HospitalInspections.org

Based on observations during the survey walk of Building 4 on the morning of 6/06/2012, with the Engineering Team Leader and two technicians on the engineering staff, the facility failed to maintain corridors systems in accordance with the 2000 edition of the Life Safety Code, NFPA 101 (National Fire Protection Association). Findings include: Surveyor observed between 10:00 and 11:00 am on 6/06/12 that HVI building HVI Level 8 Room 140 door to nourishment room were open to corridor with unattended coffee pot. No smoke detection was observed to be present. This condition was also present in other patient care floors in this building. This does not meet NFPA 101, 19.3.6.1. Corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5.

Based on observations during the survey walk of Building 4 on the morning of 6/06/2012, with the Engineering Team Leader and two technicians on the engineering staff, the facility failed to maintain door to corridor opening in accordance with the 2000 edition of the Life Safety Code, NFPA 101 (National Fire Protection Association). Findings include:
Surveyor observed between 10 and 10:30 am on 6/06/12 that HVI Level 3, door to Room 127, a door wedge provided impediment to closing the door. This does not meet NFPA 101, 19.3.6.3

Based on observations made during the tour of the Building 3 on the afternoon of 06/06/12, with the Director of Engineering and two technicians on the engineering staff, the facility failed to assure that all doors were automatic-closing in accordance with 19.2.2.2.6. The northwest cross corridor smoke compartment doors on the 8th floor did not close on activation of the smoke detector at that location during fire alarm testing.

Based on observations made during the tour of the Building 4 on the morning of 06/06/12, with the Director of Engineering and two technicians on the engineering staff, the facility failed to maintain one of two double exit doors in accordance with the Life Safety Code, NFPA 101. Findings included the following:
Surveyor observed between 10: 30 and 11:00 am on 6/06/12 that one two double doors exiting building near first level MRI Suite were not opening appropriately. This is not in accordance with NFPA 19.2.1 and 7.2.1.4.5. The force required to fully open any door manually in a means of egress shall not exceed 15 lbf to release the latch, 30 lbf to set the door in motion, and 15 lbf to open the door to minimum required width.

Based on observations during the survey walk of Building 1 on the afternoon of 6/06/2012, with the Engineering Team Leader and two technicians on the engineering staff, the facility failed to maintain a clear and unobstructed egress path. The ICU corridor contained a copier which impeded egress path.

Based on observations made during the tour of the Building 3 on the afternoon of 06/06/12 with the Director of Engineering, and technicians on the engineering staff, the facility failed to assure that corridors were clear and unobstructed in accordance with 18.2.3.3. There were a lot of carts and medical equipment parked in egress corridors on the 7th floor.

Based on observations during the survey walk of Building 1 on the afternoon of 6/05/2012, with the Chief Operating Officer, the facility failed to provide an exit sign indicating the exit path from the suite into the egress corridor. An exit sign was present but could not be seen since the sign was parallel to the exit pathway, not perpendicular, at both the sixth ' s floor performance improvement suite and the fifth floor ' s sleep lab. No exit sign existed at egress corridor ' s corner, near pedi operating room surgical physician lounge. A sign shall be placed in every location where the direction of travel to reach the nearest egress corridor is not apparent.


Based on observations during the survey walk of Building 1 on the afternoon of 6/05/2012, with the Chief Operating Officer, the facility failed to maintain the exit signs. The exit sign was not lit in fourth floor ' s house staff lounge.

Based on observations during the survey walk of Building 1 on the afternoon of 6/06/2012, with the Engineering Team Leader and two technicians on the engineering staff, the facility failed to correctly identify the Fire Alarm Control Panel breaker. The label shall be placed immediately adjacent to the breaker and say " Fire Alarm Control Panel " and the breaker shall be colored red and this panel is located on the first floor ' s PBX room.

Based on observations during the survey walk of Building 1 on the afternoon of 6/06/2012, with the Engineering Team Leader and two technicians on the engineering staff, the facility failed to provide a sprinklered smoke compartment. The entire smoke compartment was sprinklered except for the previous medical records suite on the first floor ' s administration area. This area did have halon system but this system is no longer operational. Additionally two rooms were unsprinklered (one on the sixth floor in the administration suite and one in the third floor ' s fire command room).

