HospitalInspections.org

Based on observation, not all stairs or smokeproof enclosures are constructed and maintained as required including stair components within the stair enclosure. This deficient practice could affect patients, staff, and visitors in the building because their egress from the building could be impeded if the stairs and smokeproof enclosures are not properly constructed and maintained.

Findings include:

A. On 07/26/2022, at 1:20pm while in the company of the ME, it was observed that a storage room is located within an exit stair. This condition does not comply with 7.1.3.2.1(10). This condition does not comply with 7.2.2.5.3., there can be no usable space located within a stair enclosure, the entrance to the storage space is also within the exit stair which does not comply with 7.2.2.5.3.2. Location observed: Exit Stair #7 Basement level.

B. On 07/26/2022, at 1:25pm while in the company of the ME, it was observed that a through wall drainage pipe is open to the noncompliant storage room located within a exit stair #7. This condition does not comply with 7.1.3.2.1(10) and 7.1.3.2.1(3) for a 2 hour fire rated separation.

C. On 07/26/2022, at 10:10am while in the company of the ME, it was observed that an entry door to an exit stair does not maintain the 2-hour fire rating of the stair enclosure due to a hole in the door frame. Location observed First floor Stair #3 door frame - hinge side.

Based on observation, not all egress paths lead to an exit. This deficient practice could require a person to traverse a longer route to reach an exit. This deficient practice may compromise the prompt care and movement of patients, visitors and staff during a fire/smoke emergency.

The findings: are

A. On 07/26/2022 at 9:50am while accompanied by the ME, the designated means of egress (exit sign above doorway) from the Dining areawas observed leading to an exterior dining area with no viable means of egress to the public way. The Dining room lacks two required exits to comply with 7.5.1.1. and 7.5.1.3.

B. On 07/26/2022 at 1:07pm while accompanied by the ME, there was no designated exit path to a corridor in order to comply with 19.2.5.6. Location observed: MRI suite

Based on observation, the facility failed to provide exit paths that are maintained as a continuously protected path to a public way. This deficient practice could affect staff and patients during egress due to a fire emergency evacuation from the building.

Findings include:

A. On 07/26/2022 at 10:30am while in the company of the ME an exterior means of egress was observed in which the path is nonreliable. Location observed: Exterior stair top landing is uneven contains changes in elevation which does not comply with 7.1.7, and is not stable and is obstructed which does not comply with 19.2.7 and 7..1.6.2 and 7.1.6.3. Location: exterior exit from Dining room

B. On 07/26/2022 at 1:05pm while accompanied by the ME, exit paths to the discharge do not maintain a safe means of egress to a discharge which does not comply 7.1.9, 7.1.10. Locations observed: designated exit from MRI through a mechanical room which contains multiple items stacked, stored within the path of egress.

Based upon observation, exit signage was not provided, was not fully visible, or incorrectly identified paths of egress. Failure to provide exit signs to identify exit access can prevent occupants from reaching a required exit if the primary exit is blocked by a fire/smoke condition. This deficient practice could affect the safety of patients, staff, and visitors.

The finding is:

On 07/26/2022 while in the company of the ME exit signage was observed to be partially obstructed or missing which provides for dead end corridor conditions, and further does not comply with 19.2.5.2, 7.5.1, 7.10.1.2.1 or 7.10.1.5.1. Example locations:

1. At 10:55am Second floor, exit sign is partially covered by the nurse station soffit as veiwed from Prep/Recovery #9 toward Prep/Recovery #4.

2. At 11:15am Second floor, Stair #6 as viewed from corridor adjacent to a Mechanical room and "Open Office" lacks a designated exit sign.

Based upon observation, hazardous areas are not separated from the remainder of the occupancy or from a means of egress. Failure to properly separate storage of combustible material (which represents a degree of hazard greater than that normal to the general occupancy due to quantity and density of materials) from required means of egress paths can compromise the safety of occupants if a fire were to originate at the stored material to block exiting.

Findings are:

On 07/26/2022 while in the company of the ME a hazardous area was observed which does not comply with 19.3.2.1.3 for having a self closing door. Locations observed:

1. At 11:01am First floor ICU supply room (former office)
2. At 12:01pm First floor Resp Storage (Sleep Center)
3. At 12:05pm First floor Storage room (former staff room in Sleep Center)

Based on document review and staff interview record of inspection and cleaning activity is not documented for the kitchen grease hood and duct system. Failure to inspect and clean this system may affect the safety of patients, staff and visitors.

The finding is:

On 07/26/2022 at 11:40am in the company of the ME, The inspection, testing and maintenance of the fire-extinguishing system of grease hood did not comply for the provision of an inspection tag attached to the system. There is no provision for the monthly inspection and signature/initial by the installer/inspector of the system to further comply with NFPA 17 2009, 11.2.4/ NFPA 17A 2009, 7.2.5.

Based upon observation, fire alarm components are not installed in accordance with Code requirements. Failure to install components as required can result in delayed initiation of the fire alarm system to provide occupant notification of a fire/smoke condition.

The finding is:

On 07/26/2022 at 2:20pm while in the company of the ME it was observed that a wall mounted Fire Alarm remote annunciator lacked a smoke detector in-compliance with NFPA 72-2010. Location observed: Emergency Department Reception area

Based on observation the facility failed to install all require components of the wet pipe fire suppression system. Failure to install and maintain these systems could result in malfunction and delayed response. This deficient practice could affect patients, staff and visitors during a fire event.

The findings are:

A. On 07/26/2022 at 12:30pm accompanied by the ME, it was observed that 4 ceiling pockets with sky lights approximately 5 feet square by 5 feet deep are without sprinkler fire protection to comply with NFPA 13, 2010,8.6.7. Location observed Ground floor Imaging Services corridor.

B. On 07/26/2022 at 11:50am accompanied by the ME, it was observed that sprinkler heads are located more than 12 inches below the ceiling of the interstitial space that is created by an opening within the suspended acoustical tile ceiling. This condition does not comply with NFPA 13, 2010, 8.6.4.1. The interstitial space allows for the delayed activation of the sprinkler heads Location observed Ground floor MRI equipment room.