HospitalInspections.org

A). Corrected 04/15/2010

B). Corrected 04/15/2010.





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C) From random observations, the surveyors find that vertical openings are not enclosed and protected in accordance with 19.3.1.1 and NFPA 90A. There are no shafts identified on the 2009 Life Safety Code Plans. In too many locations to list, the surveyors observed shaft enclosures that were not enclosed in fire rated enclosures. General deficiencies include but are not limited to:

* Shafts are open to the ceiling cavities of adjacent spaces.

* Shafts have multiple penetrations of voids that are not sealed

* Shafts have access panels that are not fire rated and not self closing

Example locations include but are not limited to:

1. First floor Pharmacy Storage (deemed a hazardous area): The shaft located on the west wall (approximatley the center of this wall) is incomplete above the finished ceiling.
2. Corrected 04/15/2010
3. Corrected 04/15/2010

D). Corrected 8/18/10
E). Corrected 04/15/2010

Surveyor: 26665

F). Patient bathrooms were observed to have recessed medicine cabinets in the exhaust duct chase with no fire rating on the medicine cabinets in accordance with 3-3.4.1. Areas include;

1. Fourth Floor.

2. Fifth floor.

3. Sixth floor.

4. Seventh floor.

5. Eighth floor.

G). Corrected 08/18/10
H). Corrected 08/18/10

A). Corrected 04/15/2010.



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B) UPDATE: 04/15/2010 It is the understanding that this item has become a project # 8791. (Revised 7/8/10 to 8971 by 13755) From random observation the surveyors find that means of egress are not readily available at all times:
UPDATE 08/18/10: Project 8971 remains open and will need to be inspected prior to clearing this tag.

1. Corrected 08/18/10
2. Corrected 08/18/10

C). Corrected 04/15/2010.

A) Corrected 08/18/10

B) Third floor ICU suite "A"shown as a designated suite on the Life Safety plans was observed to have a pair of cross corridor doors which do not latch. Location observed: East exit out of the suite to a corridor adjacent to Surgery.

A) From random observation, the surveyors find that fire barriers (with two hour or greater fire ratings) are not installed and maintained in accordance with 8.2.3. This includes fire barriers that are used as horizontal exits and fire barriers that are used to separate buildings:

1. Corrected 08/18/10
2. Corrected 04/15/2010.

3. Third floor 2-hour fire rated barrer between buildings located at West end patient care and MOB (not a designated horizontal exit) lacks a continuous fire rated separation due to the following:

a. Pair of cross corridor B-Labeled doors did not close and latch upon activation of the fire alarm.
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B). Corrected 08/18/10

A.) The surveyors find, from document review and facility walk through, that there is no definitive floor plan showing the necessary elements for evacuation and areas of refuge to comply with 19.7.2.2. Life Safety floor plans provided by the facility representatives lacked clearly defined smoke compartments. Facility personnel's knowledge related to location of smoke barriers, direction of travel for exit access (dead end corridor issues) and locations and sizes of suites (to comply with 19.2.5) appeared to conflict with the provided Life Safety floor plans.






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B). During a review of the facility's fire protection plan documents, compared to the survey walk through it was determined that the facility has not accurately maintained a comprehensive set of building floor plans, which show critical elements of its egress and fire/smoke compartmentalization systems, for compliance with 19.7.1.1. Critical elements of these systems which are not shown not shown accurately on the facility's Life Safety Master Plans include:

1. Locations and sizes of smoke compartments.

2. Designated suites including the perameter of the suite.

3. Corrected 08/18/10
4. Corrected 08/18/10

5. The information shown on the facility's CADD generated Life Safety Plans is not clear due to indicating smoke barriers, fire resistant barriers(both 2 and 1 hour) and smoke tight walls all with similar line weight and color designations (i.e. red and orange).

UPDATE 08/18/10 : The drawings indicate the smoke compartment size and suite size, it is unclear as to what walls were being utilized to enclose these areas.


C) Corrected 08/18/10
D) Corrected 08/18/10

A) Based upon a random review of fire drill documentation for the past 6 months, the surveyor finds that fire drills are not conducted in accordance with the Hospital's policies and/or not in accordance with 19.7.1.1, 19.7.1.2 and 19.7.2. of NFPA 101-2000.

1 Corrected 08/18/10
2 Corrected 08/18/10
3 Corrected 08/18/10

UPDATE 08/18/10: The time the tests are being conducted per shift must vary.

A.) First Floor ITT Department 1600: The corridor door leading to this suite did not latch to close upon activation of the fire alarm.


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B). Rooms or spaces were observed at which the fire alarm system audible alarm was not at least 10 dBA above the ambient noise level to comply with NFPA 72 1999 4-3.2.2. Locations observed:

1. Second floor Lab area near managers office. This part of the suite is used for patients and is not exclusive to staff.

C). Visual notification (strobe) devices were observed which did not activate during the test of the fire alarm system to comply with NFPA 72 1999 4-4.4.2.2. Location observed:

1. Second floor Lab near East Elevators




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D). During the tour of the first floor by the maintenance shop, eggcrate panels were observed in the ceiling grid compromising smoke detection by allowing byproducts of combustion to escape into the void above the detectors not in accordance with NFPA 72 1999 2-3.6.1.4 for flat ceiling surfaces.

E). During the fire alarm testing, smoke detector 4318 on the second floor was activated and the alarm notification devices did not function in accordance with NFPA 72 1999 1-5.4.2.2.

F). During the fire alarm testing, smoke detector 4318 on the second floor was activated and the double doors into the west business occupancy did not release in accordance with NFPA 72 1999 3-9.6.

A) Corrected 08/18/10







26665

UPDATE 04/15/2010
B). Corrected 08/18/10

UPDATE 04/15/2010
C). Corrected 08/18/10

UPDATE 04/15/2010
D). During the fire alarm testing, smoke detector 4318 on the second floor was activated and the double doors into the west business occupancy did not release in accordance with NFPA 72 1999 3-9.6.

UPDATE 08/18/10: Due to the surgery schedule, the detector was activated just to verify that is was identifying the proper location ("C"). All other items were by-passed for this test.

A). Interim Life Safety Measures: Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

A). Outlets were observed in critical patient care areas not identified with the panel and circuit serving the outlets to comply with NFPA 70 1999 517-19 (a). Example locations:

1. ICU patient rooms.

2. Emergency Department exam rooms.

3. PACU rooms.

4. CCU rooms.

5. Cardiac Cath rooms.

UPDATE 08/18/10: Not all receptacles connected to critical emergency power for critical care patient bed locations were color coded.