HospitalInspections.org

On 4-5-2016 while surveying the facility with the maintenance director, President, surveyor 14971 and 36434 this surveyor did observe:

90 minute fire rated doors leading into the ED corridor from main reception area would not close and latch

K 12 not met.
On April 5, 2016 inspector 14971 and inspector 36434 observed in the presences of the facility manager the facility failed to maintain required building construction type as required by the standard. The evidence includes:
1) Electrical closet on second floor ,steel beam missing protective insulation

2)Compactor room second floor,exposed steel beam missing protective insulation.

3) Boiler room first floor exposed steel beam missing protective insulation.

On 4-5-2016 while surveying the facility with the maintenance director, President, surveyor 14971 and 36434 this surveyor did observe:

FRP board attached to corridor walls, with no documentation on the finish rating of the material.

On 4-5-2016 while surveying the facility with the maintenance director, President, surveyors, 14971 and 36434 this surveyor did observe :


Fourth floor electrical room door located across the corridor from Case Management; door does not latch.

Fourth floor visitors room storage area double doors; fixed leaf was found unlatched.

Dutch doors on the mental health unit; top door shall be equiped with positive latching device and meeting edges of both doors shall be provided with rabbited joint or astragal installed.

Third floor electrical room door would not latch.

Roller latches found in the built in storage closet located in the exit access/ambulatory entrance/ Exit.


Radiology area Storage room CT #1 doors not latching and office storage door not latching.

On 4-5-2016 while surveying the facility with the maintenance director, President, surveyor 14971 and 36434 this surveyor did observe :

Opening in cooridor wall located in the ambulatory care area. Vision panel not fixed; opening greater than allowed area. (24" x 48")

K 20 not met.
On April 5, 2016 inspector 14971 and inspector 36434 observed the facility failed to maintain the required one hour fire rated utility shaft from Human Resources to the forth floor. In several locations it was observed that gypsum wallboard (Sheetrock) was missing or compromised.

K 25 This standard is not met.

On April 5, 2016 inspector 14971 and inspector 36434 observed in the presences of the facility manager the facility failed to maintain required smoke barriers as required by the standard.
The evidence includes:
(a) Unsealed penetrations were observed in the smoke barrier wall by Engineering 2 hr wall second floor pipe penetrations missing fire stops.
(b) Unsealed penetrations were observed in the smoke barrier wall in the second
floor mechanical room, separating the space from the occupational health unit.

On 4-5-2016 while surveying the facility with the maintenance director, President, surveyor 14971 and 36434 this surveyor did observe :

Nutrition room on the fourth floor; the room requires a self-closing device to be added to the corridor door.

Main Mechanical room; seal penetrations around medical gas pipe. No fire stopping found at pipe penetrations.

On 4-5-2016 while surveying the facility with the maintenance director, President, surveyor 14971 and 36434 this surveyor did observe :

Emergency department :
Ambulatory entrance/Exit storge located in the exit access. A large storage closet was placed in the exit access where it blocked the full opening of the exit door.

On 4-5-2016 while surveying the facility with the maintenance director, President, surveyors, 14971and 36434 this surveyor did observe :

During record reveiw a heat detector located in the elevator machine room near Radiology was called out in the annual fire alarm testing and maintenance report as not working. Please provide paper work indicating that this item has been corrected.

K56: On April 5, 2016 inspector 14971 and inspector 36434 observed while touring the facility with the maintenance manager it was observed the facility failed to maintain required sprinkler system as required by the standard. The evidence includes

(1) 1998 NFPA 25 2.2.1: Painted or loaded fire sprinkler heads in various locations. Penthouse/elevator machine room, by stairway in MHU, film storage, biomed.

(2) 1999 NFPA 13 5-1.1: Missing fire sprinkler coverage or obstructed throughout building: Special care unit, storage closet classroom B, electrical closet by worewell, head under duct work in mechanical, sidewall fire sprinkler heads under duct work not proper application, administration, hearing booth, switch room. It was observed during the inspection that sidewall sprinkler heads had been installed and are not listed for use under ductwork.

(3) 1999 NAPA 13 5-5.3.4: Fire sprinkler heads too close together: 2nd floor cafeteria, Facility management office

(4) 1998 NFPA 25 2.2.3, 1999 NFPA 13 6.1.1.5: Fire sprinkler piping supporting other piping Mechanical by quality, generators. Piping supports/hangers off in generator room. Sprinkler piping in the mechanical room was observed supporting other non-sprinkler piping. Also in the generator room it was observed that sprinkler piping support (hangers) had been disabled or removed.


