HospitalInspections.org

Based on observation and staff interview during the course of the revisit survey conducted on November 8, 2013, it was determined that the facility failed to maintain separation from corridors to use areas in accordance with sections 19.3.6.1, 19.3.6.2.1, and 19.3.6.5 of the Life Safety Code. This was evidenced by the following:

During the walk through with the facility staff:

1. The main entry lobby and it's "mezzanine" level is open to the corridor. Exception number one items (b) and (c) to 19.3.6.1 are not met as the space does not contain smoke detection, quick response sprinklers and/or is not arranged to allow direct supervision of the space. Exceptions two through seven do not meet by definition.
2. The front business office and registration area is a suite which is not separated from the main entry lobby and subsequently the corridors.
3. Throughout the facility the corridor walls were observed to terminate above the grid ceiling and not continue to the underside of the of the floor or roof deck above. Exception number one to 19.3.6.2.1 is not met based on the inspection report from the facility fire sprinkler contractor dated December 5, 2011 indicating that numerous areas required additional sprinkler heads to be added to provide full coverage in accordance with NFPA 13. The lack of sprinkler coverage in areas throughout the hospital was confirmed through observation during the walkthrough.

Staff indicated no corrective action had been taken for items one and two since the original survey. Staff indicated sprinkler work to correct item number three was ongoing and was not complete at the time of survey.

Based on observation and staff interview during the course of the revisit survey conducted on November 8, 2013, it was determined that the facility failed to maintain the doors to the corridor in accordance with section 19.3.6.3 of the Life Safety Code. This was evidenced by the following:
During the walk through with the facility staff:

1. The left leaf of the pair of doors into the kitchen did not latch into the frame and the hardware failure prevented the door from closing completely to be smoke resistive.

2. Rooms 108, 109, 110, 111 ICU sliding doors were not smoke resistive when latched as there was a significant gap observed of approximately ?" between the door and the frame when closed.

The corridor door deficiency items were discussed during the survey. Staff indicated no action had been taken to correct item number one since the original survey.

Based on observation and staff interview during the course of the revisit survey conducted on November 8, 2013, it was determined that the facility failed to maintain and protect vertical openings in accordance with section 19.3.1.1 of the Life Safety Code. This was evidenced by the following:

The main entry lobby contains an upper level "mezzanine" containing offices and meeting rooms. Unprotected openings in accordance with 8.2.5.5 are not permitted.

The area does not meet the requirements of 8.2.5.8 for unenclosed vertical openings due to the following:

1. The lobby and upper floor opening is not separated from corridors as the lobby is open to the corridors leading to multiple other areas of the facility.

2. The opening is a required means of egress from payroll and the other upstairs office space.

The area does not meet the requirements of 8.2.5.6 for atriums due to the following:

3. The entire building is not protected throughout by an approved automatic sprinkler system

4. An engineering analysis has not been performed in accordance with 8.2.5.6 (5)

5. An engineered smoke control system is not installed in accordance with 8.2.5.6 (6)

The vertical opening deficiency items were discussed during the survey. Staff indicated an engineering analysis had been performed but no physical modifications had been started since the original survey.

Based on observation and staff interview during the course of the revisit survey conducted on November 8, 2013, it was determined that the facility failed to maintain the smoke barrier doors in accordance with section 19.2.2.2.6 of the Life Safety Code. This was evidenced by the following:

During the walk through with the facility staff:

The doors to the Emergency Department suite which are within a smoke barrier wall were stated to often be held open by closer hold opens for patient observation purposes. The hold opens are not equipped with a means to release upon activation of the manual fire alarm system, activation of smoke detection systems, or the automatic sprinkler system.

The door closing deficiency items were discussed during the survey. Staff indicated no corrective action had been taken for the listed items since the original survey.

Based on observation and staff interview during the course of the revisit survey conducted on November 8, 2013, it was determined that the facility failed to maintain the fire rated smoke barrier walls in accordance with section 19.3.7.3 of the Life Safety Code. This was evidenced by the following:

1. Smoke barriers walls were constructed of metal studs with lath and plaster on one side only. At the time of the survey no documentation was available demonstrating that the wall was constructed with a fire resistance rating of not less than ? hour.

