HospitalInspections.org

Egress doors are locked in a manner not permitted by the Code. Failure to provide locking systems for means of egress doors in accordance with Code requirements can compromise the safety of occupants during a fire/smoke emergency by not providing the safeguards afforded by the Code for exiting from a fire/smoke condition.

Findings include:

On 11/30/2021 at 1:40pm, while in the company of the DSS on the 4th floor of the West Building it was observed that locking devices are not installed in accordance with 19.2.2.2.4. All egress doors from the floor were observed to be equipped with Delayed Egress magnetic locking devices which do not comply with 19.2.2.2.4(2) and 7.2.1.6.1.1 because the building is not protected throughout by the automatic sprinkler system.

Based on observation, construction in horizontal exits is not maintained to provide separation of building areas. Failure to provide required separations can contribute to the spread of fire & smoke beyond the compartment of fire origin and compromise the safety of building occupants in adjacent compartments.

Findings include:

On 11/30/2021 at 1:58pm, while in the company of the DSS on the 4st floor of the West Building it was observed that an above ceiling penetration was not sealed against fire in the 2 hour fire barrier at the southeast corner of the building as shown on the Life Safety plans provided by the facility. This penetration does not comply with 8.3.5.1.

Based on observation, not all exit signs are installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because their egress under emergency conditions could be impeded if exit signs are not properly installed and maintained.

Findings include:

On 12/01/2021 at 10:10am, while accompanied by the DSS and CE it was observed that the sign above the southeast cross-corridor doors of the patient room wing is installed with directional arrow pointing away fromt he exit and is therefore not in compliance with 7.10.3.1.

Based an observations, not all exit doors are installed or maintained to provide protection of the exit enclosure. This deficiency could affect patients, staff and visitors if the exit access door did not provide the proper protection during a fire emergency.

The findings are:

A. On 12/01/2021 at 9:45am, while in the company of the DSS and CE on the 4th floor of the East Building it was observed that the door serving Stair #2 failed to self-close and self-latch. This does not comply with the requirements of Table 8.3.4.2 and NFPA 80, 2010 6.4.1.1.

B. On 12/01/2021 at 9:52am, while in the company of the DSS and CE on the 3rd floor of the East Building it was observed that the door serving Stair #1 failed to self-close and self-latch. This does not comply with the requirements of Table 8.3.4.2 and NFPA 80, 2010 6.4.1.1.

C. On 12/01/2021 at 9:52am, while in the company of the DSS and CE on the 3rd floor of the East Building it was observed that the door serving Stair #1 has a hole in the upper right corner. This does not comply with the requirements of NFPA 80, 2010 5.2.4.2(1).

Based upon observation, hazardous areas are not properly separated from the remainder of the occupancy and the means of egress. Failure to properly separate hazardous area from required means of egress paths can compromise the safety of all occupants. If a fire were to originate in the hazardous area, then the adjacent corridor necessary for exiting would be compromised due to the areas are not being properly separated.

Findings include:

A. On 11/30/2021 at 2:50pm, while in the company of DSS on the 1st floor of the West Building it was observed that the door serving the room labeled X-Ray File Room as shown on the Life Safety plans provided by the facility is not installed with a closer and therefore failed to comply with 19.3.2.1.3 and 19.3.6.3.5.

B. On 12/01/2021 at 9:35pm, while in the company of DSS and CE on the 5th floor of the East Building it was observed that an above ceiling penetration was not sealed against fire in the fire barrier around the Clean Supply as shown on the Life Safety plans provided by the facility. This penetration does not comply with 8.3.5.1.

C. On 12/01/2021 at 9:38pm, while in the company of DSS and CE on the 5th floor of the East Building it was observed that an above ceiling penetration was not sealed against fire in the fire barrier around the Soiled Utility as shown on the Life Safety plans provided by the facility. This penetration does not comply with 8.3.5.1.

D. On 12/01/2021 at 10:49am, while in the company of DSS and CE on the 1st floor of the East Building it was observed that an above ceiling penetration was not sealed against fire in the fire barrier around the Dry Storage as shown on the Life Safety plans provided by the facility. This penetration does not comply with 8.3.5.1.

Based on observation the facility failed to provide required smoke detection protection. This deficient practice could result in the untimely notification of fire which may affect patients, staff and visitors.

The findings are:

A. On 11/30/21 at 2:15pm in the company of the CE it was observed that smoke detection is not provide at the Fire Alarm Control Panel located in "Fire Alarm Control Room M-H-1". NFPA 72, 2010, 10.15


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B. On 11/30/2021 at 2:20pm, while in the company of DSS it was observed on the 4th floor of the West in the corridor serving Respiratory Care, there are large gaps in the ceiling. No complete and continuous physical separation from the room to the ceiling cavity above exists. The missing ceiling material would allow heat and products of combustion to bypass the installed smoke detector and therefore does not comply with NFPA 72-2012, 17.7.3.2.4.2.

C. It was observed that detectors are located where airflow may prevent normal operation of the device as stated in NFPA 72-2012, 17.7.4.1. Locations & conditions observed include the following:

1. On 12/01/2021 at 10:05am, while in the company of DSS and CE on the 2nd floor of the East Building it was observed that that a smoke detector was within 3"-0" of an HVAC diffuser in the southwest corner of the ICU.

