HospitalInspections.org

Based on observation the facility failed to provide an acceptable 2 hour separation between the hospital and the clinic.

The inspector observed while accompanied by the Maintenance Director during the hours of the inspection from 11:30 am to 3:45 pm that there were multiple penetrations in the 2 hour wall above the door separating the two facilities. In addition, the closer on the door at this location must cause the door to latch when it closes.

Based on observation the facility failed to provide acceptable door hardware at corridor doors.

The inspector observed while accompanied by the Maintenance Director during the hours of the inspection from 11:30 am to 3:45 pm that there were doors at the following locations in question: 1) the dishwashing room, 2) the nursery, 3) medical records, and 4) the gift shop. The code states: " Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf is applied at the latch edge of the door. " NFPA 101, 2000, 19.3.6.3.2. We can not accept dead bolts in new construction. However, in existing construction we can accept the use of a closer if it is capable of keeping the door closed with a 5 lbf. Please verify that the closers are present and will provide this measure of safety on all these doors.

Based on observation the facility failed to provide an acceptable separation between hazardous areas and the rest of the building.

The inspector observed while accompanied by the Maintenance Director during the hours of the inspection from 11:30 am to 3:45 pm that there were locations that the doors were held open. They were: 1) the lab storage room, and 2) the surgical storage room.

Based on observation the facility failed to provide acceptable smoker barrier separations.

The inspector observed while accompanied by the Maintenance Director during the hours of the inspection from 11:30 am to 3:45 pm that there were multiple locations where there where penetrations in the smoke barrier wall above the cross corridor doors. They were at the following locations: 1) adjacent to the P.T. room, 2) adjacent to the administration , 3) adjacent to the medical records, 4) adjacent to the business office, 5) adjacent to the E.R., and 6) adjacent to the O.B. suite.

Based on observation the facility failed to provide acceptable enclosures for hazardous areas.

The inspector observed while accompanied by the Maintenance Director during the hours of the inspection from 11:30 am to 3:45 pm that there were problems with enclosures for hazardous areas. There were missing closures or the existing closures require adjustment in the following locations: 1) the main supply room, 2) the boiler room, 3) clean linen storage, and 4) clean utility room.

Based on observation the facility failed to provide an acceptable cross referencing of the fire alarm control panel and the panel and breaker supplying power.

The inspector observed while accompanied by the Maintenance Director during the hours of the inspection from 11:30 am to 3:45 pm that there was not cross referencing of the fire alarm control panel and the panel and breaker supplying power. The fire alarm control panel must have a label indicating the panel and breaker supplying power and the breaker in the electrical panel must have a label adjacent to the breaker indicating " FIRE ALARM CIRCUIT CONTROL " and the breaker shall be colored red.

Based on observation the facility failed to prevent excessive combustible material in a storage room.

The inspector observed while accompanied by the Maintenance Director during the hours of the inspection from 11:30 am to 3:45 pm that there was a soiled utility room with greater than the allowable amount of combustible storage. This was a 8 ' x 12 ' room for a total area of 96 sq.ft. There were four containers in the room that were 5 ' x 2.5 ' x 2.5 ' for a total volume of 936 gallons. This creates a density of 9.75 gal/sq.ft. that greatly exceeds the maximum of 0.5 gal/sq.ft. There is an exception in the code that allows unlimited container size and density as long as the room is protected as a hazardous area. This means that the room must be either a 1 hour room with 45 minute doors and closers or the room must be sprinkled with a smoke tight wall, doors, and door closers. Since this room does have fire sprinklers, the doors must have closers.

This would also apply to the clean linen storage room adjacent to the soiled utility room.

Based on observation the facility failed to provide acceptable protection of medical gas lines.

The inspector observed while accompanied by the Maintenance Director during the hours of the inspection from 11:30 am to 3:45 pm that there was dissimilar metal contact between the copper medical gas lines and the steel uni-struts that support the oxygen lines. The electrolytic action between the two dissimilar metals will corrode the oxygen lines causing a leak and a highly hazardous situation. This situation exists throughout the hospital.

Based on observation the facility failed to keep storage of materials the correct distance below the sprinkler heads.

The inspector observed while accompanied by the Maintenance Director during the hours of the inspection from 11:30 am to 3:45 pm that there was material stacked above the 18 inch plane below the shield of the sprinkler heads in the central supply room.

Based on observation the facility failed to provide an acceptable generator room.

The inspector observed while accompanied by the Maintenance Director during the hours of the inspection from 11:30 am to 3:45 pm that there was storage of miscellaneous materials within the generator room. " The room in which the EPS equipment is located shall not be used for storage purposes. " NFPA 110, 1999, 5-11.1.

Based on observation the facility failed to provide an acceptable generator test schedule.

The inspector observed while accompanied by the Maintenance Director during the hours of the inspection from 11:30 am to 3:45 pm that there was an incomplete generator testing schedule. " The EPSS shall be tested for the duration of its assigned class (see Section 4.2), or for a duration agreed to by the authority having jurisdiction for at least 4 hours, at least once within every 36-48 months. The load shall be the EPSS system load running at the time of the test. The test shall be initiated by opening all switches or breakers supplying normal power to the EPSS. " NFPA 110, 8.4.8 and 8.4.8.1. There was no record of such longer duration tests under full load at 36 to 48 month intervals.

