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Based on direct observations the facility failed to maintain the two hour fire barrier between differing occupancies and building construction types. This deficient practice could affect patients, staff and visitor if fire were to spread beyond the fire origin and compromise exit paths.

Findings include:

On 04/25/2016 at 2:30 PM while accompanied by the CFO, the surveyor observed the following:

a. The two hour fire barrier on the first floor exit corridor between the portion of north pavilion and the first floor of Busse Center was found to be incomplete, as it does not extends from outside wall to the outside wall in accordance with the NFPA 101 sections 18.1.1.4.1, 18.1.1.4.2 and 18.2.3.2.

b. Two HVAC ducts penetrating the two hour fire barrier above the fire doors in the exit corridor was not installed with fire dampers, in accordance with the NFPA 101 sections. This does not comply with 18.1.1.4.1, 18.1.1.4.2 and 18.2.3.2.

Based on direct observations of Exam rooms, facility failed to provide properly operated positive latching hardware that provides separation between patient exam room and exit access corridor. This deficient practice could affect patients, staff and visitors if a fire or smoke could spread without proper fire/smoke separation.

Finding includes:

On 04/27/2016 at 8:30 AM while accompanied by CFO, an observation determined that Patient Exam Room # 8 the door did not latched closed to the frame and does not comply with NFPA 101, section 18.3.6.3.

Based on direct observations, facility failed to maintain the two hour elevator shaft wall. This deficient practice could affect patients, staff and visitor if fire/smoke were to spread beyond the room of fire origin.

Finding includes:

On 04/25/2016 at 3:05 PM while accompanied by the CFO, it was determined that a portion of 2-foot by 4-foot elevator shaft wall in the basement storage room adjacent to the elevator shaft was missing. This does not comply with NFPA 101, section 18.3.1.1.

Based on an observation and document review of the placement of exit fixtures, it was determined that the facility has not provided approved directional emergency illuminated exit signs readily visible from any direction of exit access where the nearest exit is not apparent. This deficient practice could affect patient, staff and visitors if an evacuation of the building was required.

Findings include:

1. On 4/26/16 at 1:55 pm while reviewing the Basement area of the North Pavilion Boiler room in the company of the CPO, the surveyor observed that access to the exits from the Boiler room were not clearly marked to comply with 19.2.10.1. Directional Exit signage was not provided to identify two Exits remote from each other and Exit signs at the west Exit doors were obscured by piping and temporary wall construction.

2. On 4/26/16 at 2:00 pm while reviewing the Basement area of the North Pavilion Boiler room in the company of the CPO, the surveyor observed that access to the exits from the Basement/Sub-basement room containing the trash lift and open stair were not clearly marked to comply with 19.2.10.1. Directional Exit signs to identify access to two remote exits was not provided. The door to the lower level Boiler room was marked with exit signage but was locked with a combination lock. Exit signage at the upper level and through the exterior compactor court was not visible to direct occupants to the door leading to the public way. Directional Exit signage to the south for the path which leads through the parking garage was not provided.

3. On 4/26/16 at 3:00 pm while reviewing the Basement area of the North Pavilion in the company of the CPO, the surveyor observed that exit signage was not provided or was obscured by other signage to identify exit access in both directions in the corridor to comply with 19.2.10.1. Locations observed include:

a. At the east-west corridor (leading to the Loading Dock area) lacked exit signage to the west.

b. At the west north-south corridor when looking north.

c. At the north-south corridor when looking north (other signage blocked exit signs).

4. On 4/27/16 at 11:45 am while in the company of the CPO, the surveyor observed that the northern-most corridor in the Radiation Oncology area lack exit signage at the west end of the corridor to identify the exit access to the main north-south corridor to comply with 19.2.10.1.





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5. On 4/26/16 at 3:00 PM, while accompanied by EDFM it was determined that in the NP, 1st floor, outpatient diagnostic area is missing a directional " EXIT " sign. There is no exit sign installed at the cross corridor pointing to the holding bay corridor. This does not comply with NFPA 101, section 7.10.1.4.

Based on smoke barrier observations and interviews, it was determined that the facility failed to provide properly constructed smoke barriers to meet at least 30 minutes fire resistance rating. These deficiencies to the smoke barriers could affect patients, staff and visitors if smoke or fire was allowed to pass from one smoke compartment to another.

