HospitalInspections.org

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1. Based on observation and interview, the building failed to provide a building construction type allowed for a four story sprinkled building per the requirements of:

2012 NFPA 101, 19.1.6.1

Findings include:

On 08/22/2017, during a tour of the building from 8:00 am to 6:00 pm, the building was observed from the third floor to have structural floor members supporting the fourth floor without a two hour fire rating.

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

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36148

Based on observation and interview, the building failed to provide a building construction type allowed for a four story sprinkled building per the requirements of:

2012 NFPA 101, 19.1.6.1

Findings include:

On 08/21/2017, during a tour of the building from 11:00 am to 5:30 pm, the building was observed with a single story unprotected wood frame structure attached to the back of the four story building.

A member of the maintenance staff was present when this deficiency was identified.
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Based on observation and interview, the building failed to maintain the horizontal exits (2 hour fire rated walls) per the requirements of:

2012 NFPA 101, 19.2.2.5
2012 NFPA 101, 7.2.4.3.1

Findings include:

On 08/21/2017, during a tour of the building from 11:00 am to 5:30 pm, an orange foam substance, that the facility could not verify having a 2 hour fire rating was observed in the following horizontal exits/2 hour fire rated walls located on the second floor:

1. At the MOB
2. At room 2332 - above fire doors FID 2010

A member of the maintenance staff was present when this deficiency was identified.
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Based on observation and interview, the building failed to maintain an exit sign per the requirements of:

2012 NFPA 101, 19.2.10.1
2012 NFPA 101, 7.10.5.2.1

Findings include:

On 08/21/2017, during a tour of the building from 11:00 am to 5:30 pm, the exit sign at the kitchen's westside entrance, by the Locker Room was not illuminated.

A member of the maintenance staff was present when this deficiency was identified.
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1. Based on observation and interview, the building failed to provide a self-closing device on a hazardous room's door per the requirements of:

2012 NFPA 101, 19.3.2.1.3

Findings include:

On 08/21/2017, during a tour of the building from 11:00 am to 5:30 pm, 1st floor Electrical Room 102 was observed to be over 50 sq. ft. with combustibles and the door to this room did not have a self-closing device.

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

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33932


2. Based on observation and interview, the building failed to provide separation of hazardous areas allowed for sprinkled buildings per the requirements of:

2012 NFPA 101, 19.3.2.1.2

Findings include:

On 08/21/2017, during a tour of the building from 11:00 am to 5:30 pm, a Soiled Utility Room on third floor was observed with unsealed penetrations.

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

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3. Based on observation and interview, the building failed to ensure a hazardous room door's self-closing device brought the door to close and positive latch per the requirements of:

2012 NFPA 101, 19.3.2.1.3
CFR 42 482.41 (b) (ii)

Findings include:

On 08/21/2017 during a tour of the building from 8:00 am to 6:00 pm, the surveyor observed the door to Soiled Utility Room 4361 on the fourth floor did not positive latch upon closing.

A member of the maintenance staff was present when this deficiency was identified.
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1. Based on observation and interview, the building failed to maintain the kitchen's multiple hoods' filters per the requirements of:

2012 NFPA 101, 19.3.2.5.1
2012 NFPA 101, 9.2.3
2011 NFPA 96, 6.2.3.3

Findings include:

On 08/22/2017, during a tour of the building from 8:00 am to 5:30 pm, the kitchen's multiple hoods' filters were observed with gaps ranging from approximately 1/4" to 2".

A member of the maintenance staff was present when this deficiency was identified.
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1. Based on observation and interview, the building failed to maintain the digital alarm communicator transmitter (DACT) for the fire alarm system per the requirements of:

2012 NFPA 101, 19.3.4.3.2 and 9.6.4
2010 NFPA 72, Table 14.4.2.2 18 (b)

Findings include:

On 08/22/2017, during a tour of the building from 8:00 am to 6:00 pm, when the fire alarm system's DACT phone line 1 was disconnected for over 5 minutes, no signal of line failure was received at the remote station on the protected premises (the Security Office).

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

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36148

2. Based on observation and interview, the building failed to maintain some of the strobe devices for the fire alarm system per the requirements of:

2012 NFPA 101, 19.3.4.3.1
2012 NFPA 101, 9.6.3

Findings include:

On 08/22/2017, during a tour of the building from 8:00 am to 5:30 pm, the following locations of the fire alarm strobe devices were observed not working during the testing of the fire alarm system:

1. The stairwell at 1st Hall
2. The 1st Hall Stair and Egress to the Outside Egress Exit

A member of the maintenance staff was present when this deficiency was identified.
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Based on observation and interview, the building failed to maintain the post indicator valve (PIV) per the requirements of:

2012 NFPA 101, 19.3.5.1
2012 NFPA 101, 9.7.5
2012 NFPA 101, 9.7.7
2012 NFPA 101, 9.7.8
2011 NFPA 25, 13.8.1 and Table 13.8.1

Findings include:

On 08/21/2017, during a tour of the building from 11:00 am to 5:30 pm, the PIV located outside near the Generator Room was observed with the following:

1. A missing sight glass
2. A sight glass was distorted

A member of the maintenance staff was present when this deficiency was identified.
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Based on observation and interview, the building failed to maintain a corridor door per the requirements of:

2012 NFPA 101, 19.3.6.3.5
CFR 42 482.41 (b) (ii)

Findings include:

On 08/21/2017, during a tour of the building from 8:00 am to 6:00 pm Housekeeping Room 4348 corridor door on 4th floor failed to positive latch in the frame.