Based on observations during the survey walk of Building 4 on the afternoon of 6/06/2012, with the Engineering Team Leader and two technicians on the engineering staff, the facility failed to maintain sprinkler systems in accordance with the 2000 edition of the Life Safety Code, NFPA 101 and the 1999 edition of the Standard for Fire Sprinkler Installation, NFPA 13. Findings included the following:
Surveyor observed between 11:00 and 11:30 on 06/06/12 that one sprinkler escutcheon plate was missing from the fire sprinkler protecting the west linen chute room in the basement of the Cullen Building. This does not meet NFPA 13, 1999: 3.2.7.2. Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.

Based on observations during the survey walk of Building 1 on the afternoon of 6/05/2012, with the Chief Operating Officer, the facility failed to maintain the fire extinguishers. Several fire extinguishers ' tag indicated they were last inspected April 2012 and these occurred throughout the sixth floor (i.e. R14). Annual inspections and maintenance must be provided in accordance with NFPA requirements.

Based on observations made during the tour of the Building 3 on the morning and afternoon of 06/06/12 with the Director of Engineering and technicians on the engineering staff, the facility failed to assure that fire extinguishers were being subjected to maintenance on an annual basis in accordance with NFPA 10. Several extinguishers located on the 10th, 9th, 8th, 7th, 5th, 3rd, 1st and ground floors had expired maintenance tags.

Based on observations during the survey walk of Building 4 on the morning of 6/06/2012, with the Engineering Team Leader and two technicians on the engineering staff, the facility failed to maintain corridors because med gas outlets were in surgical egress corridor. Corridors shall be separated from all other areas by partitions complying with 18.3.6.2. through 18.3.6.5 unless otherwise permitted by the following: (1) Spaces shall be permitted to be unlimited in area and open to the corridor, provided that the following criteria are met: (1) The spaces are not used for patient sleeping rooms, treatment rooms, or hazardous areas.

Based on observations during the survey walk of Building 1 on the afternoon of 6/06/2012, with the Engineering Team Leader and two technicians on the engineering staff, the facility failed to assure that the essential electrical system was in full compliance. Lab ' s freezer and blood bank were supplied with power from the life safety branch of the essential electrical system. This equipment should be powered from the critical branch panel. The life safety branch of the emergency system shall supply power for the following lighting, receptacles and equipment: 1. Illumination of means of egress as required in NFPA 101, Life Safety Code; 2. Exit signs and exit direction signs required in NFPA 101, Life safety Code; 3. Alarm and alerting systems including the following: a. Fire Alarms, b. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, "Gas and Vacuum Systems;" 4. communication systems, where used for issuing instruction during emergency conditions; 5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location; 6. Elevator ... 7. Automatically opened doors used for building egress. No functions other than those listed above in items 1 through 7 shall be connected to the life safety branch.

Based on observations made during the tour of the Building 3 on the morning and afternoon of 06/06/12 with the Director of Engineering and technicians on the engineering staff, the facility failed to assure that the Hospital ' s Type 1 Essential Electrical System was in full compliance with NFPA 99, 3.4.2.2.2.
(1) Emergency ' EQUIPMENT ' panels ' ZLU10A-1 ' and ' ZLU9A-1 ' located on the 10th floor had critical branch emergency receptacles listed on their respective directories.
(2) Life Safety branch panel ' ZLS1B ' located on the 1st floor had ' DAMPERS ' listed on its panel directory, instead of an equipment branch panel.
(3) The medication refrigerator at the 1st floor Clinical Observation Unit was plugged into a normal power receptacle, instead of an emergency receptacle.
(4) Critical branch panel ' ZLCGK1 ' , on the Ground floor, was serving medical gas and fire alarm systems, instead of them being served from the life safety branch. This panel was also serving a walk-in cooler and a walk-in freezer, instead of them being served from an equipment branch panel.