Findings include:

On 4/25/2016 at 2:24 PM, while accompanied by EDFM it was determined that in the EP-N, 8th floor, smoke barrier, above the ceiling at the cross corridor doors, adjacent to sleep lab room E872 contained a 6-inch pipe sleeve with data cabling passing through. The pipe sleeve was not installed with a fire stopping material. This is not per NFPA 101, Sections 8.3 and 19.3.7.3.

Based on direct observations on third floor ICU, facility failed to maintain the smoke doors in the one hour fire rated smoke barriers. This deficient practice could affect patients, staff and visitors if smoke were to travel to and from one smoke compartment suite to another smoke compartment suite due to non-compliant smoke doors.
Findings include:

On 04/26/2016 at 1:30 PM while accompanied by the CFO, observations determined pair of smoke doors in the smoke barriers of the suites swings in the same direction with one door installed with metal Astragal without the door coordinators relying solely at the adjusted speed of door closures which is not a reliable method of keeping the doors closed which may create a vertical gap if the door with metal Astragal closed before the door without Astragal and would not stop migration of smoke from one smoke compartment to another smoke compartment not in accordance with the NFPA 101 sections 18.3.7.5, 18.3.7.6 and 18.3.7.8.

Based on direct observations of hazardous areas and interviews, the facility failed to provide properly operating latching and self- closing door hardware that provides separation between hazardous areas and exit access corridors. This deficient practice could affect patients, staff and visitors if a fire could spread without proper fire separation and spread beyond the room of fire origin.

Findings include:

On 04/27/2016 at 3:15 PM while accompanied by CFO, the surveyor observed the storage room door adjacent to the office in the basement was not self closing as it was not installed with the door closure to keep the door closed at all times to resist the passage of smoke to and from the storage room not in accordance with the NFPA 101, section 18.3.2.1 and 18.3.5.1:
Examples include:

1. Learning Center in the basement contained a large amount of combustible material and the door was found in the open position to the exit corridor although a door closure was installed.

2. Basement Copy Room door wide open to the exit corridor and also not installed with the system sensor smoke detector.

3. Staff Locker and Break Room on second floor contained two micro-wave ovens, a coffee machine and a refrigerator, the door was not self closing and neither installed with system sensor smoke detector

4. Office on second floor contained cardboard boxes and papers deemed excessive of normal office stationary, the door was not installed with door closure and wide open to the exit corridor, also not installed with the system sensor smoke detector.

Based on observations and interviews, the facility failed to provide construction of exit components having a proper fire resistance rating. The exit components are to be arranged to provide a continuous path of escape, and to provide protection against fire or smoke from other parts of the building. This deficient practice could affect patients, staff and visitor if fire and smoke were allowed to enter an egress path during an evacuation.

Findings include:

On 4/26/16 at 11:20 AM, while accompanied by EDFM it was determined that in the EP-E, 1st floor, stair J5 the stair door did not close and latch to the door frame with the use of the door closer. This does not comply with NFPA 101, section 19.3.1.1, 7.1.3.2 and 8.2.5.2.

Based on observation during the survey walk-through, not all exit access doors are arranged so that exits are readily accessible at all times. These deficiencies could affect patients, staff and visitors if doors and exits were obstructed and prevented occupants from reaching an exit from the building.

Findings include:

1. At various times during the survey walk through while in the company of the CPO and other staff in multiple locations in the South Pavilion, egress doors were observed that are equipped with magnetic locking devices. The magnetic locking devices are not in compliance with the requirements of 18.2.2.2.4 and 7.2.1.6.1.

Examples include:

A. The surveyor observed while in the company of the CPO that the magnetic locking systems used at the OB Dept. 4th floor Mother-baby unit & 5th floor Postpartum unit in the South Pavilion are not in compliance with NFPA 101-2000, 18.2.2.2.4 and 7.2.1.6.1. The EDFM stated that Categorical Waiver, S & C Memo 13-58-LSC paragraph 4. Doors, was not otherwise currently being used for the locking systems installed.

The following locations were identified.

1. On 04/25/16 at 3:10 pm it was observed that not all doors equipped with magnetic locks were provided with signage to indicate the delay feature to comply with 7.2.1.6.1(d).

2. On 04/27/16 at 10:00 am it was observed that not all doors equipped with magnetic locks released during sprinkler flow activation of the fire alarm system to comply with 7.2.1.6.1(a).

