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Based on random observation during the survey walk-through, not all doors in smoke barrier walls are resistant to the passage of smoke in accordance with 19.3.7.5., 19.3.7.6., and 19.3.7.7. This deficiency could affect any patients, staff, or visitors on the building's Second Floor by permitting smoke to pass between adjacent smoke compartments.

Findings include:

A. During a test of the building fire alarm system conducted at 9:18 AM on February 27, 2013, the hold-open feature of the automatic door operator installed on the cross-corridor door in the smoke barrier adjacent to Exit Stair 2-055 was observed to not release to close as required by 19.3.7.6.

Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1. This deficiency could affect any staff and visitors in the immediate area by permitting smoke or fire to pass from the Pharmacy to the adjacent Corridor.

Findings include:

A. During a test of the building fire alarm system conducted at 9:22 AM on February 27, 2013, the fire shutter in the Corridor wall of First Floor Pharmacy 1-038 (which constitutes a hazardous area) was observed to not close completely as required by 19.3.2.1. and 8.2.3.2.3.1(1).

Based on random observation during the survey walk-through, not all exit stair shafts are constructed or maintained as fire resistive assemblies in accordance with 39.3.1.1. These deficiencies could affect any patients, staff or visitors within the Imaging/Lab Unit by permitting smoke or fire to enter the protected fire rated Exit Stair enclosure.

Findings include:

A. At 10:50 AM on February 27, 2013, 2 duct penetrations were observed, 1 through the the floor slab and 1 through the side wall of the Exit Stair Enclosure serving the Imaging/Lab Unit, which are not equipped with fire dampers as required by 8.2.3.2.4.1. and NFPA 90A 1999 3-3.4.1.

Based on random observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1. These deficiencies could affect any patients, staff, or visitors on the Second Floor because the lack of guard rails or compliant hand rails could result in falls.

Findings include:

A. At 2:16 PM on February 26, 2013, the following deficiencies were observed at the West Exit Stair (Stair 1-136/2-239):
1. The Exit Stair was observed to lack guard rails required by 7.2.2.4.1. This was observed to include both landings and each stair segment.

2. The railing assembly present was observed to be spaced far enough apart to permit a 4" sphere to pas through the openings in the assembly as prohibited by 7.2.2.4.6(3).

Based on random observation during the survey walk-through, document review, and staff interview, the facility's written plan for the protection of patients is not complete as required by 19.7.1.1. These deficiencies could affect any patients, staff, or visitors in the facility because necessary life safety components may not be properly protected.

Findings include:

A. During the document review process, it was determined that the facility's written fire safety plan does not comply with 19.7.2.2. because the graphic representation of that plan (the Life Safety Master Plans) are inaccurate. Examples of errors in these plans discovered during the survey walk-through include:
1. Exit Stairs are shown on the Life Safety Master Plans as 2 hour fire rated enclosures; the doors to these Stairs were observed to carry a 1 hour fire resistance rating. Refer to 8.2.5.4(2) and 8.2.3.2.3.1(2).

2. First Floor Exit Stair 1-138/Vestibule 1-191 are shown as separate rooms; they are contiguous and form the fire rated enclosure/exit discharge for the Exit Stair.
3. Regarding Second Floor Suite A, the Sleep Study Suite:

a. During the survey walk-through conducted at 2:20 PM on February 26, 2013, the provider's Facilities Engineering Manager was not able to accurately identify the limits of the suite, or whether the area is a series of rooms served by exit access corridors.
b. The Sleep Study Suite is incorrectly identified on the Life Safety Master Plans as constituting a sleeping suite.

Based on document review and staff interview, fire drills are not held at varying times and varying conditions in accordance with 19.7.1.2. These deficiencies could affect any patients, staff, or visitors in the facility because the staff may not be properly prepared to respond under emergency circumstances.

Findings include:

A. Based on document review, fire drills are not conducted at varying times as required by 19.7.1.2. These observations were confirmed by the provider's Safety/Disaster Preparedness Coordinator during an interview held in a Conference Room at 9:05 AM on February 27, 2013. During the calendar year 2012, fire drills for the following quarters/shifts were conducted at the similar times listed:

1. Second Shift:

a. February 18, 2012: 4:00 PM.

b. May 25, 2012: 3:13 PM.

c. August 9, 2012: 4:01 PM.

d. November 20, 2012.

