HospitalInspections.org

By random observation the surveyor finds:

A.. Data Closet E1 - 1DF-1, believed to be in basement of the 1985 building, was observed to have a ceiling tile missing where cables entered into the ceiling cavity. The construction type relies upon a floor ceiling assembly. Therefore the floor ceiling assembly is compromised by missing tile.



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B. The 1993 building area is indicated to be of Type I (332) construction type utilizing spray-on fire proofing. The 1985 building area is indicated to be of Type II (222) construction type utilizing floor-ceiling and roof-ceiling assemblies. The location of the 2-hour fire barrier indicated to be between these two construction types on the drawing was deficient at the radiology x-ray room door. The radiology x-ray room door was not 1 1/2-hour rated. The other possible location for this barrier wall between the radiology x-ray room and the corridor waiting area was not otherwise constructed to meet the 2-hour rating as observed. This wall was penetrated by a duct without a fire damper and a cut-out of one layer of gyp board above the ceiling appeared to compromise the required rating.

C. The 2003 Chapel addition was indicated to be Type II (000) and not separated from the 1962 building Type II (222) construction type. The Chapel roof construction is noted to be 1-hour rated but not UL Design is identified. Therefore, it is not clear that the Chapel construction complies with Type II (222) where a 1 1/2-hour roof is required.

By random observation the surveyor finds:

1. The 1993 Building First Floor Main Open Waiting Area does not have a electrically supervised automatic smoke detector system as required by NFPA 101-19.3.6.1 exception #1 (c).

A. It is not clear how the exit stairs from the 1962 building 2nd floor level comply with Chapter 7. The first floor corridor area between the open stair to the 2nd floor and the open stair to the Basement is considered part of the stair enclosure. Therefore, the east stair of the 1962 building must discharge directly to the exterior (or through and exit passageway to the exterior) to comply with 7.7.2.

1. It was indicated that the east stair discharges directly to the exterior where a portion of the corridor leading from the base of the stair to the exterior door is open to the stair and the corridor area is designated as an exit passageway. Two rooms utilized as storage rooms and therefore considered not normally occupied open into the stair enclosure corridor in non-compliance with 7.1.3.2.1(d).

A. The exit discharge for the boiler room area-way exit door and the 1985 building first floor east exit door does not comply with Chapter 7.

1. The concrete walking surfaces are not nominally level and without tripping hazards to comply with 7.1.6.3. The concrete walk adjacent the building has settled to create a non-uniform bottom riser at the stair serving the landing for the exterior door of the first floor. The joints with the adjacent walking surfaces creates a tripping hazard.

2. The top of the stair from the basement boiler room has a projected step which is only half the width of the stair and not even with the top landing walk surface to comply with 7.2.2.3.6 dimensional uniformity.

3. The stair from the basement boiler room and the stair from the 1985 building first floor east door landing area do not have handrails on both sides to comply with 7.2.2.4.2.

B. The ramp from the Basement level to the Boiler room floor level does not comply with 7.2.5.3 requirements.

1. A landing is not provided at the top of the ramp where the door swings onto the ramp. Compliance with 7.2.5.3.2(a) is not met.

2. The edge of the ramp does not have a guard or curb to comply with 7.2.5.3.3. The handrail is positioned beyond the edge of the ramp in lieu of within the width of the ramp.

By random observation the surveyor finds:

A. The outside exit discharge path from the basement mechanical room does not have lighting to provide discharge path exterior lighting to comply with NFPA 101-7.8.1.1, 101-7.8.1.3 and 101-7.8.1.4 and NFPA 70-700-22. Some, or all, of the fixtures shall be connected to the Life Safety branch of emergency power to provide a minimum of 1 foot-candle.


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B. The exit discharge lighting provided at the main entry, Emergency canopy and the Emergency pedestrian entrance could not be confirmed to comply with NFPA 101, 7.8 and 7.9.

1. The uplighting provided at the main entry canopy and the Emergency pedestrian entry was provided by multiple fixtures but the type of lamp could not be confirmed to be of the instant-on type such as incandescent, fluorescent or quartz.

2. The two fixtures provided at the Emergency canopy appeared to be of the HID type with quartz restrike lamps to provide the instant-on capability required. However, one fixture was missing the quartz lamp.

