HospitalInspections.org

Based on observation and staff interview, the facility failed to ensure 5 of 9 fire barrier walls were complete from floor to ceiling. The findings were:

1. Observation of the basement electrical server room on 3/19/12 at 6:30 PM showed the north wall separated the emergency generator room. Further observation showed there were three unsealed gaps at the top of the cinder block wall. The largest gap measured 12 inches by 24 inches. At the time of the observation, the facility services manager reported the room was not routinely inspected for separation.

2. Observation on 3/20/12 between 10:30 AM and 5:30 PM showed the 90 minute double corridor doors to material management and the medical arts complex were equipped with self-closing devices. Further observation showed the closing devices on one of each set of doors were not able to fully latch the door into the door frame, with three attempts. At 10:55 AM the facility services manager reported the doors were only inspected semi-annually to ensure they fully latched into the frames.

3. Observation on 3/21/12 between 8:30 AM and 9:30 AM showed the 2-hour fire barrier wall above conference room A, conference room B, and the billing office in the plenum space had eight total unsealed wall penetrations. Further observation showed the largest gap measured 2 inches square. On 3/21/12 at 8:50 AM the facility services manager reported fire barrier walls were inspected annually, but only on the corridor side not on both sides.

Based on observation and staff interview, the facility failed to ensure ceilings were smoke resistant on 2 of 4 floors. The findings were:

1. Observation of the material management storeroom on 3/20/12 at 9:14 AM showed there were eight unsealed conduit penetrations. The largest gap measured 1 inch by 3 inches across. At the time of the observation, the facility services manager reported he was unaware ceilings were required to be smoke resistant to ensure heat and smoke transmission to smoke detector and sprinkler heads.

2. Observation of the condenser room on 3/20/12 at 12:52 PM showed there were five unsealed pipe penetrations. The largest gap measured 2 inches by 12 inches across.

3. Observation of the human resources closet #213 on 3/20/12 at 4:21 PM showed the top of the wall was incomplete. The gap measured 8 inches by 48 inches. At the time of the observation the facility services manager reported the wall was modified in September 2011. He could not explain why the wall was not repaired.

Based on observation and staff interview, the facility failed to ensure corridor doors were smoke resistant on 1 of 4 floors. The findings were:

Observation of the medical south dietary room on 3/20/12 at 4:01 PM showed the door was not able to be latched into the door frame, with three attempts. At the time of the observation the facility services manager could not explain why the door had not been noticed and repaired during the quarterly inspection.

Based on observation and staff interview, the facility failed to ensure 1 of 9 stairwells was smoke resistant. The findings were:

Observation of the central stairwell on 3/19/11 at 8:05 PM showed the stairwell transversed four floors. Further observation showed the stairwell was open to the corridor on the first floor. At the time of the observation the facility services manager reported he was unaware stairwells that were transversed more than two floors had to be closed to the corridor on all floors.

Reference, NFPA 101, 2000 Edition, 19.3.1.1;
8.2.5.8
Where permitted by Chapters 12 through 42, unenclosed vertical openings not concealed within the building construction shall be permitted as follows:
(1) Such openings shall connect not more than two adjacent stories (one floor pierced only).
(2) Such openings shall be separated from unprotected vertical openings serving other floors by a barrier complying with 8.2.5.4.
(3) Such openings shall be separated from corridors.
(4) * Such openings shall not serve as a required means of egress.

Based on observation and staff interview, the facility failed to ensure 1 of 12 smoke barrier walls was smoke resistant. The findings were:

Observation of the ICU/Surgery smoke barrier wall on 3/21/12 at 9:15 AM showed there were two unsealed cable pass through tubes. Further observation showed the largest tube had a 1 inch diameter. At the time of the observation the facility services manager could not explain why the pass through had not been filled after the wires were pulled or modified.

Based on observation and staff interview, the facility failed to ensure the egress system was unobstructed on 1 of 4 floors. The findings were:

1. Observation of the maintenance shop on 3/19/12 at 7:09 PM showed the exit door was blocked by a chair and surplus wood. At the time of the observation the facility services manager reported he was aware all exit doors were required to be unobstructed at all times. He could not explain why the items had been stored in front of the door.

2. Observation of the basement northeast corridor on 3/19/12 at 7:12 PM showed four carts were stored across from the laundry entrance. Further observation showed the carts stored floor cleaning supplies and clean linens. At the time of the observation the facility services manager reported the carts were usually stored in this location. He reported he was unaware items could not be stored in corridors.

