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Based on random observation during the survey walk-through, not all stair or ventilation shafts are constructed or maintained as fire resistive assemblies in accordance with 19.3.1.1. This deficiency could affect any patients, staff, or visitors on the Third or Fourth Floors by permitting fire to pass between them.

Findings include:

A. At 12:47 PM on August 21, 2012, unsealed floor openings were observed, at pipe chases in Fourth Floor Patient Sleeping Rooms 409 and 411, as prohibited by 19.3.1.1. These pipe chases had become accessible due to an ongoing construction project in the building, and the floor openings at the bottoms of the pipe chases, as observed, communicated with at least the building story below.

Based on random observation during the survey walk-through, not all designated or required smoke barrier walls are constructed or maintained as minimum 30 minute fire rated assemblies in accordance with 19.3.7.3. This deficiency could affect any patients, staff, or visitors in the adjacent smoke compartments by permitting smoke to cross the barrier between them.

Findings include:

A. At 10:31 AM on August 22, 2012, the designated smoke barrier immediately northwest of the First Floor Elevators (above the pair of cross-corridor doors) was observed to not form a complete barrier, as required by 19.3.7.3. and 8.3.2. because the wall does not extend to the underside of the deck above.

Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 39.3.2.1. These deficiencies could affect any patients, staff, or visitors in the building by permitting smoke or fire to pass from the hazardous areas to the remainder of the building.

Findings include:

A. Pipe or other penetrations through enclosure walls of hazardous areas were observed that are not sealed against the passage of fire as required by 39.3.2.1., 8.4.1.1., and 8.2.3.2.4.2. Locations observed include:

1. 8:35 AM August 22, 2012, Mechanical Room 137.
2. 8:40 AM August 22, 2012, Mechanical Room 181.

B. At 8:49 AM on August 22, 2012, the door to Mechanical Room 849 was observed to include a louver prohibited by 39.3.2.1. and 8.4.1.1.

Based on random observation during the survey walk-through and staff interview, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1. These deficiencies could affect any patients, staff, or visitors in the Mother/Baby Unit by preventing their egress from the building under emergency conditions.

Findings include:

A. At 2:19 PM on August 21, 2012, the provider's Plant Operations Manager stated that the magnetic locking devices installed on the doors listed below are activated by the infant security (HUGS) system and do not release upon activation of the building fire alarm system as required by 19.2.2.2.4. and 7.2.1.6.1. Doors at which this condition was identified include (all Second Floor):
1. The door to Exit Stair 1.

2. The door to Exit Stair 2.

3. The pair of cross-corridor doors at the east end of the Mother/Baby Unit (east of Exit Stair 2).

Based on staff interview, exit signs are not tested periodically in accordance with 7.9. These deficiencies could affect any patients, staff, or visitors in the building because egress paths may not be illuminated under emergency conditions.

Findings include:

A. During an interview held in the Conference Room at 8:45 AM on August 22, 2012, the provider's Plant Operations Manager stated that battery-powered emergency lights are not tested for a period of 30 seconds at least once every 30 days as required by 7.9.3.

B. During an interview held in the Conference Room at 8:45 AM on August 22, 2012, the provider's Plant Operations Manager stated that battery-powered emergency lights are not tested for a period of 1-1/2 hours at least once each year as required by 7.9.3.

Based on random observation during the survey walk-through, exit signs did not illuminate a continuous path of egress in all cases in accordance with 19.2.10.1. and 7.10. This deficiency could affect any patients or staff in the Inpatient Behavioral Health Unit because they may not be aware of a required egress path under emergency conditions.

Findings include:

A. At 2:04 PM on August 21, 2012, the egress path toward the south at the west and of the Second Floor Inpatient Behavioral Health Unit (south of the Nurses' Station) was observed to not be identified by an exit sign as required by 7.10.1.1.

Based on staff interview, exit signs are not tested periodically in accordance with 19.2.10.1. and 7.10. These deficiencies could affect any patients, staff, or visitors in the building because egress paths may not be identified under emergency conditions.

Findings include:

A. During an interview held in the Conference Room at 8:45 AM on August 22, 2012, the provider's Plant Operations Manager stated that battery-powered exit lights are not tested for a period of 30 seconds at least once every 30 days as required by 7.10.9.2. and 7.9.3.

B. During an interview held in the Conference Room at 8:45 AM on August 22, 2012, the provider's Plant Operations Manager stated that battery-powered exit lights are not tested for a period of 1-1/2 hours at least once each year as required by 7.10.9.2. and 7.9.3.

Based on random observation during the survey walk-through, not all portions of the building fire alarm system are installed in accordance with 19.3.4. This deficiency could affect any patients, staff, or visitors on the Third Floor because the unsynchronized strobe lights could trigger seizures.

Findings include:

A. During a test of the building fire alarm system conducted at 11:49 AM on August 22, 2012, more than two unsynchronized visual notification (strobe) devices less than 55'-0" apart were visible at the Third Floor Corridor in Smoke Compartment 2, as prohibited by NFPA 72 1999 4-4.4.2.2.

