HospitalInspections.org

.

Based on observation and interview, the facility failed to maintain the automatic locking system on the exit doors per the requirements of:

2012 NFPA 101, 19.2.2.2.5.2

Findings include:

1. On 03/27/2018, during a tour of the facility from 9:45 am to 4:00 pm, the full time locked egress doors failed to automatically unlock upon activation of the fire alarm at the First Floor Sub Sterile Hall.


36148

2. On 03/27/2018, during a tour of the facility from 9:45 am to 4:00 pm, the full time locked egress doors failed to automatically unlock upon activation of the fire alarm in the following locations:

1. 3rd Floor stairway "B"
2. 2nd Floor stairway "C"

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

.

Based on review and interview, the facility failed to provide emergency lighting per requirements of:

2012 NFPA 101, 19.2.9.1, and 7.9.2.6

On 3/27/2018, during a tour of the facility from 9:45 am to 4:00 pm, when testing of the emergency lighting in the Minor Operating Room the emergency battery lighting failed to operate.

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

.

Based on observation and interview, the facility failed to maintain the exit signage per the requirements of:

2012 NFPA 101, 19.2.10.1, and 7.10.1.2.1

Findings include:

On 03/28/2018, during a tour of the facility from 7:45 am to 4:15 pm, the Physical and Sports Rehabilitation Room was observed with two exits that were not provided with directional signs. This room is approximately 2,430 square feet.

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

.

.

Based on observation and interview, the facility failed to maintain the minimum fire resistance rating for Stairways, per the requirements of:

2012 NFPA 101 19.3.1, and 8.6

Findings include:

On 3/27/2018, during a tour of the facility from 9:45 am to 4:00 pm, the surveyor observed unsealed penetrations around a group of wiring, over the "C" Stairwell Door Second Floor.

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

.

Based on observation and interview, the facility failed to provide separation from a hazardous area per the requirements of:

42 CFR 483.90 (a) (1) (ii)
2012 NFPA 101, 19.3.2.1.3

Findings include:

On 3/28/2018, during a tour of the facility from 7:45 am to 4:15 pm, the surveyor observed the door to the Bulk Storage Room, located in Central Supply (this room is used for the storage of combustible items and is over 50 sq. ft.) failed to positive latch.

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

.

.

Based on observation and interview, the facility failed to maintain a hazardous area per the requirements of:

2012 NFPA 101, 19.3.2.1.3

Findings include:

On 03/28/2018, during a tour of the facility from 7:45 am to 4:15 pm, the Medical Records Office was observed to be greater than 50 square feet with stored combustibles (papers, files) and without a self-closing device on the door.

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

.

Based on observation and interview, the facility failed to install an Alcohol-Based Hand-Rub (ABHR) Dispenser per the requirements of:

2012 NFPA 101, 19.3.2.6 (8)

Findings include:

On 03/28/2018, during a tour of the facility from 7:45 am to 4:15 pm, the surveyor observed that an ABHR dispenser was mounted directly above a light switch (ignition source) in the Outpatient Wellness Room.

A member of maintenance staff was present when this deficiency was found.

.

.
Based on observation and interview, the facility failed to maintain automatic sprinkler coverage per the requirements of:

2012 NFPA 101, 19.3.5.3, and 9.7.1.1 (1)
2010 NFPA 13, 8.10.3, and 8.6.4.1.1.1

Findings include:

1. On 03/28/2018, during a tour of the facility from 7:45 am to 4:15 pm, the surveyor observed sprinkler coverage was not provided behind the dryer in the Laundry Room, located in the Basement. This space only had one sprinkler, and it failed to meet distances between sprinklers for this area.


36148


2. On 03/28/2018, during a tour of the facility from 7:45 am to 4:15 pm, the distance between the sprinkler deflectors and the ceiling did not meet the minimum requirements of 1 in.(25.4 mm) and a maximum of 12 in. (305 mm) throughout the area of coverage for the sprinklers in the following locations:

1. The Corner Storage Room
2. The Outpatient Pink Lady Storage Room

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

.

.

Based on observation and interview, the facility failed to maintain the automatic sprinkler system per the requirements of:

2012 NFPA 101, 19.3.5.1, and 9.7.8
2011 NFPA 25, 5.1.1.2 , and Table 5.1.1.2

Findings include:

On 03/28/2018, during a tour of the facility from 7:45 am to 4:15 pm, the facility failed to provide documentation for the quarterly sprinkler inspection that was due in January 2018.

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

.

Based on observation and interview, the facility failed to maintain the automatic sprinkler system per the requirements of:

2012 NFPA 101, 19.3.5.1, and 9.7.8
2011 NFPA 25, 5.1.1.2, and Table 5.1.1.2

Findings include:

On 03/28/2018, during a tour of the facility from 7:45 am to 4:15 pm, the facility failed to provide documentation for the quarterly sprinkler inspection that was due in January 2018.

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

.

Based on observation and interview, the facility failed to ensure the correct height of the fire extinguishers per requirements of:

2012 NFPA 101, 19.3.5.12, and 9.7.4.1
2010 NFPA 10, 6.1.3.8.1

Findings include:

On 3/27/2017, during a tour of the facility from 9:45 am to 4:00 pm, the surveyor observed that the fire extinguisher in the Cat Scan Room was on the floor and not properly mounted.

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

.

Based on observation and interview, the facility failed to maintain the corridor doors per the requirements of:

2012 NFPA 101, 19.3.6.3.2 (2), and 19.3.6.3.5
42 CFR 483.90 (a) (1) (ii)

Findings include:

On 3/27/2018, during a tour of the facility from 9:45 am to 4:00 pm, the surveyor observed the following corridor doors:
1. The corridor door by the Service Elevator failed to positive latch
2. Room 200's corridor door had four holes around the door handle

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

.