Based on observation and staff interview, the facility failed to ensure corridors were provided with adequate headroom and unobstructed width on 2 of 4 floors. The findings were:

1. Observation of the southeast operating room exit on 3/19/12 at 7:54 PM showed an exit sign was placed over a 41 inch door. The hallway measured 40 inches wide in its narrowest point. At the time of the observation the facility services manager reported he was aware all corridors were required to be 8 feet wide. He could not explain why the narrow hallway had been marked as an exit passageway.

2. Observation of the medical information north corridor on 3/20/12 at 10:39 AM showed the corridor height did not measure 7 feet 6 inches. Further observation showed the corridor measured 6 foot 9 inches for a 45 foot long section. The corridor extended from the non-patient medical records storeroom to the quality department. Further observation showed the quality department administrative assistant office was placed in the corridor alcove. The office desk limited the corridor to 5 feet wide. At the time of the observation the facility services manager reported he was unaware of the aforementioned requirements.

Reference, NFPA 101, 2000 Edition, 19.2.1;
7.1.5* Headroom. Means of egress shall be designed and maintained to provide headroom as provided in other sections of this Code and shall be not less than 7 ft 6 in. (2.3 m) with projections from the ceiling not less than 6 ft 8 in. (2 m) nominal height above the finished floor. The minimum ceiling height shall be maintained for not less than two-thirds of the ceiling area of any room or space, provided the ceiling height of remaining ceiling area is not less than 6 ft 8 in. (2 m). Headroom on stairs shall be not less than 6 ft 8 in. (2 m) and shall be measured vertically above a plane parallel to and tangent with the most forward projection of the stair tread.
Exception No. 1: In existing buildings, the ceiling height shall not be less than 7 ft (2.1 m) from the floor with no projection below a 6-ft 8-in. (2-m) nominal height from the floor.
7.1.10.1* Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Based on observation and staff interview, the facility failed to ensure 6 of 6 emergency generator automatic transfer switches (ATSs) had task illumination and failed to ensure the two emergency battery lights for the generator were supplied with emergency power. The findings were:

1. Observation of the six ATSs on 3/19/12 at 6:25 PM showed they did not have battery powered task illumination. At the time of the observation the facility services manager reported he was aware the ATSs required task illumination, but could not explain why only the generator had the required illumination.

2. Observation on 3/19/12 at 6:26 PM of the two emergency battery lights for the generator showed the lights were supplied with power from normal power. In this configuration, the battery lights would activate when the generator starts, not after the potential failure of the generator. At the time of the observation the facility services manager reported he was unaware the battery lights were required to be supplied by emergency power.

Reference, NFPA 101, 2000 Edition, 19.2.9.1, 7.9.2.3, NFPA 110, 1999 Edition;
3-5.5.6 All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to the break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building.
3-5.6.1 A remote, common audible alarm powered by the storage battery shall be provided as specified in 3-5.5.2 (d). This remote alarm shall be located outside of the EPS service room at a work site readily observable by personnel.
Reference, NFPA 101, 2000 Edition, 19.2.9.1, 7.9.2.4, NFPA 70, 1999 Edition;
517-32 "...The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment. (e) Generator Set Location, task illumination battery charger for emergency battery-powered lighting unit(s) and selected receptacles at the generator set location.

Based on observation and staff interview, the facility failed to ensure exit signs were provided with two illuminated light bulbs on 1 of 4 floors. The findings were:

Observation of the intensive care unit on 3/20/12 at 1:35 PM showed three exit signs had 1 of 2 light bulbs that were burned out. At the time of the observation, the facility services manager could not explain why the signs had not been noticed and replaced during the quarterly inspections.

Based on observation and staff interview, the facility failed to ensure smoke detectors were properly installed on 1 of 4 floors. The findings were:

Observation of the shell storage area on 3/20/12 at 11:43 AM showed the ceiling structure was constructed of 18 inch and 24 inch "I" beams set perpendicular to each other. Further observation showed smoke detectors were not installed in each beam pocket. Observation of the corridor doors showed they were held open with magnetic hold open devices, but a smoke detector was not installed in the beam pocket above the door. At the time of the observation the facility services director reported he was unaware detectors were required above the corridor door hold open devices.