Based on observation the facility failed to provide an acceptable 2 hour separation between the hospital and the clinic.

The inspector observed while accompanied by the Maintenance Director during the hours of the inspection from 11:30 am to 3:45 pm that there were multiple penetrations in the 2 hour wall above the door separating the two facilities. In addition, the closer on the door at this location must cause the door to latch when it closes.

Based on observation the facility failed to provide acceptable door hardware at corridor doors.

The inspector observed while accompanied by the Maintenance Director during the hours of the inspection from 11:30 am to 3:45 pm that there were doors at the following locations in question: 1) the dishwashing room, 2) the nursery, 3) medical records, and 4) the gift shop. The code states: " Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf is applied at the latch edge of the door. " NFPA 101, 2000, 19.3.6.3.2. We can not accept dead bolts in new construction. However, in existing construction we can accept the use of a closer if it is capable of keeping the door closed with a 5 lbf. Please verify that the closers are present and will provide this measure of safety on all these doors.

Based on observation the facility failed to provide an acceptable separation between hazardous areas and the rest of the building.

The inspector observed while accompanied by the Maintenance Director during the hours of the inspection from 11:30 am to 3:45 pm that there were locations that the doors were held open. They were: 1) the lab storage room, and 2) the surgical storage room.

Based on observation the facility failed to provide acceptable smoker barrier separations.

The inspector observed while accompanied by the Maintenance Director during the hours of the inspection from 11:30 am to 3:45 pm that there were multiple locations where there where penetrations in the smoke barrier wall above the cross corridor doors. They were at the following locations: 1) adjacent to the P.T. room, 2) adjacent to the administration , 3) adjacent to the medical records, 4) adjacent to the business office, 5) adjacent to the E.R., and 6) adjacent to the O.B. suite.

Based on observation the facility failed to provide acceptable enclosures for hazardous areas.

The inspector observed while accompanied by the Maintenance Director during the hours of the inspection from 11:30 am to 3:45 pm that there were problems with enclosures for hazardous areas. There were missing closures or the existing closures require adjustment in the following locations: 1) the main supply room, 2) the boiler room, 3) clean linen storage, and 4) clean utility room.

Based on observation the facility failed to provide an acceptable cross referencing of the fire alarm control panel and the panel and breaker supplying power.

The inspector observed while accompanied by the Maintenance Director during the hours of the inspection from 11:30 am to 3:45 pm that there was not cross referencing of the fire alarm control panel and the panel and breaker supplying power. The fire alarm control panel must have a label indicating the panel and breaker supplying power and the breaker in the electrical panel must have a label adjacent to the breaker indicating " FIRE ALARM CIRCUIT CONTROL " and the breaker shall be colored red.

Based on observation the facility failed to prevent excessive combustible material in a storage room.

The inspector observed while accompanied by the Maintenance Director during the hours of the inspection from 11:30 am to 3:45 pm that there was a soiled utility room with greater than the allowable amount of combustible storage. This was a 8 ' x 12 ' room for a total area of 96 sq.ft. There were four containers in the room that were 5 ' x 2.5 ' x 2.5 ' for a total volume of 936 gallons. This creates a density of 9.75 gal/sq.ft. that greatly exceeds the maximum of 0.5 gal/sq.ft. There is an exception in the code that allows unlimited container size and density as long as the room is protected as a hazardous area. This means that the room must be either a 1 hour room with 45 minute doors and closers or the room must be sprinkled with a smoke tight wall, doors, and door closers. Since this room does have fire sprinklers, the doors must have closers.

This would also apply to the clean linen storage room adjacent to the soiled utility room.

Based on observation the facility failed to provide acceptable protection of medical gas lines.

The inspector observed while accompanied by the Maintenance Director during the hours of the inspection from 11:30 am to 3:45 pm that there was dissimilar metal contact between the copper medical gas lines and the steel uni-struts that support the oxygen lines. The electrolytic action between the two dissimilar metals will corrode the oxygen lines causing a leak and a highly hazardous situation. This situation exists throughout the hospital.

Based on observation the facility failed to keep storage of materials the correct distance below the sprinkler heads.

The inspector observed while accompanied by the Maintenance Director during the hours of the inspection from 11:30 am to 3:45 pm that there was material stacked above the 18 inch plane below the shield of the sprinkler heads in the central supply room.

Based on observation the facility failed to provide an acceptable generator room.

The inspector observed while accompanied by the Maintenance Director during the hours of the inspection from 11:30 am to 3:45 pm that there was storage of miscellaneous materials within the generator room. " The room in which the EPS equipment is located shall not be used for storage purposes. " NFPA 110, 1999, 5-11.1.

Based on observation the facility failed to provide an acceptable generator test schedule.

The inspector observed while accompanied by the Maintenance Director during the hours of the inspection from 11:30 am to 3:45 pm that there was an incomplete generator testing schedule. " The EPSS shall be tested for the duration of its assigned class (see Section 4.2), or for a duration agreed to by the authority having jurisdiction for at least 4 hours, at least once within every 36-48 months. The load shall be the EPSS system load running at the time of the test. The test shall be initiated by opening all switches or breakers supplying normal power to the EPSS. " NFPA 110, 8.4.8 and 8.4.8.1. There was no record of such longer duration tests under full load at 36 to 48 month intervals.