HospitalInspections.org

Based on observations surveyors 35163 and 39983 on 04/10/18, in the presence of the engineering technician the following was not met;

1. @11:00 The second floor-north stairwell located near radiology had penetrations on both sides of the rated wall, with no fire stopping material present.

2. @11:08 The rated wall above the double doors located on the second floor near ultrasound, had penetrations and approximately a 1'x6' area of missing gypsum. The gypsum board also did not extend fully to the roof deck and was not sealed.

3. @ 11:17 The 2nd floor ultrasound room door which is part of the rated wall assembly is missing a self closing device and has been damaged
( semi-repaired) which brings into question the doors integrity. Please provide documentation on what product was used to repair the door and that the repairs were done per manufacturers recommendations.

4. @ 11:30 The "old" bone density room-2nd floor (currently being used as a storage room) has penetrations in the rated wall assembly with no fire stopping material present. The wall also has duct work that passes through the rated wall assembly and it could not be verified that there was a fire damper in the duct work. Provide documentation that a fire damper is in place.

5. @11:37 The double doors located central stairwell had two 1" holes on each side of the rated frame. The rated wall above these door had penetrations and missing gypsum board with no fire stopping material present.

6. @11:40 The rated wall located near OR workroom had several penetrations (wires, sprinkler piping ductwork etc.) with no fire stopping material present. The wall also has duct work that passes through the rated wall assembly and it could not be verified that there was a fire damper in the duct work. Provide documentation that a fire damper is in place.

7. @11:44 The rated wall that is located along the staff locker rooms had pipe penetrations that were not sealed with fire stopping material. The locker room doors/frames that are within the rated wall assembly were not labeled/ rated

8. @11:52 The rated wall-above the double doors located near PACU had several penetrations, open conduit pipes, wires that penetrated the wall and no fire stopping material was present. The doors and frames had penetrations that have not been repaired. The fire rated doors do not latch on the top or the bottom

9. @ 11:55 The rated wall above the double doors located near surgery nursing station had penetration with no fire stopping material present.

10. @12:02 The rated wall-above the double fire rated doors located next to pharmacy had penetrations with no fire stopping material present. The double fire rated doors had a gap of 1/2" between the doors and would not prevent the passage of smoke/fire.


11. @ 12:10 The rated wall, above the double doors located next to acute care had penetrations with no fire stopping material present.

It was observed by surveyor 37696 & an apprentice with the Director of Environmental Services that this was not met due to: wheeled items being stored and/or were charging on both sides of the corridors of the acute care patient wing (2nd level)

Based on the observation of surveyor 37695 and 16732, there needs to be a illuminated exit sign in the kitchen above the exit door replacing the paper exit sign that is currently in place. This was found in the presence of the maintenance department.

Based on the observation of surveyor 37695 and 16732 located in the mechanical room by the kitchen, oily rags need to be removed. This was found in the presence of the maintenance department.

Based on the observation of surveyor 37695 and 16732, storage room located near the back door of the lab has penetrations in it. This room needs to be sealed and resist the passage of smoke. This was found in the presence of the maintenance worker.





38667

Based on observations by surveyor 38667 and 36434 with a facilities engineering representative that this standard is not met as evidenced by:

Boiler Room to the hallway, in the area of the door and stairs entering the boiler room, has multiple pipe penetrations unsealed

Boiler room, in the area of the Halco chemical (boiler treatment) storage tanks, has multiple pipe penetrations through the ceiling to the office space above that was only packed with mineral wool. This does not provide the proper protection for the space above

The elevator machine room in the basement had a pipe penetration to the hallway that was not sealed. Penetration observed from the hallway into the mechanical space.

The biohazard room in the basement has an electrical conduit (labeled Panel A) penetration through cmu wall with no sealant

The 1-hour wall outside of the morgue in the basement has a 1" sprinkler pipe penetration that is not sealed. It was observed from the hallway, across from the bulletin board

Electric room/fire alarm panel room storage of facility painting cart and materials were found

It was observed by fire marshal inspectors 37696 & an apprentice with the Director of Environmental Services that this was not met due to the following:

1) The 2 storage rooms across from patient room 207 are to be self-closing positive latching.

2) in the 2nd level outpatient surgery recovery area waiting room, a storage room door in the waiting room shall be self-closing positive latching.

3) The mechanical closet located across from the outpatient surgery waiting room (recovery corridor) had multiple open penetrations in the ceiling.