Reference, NFPA 101, 2000 Edition, 19.3.4.1, 9.6.1.4, NFPA 72, 1999 Edition;
2-3.4.6.1 Flat Ceilings.
...For beams depth exceeding 1 ft or for ceilings heights exceeding 12 ft, spot-type detectors shall be located on the ceiling in every beam pocket ...

Based on record review and staff interview, the facility failed to test 1 of 6 fire alarm system components. The findings were:

Review of the fire alarm system testing record showed the biannual smoke detector sensitivity test had not been conducted in the past two years. The facility did not have record of the last time the test was conducted. On 3/21/12 at 2:15 PM the facility services director could not explain why the test had not been performed.

Based on observation and staff interview, the facility failed to ensure 1 of 4 floors had complete sprinkler coverage. The findings were:

1. Observation of the east stairwell on 3/19/12 at 7:22 PM showed the stairwell transversed four floors. Further observation showed a sprinkler head was not provided at the bottom landing. At the time of the observation, the facility services manager reported the sprinkler system was inspected annually by an outside contractor. The last annual inspection report did not indicate any areas were not sprinkled.

2. Observation throughout the survey from 3/19/12-3/20/12 showed the sprinkler heads in the laundry washer room and intensive care unit nurses' station were installed 10 feet from the farthest wall.

3. Observation of the veterans' administration closet on 3/20/12 at 9:26 AM showed the closet measured 3 feet by 5 feet. Further observation showed the area was not provided with sprinkler coverage.

4. Observation of information technology repair lab on 3/20/12 at 10:08 AM showed the room measured 6 feet by 18 feet. Further observation showed the lab did not have sprinkler coverage.

5. Observation of the light bulb storeroom on 3/20/12 at 10:43 AM showed the ceiling "I" beams were 24 inches deep. Further observation showed the "I" beams made a 7 foot by 30 foot pocket that was 24 inches deep, above the elevator door. The pocket was not provided with a sprinkler head and the other heads in the room were obstructed by the "I" beams.

6. Observation of the basement shell storeroom on 3/20/12 at 11:49 AM showed three locations had 24 inch deep beam pockets that were not provided with complete sprinkler coverage. The largest unprotected space measured 12 feet by 40 feet.

7. Observation of the interior walk-in freezer on 3/20/12 at 12:49 PM showed the freezer measured 10 feet square. Further observation showed the freezer was not provided with sprinkler coverage.

Reference, NFPA 101, 2000 Edition, 19.3.5.1, 9.7.1.1, NFPA 13, 1999 Edition;
5-5.3.2 Maximum Distance From Walls. The distance from sprinklers to walls shall not exceed one-half of the allowable maximum distance between sprinklers. The distance from the wall to the sprinkler shall be measured perpendicular to the wall.
Table 5-6.2.2 (b) Protection Areas and Maximum Spacing (Standard Spray Upright/Standard Spray Pendent) for Ordinary Hazard
Construction Type ... ... ... ... .....All
System Type ... ... ... ... ... ... ... ....All
Protection Area ... ... ... ... ... .....130 sf
Spacing ... ... ... ... ... ... ... ... ... ....15 ft
5-6.4.1.1 Under unobstructed construction, the distance between the sprinkler deflector and the ceiling shall be a minimum of 1 in. and a maximum of 12 in.

Based on observation and staff interview, the facility failed to ensure sprinklers were unobstructed, failed to ensure sprinklers had complete coverage, and failed to ensure the sprinkler were properly maintained on 2 of 4 floors. The findings were:

1. Observation throughout the survey from 3/19/12-3/21/12 showed sprinkler heads were obstructed by ceiling mounted lights [and concrete structure] in the south central sterile soiled room, south central sterile clean room, laundry dryer room, laundry washer room, cart washer room, storeroom 142s, oxygen storeroom, basement ladies restroom, 1997 electrical distribution room, radiology corridor, angiography exam room, wound care room, women's health equipment storeroom. The aforementioned locations did not have complete sprinkler coverage because of the obstructions. At the time of the observation the facility services manager reported the sprinkler system was inspected annually by an outside contractor. The last annual inspection report did not indicate any areas did not have complete sprinkler coverage.

2. Observation of the radiology corridor and exam rooms on 3/20/12 between 2:24 PM and 3 PM showed five locations where sprinkler heads were maintained at less than 1 inch from the ceiling.