A. Clarification of the written policy for Fire Drill Procedures is needed. The written policy states that the facility switchboard and Surgical Dept. are to be contacted before the fire drill. Although facility staff indicated that this notification was for switchboard operators only and to avoid unnecessary disruption of surgical procedures, the policy could be interpreted as written to indicate that an announcement for the conducting of a fire drill was being made. Although preparatory precautions for scheduled fire drills are acceptable to coordinate with surgery schedules, the policy needs to make clear that fire drills for the general occupancy are unannounced.

B. During review of the past year of fire drill documentation, it could not be determined that all personnel on all three shifts participated in a drill each quarter. It was indicated that not all staff worked the same schedule. Both a 12-hour shifts and 8-hour shifts are utilized. It could not be determined that 3rd shift personnel participated in a fire drill during the 2nd quarter.

By random observation the surveyor finds:

1. Fire Alarm Control Panel is not labeled with the electrical panel designation and circuit number from which it is fed as required by NFPA 72-1-5.2.5.

2. Electrical panel #LS1, in the 1993 building, - The circuit breaker feeding the fire alarm panel is not labeled, or have a red marking or have lock-on device as required by NFPA 72-1-5.2.5.

A. The written documentation for the fire alarm system annual testing dated 10/15/09 indicated that at least five devices were not tested. Although the 2010 annual inspection and testing of the system was indicated to have just taken place, no documentation was readily available to indicate that the devices were tested and deemed operational during at least the past year.

1. Based on direct observation, the surveyor finds the facility failed to provide automatic sprinkler protection for the following area:

Basement Housekeeping Department service room.
The main area of this space has fire sprinkler protection installed however the segregated portion housing the water heaters is not protected with fire sprinklers.

2. Based on document review and staff interview, the surveyor finds the facility does not conduct a from-the-floor inspection of the installed fire sprinkler system annually. (NFPA 25, 1998, 2-2.1.1).

Based on direct observation within the Same Day Surgery Prep/Recovery suite the facility failed to provide:

Separation of oxygen medical gas zone control valve from supplied outlets. NFPA 99, 1999, 4-3.1.2.3 (d).

By random observation the surveyor finds:

1. The generator starting batteries have corroded terminals and not maintained as required by NFPA 110-6.

By direct observation the surveyor find the facility failed:

To install emergency eye wash devices with a means to temper and regulate the water pressure in compliance with ANSI Z358-1. Locations include but not limited to:

a. Laboratory
b. Basement Housekeeping Service Room

By random observation the surveyor finds:

1. The second floor patient rooms do not have the bed head wall receptacles labeled or color marked as emergency power outlet as required by NFPA 99-3-4.2.2.4(b) (2).

2. The second floor patient rooms do not have the bed head wall receptacles divided into normal and emergency circuits as required by NFPA 70-517-18 and NFPA 99-3-4.2.2.2(c)(8)(a).

3. The emergency room treatment areas and operating rooms and stage 1 recovery rooms do not have the panel and circuit number designations as required by NFPA 70-517-19 and NFPA 99-3-4.2.2.2(c)(1) and (8).

By random observation the surveyor finds:

1. The second floor electrical panel #LP2A does not have a completely filled out panel directory as required by NFPA 70-384-13. Some breakers were on but not designated.

2. The second floor electrical panel #62AA does not have a circuit directory as required by NFPA 70-384-13.

3. The Mechanical Room electrical panel #62N does not have a circuit directory as required by NFPA 70-384-13.

4. Basement Facilities Office, 1993 building, light fixtures are supported from conduits and piping and does not comply with NFPA 70-410-16.

5. Basement Electrical Room, light fixtures are supported from conduits and piping and does not comply with NFPA 70-410-16.

6. Basement Mechanical Room, light fixtures are supported from conduits and piping and does not comply with NFPA 70-410-16.

7. Basement Mechanical Room, Communications, nurse call, clock, music, paging, data, fire alarm and other systems cables/wires are strapped, taped, or attached by other means to the exterior of any piping, duct, conduit or raceway as a means of support. NFPA 70-760 & 70-800 and NFPA 70-300.11 states that the cables/wires shall be supported from the building structure.

8. The metal piping systems are not bonded as required by NFPA 70-250.104(c).

9. Basement House Keeping, receptacle below electrical panel #E1 has an extension cord running over and draped on piping and connected to a 4 square box with a 4 plex receptacle with extension cord running into a open round duct. Does not comply with NFPA 70-400-8.