2. Third Shift:

a. March 7, 2012: 6:34 AM.

b. June 1, 2012: 6:54 AM.

c. September 21, 2012: 6:45 AM.

d. December 7, 2012: 6:50 AM.

Based on random observation during the survey walk-through, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency in accordance with 19.2.3.3. This deficiency could affect any patients, staff, or visitors on the Second Floor because their egress path could be obstructed during an emergency condition.

Findings include:

A. A workstation on wheels was observed, in Second Floor Corridor 2-061, which obstructs egress as prohibited by 19.2.3.3. and 7.1.10.2.1.

Based on random observation during the survey walk-through the surveyor found that the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised by the loss of a single transfer switch.


Findings include:

1. Some of the critical panels were serving items other than those allowed on the critical power system. Critical panels ECD, ECB2, ECR1A were serving some life safety loads, (ECR1A was serving fire alarm and oxygen alarm), and ECD and ECB2 were serving large equipment that should be served from the equipment transfer switch and panels. This does not meet the requirements of NFPA-70, Section 517-32 though 517-34.

2. Life safety panel ELA is serving the nurse call system, and several room receptacles that should be served by the critical system which does not meet the requirements of NFPA-70, Section 517-32.

3. The 110 KW generator is serving a single transfer switch and the load served by this transfer switch is a mixture of life safety, critical, and equipment branch loads. This is not allowed by NFPA-70, Section 517- 30 through 517-35. Based on the combined results of the monthly generator tests the connected emergency load is over 120 KW and 150 KVA which initiates the requirements for each branch to be served from a separate transfer switch.

Based on random observation during the survey walk-through not all portions of the building systems are installed in accordance with NFPA 70 (1999).

Findings include:

1. Normal power receptacles were not provided in the ER rooms as required by NFPA-70, Section 517-19, and NFPA-99, Section 3-3.2.1.2(a)1. In the event of a transfer switch failure upon return to normal power, these rooms could be left with no power.

2. The surveyor did not find a single disconnect for each elevator's emergency lighting, receptacle, and ventilation located in the elevator machine room, or proper signage identifying the source feeding these disconnects as required by NFPA-70, Section 620-53. NFPA-99, Section 3-4.2.2.2(b)6 requires these disconnects to be served from the Life Safety branch of the emergency power system.

Based on random observation during the survey walk-through, not all doors in smoke barrier walls are resistant to the passage of smoke in accordance with 19.3.7.5., 19.3.7.6., and 19.3.7.7. This deficiency could affect any patients, staff, or visitors on the building's Second Floor by permitting smoke to pass between adjacent smoke compartments.

Findings include:

A. During a test of the building fire alarm system conducted at 9:18 AM on February 27, 2013, the hold-open feature of the automatic door operator installed on the cross-corridor door in the smoke barrier adjacent to Exit Stair 2-055 was observed to not release to close as required by 19.3.7.6.

Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1. This deficiency could affect any staff and visitors in the immediate area by permitting smoke or fire to pass from the Pharmacy to the adjacent Corridor.

Findings include:

A. During a test of the building fire alarm system conducted at 9:22 AM on February 27, 2013, the fire shutter in the Corridor wall of First Floor Pharmacy 1-038 (which constitutes a hazardous area) was observed to not close completely as required by 19.3.2.1. and 8.2.3.2.3.1(1).

Based on random observation during the survey walk-through, not all exit stair shafts are constructed or maintained as fire resistive assemblies in accordance with 39.3.1.1. These deficiencies could affect any patients, staff or visitors within the Imaging/Lab Unit by permitting smoke or fire to enter the protected fire rated Exit Stair enclosure.

Findings include:

A. At 10:50 AM on February 27, 2013, 2 duct penetrations were observed, 1 through the the floor slab and 1 through the side wall of the Exit Stair Enclosure serving the Imaging/Lab Unit, which are not equipped with fire dampers as required by 8.2.3.2.4.1. and NFPA 90A 1999 3-3.4.1.

Based on random observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1. These deficiencies could affect any patients, staff, or visitors on the Second Floor because the lack of guard rails or compliant hand rails could result in falls.

Findings include:

A. At 2:16 PM on February 26, 2013, the following deficiencies were observed at the West Exit Stair (Stair 1-136/2-239):
1. The Exit Stair was observed to lack guard rails required by 7.2.2.4.1. This was observed to include both landings and each stair segment.

2. The railing assembly present was observed to be spaced far enough apart to permit a 4" sphere to pas through the openings in the assembly as prohibited by 7.2.2.4.6(3).

