HospitalInspections.org

03245

Based on facility observation and staff interview, the facility failed to ensure that corridors were separated from use areas by walls constructed with at least ½ hour fire resistance rating. In non-sprinklered buildings, walls properly extend above the ceiling. The facility had a capacity of 441 beds with a census of 197 patients at the time of the survey. Potentially all patients, visitors and staff could be affected.

Findings include:

On 07/07/14 between the hours of 10:30 A.M. and 3:50 PM, tour was conducted with Staff H, G, and I. On 07/08/14 between 9:15 AM and 12:30 PM, tour of the facility was conducted with Staff H, I, and J. Staff H and I confirmed the facility had not completed their plan to install sprinkler heads for the corridors cited on the 05/02/14 survey that was not separated from use areas by walls constructed with at least 1/2 hour fire resistance rating. These areas are as follows:

Fourth Floor:

1. Above the ceiling tiles on the "4 Bridge" with Staff PP revealed the corridor wall between Room 476 and Room 484 had a 1 foot by 25 feet section that did not extend to the floor decking above.

Third Floor

2. Above the ceiling tiles on 04/30/14 at 11:00 AM, of the "3C Wing", revealed the south corridor wall between the Mercy Heart Center Administrative Director doors had a three fourths inch conduit with two data cables passing through and a one half inch conduit with open annular spaces.

3. Above the ceiling tiles revealed multiple penetrations varying in size and shape in the north corridor wall from the EP lab programmer room past the Respiratory Care Director office. Additionally the wall did not extend to the floor decking above.

4. On the third floor, "3 Bridge area", revealed a one and one half foot by one foot penetration above the ceiling tiles at the corridor doors between "3 Bridge" and "3A Wing".

5. Above the ceiling tiles of the north corridor wall revealed two, one and a half inch chilled water pipes passing through the wall of the corridor with an open annular space.

These areas were observed with an automatic sprinkler system in place during the tour. On 07/07/14 at 11:50 AM, Staff H stated the facility was installing sprinkler heads/system in three phases. Phase 1 (C-Wing 3rd floor) was currently in process; however, was not completed. Staff H further stated Phase 2 (3rd floor core) and Phase 3 (4 Bridge area by Room 484) had not been initiated.

During the aforementioned tour, sprinkler heads were observed on the 3rd floor C-Wing; however, were not visible in all areas. There were no sprinkler heads observed in the 3rd floor Core or 4th floor areas. Staff H and I confirmed the lack of sprinkler heads in these areas.

Based on facility observation and staff interview, the facility failed to ensure the hospital met the applicable provisions of the Life Safety Code of the National Fire Protection Association. The facility had a capacity of 441 beds with a census of 197 patients at the time of the survey. Potentially all patients, visitors and staff could be affected.


Findings include:


On 07/07/14 between the hours of 10:30 A.M. and 3:50 PM, tour was conducted with Staff H, G, and I. On 07/08/14 between 9:15 AM and 12:30 PM, tour of the facility was conducted with Staff H, I, and J. The following observations of life safety measure revealed the following findings:

1. The 4th floor Sleep Clinic area was observed with six sleeping rooms. This area contained a medical records storage room equipped with multiple shelves filled with paper medical records. The room was observed with two wooden doors. One of the two doors was a sliding wooden pocket door. There was no fire resistance rating on either of the two wooden doors.

2. Observation of the walls above the ceiling tiles on the outside of the room revealed one layer of 5/8 inch drywall. Staff I confirmed the drywall provided a 1/2 hour fire resistance rating instead of the one hour fire resistance rating as required by the code for hazardous areas.

3. Observation of the medical records room, and area in which the sleeping rooms were located, revealed the entire space lacked automatic sprinklers.

Interview with Staff H and I during tour confirmed the doors to this room had been ordered, but would not be available until August 2014.

03245

Based on facility observation and staff interview, the hospital failed to ensure that smoke detectors in spaces serviced by air-handling systems were not located where airflow patterns could prevent the normal operation of the detectors. The requirement is located in the National fire Protection Association (NFPA) 72, National Fire Alarm code, 1999 Edition, chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1. The facility had a capacity of 441 beds with a census of 197 patients at the time of the survey. Potentially all
patients, visitors and staff could be affected.

Findings include:

On 07/07/14 between the hours of 10:30 A.M. and 3:50 PM, a tour was conducted with Staff H, G, and I on the first floor surgery and post-operative areas. Smoke detectors were observed within two feet of an air diffuser. These smoke detectors were observed on the first floor as follows:

1. In the operating room clean core area, between OR rooms three and four.

2. In the main corridor near OR two and three.

3. In two Soiled utility rooms in the operating room area. One soiled utility room was shared with the operating rooms. The second soiled utility room was located in the post-operative area 18-22.

Staff I confirmed during tour the smoke detectors were less than 36 inches from the air supply diffusers.