3. On 04/25/16 at 3:10 pm it was observed that exiting for the public elevator lobbies is through the OB unit to reach the exit stairs. Surveyor notes that the west exit access doors are 2-hour rated Smoke barrier/Horizontal Exits. The locking arrangement is not in compliance with 18.2.2.2.4 Exception No. 2 because delayed egress locks in the exit path exist at both the elevator lobby doors and the stair doors. Compliance with a Categorical Waiver is not being used to permit two delayed egress locks in a path or delayed egress locks at the elevator lobby and staff controlled locked doors at the stairs within the locked unit.

B. On 04/26/16 at 9:40 am on the 2nd floor South Pavilion, the surveyor observed while in the company of the CPO that magnetic locking devices were installed (but not functioning at the time of observation) at the smoke barrier cross corridor doors between the South Pavilion and the East Pavilion West Wing. Signage to comply with 7.2.1.6.1(d) was not provided and if activated, compliance with 18.2.2.2.4 Exception No. 2 which limits use of delayed egress to one in an exit path would not be met.

C. On 04/26/16 at 10:25 am on the 1st floor South Pavilion, south corridor, east end near Procedure room E1, the surveyor observed while in the company of the CPO that the (damaged) cross corridor doors have magnetic locks installed (but not functional at the time of observation). Signage to comply with 7.2.1.6.1(d) was not provided. Compliance with a Categorical Waiver was not otherwise indicated by the EDFM.

Based on observation during the survey walk-through, not all Horizontal Exits and 2-hour rated barriers are constructed to provide the required fire resistance rating to resist the spread of fire and smoke. These deficiencies could affect patients, staff and visitors if the barrier protecting adjacent occupancies was compromised.

Findings include:

1. Doors in Horizontal Exits and 2-hour rated fire/smoke barriers were observed during the survey walk-through, while in the company of the CPO, that are not in compliance with 8.2.3.2.3.1 because the glazing panels are not of the required rating to match the labeled door rating. Pairs of doors were observed with 90 minute labels but the glazed panels were observed as both 45 min and 90 minute rated. Locations observed include:

Examples include:

a. On 4/26/16 at 9:55 am, 2nd floor Horizontal Exit barrier at the Staff Elevators

b. On 4/26/16 at 10:00 am, 2nd floor Horizontal Exit barrier at the north corridor cross corridor doors

c. On 4/26/16 at 10:00 am, 2nd floor Horizontal Exit barrier at the south corridor cross corridor doors

d. On 4/26/16 at 10:30 am1st floor 2-hour fire/smoke barrier doors near the northeast corner of the Emergency Dept.

2. The 4" PVC pipe penetration in designated 2-hour barrier between the South Pavilion and North Pavilion at the Basement corridor near the Food & Nutrition offices could not be confirmed to be sealed with a tested design assembly to comply with 8.2.3.2.4.2 because one side was inaccessible and the observable side lacked a fire sealant.
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Based on observation and staff interview during the survey walk-through, not all exit discharge locations are provided with illumination. This deficient practice could affect patients, staff and visitors if required exits were not illuminated during an emergency evacuation to the public way.

Findings include:

1. On 04/27/16 at 8:00 am while in the company of a CM and two building maintenance personnel, the surveyor observed that the emergency lighting system was battery powered. Although monthly testing of the lighting was indicated to have been performed by the maintenance personnel, no records to document the procedure or results of 30 second monthly testing and 90 minute annual testing were available for review to comply with 7.9.3.

2. On 04/27/16 at 8:45 am while in the company of a CM, the surveyor observed that the lighting provided at the exit discharges for the stairs and main entry were not in accordance with 38.2.9.2 and 7.8.1.4. The majority of exterior lighting was HID type lamps and not of the instant-on type (incandescent, fluorescent, quartz or LED) to provide lighting of the means of egress in accordance with requirements. Only a single incandescent or quartz lamp was otherwise observed at each exit discharge rather than a minimum of two such lamps and/or fixtures.

Based on direct observations and staff interview, facility failed to maintain the Battery Back-Up emergency lights. This deficient practice could affect patients, staff and visitors, if the emergency lights failed to light in an emergency.

Findings include:

On 04/27/2016 at 8:20 AM while accompanied by the CFO, it was observed that every patient exam room was installed with emergency battery back-up light fixtures, but the facility failed to conduct monthly 30 seconds and yearly 90 minutes testing log in accordance with the NFPA 101 section 18.2.9.1 and 7.9.