3. Observation of the outpatient server room on 3/20/12 at 2:47 PM showed the sprinkler head was installed more than 12 inches from the ceiling. The sprinkler head was installed 20 inches from the ceiling. At the time of the observation the facility services manager reported he was unsure when the drop ceiling was removed.

Reference, NFPA 101, 2000 Edition, 19.3.5.1, 9.7.1.1, NFPA 13, 1999 Edition;
5-6.4.1.1 Under unobstructed construction, the distance between the sprinkler deflector and the ceiling shall be a minimum of 1 in. and a maximum of 12 in.
Table 5-6.5.1.2 Positioning of Sprinklers to Avoid Obstructions to Discharge (Standard Spray Upright/Standard Spray Pendent)

Distance from Maximum allowable
sprinkler to side distance from
of obstruction deflector above
bottom of obstruction
-------------------------------------------------------
Less than 1 ft ... ... ... ... ... ... ............. ....0
1 ft to less than 1 ft 6 in. ... ... ... ... ... ...2 ?
1 ft 6 in. to less than 2 ft .... ... ... ... ......3 ?
2 ft to less than 2 ft 6 in. ...... ... ... ... ...5 ?
2 ft 6 in. to less than 3 ft ... ... ... ...........7 ?
3 ft to less than 3 ft 6 in ... ... .... ... ... ...9 ?
3 ft 6 in. to less than 4 ft ... ... ... ... ... ...12
4 ft to less than 4 ft 6 in. ......................14

Based on record review and staff interview, the facility failed to ensure safety policies were reviewed during the past year. The findings were:

On 3/20/12 at 9:50 AM the lab manager reported safety policy and procedures were only reviewed when employees were originally hired. He confirmed there were no training documents to review. He also reported he was unaware safety training was required to be reviewed on an annual basis.

Based on observation and staff interview, the facility failed to ensure the liquid oxygen storage locations was provided with a "No Smoking" sign. The findings were:

Observation of the liquid oxygen storage area on 3/20/12 at 8:40 AM showed the chain link fence enclosure was not provided with a "No Smoking" sign. At the time of the observation the facility services manager reported he was unaware of the aforementioned requirement.

Based on observation, staff interview, and blue print review, the facility failed to ensure the emergency generator annunciator panel was located at an observable location, failed to ensure the generator was provided with an emergency remote stop button, and failed to ensure essential electrical system (EES) panels were separated on 2 of 4 floors. The findings were:

1. Observation of the emergency generator on 3/19/12 at 6:19 PM showed the main control panel was installed at the loading dock. Further observation showed an annunciator panel was designed to be installed at the emergency department nurses' station during the 2006 project. At the time of the observation, the facility services manager reported the annunciator panel was placed at the nurses' station and wires pulled to the main transfer switch, but the panel was not connected. He could not explain why the panel was not connected.

2. Observation of the emergency generator on 3/19/12 at 6:23 PM showed the electrical system was last modified in 2006. Further observation showed a remote emergency stop button had not been installed with the last modification to the system.

3. Observation of EES panel ELEA on 3/19/12 at 6:40 PM showed this panel was supplied with power from an equipment branch automatic transfer switch (ATS). Review of the panel directory showed circuit #11 med gas alarm lights, circuit #15 door openers, circuit #20 fire door holders, circuit #22 fire dampers, and circuit #24 generators fuel storage and alarm. The aforementioned devices are defined as life safety branch equipment and are only allowed in life safety panels. At the time of the observation the facility services manager reported the electrical panels were not routinely inspected to ensure only approved devices are installed in each panel.

4. Observation of EES panel EHEA on 3/19/12 at 6:45 PM showed this panel was supplied with power from an equipment branch ATS. Review of the panel directory showed circuits #20, #22, #24, and #25 all supplied power to medical gas equipment. The aforementioned equipment is defined as life safety branch equipment and is only allowed in life safety panels.

5. Observation of EES panel EHCIA on 3/19/12 at 7:40 PM showed the panel was supplied with power from a critical branch ATS. Review of the panel directory showed circuit #19 supplied power to exit lights in the ER hall. This piece of equipment is defined as life safety branch equipment and is only allowed in life safety panels.

6. Observation of EES panel EPI on 3/20/12 at 9:09 AM showed the panel was supplied with power from a life safety branch ATS. Review of the panel directory showed circuit #3 supplied power to the surgery lounge, #8 220 V. outlet, and #10 supplied power to the mammography room. The aforementioned pieces of equipment are defined as critical branch equipment and are only allowed in critical branch panels.

