HospitalInspections.org

Based on observations during the survey walk of the facility on the afternoon of 3/30/2017 with the Market Chief Operating Officer, System Manager of Plant Operations and System Manager of Security and Environment of Care, the facility failed to maintain the rated barrier. It appeared that top of one hour rated barriers were not properly sealed with fire rated sealant at Kurth tower's soiled linen room.

Hole compromised the one hour rated fire barrier at doctor tower's level 2 south stairwell, doctor tower's level 2 electrical room, level 1 surgical suite's equipment room and Kurth tower level 3 soiled linen.

NFPA 101, 2003: Section 8.7. ... The fire barrier partition are required to have a fire resistance rating of at least one hour, be sealed to the underside of the deck above and any penetrations to be filled with a material capable of maintaining the fire resistance of the fire barrier partition.

Based on observations during the survey walk of the facility on the afternoon of 3/30/2017 with the Market Chief Operating Officer, System Manager of Plant Operations and System Manager of Security and Environment of Care, the facility failed to maintain the clearance under sprinkler heads. Sprinkler head locations were right under storage box at storage room, thereby reducing sprinkler coverage.
NFPA 13, 2002: 8.5.6.1 ..... A minimum clearance of 18 inches shall be maintained between the top of storage and sprinkler deflectors

Based on observations during the survey walk of the facility on the afternoon of 3/30/2017 with the Market Chief Operating Officer, System Manager of Plant Operations and System Manager of Security and Environment of Care, the facility failed to maintain the smoke compartment barriers. A few smoke compartment walls had penetrations through them. The smoke compartment must remain intact and prevent ay smoke to migrate from one compartment to another.
NFPA 101, 2003: 8.3.5.1 ..... Penetrations for cables, cable trays, conduits, pipes, tubes, combustion vents and exhaust vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a firestop system or device.

Based on review of records during the survey of the facility on the afternoon of 3/30/2017 with the Market Chief Operating Officer, System Manager of Plant Operations and System Manager of Security and Environment of Care, the facility failed to provide documentation of maintenance to Heating, Cooling, Ventilating, and Process Systems.
Air filter log shall be initiated.
ASHRAE 170, Ventilation of Health Care Facilities, shall be provided in accordance with ASHRAE 170. (NFPA 99, 9.3.1).
Final filters and filter frames should be visually inspected for pressure drop and for bypass monthly. Filters should be replaced based on pressure drop with filters that provide the efficiencies specified.
ASHRAE 170, Informative Appendix A, Operations and Maintenance Procedures
Records demonstrating that the RH was being monitored in anesthetizing locations and that they have taken timely corrective actions in instances when internal monitoring determines the RH levels are below the permitted range (20-60% RH).
ASHRAE 170, Table 7.1

Based on review of records during the survey of the facility on the afternoon of 3/30/2017 with the Market Chief Operating Officer, System Manager of Plant Operations and System Manager of Security and Environment of Care, the facility failed to provide documentation of the testing of grounding system at inpatient care areas. The electrical grounding of duplex outlets in general patient care areas shall be tested annually and critical care areas tested semi-annually. The facility must initiate a file on site to retain these records.
Receptacle testing in patient care areas shall be tested as follows:
Physical integrity of each receptacle. (Visual)
Continuity of the grounding of each receptacle. (Test)
Correct polarity of hot and neutral connections in each receptacle. (Test)
The retention force of the grounding blade shall be not less than 4 oz. (test)
NFPA 99: 6.3.4