Based on observation during the survey walk-through, exit signs were not provided, were not fully visible, or incorrectly identified paths of egress. These deficiencies could affect patients, staff and visitors if the areas of the facility prevented occupants from readily identifying the path to an available exit from the building.

Findings include:

1. Exit signs were not provided in accordance with 18.2.10.1. and 7.10. The following conditions were observed:

a. On 4/25/16 at 2:00 pm the surveyor observed while in the company of the CPO that the South Pavilion 9th floor west side of the smoke barrier cross corridor double egress doors had the exit sign placed above the door leaf which did not swing in the direction of travel. This exit sign would otherwise be obscured by other building signage if placed above the door leaf required to be the designated exit door.

b. On 4/25/16 at 3:00 pm the surveyor observed while in the company of the CPO that the South Pavilion 7th floor west side of the smoke barrier cross corridor double egress doors had the exit sign placed above the door leaf which did not swing in the direction of travel. This exit sign would otherwise be obscured by other building signage if placed above the door leaf required to be the designated exit door.

c. On 4/26/16 at 1:00 pm the surveyor observed while in the company of the CPO that the South Pavilion Sub-basement Elevator lobby had an exit sign directing occupants into a room identified as "Storage". The door was locked to prevent its use as a means of egress. Surveyor notes that the other exit from the elevator lobby is directed to a corridor space which is directed into the same "Storage" room which provides access to the Exit stair. (Surveyor notes that this floor level is not healthcare occupancy and considered to be a Storage occupancy.)

d. On 4/26/16 at 1:25 pm the surveyor observed while in the company of the CPO that the South Pavilion Basement east-west corridor lacked exit signage at the west end of the corridor to identify the second required exit access. Surveyor notes that this corridor is a required means of egress for healthcare occupants since the service elevators served by this required corridor accessing the exit stair was observed to be used for patient transport between the Bed Tower and Radiation Oncology located in the North Pavilion Basement.

e. On 4/26/16 at 11:10 am the surveyor observed while in the company of the CPO that the single swing pair of doors just south of the double egress smoke barrier doors at the northwest corner of the 1st floor South Pavilion Emergency Dept. were marked with exit signage. The single swing doors swing against the direction of exiting from the Emergency Dept. to the north in non-compliance with 7.2.1.4.2.

Based on observation during the survey walk-through, and document review, the facility's written plan for the protection of patients is not completely accurate. These deficiencies could affect any patients, staff, or visitors in the building because the failure to identify key life safety components could result in the failure to protect them properly.

Findings include:

On 4/25/16 and during the walk-through survey, a series of apparent errors were observed in the Life Safety Plans dated 5/24/13. These plans are thus not sufficiently accurate to comply with 18.7.1.1. The South Pavilion was reviewed as NEW construction and the adjacent East Pavilion West Wing was reviewed as EXISTING construction. The reference plans appear to indicate only a 1-hour Fire/Smoke barrier rather than a 2-hour Fire/Smoke barrier between these two building areas on the 2nd & 4th floors to comply with 18.1.1.4.1.

Based on direct observation during the survey walk-through, accompanied by facility staff, the facility failed to provide a fire alarm system with approved components, devices or equipment installed in accordance with NFPA 72. This deficiency would affect patients, staff and visitors if there was a delay in the fire alarm system's response time during a fire.

Findings include:

On 04/27/16 at 8:45 am while in the company of a CM, the surveyor observed at the first floor Electrical room in Panel LRP-HS that the #17 & #18 circuits that power fire alarm system components were not marked in red and #18 circuit which powered the Fire Alarm Control Panel was not provided with a mechanical lock-on device as required by NFPA 72 1999 1-5.2.5.2.

Not all portions of the fire protection sprinkler system are installed and maintained in compliance with NFPA 13 & 25. This deficient practice could affect patients, staff and visitor if a delay in notification results in slow response to the affected area.

Findings include:

1. On 4/27/16 at 10:15AM in the company of the Facility ' s CEPO it was observed during fire alarm testing at the Cafeteria, operation of the sprinkler system inspectors ' test did not result in the notification of the zone of activation nor control and closure of the barrier fire protection features (i.e. won doors and fire shutters) as required by NFPA 101, 2000, 19.2.2.2.6. Public Address notification was for Mechanical Room 4 Lower Level not first floor Cafeteria. Further testing could not be completed at the request of the facility ' s Administration.