Based on random observation during the survey walk-through, document review, and staff interview, the facility's written plan for the protection of patients is not complete as required by 19.7.1.1. These deficiencies could affect any patients, staff, or visitors in the facility because necessary life safety components may not be properly protected.

Findings include:

A. During the document review process, it was determined that the facility's written fire safety plan does not comply with 19.7.2.2. because the graphic representation of that plan (the Life Safety Master Plans) are inaccurate. Examples of errors in these plans discovered during the survey walk-through include:
1. Exit Stairs are shown on the Life Safety Master Plans as 2 hour fire rated enclosures; the doors to these Stairs were observed to carry a 1 hour fire resistance rating. Refer to 8.2.5.4(2) and 8.2.3.2.3.1(2).

2. First Floor Exit Stair 1-138/Vestibule 1-191 are shown as separate rooms; they are contiguous and form the fire rated enclosure/exit discharge for the Exit Stair.
3. Regarding Second Floor Suite A, the Sleep Study Suite:

a. During the survey walk-through conducted at 2:20 PM on February 26, 2013, the provider's Facilities Engineering Manager was not able to accurately identify the limits of the suite, or whether the area is a series of rooms served by exit access corridors.
b. The Sleep Study Suite is incorrectly identified on the Life Safety Master Plans as constituting a sleeping suite.

Based on document review and staff interview, fire drills are not held at varying times and varying conditions in accordance with 19.7.1.2. These deficiencies could affect any patients, staff, or visitors in the facility because the staff may not be properly prepared to respond under emergency circumstances.

Findings include:

A. Based on document review, fire drills are not conducted at varying times as required by 19.7.1.2. These observations were confirmed by the provider's Safety/Disaster Preparedness Coordinator during an interview held in a Conference Room at 9:05 AM on February 27, 2013. During the calendar year 2012, fire drills for the following quarters/shifts were conducted at the similar times listed:

1. Second Shift:

a. February 18, 2012: 4:00 PM.

b. May 25, 2012: 3:13 PM.

c. August 9, 2012: 4:01 PM.

d. November 20, 2012.

2. Third Shift:

a. March 7, 2012: 6:34 AM.

b. June 1, 2012: 6:54 AM.

c. September 21, 2012: 6:45 AM.

d. December 7, 2012: 6:50 AM.

Based on random observation during the survey walk-through, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency in accordance with 19.2.3.3. This deficiency could affect any patients, staff, or visitors on the Second Floor because their egress path could be obstructed during an emergency condition.

Findings include:

A. A workstation on wheels was observed, in Second Floor Corridor 2-061, which obstructs egress as prohibited by 19.2.3.3. and 7.1.10.2.1.

Based on random observation during the survey walk-through the surveyor found that the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised by the loss of a single transfer switch.


Findings include:

1. Some of the critical panels were serving items other than those allowed on the critical power system. Critical panels ECD, ECB2, ECR1A were serving some life safety loads, (ECR1A was serving fire alarm and oxygen alarm), and ECD and ECB2 were serving large equipment that should be served from the equipment transfer switch and panels. This does not meet the requirements of NFPA-70, Section 517-32 though 517-34.

2. Life safety panel ELA is serving the nurse call system, and several room receptacles that should be served by the critical system which does not meet the requirements of NFPA-70, Section 517-32.

3. The 110 KW generator is serving a single transfer switch and the load served by this transfer switch is a mixture of life safety, critical, and equipment branch loads. This is not allowed by NFPA-70, Section 517- 30 through 517-35. Based on the combined results of the monthly generator tests the connected emergency load is over 120 KW and 150 KVA which initiates the requirements for each branch to be served from a separate transfer switch.

Based on random observation during the survey walk-through not all portions of the building systems are installed in accordance with NFPA 70 (1999).

Findings include:

1. Normal power receptacles were not provided in the ER rooms as required by NFPA-70, Section 517-19, and NFPA-99, Section 3-3.2.1.2(a)1. In the event of a transfer switch failure upon return to normal power, these rooms could be left with no power.

2. The surveyor did not find a single disconnect for each elevator's emergency lighting, receptacle, and ventilation located in the elevator machine room, or proper signage identifying the source feeding these disconnects as required by NFPA-70, Section 620-53. NFPA-99, Section 3-4.2.2.2(b)6 requires these disconnects to be served from the Life Safety branch of the emergency power system.