By random observation the surveyor finds:

A.. Data Closet E1 - 1DF-1, believed to be in basement of the 1985 building, was observed to have a ceiling tile missing where cables entered into the ceiling cavity. The construction type relies upon a floor ceiling assembly. Therefore the floor ceiling assembly is compromised by missing tile.



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B. The 1993 building area is indicated to be of Type I (332) construction type utilizing spray-on fire proofing. The 1985 building area is indicated to be of Type II (222) construction type utilizing floor-ceiling and roof-ceiling assemblies. The location of the 2-hour fire barrier indicated to be between these two construction types on the drawing was deficient at the radiology x-ray room door. The radiology x-ray room door was not 1 1/2-hour rated. The other possible location for this barrier wall between the radiology x-ray room and the corridor waiting area was not otherwise constructed to meet the 2-hour rating as observed. This wall was penetrated by a duct without a fire damper and a cut-out of one layer of gyp board above the ceiling appeared to compromise the required rating.

C. The 2003 Chapel addition was indicated to be Type II (000) and not separated from the 1962 building Type II (222) construction type. The Chapel roof construction is noted to be 1-hour rated but not UL Design is identified. Therefore, it is not clear that the Chapel construction complies with Type II (222) where a 1 1/2-hour roof is required.

By random observation the surveyor finds:

1. The 1993 Building First Floor Main Open Waiting Area does not have a electrically supervised automatic smoke detector system as required by NFPA 101-19.3.6.1 exception #1 (c).

A. It is not clear how the exit stairs from the 1962 building 2nd floor level comply with Chapter 7. The first floor corridor area between the open stair to the 2nd floor and the open stair to the Basement is considered part of the stair enclosure. Therefore, the east stair of the 1962 building must discharge directly to the exterior (or through and exit passageway to the exterior) to comply with 7.7.2.

1. It was indicated that the east stair discharges directly to the exterior where a portion of the corridor leading from the base of the stair to the exterior door is open to the stair and the corridor area is designated as an exit passageway. Two rooms utilized as storage rooms and therefore considered not normally occupied open into the stair enclosure corridor in non-compliance with 7.1.3.2.1(d).

A. The exit discharge for the boiler room area-way exit door and the 1985 building first floor east exit door does not comply with Chapter 7.

1. The concrete walking surfaces are not nominally level and without tripping hazards to comply with 7.1.6.3. The concrete walk adjacent the building has settled to create a non-uniform bottom riser at the stair serving the landing for the exterior door of the first floor. The joints with the adjacent walking surfaces creates a tripping hazard.

2. The top of the stair from the basement boiler room has a projected step which is only half the width of the stair and not even with the top landing walk surface to comply with 7.2.2.3.6 dimensional uniformity.

3. The stair from the basement boiler room and the stair from the 1985 building first floor east door landing area do not have handrails on both sides to comply with 7.2.2.4.2.

B. The ramp from the Basement level to the Boiler room floor level does not comply with 7.2.5.3 requirements.

1. A landing is not provided at the top of the ramp where the door swings onto the ramp. Compliance with 7.2.5.3.2(a) is not met.

2. The edge of the ramp does not have a guard or curb to comply with 7.2.5.3.3. The handrail is positioned beyond the edge of the ramp in lieu of within the width of the ramp.

By random observation the surveyor finds:

A. The outside exit discharge path from the basement mechanical room does not have lighting to provide discharge path exterior lighting to comply with NFPA 101-7.8.1.1, 101-7.8.1.3 and 101-7.8.1.4 and NFPA 70-700-22. Some, or all, of the fixtures shall be connected to the Life Safety branch of emergency power to provide a minimum of 1 foot-candle.


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B. The exit discharge lighting provided at the main entry, Emergency canopy and the Emergency pedestrian entrance could not be confirmed to comply with NFPA 101, 7.8 and 7.9.

1. The uplighting provided at the main entry canopy and the Emergency pedestrian entry was provided by multiple fixtures but the type of lamp could not be confirmed to be of the instant-on type such as incandescent, fluorescent or quartz.

2. The two fixtures provided at the Emergency canopy appeared to be of the HID type with quartz restrike lamps to provide the instant-on capability required. However, one fixture was missing the quartz lamp.