4) janitor closet on acute patient wing to be self-closing and positive latching

5) phone closet in out patient waiting room has hole in the ceiling and shall be sealed

6) storage room 8'x12' near Director of Surgical Services to have self-closing and positive latching door

7) radiology storage next to restroom to be self-closing and positive latching

8) soiled lined containers are being stored in the corridors of the acute patient wing

9) Electric room across from Directors Office, 2nd level, had open penetrations and the inactive door leaf was not latched making the pair of doors not latching

Based on observations by surveyor 38667 and 36434 with a facilities engineering representative that this standard is not met as evidenced by:

The exposed plywood in the main server room where data connections are mounted did not appear to be fire treated meeting the requirements of interior finish

Based on observation of surveyor 37695 and 16732 the smoke detector located in the mechanical room next to the kitchen has become detached from the ceiling. This was found in the presence of the maintenance department.

Based on observations by surveyor 38667 and 36434 with a facilities engineering representative that this standard is not met as evidenced by:

1) Rubber hose on air compressor connection for dry fire sprinkler system located in main sever room is not listed for fire sprinkler use.

2) Elevator machine room in basement next to mail room has no fire sprinkler coverage and is not a two hour fire rated room.

3) Elevator machine room by cafeteria fire sprinkler head too far down from ceiling and coverage in room is inadequate

4) Walk in cooler and freezer in kitchen has no fire sprinkler coverage

It was observed by fire marshal inspectors 37696 & an apprentice with the Director of Environmental Services that this was not met due to: no sprinkler coverage in the IT closet by Rm 214

Based on observations by surveyor 38667 and 36434 with a facilities engineering representative that this standard is not met as evidenced by:

Fire sprinkler control valve for antifreeze loop located in boiler room is not supervised.

Based on observations by surveyor 38667 and 36434 with a facilities engineering representative that this standard is not met as evidenced by:

No evidence provided that fire department connection has been hydrostatically test in last 5 years

It was observed by fire marshal inspectors 37696 & an apprentice with the Director of Environmental Services that this was not met due to:

1) the office of the case managers on the 2nd level across from patient room 203, had items stored on a shelf within 18" of the sprinkler head.

2) the 2nd level imaging area, X-Ray storage room for X-Ray records shelving, items stored on top of moveable shelves are within 18" of sprinkler heads.

3) Nuclear Med Office. top shelf over the desk has items stacked closer than 18"

Based on observations by surveyor 38667 and 36434 with a facilities engineering representative that this standard is not met as evidenced by:

Carbon Dioxide fire extinguisher, in boiler room area near maintenance office, was found to be blocked from access by a 5- gallon oily waste can as well as an unknown 55-gallon horizontal drum

Based on observation of surveyor 16732 on 04/10/18

The exit enclosure for the MRI area exits from door to an exit enclosure that has black plastic material for weather enclosure around the MRI trailer that is parked there. There is no documentation as to that the fire rating of the material is.


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It was observed by fire marshal inspectors 37696 & an apprentice with the Director of Environmental Services that this was not met due to the following:

1) When patient room bathroom doors are left open, they hold the patient room corridor door open preventing them from closing.

2) Patient room 206 & 217 door, metal astragal on wing door was bent, not allowing door to latch properly.

3) door on patient room 215 did not latch. The door latch appeared to be lower than the frame catch

4) The following rooms had, the gap between the slab and frame exceeds allowable
a. room 1 in X-Ray
b. administration originator, next to the pharmacy, (measured 1")
c. out patient rm #4 recovery

5) the following doors had "precautionary supplies" stored in hanging pouches that hung over the door. The metal hooks prevent the doors from closing and latching: Rm 201, 207,

Based on observations by surveyor 38667 and 36434 with a facilities engineering representative that this standard is not met as evidenced by:

Ceiling tiles were found to have been removed in various locations of the monolithic ceiling in the main server room exposing CPVC sprinkler piping

Based on observations by surveyor 38667 and 36434 with a facilities engineering representative that this standard is not met as evidenced by:

An unknown, unlabeled 55-gallon drum container was observed to be laying in a horizontal position, blocking access to a fire extinguisher as well as 2 large service disconnect switched for the boiler system. The facility representative mentioned that this product was some sort of sludge cutter for the old oil boilers that are no longer in use.

On 4/11/18 at 12:35 PM, two Duraflame electric oil heaters were observed, by two health surveyors, in the clean storage room in The Birthing Center, which is an inpatient unit. The Engineering Manager, who was present at the time of the observation, indicated the heaters were not supposed to be on the unit.

On 4/12/18 at 7:42 AM, the Nurse Manager of The Birthing Center indicated that the heaters were not used by patients but used by Physicians in the Physician call room. She verified that the heaters would be used while Physicians were sleeping in the call room.

Oiled filled heaters can only be used in staff areas and the staff must be awake at all times..

It was observed by fire marshal inspectors 37696 & an apprentice with the Director of Environmental Services that this was not met due to:

1) in the office of the Case Managers on the 2nd level, located across from patient room 203, a microwave oven is plugged into a power strip

2) Director of Surgical Services there was an a/c unit plugged into a yellow extension cord