foot area. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Director).
2. On 2/1/2017 at 2:45 PM, observation revealed on the 1st floor in toilet room 1173T, that there was more than 32 gallons of soiled linen and trash containers in a 64 square foot area. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Director).

Based on observation and interview, the facility did not maintain the oxygen storage tank as required by NFPA 99 (2012 edition), 5.1.3.3.1.9 and NFPA 55, (2010 edition) 9.3.2.(8). This observed situation was not compliant with NFPA 101 (2012 edition), 19.3.2.4

FINDINGS INCLUDE:

1. On 01/30/2017 at 1:34 PM, observation revealed on the parking lot next to the oxygen storage tanks, that a vehicle was parked within 10 feet of the bulk oxygen tank system. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W, (Facilities Director ).

Based on observation and interviews, the facility did not provide the correct clearance in front of electrical panels and a ground fault interrupter (GFI) was not installed in a wet location. This observed situation was not compliant with NFPA 70 (2011 edition), 110-26 and 210.8(B)This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W, (Facilities Director).

FINDING INCLUDE:

1. On 1/31/2017 at 2:39 PM, observation revealed on the 1st floor in room 370, that access to the electrical panel was less than 3'-0" clearance. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W, (Facilities Director).
2. On 1/31/2017 at 3:32 PM in shower room of the medical/surgical unit, a microwave oven was plugged into a outlet that did not have a ground fault interrupter and the outlet was installed within 6 feet of the shower (a wet location). This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W, (Facilities Director).

Based on observation and interviews, the facility did not provide a remote annunciator panel for the emergency generator in a location readily observed by operating personnel. This observed situation was not compliant with NFPA 99 (2012 edition), 6.4.1.1.17.

FINDING INCLUDE:

1. On 2/1/2017 at 8:35 AM, observation revealed on the 1st floor maintenance shop that there was only an alarm for the generator and not a full annuciator panel with all the required alarms identified. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W, (Facilities Director).

Based on observation and interviews, the facility did not provide the correct identification or labeling of the emergency receptacles in the operating rooms per NAPA 99 (2012 edition), 6.4.2.2.6.2 (B).

FINDINGS INCLUDE:

1) On January 30, 2017 at 3 PM observation revealed on the 2nd floor in the 1976 vintage operating rooms, that only one of the receptacles in each of the operating room is indicated to be on the emergency power when in fact, all of the receptacles are on emergency power. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff NW, (Facilities Director).