34673

On 4-5-2016 while surveying the facility with the maintenance director, President, surveyor 14971 and 36434 this surveyor did observe :

Radiology room #2; Sprinkler side wall head damaged.

K 62 not met.
On April 5, 2016 inspector 14971 and inspector 36434 observed in the presences of the facility manager the facility failed to maintain required sprinkler system as required by the standard. The evidence includes:
1) Mechanical room on Level 4 a sprinkler head due to insulation overspray.
2) Special cure unit cubby on Level four requires sprinkler head.
3) Electrical closet second floor requires sprinkler protection.
4) Missing sprinkler head in mechanical room level 2 located under a large piece of ductwork.
5) Mechanical room sprinkler station missing spare sprinkler head box.
6) Obstructed sprinkler head in level 2 mechanical room due to insulation over spray.

K 72 This standard is not met as evidence by:
On April 5, 2016 inspector 14971 and inspector 36434 observed while touring the facility with the maintenance manager it was observed, on the fourth level of the facility, corridors are obstructed with stored items e.g. four beds.

On 4-5-2016while surveying the facility with the maintenance director, President, surveyor 14971 and 36434 this surveyor did observe :


Decorations and paintings found in the main reception / Lobby area and adjacent Emergency department corridor are not allowed unless flame retardent.
No documentation was provided at the time of inspection of items being treated with flame retardent.

K 78 not met.
On April 5, 2016 inspector 14971, inspector 36434 and inspector 34673 observed that the facility failed to provide the required signage for the piped medical gases (oxygen) valves in 4th floor located just before the mental health unit.


34673


On 4-5-2016 while surveying the facility with the maintenance director, President, surveyor 14971 and 36434 this surveyor did observe :

Medical Vacuum listed in the 6-16-2015 report as unknown if it is tied into the critical power branch. Please provide documentation that the Medical vacuum is tied into the critical power branch.


Medical gas pipe found open ended in the main mechanical room second floor.
Contamination of this pipe is probable due to not knowing how long it has been open to contaminants; recommend discontinued future use of this pipe.

On 4-5-2016 while surveying the facility with the maintenance director, President, surveyor 14971 and 36434 this surveyor did observe:

90 minute fire rated doors leading into the ED corridor from main reception area would not close and latch

K 12 not met.
On April 5, 2016 inspector 14971 and inspector 36434 observed in the presences of the facility manager the facility failed to maintain required building construction type as required by the standard. The evidence includes:
1) Electrical closet on second floor ,steel beam missing protective insulation

2)Compactor room second floor,exposed steel beam missing protective insulation.

3) Boiler room first floor exposed steel beam missing protective insulation.

On 4-5-2016 while surveying the facility with the maintenance director, President, surveyor 14971 and 36434 this surveyor did observe:

FRP board attached to corridor walls, with no documentation on the finish rating of the material.

On 4-5-2016 while surveying the facility with the maintenance director, President, surveyors, 14971 and 36434 this surveyor did observe :


Fourth floor electrical room door located across the corridor from Case Management; door does not latch.

Fourth floor visitors room storage area double doors; fixed leaf was found unlatched.

Dutch doors on the mental health unit; top door shall be equiped with positive latching device and meeting edges of both doors shall be provided with rabbited joint or astragal installed.

Third floor electrical room door would not latch.

Roller latches found in the built in storage closet located in the exit access/ambulatory entrance/ Exit.


Radiology area Storage room CT #1 doors not latching and office storage door not latching.

On 4-5-2016 while surveying the facility with the maintenance director, President, surveyor 14971 and 36434 this surveyor did observe :

Opening in cooridor wall located in the ambulatory care area. Vision panel not fixed; opening greater than allowed area. (24" x 48")

K 20 not met.
On April 5, 2016 inspector 14971 and inspector 36434 observed the facility failed to maintain the required one hour fire rated utility shaft from Human Resources to the forth floor. In several locations it was observed that gypsum wallboard (Sheetrock) was missing or compromised.

K 25 This standard is not met.

On April 5, 2016 inspector 14971 and inspector 36434 observed in the presences of the facility manager the facility failed to maintain required smoke barriers as required by the standard.
The evidence includes:
(a) Unsealed penetrations were observed in the smoke barrier wall by Engineering 2 hr wall second floor pipe penetrations missing fire stops.
(b) Unsealed penetrations were observed in the smoke barrier wall in the second
floor mechanical room, separating the space from the occupational health unit.