Based on observations during the survey walk of Building 4 on the morning of 6/06/2012, with the Engineering Team Leader and two technicians on the engineering staff, the facility failed to maintain corridors systems in accordance with the 2000 edition of the Life Safety Code, NFPA 101 (National Fire Protection Association). Findings include: Surveyor observed between 10:00 and 11:00 am on 6/06/12 that HVI building HVI Level 8 Room 140 door to nourishment room were open to corridor with unattended coffee pot. No smoke detection was observed to be present. This condition was also present in other patient care floors in this building. This does not meet NFPA 101, 19.3.6.1. Corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5.

Based on observations during the survey walk of Building 4 on the morning of 6/06/2012, with the Engineering Team Leader and two technicians on the engineering staff, the facility failed to maintain door to corridor opening in accordance with the 2000 edition of the Life Safety Code, NFPA 101 (National Fire Protection Association). Findings include:
Surveyor observed between 10 and 10:30 am on 6/06/12 that HVI Level 3, door to Room 127, a door wedge provided impediment to closing the door. This does not meet NFPA 101, 19.3.6.3

Based on observations made during the tour of the Building 3 on the afternoon of 06/06/12, with the Director of Engineering and two technicians on the engineering staff, the facility failed to assure that all doors were automatic-closing in accordance with 19.2.2.2.6. The northwest cross corridor smoke compartment doors on the 8th floor did not close on activation of the smoke detector at that location during fire alarm testing.

Based on observations made during the tour of the Building 4 on the morning of 06/06/12, with the Director of Engineering and two technicians on the engineering staff, the facility failed to maintain one of two double exit doors in accordance with the Life Safety Code, NFPA 101. Findings included the following:
Surveyor observed between 10: 30 and 11:00 am on 6/06/12 that one two double doors exiting building near first level MRI Suite were not opening appropriately. This is not in accordance with NFPA 19.2.1 and 7.2.1.4.5. The force required to fully open any door manually in a means of egress shall not exceed 15 lbf to release the latch, 30 lbf to set the door in motion, and 15 lbf to open the door to minimum required width.

Based on observations during the survey walk of Building 1 on the afternoon of 6/06/2012, with the Engineering Team Leader and two technicians on the engineering staff, the facility failed to maintain a clear and unobstructed egress path. The ICU corridor contained a copier which impeded egress path.

Based on observations made during the tour of the Building 3 on the afternoon of 06/06/12 with the Director of Engineering, and technicians on the engineering staff, the facility failed to assure that corridors were clear and unobstructed in accordance with 18.2.3.3. There were a lot of carts and medical equipment parked in egress corridors on the 7th floor.

Based on observations during the survey walk of Building 1 on the afternoon of 6/05/2012, with the Chief Operating Officer, the facility failed to provide an exit sign indicating the exit path from the suite into the egress corridor. An exit sign was present but could not be seen since the sign was parallel to the exit pathway, not perpendicular, at both the sixth ' s floor performance improvement suite and the fifth floor ' s sleep lab. No exit sign existed at egress corridor ' s corner, near pedi operating room surgical physician lounge. A sign shall be placed in every location where the direction of travel to reach the nearest egress corridor is not apparent.


Based on observations during the survey walk of Building 1 on the afternoon of 6/05/2012, with the Chief Operating Officer, the facility failed to maintain the exit signs. The exit sign was not lit in fourth floor ' s house staff lounge.

Based on observations during the survey walk of Building 1 on the afternoon of 6/06/2012, with the Engineering Team Leader and two technicians on the engineering staff, the facility failed to correctly identify the Fire Alarm Control Panel breaker. The label shall be placed immediately adjacent to the breaker and say " Fire Alarm Control Panel " and the breaker shall be colored red and this panel is located on the first floor ' s PBX room.

Based on observations during the survey walk of Building 1 on the afternoon of 6/06/2012, with the Engineering Team Leader and two technicians on the engineering staff, the facility failed to provide a sprinklered smoke compartment. The entire smoke compartment was sprinklered except for the previous medical records suite on the first floor ' s administration area. This area did have halon system but this system is no longer operational. Additionally two rooms were unsprinklered (one on the sixth floor in the administration suite and one in the third floor ' s fire command room).

