HospitalInspections.org

D) (Modified 01/19/11): One of two fire alarm projects has been completed and one remains with deficiencies

1) Corrected 01/19/11

2) (New 11/16/10): IDPH Project 8788 (to provide a new fire alarm panel in the Jones building) is currently incomplete with deficiencies that do not comply with NFPA 101 and/or NFPA 72.

a. The fire alarm system in the Jones/Murdock/Pavilion Buildings is controlled from the above referenced new fire alarm panel. The fire alarm system is not audible in multiple locations, including all of the 5th Floor of the Pavilion (patient sleeping wing), and parts for the 3rd Floor of the Pavilion Building. The fire alarm system is barely audible in the 1st Floor E D Treatment Suite and is not audible at all in Nuclear Medicine and at the E D Entrance and Security Desk.

The fire alarm system nor the interim measures provided comply with the occupant notification requirements of Chapter 19 (NFPA 101) and within 70 seconds of activation of a fire alarm device in accordance with NFPA 72.

b. A component of the provider's interim measures for the above condition require the security office to notify the paging operator of an activation of the fire alarm system. The security office lacks a notification device that is analog or digital that identifies the floor and zone of activation for the Jones Fire Alarm panel. The current interim measure (to have the security office count the chime code and then notify the paging operator) does not meet the intent of NFPA 101 or NFPA 72 and is not acceptable and an interim measure for the above condition.

c. The security office is only able to identify one fire alarm trouble condition. Additional trouble signals will not be annunciated in a constantly attended location.

d. The provider has not tested the evacuation mode of this fire alarm system to confirm that it is audible in all patient areas and in all staff work areas. This mode could not be tested by the surveyor

Although this is a fire alarm deficiency, it was cited and is being tracked under K056 as part of a sprinkler project that has been completed and cleared under item 1 above. The corrective actions for item 2 are incomplete. K056 will not be cleared until the above project have been completed, certified and inspected.

The surveyor notes that all patient areas in Jones/Murdock/Pavilion are scheduled to be relocated into the new East Tower upon completion of that building..... and that these buildings will then no longer be used as health care occupancies. Further it is noted that one or more of these buildings may be demolished. If interim measures are proposed in place of full correction the following is required

1) The PoC for this item must clearly indicate why interim measures should be permitted (some form of statement similar to the paragraph above).

2) Specific written procedures must be included in the interim measures proposed that address the deficiencies cited.

D) (Modified 01/19/11): One of two fire alarm projects has been completed and one remains with deficiencies

1) Corrected 01/19/11

2) (New 11/16/10): IDPH Project 8788 (to provide a new fire alarm panel in the Jones building) is currently incomplete with deficiencies that do not comply with NFPA 101 and/or NFPA 72.

a. The fire alarm system in the Jones/Murdock/Pavilion Buildings is controlled from the above referenced new fire alarm panel. The fire alarm system is not audible in multiple locations, including all of the 5th Floor of the Pavilion (patient sleeping wing), and parts for the 3rd Floor of the Pavilion Building. The fire alarm system is barely audible in the 1st Floor E D Treatment Suite and is not audible at all in Nuclear Medicine and at the E D Entrance and Security Desk.

The fire alarm system nor the interim measures provided comply with the occupant notification requirements of Chapter 19 (NFPA 101) and within 70 seconds of activation of a fire alarm device in accordance with NFPA 72.

b. A component of the provider's interim measures for the above condition require the security office to notify the paging operator of an activation of the fire alarm system. The security office lacks a notification device that is analog or digital that identifies the floor and zone of activation for the Jones Fire Alarm panel. The current interim measure (to have the security office count the chime code and then notify the paging operator) does not meet the intent of NFPA 101 or NFPA 72 and is not acceptable and an interim measure for the above condition.

c. The security office is only able to identify one fire alarm trouble condition. Additional trouble signals will not be annunciated in a constantly attended location.

d. The provider has not tested the evacuation mode of this fire alarm system to confirm that it is audible in all patient areas and in all staff work areas. This mode could not be tested by the surveyor

Although this is a fire alarm deficiency, it was cited and is being tracked under K056 as part of a sprinkler project that has been completed and cleared under item 1 above. The corrective actions for item 2 are incomplete. K056 will not be cleared until the above project have been completed, certified and inspected.

The surveyor notes that all patient areas in Jones/Murdock/Pavilion are scheduled to be relocated into the new East Tower upon completion of that building..... and that these buildings will then no longer be used as health care occupancies. Further it is noted that one or more of these buildings may be demolished. If interim measures are proposed in place of full correction the following is required

1) The PoC for this item must clearly indicate why interim measures should be permitted (some form of statement similar to the paragraph above).

2) Specific written procedures must be included in the interim measures proposed that address the deficiencies cited.