Based on document review, the facility's fire alarm system is not inspected, tested, and maintained in accordance with 9.6. This deficiency cold affect any staff or visitors in the area of the untested device because the device may fail to operate under smoke conditions.

Findings include:

A. Through document review, it was determined that the facility does not test fire alarm system components on a periodic basis (at least annually) as required by NFPA 72 1999 Table 7-3.2. During the document review process at 11:15 AM on August 22, 2012, it was determined that, during an inspection conducted by an outside vendor in April 2012, Smoke Detector M7-4 was not tested because the room housing it was not accessible. The device had been last tested in April 2011 and there was no record which indicates that it had been tested since that date.

Based on staff interview, the facility's fire alarm system is not inspected, tested, and maintained in accordance with 9.6. This deficiency cold affect any staff or visitors in the area of the untested device because the fire alarm system may fail to operate under smoke or fire conditions.

Findings include:

A. During an interview held in the Conference Room at 10:05 AM on August 22, 2012, the provider's Plant Operations Manager stated that the building fire alarm system components are not tested on a periodic basis (at least annually) as required by NFPA 72 1999 Table 7-3.2.

Based on staff interview, not all portions of the facility ' s automatic sprinkler system are inspected, tested, and maintained in accordance with NFPA 25. This deficiency cold affect any staff or visitors in the area of the untested device because the automatic sprinkler system may fail to operate under fire conditions.

Findings include:

A. During an interview held in the Conference Room at 10:05 AM on August 22, 2012, the provider's Plant Operations Manager stated that the building sprinkler system components are not tested on a periodic basis as required by NFPA 25 1998 Table 2-1.

Based on random observation during the survey walk-through and staff interview, not all portions of the building electrical system are installed in accordance with NFPA 70 1999. These deficiencies could affect any inpatients being treated in the Patient Sleeping Rooms because electrical power to support medical equipment may not be available under power outage conditions, and could affect any patients, staff, or visitors on the Fourth Floor because necessary power sources may be inadvertently disconnected.

Findings include:

A. At 12:36 PM on August 21, 2012, Fourth Floor Patient Sleeping Room 423 was observed to lack at least 1 circuit supplied by the building emergency electrical system as required by NFPA 70 1999 517-18(a). During an interview held at that time and location, the provider's Plant Operations Manager stated that the condition exists at all Patient Sleeping Rooms in the building except those (approximately 15) Patient Sleeping Rooms which had been recently remodeled under an ongoing construction project.

B. At 12:40 PM on August 21, 2012, Fourth Floor Electrical Panel W4N21 was observed to not be provided with an accurate panel directory required by NFPA 70 1999 384-13.

Based on random observation during the survey walk-through, not all stair or ventilation shafts are constructed or maintained as fire resistive assemblies in accordance with 19.3.1.1. This deficiency could affect any patients, staff, or visitors on the Third or Fourth Floors by permitting fire to pass between them.

Findings include:

A. At 12:47 PM on August 21, 2012, unsealed floor openings were observed, at pipe chases in Fourth Floor Patient Sleeping Rooms 409 and 411, as prohibited by 19.3.1.1. These pipe chases had become accessible due to an ongoing construction project in the building, and the floor openings at the bottoms of the pipe chases, as observed, communicated with at least the building story below.

Based on random observation during the survey walk-through, not all designated or required smoke barrier walls are constructed or maintained as minimum 30 minute fire rated assemblies in accordance with 19.3.7.3. This deficiency could affect any patients, staff, or visitors in the adjacent smoke compartments by permitting smoke to cross the barrier between them.

Findings include:

A. At 10:31 AM on August 22, 2012, the designated smoke barrier immediately northwest of the First Floor Elevators (above the pair of cross-corridor doors) was observed to not form a complete barrier, as required by 19.3.7.3. and 8.3.2. because the wall does not extend to the underside of the deck above.

Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 39.3.2.1. These deficiencies could affect any patients, staff, or visitors in the building by permitting smoke or fire to pass from the hazardous areas to the remainder of the building.

Findings include:

A. Pipe or other penetrations through enclosure walls of hazardous areas were observed that are not sealed against the passage of fire as required by 39.3.2.1., 8.4.1.1., and 8.2.3.2.4.2. Locations observed include:

1. 8:35 AM August 22, 2012, Mechanical Room 137.
2. 8:40 AM August 22, 2012, Mechanical Room 181.

B. At 8:49 AM on August 22, 2012, the door to Mechanical Room 849 was observed to include a louver prohibited by 39.3.2.1. and 8.4.1.1.

Based on random observation during the survey walk-through and staff interview, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1. These deficiencies could affect any patients, staff, or visitors in the Mother/Baby Unit by preventing their egress from the building under emergency conditions.

Findings include:

A. At 2:19 PM on August 21, 2012, the provider's Plant Operations Manager stated that the magnetic locking devices installed on the doors listed below are activated by the infant security (HUGS) system and do not release upon activation of the building fire alarm system as required by 19.2.2.2.4. and 7.2.1.6.1. Doors at which this condition was identified include (all Second Floor):
1. The door to Exit Stair 1.