Based on observations during the survey walk of Building 4 on the afternoon of 6/06/2012, with the Engineering Team Leader and two technicians on the engineering staff, the facility failed to maintain sprinkler systems in accordance with the 2000 edition of the Life Safety Code, NFPA 101 and the 1999 edition of the Standard for Fire Sprinkler Installation, NFPA 13. Findings included the following:
Surveyor observed between 11:00 and 11:30 on 06/06/12 that one sprinkler escutcheon plate was missing from the fire sprinkler protecting the west linen chute room in the basement of the Cullen Building. This does not meet NFPA 13, 1999: 3.2.7.2. Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.

Based on observations during the survey walk of Building 1 on the afternoon of 6/05/2012, with the Chief Operating Officer, the facility failed to maintain the fire extinguishers. Several fire extinguishers ' tag indicated they were last inspected April 2012 and these occurred throughout the sixth floor (i.e. R14). Annual inspections and maintenance must be provided in accordance with NFPA requirements.

Based on observations made during the tour of the Building 3 on the morning and afternoon of 06/06/12 with the Director of Engineering and technicians on the engineering staff, the facility failed to assure that fire extinguishers were being subjected to maintenance on an annual basis in accordance with NFPA 10. Several extinguishers located on the 10th, 9th, 8th, 7th, 5th, 3rd, 1st and ground floors had expired maintenance tags.

Based on observations during the survey walk of Building 4 on the morning of 6/06/2012, with the Engineering Team Leader and two technicians on the engineering staff, the facility failed to maintain corridors because med gas outlets were in surgical egress corridor. Corridors shall be separated from all other areas by partitions complying with 18.3.6.2. through 18.3.6.5 unless otherwise permitted by the following: (1) Spaces shall be permitted to be unlimited in area and open to the corridor, provided that the following criteria are met: (1) The spaces are not used for patient sleeping rooms, treatment rooms, or hazardous areas.

Based on observations during the survey walk of Building 1 on the afternoon of 6/06/2012, with the Engineering Team Leader and two technicians on the engineering staff, the facility failed to assure that the essential electrical system was in full compliance. Lab ' s freezer and blood bank were supplied with power from the life safety branch of the essential electrical system. This equipment should be powered from the critical branch panel. The life safety branch of the emergency system shall supply power for the following lighting, receptacles and equipment: 1. Illumination of means of egress as required in NFPA 101, Life Safety Code; 2. Exit signs and exit direction signs required in NFPA 101, Life safety Code; 3. Alarm and alerting systems including the following: a. Fire Alarms, b. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, "Gas and Vacuum Systems;" 4. communication systems, where used for issuing instruction during emergency conditions; 5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location; 6. Elevator ... 7. Automatically opened doors used for building egress. No functions other than those listed above in items 1 through 7 shall be connected to the life safety branch.

Based on observations made during the tour of the Building 3 on the morning and afternoon of 06/06/12 with the Director of Engineering and technicians on the engineering staff, the facility failed to assure that the Hospital ' s Type 1 Essential Electrical System was in full compliance with NFPA 99, 3.4.2.2.2.
(1) Emergency ' EQUIPMENT ' panels ' ZLU10A-1 ' and ' ZLU9A-1 ' located on the 10th floor had critical branch emergency receptacles listed on their respective directories.
(2) Life Safety branch panel ' ZLS1B ' located on the 1st floor had ' DAMPERS ' listed on its panel directory, instead of an equipment branch panel.
(3) The medication refrigerator at the 1st floor Clinical Observation Unit was plugged into a normal power receptacle, instead of an emergency receptacle.
(4) Critical branch panel ' ZLCGK1 ' , on the Ground floor, was serving medical gas and fire alarm systems, instead of them being served from the life safety branch. This panel was also serving a walk-in cooler and a walk-in freezer, instead of them being served from an equipment branch panel.