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A. Based on random observation during the survey walk through, a non-conforming connected structure (mobile MRI) is attached to the building (three days a week) forming an interior connection from the Construction Type II (222) healthcare building to the MRI. There is a lack of a continuous two hour separation to comply with 18.1.1.4.2 and 8.2. The pair of cross corridor doors leading to the MRI area are non-fire rated aluminum store front.




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A. Based on random observation during the survey walk-through, areas not designated as hazardous areas on the Life Safety floor plan are being used for storage in a quantity which the Authority Having Jurisdiction (AHJ) deems hazardous and do not comply with 18.3.2.1 and 18.3.6.3.4. Locations and conditions observed are as follows:

1. First floor Lab Storage door # 1315 (per blue print # for doors) this door is not self closing.

2. First floor Lab Water treatment room containing the water softner, contains 18 stacked cardboard boxes. The doors are bi-fold style and do not comply with self-closing latching doors with a minimum fire resistance rating of 3/4 hour to comply with 18.3.2.1. and 8.2.3.2.3.1.(2).

3. Second floor Storage room located across from Room # E2102 contains 17 E sized oxygen tanks. This room does not meet the requirements for a med-gas storage room to comply with 18.3.2.4 and NFPA 99 1999 edition.

4. Second floor Inpatient Rehab whirlpool room which is not designated as a hazardous area on the Life Safety floor plan contains equipment stacked and stored in a quantity that deems this room as storage. This room appears to be 100 square feet and lacks the separation indicated in table 18.3.2.1.


B. Based on random observation during the survey walk-through, hazardous areas which are designated as specific are being used for storage of items not related to the designated purpose of the room. Location observed:

1. First floor "Power room" containing switchgear is being used for the storage of 7 large ladders.




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A. During the survey walk through, doors in designated 2-hour fire rated separation walls were observed which do not form a complete barrier to comply with 8.2.4.3.4 and NFPA 80 1999 2-3.1.7 due to the following:

1. Pairs of cross corridor doors were observed which upon closing allow for a continuous vertical gap between the meeting stiles that exceeds the allowable 1/8 inch (+ or - 1/16 inch) provided in NFPA 80. Locations observed the Second floor cross corridor doors adjacent to the nurses station and pair of doors leading to the MOB.




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A. Based on random observation during the survey walk through, the facility does not appear to be fully sprinkler protected to comply with the automatic requirements of ch. 18. Surveyor observed a lack of sprinkler protection within the area connecting the mobile MRI unit. During the time that the MRI is connected to the facility, this space is an interior enclosed non-sprinklered area within a sprinker protected healthcare occupancy.




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A. During the survey walk-through of the facilities Dietary Department the remote activation device for the hood suppression system was observed without a placard clearly identifying the hazard protected and does not comply with NFPA 17A 3-7.1.4.




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A. Based on random observation during the document review, not all portions of the facility commercial cooking equipment are maintained in accordance with NFPA 96 1998.
It was not documented on the semi-annual hood extinguishment system inspection/maintenance report that the suppression system fusable links was replaced annually in accordance with 8-2.2.




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A During the survey walk through, the surveyor noted that the designated med-gas storage closet did not comply with the storage requirements for nonflammable gasses less than 3,000 cubic feet (NFPA 99, 1999, 4-3.1.1.2 ( c ) ). The storage closet contained 12 E-size oxygen tanks. The storage closet is located directly connected to a first floor exit access corridor. This room lacked adequate ventilation.




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A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.




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A. Based on random observation during the survey walk through, a non-conforming connected structure (mobile MRI) is attached to the building (three days a week) forming an interior connection from the Construction Type II (222) healthcare building to the MRI. There is a lack of a continuous two hour separation to comply with 18.1.1.4.2 and 8.2. The pair of cross corridor doors leading to the MRI area are non-fire rated aluminum store front.




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A. Based on random observation during the survey walk-through, areas not designated as hazardous areas on the Life Safety floor plan are being used for storage in a quantity which the Authority Having Jurisdiction (AHJ) deems hazardous and do not comply with 18.3.2.1 and 18.3.6.3.4. Locations and conditions observed are as follows:

1. First floor Lab Storage door # 1315 (per blue print # for doors) this door is not self closing.

2. First floor Lab Water treatment room containing the water softner, contains 18 stacked cardboard boxes. The doors are bi-fold style and do not comply with self-closing latching doors with a minimum fire resistance rating of 3/4 hour to comply with 18.3.2.1. and 8.2.3.2.3.1.(2).

3. Second floor Storage room located across from Room # E2102 contains 17 E sized oxygen tanks. This room does not meet the requirements for a med-gas storage room to comply with 18.3.2.4 and NFPA 99 1999 edition.

4. Second floor Inpatient Rehab whirlpool room which is not designated as a hazardous area on the Life Safety floor plan contains equipment stacked and stored in a quantity that deems this room as storage. This room appears to be 100 square feet and lacks the separation indicated in table 18.3.2.1.


B. Based on random observation during the survey walk-through, hazardous areas which are designated as specific are being used for storage of items not related to the designated purpose of the room. Location observed:

1. First floor "Power room" containing switchgear is being used for the storage of 7 large ladders.




.

A. During the survey walk through, doors in designated 2-hour fire rated separation walls were observed which do not form a complete barrier to comply with 8.2.4.3.4 and NFPA 80 1999 2-3.1.7 due to the following:

1. Pairs of cross corridor doors were observed which upon closing allow for a continuous vertical gap between the meeting stiles that exceeds the allowable 1/8 inch (+ or - 1/16 inch) provided in NFPA 80. Locations observed the Second floor cross corridor doors adjacent to the nurses station and pair of doors leading to the MOB.




.

A. Based on random observation during the survey walk through, the facility does not appear to be fully sprinkler protected to comply with the automatic requirements of ch. 18. Surveyor observed a lack of sprinkler protection within the area connecting the mobile MRI unit. During the time that the MRI is connected to the facility, this space is an interior enclosed non-sprinklered area within a sprinker protected healthcare occupancy.




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A. During the survey walk-through of the facilities Dietary Department the remote activation device for the hood suppression system was observed without a placard clearly identifying the hazard protected and does not comply with NFPA 17A 3-7.1.4.




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A. Based on random observation during the document review, not all portions of the facility commercial cooking equipment are maintained in accordance with NFPA 96 1998.
It was not documented on the semi-annual hood extinguishment system inspection/maintenance report that the suppression system fusable links was replaced annually in accordance with 8-2.2.




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A During the survey walk through, the surveyor noted that the designated med-gas storage closet did not comply with the storage requirements for nonflammable gasses less than 3,000 cubic feet (NFPA 99, 1999, 4-3.1.1.2 ( c ) ). The storage closet contained 12 E-size oxygen tanks. The storage closet is located directly connected to a first floor exit access corridor. This room lacked adequate ventilation.




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A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.




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