2. The door to Exit Stair 2.

3. The pair of cross-corridor doors at the east end of the Mother/Baby Unit (east of Exit Stair 2).

Based on staff interview, exit signs are not tested periodically in accordance with 7.9. These deficiencies could affect any patients, staff, or visitors in the building because egress paths may not be illuminated under emergency conditions.

Findings include:

A. During an interview held in the Conference Room at 8:45 AM on August 22, 2012, the provider's Plant Operations Manager stated that battery-powered emergency lights are not tested for a period of 30 seconds at least once every 30 days as required by 7.9.3.

B. During an interview held in the Conference Room at 8:45 AM on August 22, 2012, the provider's Plant Operations Manager stated that battery-powered emergency lights are not tested for a period of 1-1/2 hours at least once each year as required by 7.9.3.

Based on random observation during the survey walk-through, exit signs did not illuminate a continuous path of egress in all cases in accordance with 19.2.10.1. and 7.10. This deficiency could affect any patients or staff in the Inpatient Behavioral Health Unit because they may not be aware of a required egress path under emergency conditions.

Findings include:

A. At 2:04 PM on August 21, 2012, the egress path toward the south at the west and of the Second Floor Inpatient Behavioral Health Unit (south of the Nurses' Station) was observed to not be identified by an exit sign as required by 7.10.1.1.

Based on staff interview, exit signs are not tested periodically in accordance with 19.2.10.1. and 7.10. These deficiencies could affect any patients, staff, or visitors in the building because egress paths may not be identified under emergency conditions.

Findings include:

A. During an interview held in the Conference Room at 8:45 AM on August 22, 2012, the provider's Plant Operations Manager stated that battery-powered exit lights are not tested for a period of 30 seconds at least once every 30 days as required by 7.10.9.2. and 7.9.3.

B. During an interview held in the Conference Room at 8:45 AM on August 22, 2012, the provider's Plant Operations Manager stated that battery-powered exit lights are not tested for a period of 1-1/2 hours at least once each year as required by 7.10.9.2. and 7.9.3.

Based on random observation during the survey walk-through, not all portions of the building fire alarm system are installed in accordance with 19.3.4. This deficiency could affect any patients, staff, or visitors on the Third Floor because the unsynchronized strobe lights could trigger seizures.

Findings include:

A. During a test of the building fire alarm system conducted at 11:49 AM on August 22, 2012, more than two unsynchronized visual notification (strobe) devices less than 55'-0" apart were visible at the Third Floor Corridor in Smoke Compartment 2, as prohibited by NFPA 72 1999 4-4.4.2.2.

Based on document review, the facility's fire alarm system is not inspected, tested, and maintained in accordance with 9.6. This deficiency cold affect any staff or visitors in the area of the untested device because the device may fail to operate under smoke conditions.

Findings include:

A. Through document review, it was determined that the facility does not test fire alarm system components on a periodic basis (at least annually) as required by NFPA 72 1999 Table 7-3.2. During the document review process at 11:15 AM on August 22, 2012, it was determined that, during an inspection conducted by an outside vendor in April 2012, Smoke Detector M7-4 was not tested because the room housing it was not accessible. The device had been last tested in April 2011 and there was no record which indicates that it had been tested since that date.

Based on staff interview, the facility's fire alarm system is not inspected, tested, and maintained in accordance with 9.6. This deficiency cold affect any staff or visitors in the area of the untested device because the fire alarm system may fail to operate under smoke or fire conditions.

Findings include:

A. During an interview held in the Conference Room at 10:05 AM on August 22, 2012, the provider's Plant Operations Manager stated that the building fire alarm system components are not tested on a periodic basis (at least annually) as required by NFPA 72 1999 Table 7-3.2.

Based on staff interview, not all portions of the facility ' s automatic sprinkler system are inspected, tested, and maintained in accordance with NFPA 25. This deficiency cold affect any staff or visitors in the area of the untested device because the automatic sprinkler system may fail to operate under fire conditions.

Findings include:

A. During an interview held in the Conference Room at 10:05 AM on August 22, 2012, the provider's Plant Operations Manager stated that the building sprinkler system components are not tested on a periodic basis as required by NFPA 25 1998 Table 2-1.

Based on random observation during the survey walk-through and staff interview, not all portions of the building electrical system are installed in accordance with NFPA 70 1999. These deficiencies could affect any inpatients being treated in the Patient Sleeping Rooms because electrical power to support medical equipment may not be available under power outage conditions, and could affect any patients, staff, or visitors on the Fourth Floor because necessary power sources may be inadvertently disconnected.

Findings include:

A. At 12:36 PM on August 21, 2012, Fourth Floor Patient Sleeping Room 423 was observed to lack at least 1 circuit supplied by the building emergency electrical system as required by NFPA 70 1999 517-18(a). During an interview held at that time and location, the provider's Plant Operations Manager stated that the condition exists at all Patient Sleeping Rooms in the building except those (approximately 15) Patient Sleeping Rooms which had been recently remodeled under an ongoing construction project.

B. At 12:40 PM on August 21, 2012, Fourth Floor Electrical Panel W4N21 was observed to not be provided with an accurate panel directory required by NFPA 70 1999 384-13.