2. There were various penetrations throughout that were not completely or adequately sealed to restrict the movement of smoke.

The smoke barrier and penetrations were discussed during the survey. Staff indicated no corrective action had been taken for the listed items since the original survey.

Based on observation during the course of the revisit survey conducted on November 8, 2013, it was determined that the facility failed to maintain travel distance to exits in accordance with section 19.2.5.8 of the Life Safety Code. This was evidenced by the following:

During the walk through with the facility staff:

The front business office is a suite which contained three intervening rooms and therefore exceeds the allowable travel distances within suites.

The travel distance deficiency items were discussed during the survey. Staff indicated no corrective action had been taken for the listed item since the original survey.

Based on observation and staff interview during the course of the revisit survey conducted on November 8, 2013, it was determined that the facility failed to provide and maintain a means of egress so arranged that exits are readily accessible at all times in accordance with section 19.2.1 of the Life Safety Code. This was evidenced by the following:

During the walk through with the facility staff:

1. The exit doors from the vestibule adjacent to the operating suite on the north side were equipped with an incomplete access control system. The optical sensor was mounted in an offset location and did not reliably release the locking mechanism. There was no manual release device in accordance with 7.2.1.6.2 (c).

2. Doors from rooms in the ancillary wing are equipped with a latch located between 51" and 58" in height which contain a thumb-turn on the egress side and a key lock on the outside of the door. Releasing devices shall be located not less than 34" and not more than 48" above finished floor.

The means of egress deficiency items were discussed during the survey. Staff indicated no corrective action had been taken for the listed items since the original survey.

Based on observation, staff interview, and record review during the course of the revisit survey conducted on November 8, 2013, it was determined that the facility failed to maintain the battery backed-up emergency lighting in accordance with section 7.9 of the Life Safety Code. This was evidenced by the following:

During the walk through with the facility staff:

Emergency and exit light in the building lobby failed to function when tested.

The emergency lighting deficiency items were discussed during the survey. Staff indicated no corrective action had been taken for the listed items since the original survey.

Based on observation during the course of the revisit survey conducted on November 8, 2013, it was determined that the facility failed to install the Fire Alarm System in accordance with section 19.3.4 of the Life Safety Code and NFPA 72, National Fire Alarm Code. This was evidenced by the following:

During the walk through with the facility staff:

1. The strobe spacing in the central corridor between the patient and ancillary wing measured in excess of 15 feet per corridor spacing requirements of NFPA 72, section 4-4.4.2.2, measured from the south end of the corridor as defined by the smoke barrier doors.

2. The MRI trailer fire alarm system was not connected to the building fire alarm system and as such does not provide emergency forces notification in accordance with 19.3.4.3.2. The lack of interconnectivity does not provide automatic notification to other facility staff who may be responsible for responding in emergency conditions.

The fire alarm deficiency items were discussed during the survey. Staff indicated no corrective action had been taken for the listed items since the original survey.

Based on observation during the course of the revisit survey conducted on November 8, 2013, it was determined that the facility failed to install the automatic fire sprinkler system in accordance with NFPA 13 This was evidenced by the following:
During the walk through with the facility staff:

1. The sprinkler heads in the following locations were obstructed from the spray pattern fully developing resulting in incomplete coverage:
a. The sprinkler head outside room 110 was obstructed by the light fixture immediately adjacent which extended below the deflector.
b. The sprinkler head in the hallway outside the kitchen restroom obstructed by the light fixture immediately adjacent which extended below the deflector.
c. At the kitchen lockers sprinkler coverage was obstructed by the wall from reaching the locker area.
d. The sprinklers in the med-gas storage room were obstructed by a duct located below from providing complete coverage to the room.

2. A sprinkler head in the kitchen was of ordinary temperature and was located within 1 foot of a ceiling supply diffuser.

3. A portion of the corridors around the emergency department waiting area had been changed to quick response sprinkler heads, the adjacent corridor space within the same compartment were of the standard response type. The lintels present measured less than 8" and do not provide compartment separation. When sprinklers are converted to quick response all sprinklers in the compartmented space shall be changed in accordance with NFPA 13, section 5-3.1.5.2.

The fire sprinkler installation deficiency items were discussed during the survey. Staff indicated sprinkler work was ongoing and was not complete at the time of the revisit survey.