A. Clarification of the written policy for Fire Drill Procedures is needed. The written policy states that the facility switchboard and Surgical Dept. are to be contacted before the fire drill. Although facility staff indicated that this notification was for switchboard operators only and to avoid unnecessary disruption of surgical procedures, the policy could be interpreted as written to indicate that an announcement for the conducting of a fire drill was being made. Although preparatory precautions for scheduled fire drills are acceptable to coordinate with surgery schedules, the policy needs to make clear that fire drills for the general occupancy are unannounced.

B. During review of the past year of fire drill documentation, it could not be determined that all personnel on all three shifts participated in a drill each quarter. It was indicated that not all staff worked the same schedule. Both a 12-hour shifts and 8-hour shifts are utilized. It could not be determined that 3rd shift personnel participated in a fire drill during the 2nd quarter.

By random observation the surveyor finds:

1. Fire Alarm Control Panel is not labeled with the electrical panel designation and circuit number from which it is fed as required by NFPA 72-1-5.2.5.

2. Electrical panel #LS1, in the 1993 building, - The circuit breaker feeding the fire alarm panel is not labeled, or have a red marking or have lock-on device as required by NFPA 72-1-5.2.5.

A. The written documentation for the fire alarm system annual testing dated 10/15/09 indicated that at least five devices were not tested. Although the 2010 annual inspection and testing of the system was indicated to have just taken place, no documentation was readily available to indicate that the devices were tested and deemed operational during at least the past year.

1. Based on direct observation, the surveyor finds the facility failed to provide automatic sprinkler protection for the following area:

Basement Housekeeping Department service room.
The main area of this space has fire sprinkler protection installed however the segregated portion housing the water heaters is not protected with fire sprinklers.

2. Based on document review and staff interview, the surveyor finds the facility does not conduct a from-the-floor inspection of the installed fire sprinkler system annually. (NFPA 25, 1998, 2-2.1.1).

Based on direct observation within the Same Day Surgery Prep/Recovery suite the facility failed to provide:

Separation of oxygen medical gas zone control valve from supplied outlets. NFPA 99, 1999, 4-3.1.2.3 (d).

By random observation the surveyor finds:

1. The generator starting batteries have corroded terminals and not maintained as required by NFPA 110-6.

By direct observation the surveyor find the facility failed:

To install emergency eye wash devices with a means to temper and regulate the water pressure in compliance with ANSI Z358-1. Locations include but not limited to:

a. Laboratory
b. Basement Housekeeping Service Room

By random observation the surveyor finds:

1. The second floor patient rooms do not have the bed head wall receptacles labeled or color marked as emergency power outlet as required by NFPA 99-3-4.2.2.4(b) (2).

2. The second floor patient rooms do not have the bed head wall receptacles divided into normal and emergency circuits as required by NFPA 70-517-18 and NFPA 99-3-4.2.2.2(c)(8)(a).

3. The emergency room treatment areas and operating rooms and stage 1 recovery rooms do not have the panel and circuit number designations as required by NFPA 70-517-19 and NFPA 99-3-4.2.2.2(c)(1) and (8).

By random observation the surveyor finds:

1. The second floor electrical panel #LP2A does not have a completely filled out panel directory as required by NFPA 70-384-13. Some breakers were on but not designated.

2. The second floor electrical panel #62AA does not have a circuit directory as required by NFPA 70-384-13.

3. The Mechanical Room electrical panel #62N does not have a circuit directory as required by NFPA 70-384-13.

4. Basement Facilities Office, 1993 building, light fixtures are supported from conduits and piping and does not comply with NFPA 70-410-16.

5. Basement Electrical Room, light fixtures are supported from conduits and piping and does not comply with NFPA 70-410-16.

6. Basement Mechanical Room, light fixtures are supported from conduits and piping and does not comply with NFPA 70-410-16.

7. Basement Mechanical Room, Communications, nurse call, clock, music, paging, data, fire alarm and other systems cables/wires are strapped, taped, or attached by other means to the exterior of any piping, duct, conduit or raceway as a means of support. NFPA 70-760 & 70-800 and NFPA 70-300.11 states that the cables/wires shall be supported from the building structure.

8. The metal piping systems are not bonded as required by NFPA 70-250.104(c).

9. Basement House Keeping, receptacle below electrical panel #E1 has an extension cord running over and draped on piping and connected to a 4 square box with a 4 plex receptacle with extension cord running into a open round duct. Does not comply with NFPA 70-400-8.