2. On 12/01/2021 at 10:25am, while in the company of DSS and CE on the 2nd floor of the East Building it was observed that that a smoke detector was within 3"-0" of an HVAC diffuser in the employee lounge of the surgical suite.

3. On 12/01/2021 at 10:35am, while in the company of DSS and CE on the 1st floor of the 1990 Building it was observed that that a smoke detector was within 3"-0" of an HVAC diffuser in the hallway between Admitting and the E.R Waiting Room.

D. On 12/01/2021 at 10:44am, while in the company of DSS and CE it was observed on the 1st floor of the East Building Dry Storage, there is no smoke tight closure from the freezer to the ceiling. No complete and continuous physical separation from the room to the ceiling cavity above exists. The missing ceiling tile would allow heat and products of combustion to bypass the installed smoke detector and therefore does not comply with NFPA 72-2012, 17.7.3.2.4.2.

Based on observation the facility failed to maintain sprinkler system as required. Failure to maintain the system could result in delayed response and fire suppression. This deficient practice could affect patients, staff, and visitors during a fire event.

The findings are:

A. On 11/30/2021 at 1:45pm, while in the company of the DSS the surveyor observed missing caps on concealed sprinker heads typical in the ceiling of the 4th floor West Building. This does not comply with NFPA 13, 2010 6.2.7.1.

B. On 11/30/2021 at 1:50pm, while in the company of the DSS the surveyor observed a missing escutcheon arpund the annular opening for a concealed sprinker head in the ceiling of the 4th floor West Building Seclusion Room. This does not comply with NFPA 13, 2010 6.2.7.1.

C. On 11/30/2021 at 2:09pm, while in the company of the DSS the surveyor observed missing caps on concealed sprinker heads typical in the ceiling of the 3rd floor West Building. This does not comply with NFPA 13, 2010 6.2.7.1.

Based on document review the facility failed to perform full test for the annual fire pump testing. Failure of the fire pump during a fire event risk safety of patients, staff and visitors.

The finding is:

On 11/30/21 at 12:30 pm in the company of the CE, review of the annual fire pump test for each of 2 fire pumps completed on 4/20/21, the testing companny indicated the tests were not performed under emergency power as required by NFPA 25, 2011, 8.3.3.4.

Based on document review and staff interview the facility failed to provied proof of testing of HVAC fire sfety devices. Faillure of protective devices during a fire event risk safety of patients, staff and visitors.

The finding is:

On 11/30/21 at 12:45pm in the company of the CE, review of the testing documents for the facilities fire/fire smoke damper testing could not be provided for the East building, The last recorded testing was completed in 2013 outside thre requirement of testing every 6 years. NFPA 80, 9.4 & NFPA 105, 6.5.2

The facility does not provide evidence of verification of the transmission of the fire alarm signal during fire drills. Failure to verify transmission of the fire alarm signal can result in failure of the fire department to respond promptly during an actual fire/smoke condition.

Findings include:

On 11/30/2021 at 11:45pm while in the company of DSS during record document review, it was observed that there is no evidence within the paperwork of the completed drills showing verification of the transmission of the fire alarm signal. This does not comply with 19.7.1.4.

Based on document review, not all fire door assemblies are inspected, tested, and maintained on an annual basis. This deficient practice could affect patients, staff, and visitors in the building because the doors may fail to operate when needed if they are not periodically inspected, tested, and maintained.

Findings include:

On 11/30/2021 at 12:30pm, while in the company of DSS during record document review it was observed that the inspection and testing records of swinging doors with builders hardware or fire door hardware do not indicate any notes, observations, or evidence of corrective measures specific to any of the doors in the provided inventory to indicate the assemblies' statuses. Therefore the facility is not in compliance with the requirements of NFPA 80 2010 5.2.4.2.

Based upon observation, Electrical systems are not maintained in accordance with Code requirements. Failure to maintain electrical systems can result in shock hazard to occupants upon contact with electrical components.

Findings include:

A. On 12/01/2021 at 10:02am, while in the company of the DSS and CE it was observed on the 2nd floor of the East Building in ICU/CCU#2 a receptacle with wiring connections has a damaged cover and therefore fails to comply with NFPA 70-2011, 314.28(C).

B. On 12/01/2021 at 10:49am, while in the company of the DSS and CE it was observed on the 1st floor of the East Building above the Dry Storage ceiling that a junction box with wiring connections lacked closure of the box with a cover plate to comply with NFPA 70-2011, 314.28(C).

Based upon observation, ground fault circuit interruption (GFCI) is not provided in accordance with Code requirements. If GFCI protection is not provided, the circuit remains an electrical shock hazard to occupants. This deficient practice could affect the safety of patients, staff, and visitors.

Findings include:

A. On 12/01/2021 at 9:44am,while in the company of the DSS and CE it was observed in the 5th floor north end of the East Building that an electrical receptacle serving a drinking fountain fixture is not provided with GFCI protection to comply with NFPA 70 2011, 422.52.

B. On 12/01/2021 at 9:53am, while in the company of the DSS and CE it was observed in the 3rd floor north end of the East Building that an electrical receptacle serving a drinking fountain fixture is not provided with GFCI protection to comply with NFPA 70 2011, 422.52.

C. On 12/01/2021 at 10:35am, while in the company of the DSS and CE it was observed in the 1st floor of the 1990 Building that an electrical receptacle serving a drinking fountain fixture is not provided with GFCI protection to comply with NFPA 70 2011, 422.52.