Based on observation during the course of the revisit survey conducted on November 8, 2013, it was determined that the facility failed to maintain the automatic fire sprinkler system in accordance with NFPA 13 and 25. This was evidenced by the following:
During the walk through with the facility staff:

1. There was foreign material loading consisting primarily of lint and in some locations synthetic fibers on numerous sprinkler heads throughout the facility. Sprinklers shall be free of foreign material in accordance with NFPA 25, section 2-2.1.1. Location affected include but are not limited to: Room 312, radiology directors office, switchboard room, sterile processing, IT office, PT storage.

2. There was paint present on the sprinkler head in room 312. Sprinklers shall be free of paint in accordance with NFPA 25, section 2-2.1.1.

3. The sprinkler escutcheon in the bathroom in room 340 was deformed. Sprinklers shall be free of physical damage in accordance with NFPA 25, section 2-2.1.1.

The fire sprinkler maintenance deficiency items were discussed during the survey. Staff indicated sprinkler work was ongoing and was not complete at the time of the revisit survey.

Based on observation and staff interview during the course of the revisit survey conducted on November 8, 2013, it was determined that the facility failed to protect anesthetizing locations in accordance with section 19.3.2.3 of the Life Safety Code and NFPA 99. This was evidenced by the following:

During the walk through with the facility staff:

1. According to the Facilities Services Director, the operating rooms did not contain a mechanical ventilation system arranged to automatically vent smoke and products of combustion and prevent recirculation in accordance with NFPA 99, sections 5-4.1.2 and 5-4.1.3.

2. The humidity levels within the operating rooms were not controlled to a level of 35% or greater at the time of the survey.
a. Operating room one, the wall mounted gauge was inoperable. The battery powered desk humidity gauge read 23% at the time of survey.
b. Operating room two, The humidity gauge read 22% at the time of survey.

The anesthetizing location deficiency items were discussed during the survey. Staff indicated no corrective action had been taken for the listed items since the original survey. No documentation was available at the time of the revisit survey indicating the facility has elected to use the O.R. humidity level categorical waiver as allowed by CMS Survey and Certification letter 13-25-LSC dated April 22, 2013.

Based on observation, staff interview, and record review during the course of the revisit survey conducted on November 8, 2013, it was determined that the facility failed to install the Type I emergency electrical system in accordance with NFPA 99, section 3-4.2. This was evidenced by the following:

During the walk through with the facility staff:

The generator installed is a 350KW Generator which is supplied a single transfer switch. The second transfer switch had been abandoned since the original survey. The electrical distribution was not arranged as a Type 1 electrical system in accordance with NFPA 99. A Type 1 electrical system shall include an Emergency System comprised of a Life Safety Branch and a Critical Branch, and an Equipment System. Each branch of the Emergency System and each Equipment System shall have one or more transfer switches in accordance with NFPA 99 section 3-4.2.2.1. A single transfer switch is only permitted for systems with a maximum demand of 150 kVA (120 kW)

The generator deficiency items were discussed during the survey. Corrective actions taken as indicated by the staff since the original survey did not satisfy the deficiency and the plan or correction.

Based on observation, staff interview, and record review during the course of the revisit survey conducted on November 8, 2013, it was determined that the facility failed to install and maintain electrical wiring in accordance with NFPA 70, National Electrical Code. This was evidenced by the following:

During the walk through with the facility staff:

The front business office contained UPS devices used in series with power strips and daisy chained power strips in multiple locations which may result in potential circuit overloading.

The electrical deficiency items were discussed during the survey.

Based on observation during the course of the revisit survey conducted on November 8, 2013, it was determined that the facility failed to install the Alcohol Based Hand Rub (ABHR) dispensers correctly in accordance with CMS Guidelines and the CFR. This was evidenced by the following:

During the walk through with the facility staff:

ABHR's located within the ancillary wing were located above carpeting in multiple locations. AHBR's may only be located above carpeting if the building is fully sprinkler protected. The building is currently classified as partially sprinkler protected as sprinkler work was not complete at the time of survey.

The Alcohol Based Hand Rub (ABHR) dispenser deficiency item was discussed during the survey. Staff indicated sprinkler work was ongoing and was not complete at the time of the revisit survey.