On 4-5-2016 while surveying the facility with the maintenance director, President, surveyor 14971 and 36434 this surveyor did observe :

Nutrition room on the fourth floor; the room requires a self-closing device to be added to the corridor door.

Main Mechanical room; seal penetrations around medical gas pipe. No fire stopping found at pipe penetrations.

On 4-5-2016 while surveying the facility with the maintenance director, President, surveyor 14971 and 36434 this surveyor did observe :

Emergency department :
Ambulatory entrance/Exit storge located in the exit access. A large storage closet was placed in the exit access where it blocked the full opening of the exit door.

On 4-5-2016 while surveying the facility with the maintenance director, President, surveyors, 14971and 36434 this surveyor did observe :

During record reveiw a heat detector located in the elevator machine room near Radiology was called out in the annual fire alarm testing and maintenance report as not working. Please provide paper work indicating that this item has been corrected.

K56: On April 5, 2016 inspector 14971 and inspector 36434 observed while touring the facility with the maintenance manager it was observed the facility failed to maintain required sprinkler system as required by the standard. The evidence includes

(1) 1998 NFPA 25 2.2.1: Painted or loaded fire sprinkler heads in various locations. Penthouse/elevator machine room, by stairway in MHU, film storage, biomed.

(2) 1999 NFPA 13 5-1.1: Missing fire sprinkler coverage or obstructed throughout building: Special care unit, storage closet classroom B, electrical closet by worewell, head under duct work in mechanical, sidewall fire sprinkler heads under duct work not proper application, administration, hearing booth, switch room. It was observed during the inspection that sidewall sprinkler heads had been installed and are not listed for use under ductwork.

(3) 1999 NAPA 13 5-5.3.4: Fire sprinkler heads too close together: 2nd floor cafeteria, Facility management office

(4) 1998 NFPA 25 2.2.3, 1999 NFPA 13 6.1.1.5: Fire sprinkler piping supporting other piping Mechanical by quality, generators. Piping supports/hangers off in generator room. Sprinkler piping in the mechanical room was observed supporting other non-sprinkler piping. Also in the generator room it was observed that sprinkler piping support (hangers) had been disabled or removed.


34673

On 4-5-2016 while surveying the facility with the maintenance director, President, surveyor 14971 and 36434 this surveyor did observe :

Radiology room #2; Sprinkler side wall head damaged.

K 62 not met.
On April 5, 2016 inspector 14971 and inspector 36434 observed in the presences of the facility manager the facility failed to maintain required sprinkler system as required by the standard. The evidence includes:
1) Mechanical room on Level 4 a sprinkler head due to insulation overspray.
2) Special cure unit cubby on Level four requires sprinkler head.
3) Electrical closet second floor requires sprinkler protection.
4) Missing sprinkler head in mechanical room level 2 located under a large piece of ductwork.
5) Mechanical room sprinkler station missing spare sprinkler head box.
6) Obstructed sprinkler head in level 2 mechanical room due to insulation over spray.

K 72 This standard is not met as evidence by:
On April 5, 2016 inspector 14971 and inspector 36434 observed while touring the facility with the maintenance manager it was observed, on the fourth level of the facility, corridors are obstructed with stored items e.g. four beds.

On 4-5-2016while surveying the facility with the maintenance director, President, surveyor 14971 and 36434 this surveyor did observe :


Decorations and paintings found in the main reception / Lobby area and adjacent Emergency department corridor are not allowed unless flame retardent.
No documentation was provided at the time of inspection of items being treated with flame retardent.

K 78 not met.
On April 5, 2016 inspector 14971, inspector 36434 and inspector 34673 observed that the facility failed to provide the required signage for the piped medical gases (oxygen) valves in 4th floor located just before the mental health unit.


34673


On 4-5-2016 while surveying the facility with the maintenance director, President, surveyor 14971 and 36434 this surveyor did observe :

Medical Vacuum listed in the 6-16-2015 report as unknown if it is tied into the critical power branch. Please provide documentation that the Medical vacuum is tied into the critical power branch.


Medical gas pipe found open ended in the main mechanical room second floor.
Contamination of this pipe is probable due to not knowing how long it has been open to contaminants; recommend discontinued future use of this pipe.