.

Based on observation and interview, the facility failed to maintain the smoke barriers to restrict the movement of smoke and have a minimum 1/2 hour fire resistance rating per the requirements of:

2012 NFPA 101 19.3.7.3, and 8.5.1

Findings include:

1. On 03/28/2018, during a tour of the facility from 7:45 am to 4:15 pm, the barrier by the Admitting Business Office, was observed with an unsealed opening.


36148


2. On 03/28/2018, during a tour of the facility from 7:45 am to 4:15 pm, the surveyor observed an unsealed penetration with 2 red pix lines in the smoke barrier near the Outpatient Wellness and the Storage Room.

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

.

Based on observation and interview, the facility failed to maintain the smoke barriers to restrict the movement of smoke and have a minimum 1/2 hour fire resistance rating per the requirements of:

2012 NFPA 101 19.3.7.3, and 8.5.1

Findings include:

A. On 03/27/2018, during a tour of the facility from 9:45 am to 4:00 pm, the surveyor observed the following:

1. An unsealed penetration around three sections of conduit in the smoke barrier by Southside Nurses' Station
2. An unsealed penetration at the end of a sleeve in the smoke barrier by Northside Nurses' Station
3. An unsealed penetration around a group of wiring in the smoke barrier by Stairwell "A" Basement


36148

B. On 03/27/2018, during a tour of the facility from 9:45 am to 4:00 pm, the surveyor observed the following:

4. An unsealed penetration of a 2" pipe in the smoke barrier next to Room 302
2. An unsealed penetration of a 3/4" pipe in the smoke barrier next to Room 324
3. An unsealed penetration of a 3" pipe in the smoke barrier next to the Nuclear Medicine Room on the 1st floor

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

.

Based on observation and interview, the facility failed to maintain the smoke barrier doors per the requirements of:

2012 NFPA 101, 19.3.7.8, and 8.5.4.1

Findings include:

On 3/28/2018, during a tour of the facility from 7:45 am to 4:15 pm, the surveyor observed upon activation of the fire alarm system the smoke barrier doors failed to fully close so as to resist the passage of smoke, by Fiscal Services Conference Room.

.

.

Based on review of documentation and interview, the facility failed to exercise the diesel generator once monthly for a minimum of 30 minutes under loading that maintains the minimum exhaust gas temperature recommended by the manufacturer or under operating temperature conditions and at not less than 30% of the EPS nameplate kW rating and exercise once every 36 months for 4 continuous hours. The facility did not document the load transfers of the generator per the requirements of:

2012 NFPA 99, 6.5.4.1.1.2, 6.4.4.1.1.3,and 6.5.4.2
2010 NFPA 110, 1.3, 8.3.2.1, 8.4.1, 8.4.2, 8.4.2.3, 8.4.9, 8.4.9.1 and 8.4.9.7

Findings include:

On 03/28/2018 during a tour of the facility from 7:45 am to 4:15 pm:

1. The facility failed to provide documentation that the diesel generator was exercised once monthly for a minimum of 30 minutes with a load of not less than 30% of the diesel generator nameplate kW rating or the minimum manufacturer recommended exhaust temperature is met

OR

2. The facility failed to provide documentation of the annual 1.5 hour supplemental load bank test for the previous 12 months. A supplemental load bank test of not less than 50% of the EPS nameplate kW rating for 30 continuous minutes and at not less than 75% of the EPS nameplate kW rating for 1 continuous hour for a total test duration of not less than 1.5 continuous hours is required if the facility cannot not document item 1.

3. The facility failed to provide documentation of the Level 1 EPS test at least once within every 36 months.

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

.

Based on review of documentation and interview, the facility failed to exercise the diesel generator once monthly for a minimum of 30 minutes under loading that maintains the minimum exhaust gas temperature recommended by the manufacturer or under operating temperature conditions and at not less than 30% of the EPS nameplate kW rating and exercise once every 36 months for 4 continuous hours. The facility did not document the load transfers of the generator per the requirements of:

2012 NFPA 99, 6.5.4.1.1.2, 6.4.4.1.1.3,and 6.5.4.2
2010 NFPA 110, 1.3, 8.3.2.1, 8.4.1, 8.4.2, 8.4.2.3, 8.4.9, 8.4.9.1 and 8.4.9.7

Findings include:

On 03/28/2018 during a tour of the facility from 7:45 am to 4:15 pm:

1. The facility failed to provide documentation that the diesel generator was exercised once monthly for a minimum of 30 minutes with a load of not less than 30% of the diesel generator nameplate kW rating or the minimum manufacturer recommended exhaust temperature is met

OR

2. The facility failed to provide documentation of the annual 1.5 hour supplemental load bank test for the previous 12 months. A supplemental load bank test of not less than 50% of the EPS nameplate kW rating for 30 continuous minutes and at not less than 75% of the EPS nameplate kW rating for 1 continuous hour for a total test duration of not less than 1.5 continuous hours is required if the facility cannot not document item 1.

3. The facility failed to provide documentation of the Level 1 EPS test at least once within every 36 months.

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

.

Based on observation and interview, the facility failed to maintain the oxygen cylinders per the requirements of:

2012 NFPA 99, 11.6.2.3 (11)

On 03/28/2018, during a tour of the facility from 7:45 am to 4:15 pm, the surveyor observed an unsecured oxygen cylinder in the following locations:

1. The Sleep Center Exam Room 2
2. The Outpatient Oncology front reception desk

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