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

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Based on observation and interview, the building failed to maintain smoke barriers that would provide at least a half hour fire resistance rating and restrict the movement of smoke per the requirements of:

2012 NFPA 101, 19.3.7.3
2012 NFPA 101, 8.5.1
2012 NFPA 101, 8.5.6.2

Findings include:

1. On 08/23/2017, during a tour of the building from 8:00 am to 4:30 pm, unsealed penetrations were observed in the following smoke barrier locations:

a. Above the ceiling at room 3376
b. Above the ceiling at double doors 3007

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27382


2. On 08/22/2017, during a tour of the building from 8:00 am to 5:30 pm, the 1st floor smoke barrier in the bathroom at Infusion Room 6 & 7 was observed with an unsealed 6" square penetration with one grey wire.

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33932


3. On 08/21/2017, during a tour of the building from 8:00 am to 4:00 pm unsealed penetrations were observed in the following smoke barrier locations:

a. At the 4th floor Lab an unsealed penetration of a conduit used as a sleeve with 4 white wires
b. At the 4th floor Restricted Area an unsealed penetration of a conduit used as a sleeve with several white wires
c. At the Medical Office Center a 1 foot square hole cut in the wall
d. At 1st floor ER Room 1340 an unsealed penetration of a conduit used as a sleeve with a blue wire
e. At 1st floor Nurses Station an unsealed penetration of a conduit used as a sleeve with a blue wire and a gray wire

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36148


4. On 08/21/2017, during a tour of the building from 11:00 am to 5:30 pm, the smoke barrier near the RX4U Pharmacy was observed with a 1" unsealed conduit with black wires that penetrated the smoke barrier.

A member of the maintenance staff was present when these deficiencies were identified.
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1. Based on observation and interview, the building failed to provide a self-closing device for a door located in a smoke barrier per the requirements of:

2012 NFPA 101, 19.3.7.8 (1)

Findings include:

On 08/22/2017, during a tour of the building from 8:00 am to 5:30 pm, on the 1st floor, the door to the bathroom next to Infusion Room 6 & 7 was observed to be located in a smoke barrier and did not have a self-closing device.

A member of the maintenance staff was present when this deficiency was identified.
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Based on observation and interview, the building failed to maintain the emergency call system for one of the elevators per the requirements of:

2012 NFPA 101, 19.5.3
2012 NFPA 101, 9.4.3
ASME A17.3

Findings include:

On 08/23/2017, during a tour of the building from 8:00 am to 4:30 pm, the emergency call system for elevator #2 was observed not working during the testing of the Firefighter's Service.

A member of the maintenance staff was present when this deficiency was identified.
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Based on review of documentation and interview, the building failed to conduct fire drills per the requirements of:

2012 NFPA 101, 19.7.1.6

Findings include:

On 08/23/2017, during a tour of the building from 8:00 am to 4:30 pm, the following fire drills did not have all staff signatures on the participation sheet:

05/25/2017 - 11:01 pm
01/24/2017 - 7:18 am
11/14/2016 - 12:35 am

A member of the maintenance staff was present when this deficiency was identified.
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Based on observation and interview, the building failed to maintain line isolation monitor (LIM) 0007 per the requirements of:

2012 NFPA 99, 6.3.4.1.4

Findings include:

On 08/21/2017, during a tour of the building from 11:00 am to 5:30 pm, the LIM 0007 for OR 7 failed to give an audible alarm when tested.

A member of the maintenance staff was present when this deficiency was identified.
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Based on observation and interview, the building failed to maintain the emergency generators' remote annunciator per the requirements of:

2012 NFPA 99, 6.4.1.1.17 and Table 6.4.1.1.16.2

Findings include:

On 08/21/2017, during a tour of the building from 11:00 am to 5:30 pm, the remote annunciator for emergency generators #2 and #3 failed to give an audible alarm when these generators were taken out of the automatic position, the remote did show a visual for both generators.

A member of the maintenance staff was present when this deficiency was identified.
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Based on review of documentation and interview, the building failed to provide documentation of training personnel concerned with the application, maintenance, and handling of medical gases and cylinders per the requirements of:

2012 NFPA 99, 11.5.2.1

Findings include:

On 08/23/2017, during a tour of the building from 8:00 am to 4:30 pm, the facility failed to provide documentation of training personnel concerned with the application, maintenance, and handling of medical gases and cylinders.

A member of the maintenance staff and administrator was present, when this deficiency was identified.
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Based on review of documentation and interview, the building failed to provide documentation of procedures and continuing education the administration provides for "fire loss prevention in operating rooms." per the requirements of:

2012 NFPA 99, 15.13

Findings include:

On 08/23/2017, during a tour of the building from 8:00 am to 4:30 pm, the facility failed to provide documentation of procedures and continuing education the administration provides for "fire loss prevention in operating rooms."

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