2. On 4/27/16 at 10:30AM in the company of the Facility ' s CEPO it was observed that not all sprinkler zone inspectors' tests connections are to the outside or to a interior drain as required by NFPA 13, 1999, 5-15.4.2. Location identified but not limited to inspectors test Zone H-1-9.

Not all portions of the fire protection sprinkler system are installed in compliance with NFPA 13. This deficient practice could affect patients, staff and visitor if the facility was without the water supply needed for fire suppression affecting all occupants.

Findings include:

On 4/27/16 at 8:30AM in the company of the Facility ' s CEPO it was observed that in the lower level fire pump room, the two main city water supply valves are not listed indicating valves as required by NFPA 13, 1999, 5-14.1 and are not electronically supervised as required by NFPA 101, 2000, 19.3.5.2.

Based on document review, during the survey walk-through, not all portions of the facility's automatic sprinkler system are inspected, tested and maintained. This condition can lead to a poorly maintained system which can fail during a fire emergency affecting all patients, staff and visitors.


Findings include:

On 04/27/2016 at 8:50 AM while accompanied by the CFO, during the sprinkler system document review, following findings were not in accordance with the NFPA 101, section 18.7.6, NFPA 25, 9.7.5:

1. Quarterly inspection was conducted for the following quarters:
a. 2015 - Third and Fourth
b. 2016 - First Quarter
2. Five year calibration of the water flow gauges was not conducted.
3. Five year internal inspection of the check valve was not conducted

Based on observation during the survey walk-through, not all Medical Gas storage locations comply with NFPA 99-1999, and NFPA 101-2000. This deficient practice could affect patients, staff and visitors if medical gases are stored that can create undue hazardous conditions for building occupants.

Findings include:

1. On 4/25/16 at 2:05 pm in the South Pavilion 9th floor Equipment Room, while in the company of the CPO, the surveyor observed oxygen tank storage within 5' of combustible cardboard boxes on shelving in noncompliance with NFPA 99-1999, 8-3.1.11.2(c)2.

2. On 4/26/16 at 9:30 am in the South Pavilion 3rd floor East Oxygen Storage Room, while in the company of the CPO, the surveyor observed oxygen tank storage within 5' of combustible material stored on shelving in noncompliance with NFPA 99-1999, 8-3.1.11.2(c)2.

Based on observation, the facility failed to provide proper separation of the branches of the emergency power system. This deficient practice could affect patients, staff and visitors if the emergency power system does not operate correctly.

Findings include: On 4/26/16 between 10:00-11:30 am, while accompanied by the LEPO, an observation of critical panels on each floor of the north and south wings of the east pavilion were serving a mixture of life safety and critical loads. The following examples were not in compliance with NFPA-70, Sections 517-32 and 517-33:

a. North wing critical panel 9CL-2 served elevator car lights
b. North wing critical panel 6CL-2 had circuits feeding fire alarm loads
c. North wing critical panel 4CL-2 serves fire alarm loads
d. North wing critical panel 2CL-2 serves fire alarm loads
e. South wing panel 3E1 serves both critical and life safety loads
f. South wing panel 2E1 serves both critical and life safety loads
g. South wing panel BE1 serves both critical and life safety loads
h. ER critical panel 1LC4serves a fire alarm NAC panel

Based on observation, the facility failed to provide a proper electrical system. This deficient practice could affect patients, staff and visitors if the electrical system fails to work properly.

Findings include:

1.On 4/26/16 between 1:00-1:45 pm, while accompanied by the LEPO, the surveyor observed the following areas were not equipped with normal power receptacles or receptacles served from two separate critical transfer switches as required by the 1999 Edition of NFPA-99, Section 3-3.2.1.2(a)1.

a. Cath lab holding bays
b. Cath lab procedure rooms
c. The stage one recovery rooms for the operating rooms.

2. On 4/26/16 at 1:15 pm, while accompanied by the LEPO, the surveyor observed that the cath labs were not equipped with some battery lighting to meet the requirements of NFPA-99, Section 3-3.2.1.2(a)5e.

3. On 4/26/16 at 1:30 pm, while accompanied by the LEPO, the surveyor observed that all operating room battery lighting was served from a switched circuit that could prevent these lights from coming on instantaneously upon the loss of power. This does not comply with the intent of NFPA-99, Section 3-3.2.1.2(a)5e, which requires battery lighting in all anesthetizing locations.