7. Observation on EES panel ECBA on 3/20/12 at 11:09 AM showed the panel was supplied with power from a critical branch ATS. Review of the panel directory showed circuit #3 and #5 supplied power to auto doors and #13 supplied power to exit lights. These pieces of equipment are defined as life safety branch and are only allowed in life safety branch panels. Further review showed circuits #2, #4, #6, #8, #10, #12, and #14 all supplied power to circulation pumps which are defined as equipment branch equipment and are only allowed in equipment branch panels.

8. Observation of EES panel EESQW-Y on 3/20/12 at 4:08 PM showed the panel was supplied with power from an equipment branch ATS. Review of the panel directory showed circuit #1 supplied power to the center and east corridor lighting, #3 supplied power to the corridor lighting by #133, and #5 supplied power to the west corridor lighting. These pieces of equipment are defined as life safety branch and are only allowed in life safety branch panels. Further review showed circuit #2, #4, #9 and #11 supplied power to patient room lights and staff area lights which are defined as critical branch equipment and are only allowed in critical branch panels.

9. Observation of EES panel ELSW1-AA on 3/20/12 at 4:10 AM showed the panel was supplied with power from a life safety branch ATS. Review of the panel directory showed circuit #7 and #9 supplied power to equipment storage room #130 and circuit #31 supplied power to the pyxis room HMSI 1335. These pieces of equipment are defined as critical branch and are only allowed in critical branch panels. At the time of the observation the facility services manager reported the electrical panels were not routinely inspected to ensure only approved devices are installed each panel.

10. On 3/20/12 at 5:50 PM the facility services manager reviewed blue print one line drawings to verify the supplying ATS for all aforementioned EES electrical panels.

Reference, NFPA 101, 2000 Edition, 19.2.9.1, 7.9.2.3, NFPA 110, 1999 Edition;
3-5.5.6 All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to the break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building.
3-5.6.1 A remote, common audible alarm powered by the storage battery shall be provided as specified in 3-5.5.2 (d). This remote alarm shall be located outside of the EPS service room at a work site readily observable by personnel.

Reference NFPA 101, 2000 Edition, 19.3.2.3, NFPA 99, 1999 Edition;
3-4.2.2.1 General. Type I essential electrical system are comprised of two separate systems capable of supplying a limited amount of lighting and power services, which is considered essential for the life safety and effective facility operation during the time the normal electrical service is interrupted for any reason. These two systems are the emergency system and the equipment system. The emergency system shall be limited to circuits essential to life safety and critical patient care. They are designated the life safety branch and the critical branch ...
3-4.2.2.2 Emergency System.
(a) General. These functions of patient care depending on lighting or appliances that are permitted to be connected to the emergency system are divided into two mandatory branches, described in 3-4.2.2 (b) and (c).

Based on observation and staff interview, the facility failed to ensure electrical panels were unobstructed on 1 of 4 floors. The findings were:

Observation of the material management area on 3/20/12 at 8:52 AM showed three electrical panels were obstructed by a file cabinet and cardboard storage bins. At the time of the observation the maintenance director reported this department staff had been repeatedly warned to keep the electrical panels unobstructed.

Reference, NFPA 101, 2000 Edition, 19.5.1, 9.1.2, NFPA 70, 1999 Edition;
110-26. Spaces About Electrical Equipment. Sufficient access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment ...
(a) Working Space. Working space for equipment operating at 600 volts, nominal, or less to ground and likely to require examination, adjustment, servicing, or maintenance while energized shall comply with the dimensions of (1), (2), and (3) or as required or permitted elsewhere in this Code.
(1) Depth of Working Space. The depth of the working space in the direction of access to live parts shall not be less than indicated in table 110-26(a) ...
Table 110-26(a)
Nominal Voltage Minimum Clear Distance (ft)
To Ground
_______________________________________
0/150 3 ft.

(b) Clear Space. Working space required by this section shall not be used for storage ...

Based on policy review and staff interview, the facility failed to ensure they had a fire watch policy. The findings were:

Review of the facility policies on 3/19/12 at 4:30 PM showed the facility did not have a fire watch policy to review. At the time of the review the facility services director confirmed the facility did not have a fire watch policy.