HospitalInspections.org

Based on observation, the facility does not ensure the integrity of the fire/smoke rated walls at the hospital or at the extension clinic, Livingston Health Services (LHS).

Findings include:

During facility tour on 12/7/11 and 12/8/11 at the hospital, and on 12/7/11 at LHS, it was observed that penetrations were present in the designated fire/smoke walls of the floor plans provided by the facility. Examples of these penetrations were identified in the following locations:
- Hospital:
---The smoke barrier/fire rated walls on second and third floors that divide the floors into two smoke compartments. The floor plan indicates that these walls are smoke barrier walls and 2-hour fire rated walls.
- LHS:
---Wall penetrations were noted in the fire rated walls in the After Hours Clinic (I-99), laboratory/radiology (I-77), in the egress corridor (I-92) and in the film files (I-73).
---Ceiling penetrations were noted in the Dexascan room (I-74) in the radiology area. Walls that have a designated rating (30+ minutes) are inadequate if rock wool insulation has been installed without a proper sealant applied.
These findings were verified with Staff #4 and 52 on 12/7/11 and 12/8/11.

Based on observation, the facility does not ensure that marked exits are accessible at all times. (Room #1302)

Findings include:

During facility tour on 12/7/11, it was observed that the marked exit door entering the ambulatory surgical waiting room was locked. Egress exit doors must remain unlocked from the egress side whenever the building is occupied.

This finding was verified with Staff #4 on 12/7/11.

Based on observation, the facility does not ensure that directional arrows (chevrons) are provided on the exit signs in the ambulatory surgical suite.

Findings include:

During facility tour on 12/7/11, it was observed that chevrons were lacking on the exit sign at the intersection of corridors 1300A and 1300B. Chevrons must be provided on all exit signs where the direction of travel to reach an exit is not apparent.

This finding was verified with Staff #4 on 12/7/11.


Based on observation, the facility does not ensure that 2 of 2 doors that do not lead to an exit or exit access are properly labeled in the ambulatory surgical suite. (Rooms #1302 and 1306)

Findings include:

During facility tour on 12/7/11, it was observed that doors entering room #1302 (ASC waiting) and room #1306 (janitor's closet) were not properly labeled. These doors must be labeled and identified as "NO EXIT". Any door that is arranged so that it could be mistaken for an exit or an exit access door must be properly identified and labeled.

This finding was verified with Staff #4 on 12/7/11.

Based on interview, the facility does not ensure that the fixed temperature, non-restorable spot heat detectors are tested or replaced every 15 years.

Findings include:

During interview on 12/5/11, Staff #4 revealed that the facility has 95 fixed temperature, non-restorable spot type heat detectors that were installed in 1972. Staff #4 also revealed that the heads on these detectors are non-addressable at the fire alarm control panel, have not been replaced, and that laboratory testing has not occurred as required on two detectors.


Based on document review and interview, the facility does not ensure that 14 of 107 fire dampers were tested. (Dampers #78865-78867, 78869-78875, 78877-78879 and room #326A)

Findings include:

Review on 12/9/11 of the fire damper inspection report indicated that 14 of 107 fire dampers were not tested in 2010 because they were "inaccessible". A telephone interview with Staff #52 on 12/15/11 revealed that she did not have information regarding why these dampers were inaccessible. Review of documentation provided on 12/16/11 revealed that these dampers were last tested in 2007, but the report does not indicate the corrective action that was performed on the dampers that failed at that time.


Based on document review and interview, the facility does not ensure that 51 of 51 smoke dampers and 4 of 4 fire/smoke dampers are visually observed when tested. (6 smoke dampers at Livingston Health Services, and 45 smoke dampers and 4 fire/smoke dampers at the hospital)

Findings include:

Review on 12/7/11 of the smoke damper test report indicated that all smoke and fire/smoke dampers were tested in 11/2010. An interview with Staff #4 and 52 on 12/7/11 revealed that these dampers are not visually observed to ensure that they close completely or operate properly. Staff #4 indicated that these dampers are on a building management system and monitored via this system. He also indicated that this system verifies that the actuator on the damper is operational, but does not ensure that the damper closes completely.


Based on observation, document review and interview, the facility does not ensure that an access panel is provided on 1 of 4 smoke dampers in corridor 213.

Findings include:

During facility tour on 12/8/11, it was observed that an access panel was not provided for 1 of 4 smoke dampers in corridor 213, which is designated as a 30 minute smoke barrier and a 2-hour fire wall.

Review on 12/8/11 of the smoke damper test report revealed that four smoke dampers had been tested on 11/28/10 and were fully operational. However, without an access panel for the one damper, it is not possible to determine if the damper operates properly when the fire alarm system is activated. During interview on 12/8/11, Staff #4 indicated that he was unsure as to why an access panel was not present for the damper.

Based on observation, the facility does not ensure that the sprinkler system is visually inspected at the Livingston Health Service site.

Findings include:

During facility tour on 12/7/11 at the Livingston Health Services site, it was observed that the escutcheon was not present on the sprinkler in the laboratory area adjacent to the toiletrooms.

This finding was verified with Staff #4 and 52 on 12/7/11.

Based on document review and interview, the facility does not ensure the proper operation of the Level 1 medical gas system.

Findings include:

Review on 12/6/11 of the Annual Medical Gas System Evaluation report for 2010 did not reveal evidence that corrective action had been performed on the following identified deficient components in the medical gas system:
- Patient Terminal Tests:
---The check valve for the oxygen (O2) leaks in Room #314, 309, 306, 305, 202, 1218, and in the nursery;
---The check valve for the vacuum leaks in Rooms #305, 251, PACU bed 16, 165 and 164;
---The faceplate was worn on the vacuum in Room #347;
--- The quick connect was loose on the O2 in Room #303;
---The dynamic flow was low on the vacuum in Room #B25;
---The flow meter fitting was broken on the O2 in Room #163.
- Master Alarm Verification:
---An alarm was not present on the master alarm panel in the Emergency Room or in maintenance department for the lag unit for the compressed medical air;
---The high temperature, carbon monoxide and the dew point were not verified at the master alarm panel in the Emergency Room or in the maintenance department;
---The test switch on OB/GYN (second floor) for the oxygen, medical air and vacuum was broken.
These findings were verified with Staff #4 and 52 on 12/6/11.

Based on document review and interview, the facility does not ensure that humidity readings in 2 of 2 operating rooms and 2 of 2 procedure rooms are documented.

Findings include:

Review on 12/8/11 of the provided documentation did not show evidence that humidity readings in the 2 operating rooms and in the 2 procedure rooms are documented daily.

An interview with Staff #55 on 12/8/11 revealed that this monitoring is performed by facility maintenance on an automated building computer system. During interview on 12/8/11, Staff #4 confirmed that the humidity readings are monitored daily via the building management system (Metasys), but the readings are not documented or retrievable after 24 hours.

Based on document review and interview, the facility does not ensure that 2 of 2 emergency showers are tested weekly in 2 of 2 laboratories. (Livingston Health Services site and the hospital)

Findings include:

Review on 12/9/11 of the testing document for the emergency shower in the laboratory at the hospital revealed that the shower was last tested on 7/19/11. Interview with Staff #52 on 12/9/11 revealed that she thought the requirement for testing of the emergency shower was at intervals of every six months. During interview on 12/9/11, Staff #4 revealed that the emergency shower in the laboratory at Livingston Health Services was also last tested in 7/2011.

These devices must be tested weekly by opening water flow through the nozzles to verify that sufficient water is available. It is also required that an annual inspection, checking flow rates through the supply line, is performed to ensure that adequate pressure and flow are provided.