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Based on random observation during the survey walk-through, not all exit access corridors are separated from use areas in accordance with 18.3.6.1. These deficiencies could affect any patients, staff, or visitors in the immediate area by permitting smoke to pass from the cited rooms into the building's corridors.

Findings include:

A. 9:11 AM: Business Office d077, which was observed to be open to the adjacent corridor, was observed to lack smoke detectors required by Subpart (c) of Exception 1. to 18.3.6.1.
B. 9:40 AM: The corridor window at Pharmacy a086 was observed to be provided with a smoke detector on the Corridor side only, and not at both sides of the window as required by 18.3.6.3.2.

C. 10:45 AM: Pipe or other penetrations were observed, in the east wall of Mechanical Room d039, that are not sealed against the passage of smoke as required by 18.3.6.2. and 8.2.4.4.1.

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Based on random observation during the survey walk-through, not all doors in exit access corridors are in compliance with 18.3.6.3. These deficiencies could affect any patients, staff, or visitors in the immediate area by permitting smoke to pass from the cited rooms to the building's corridors.

Findings include:

A. Doors in exit access corridors were observed that are not positive latching as required by 18.3.6.3.2. Locations observed include:
1. 10:20 AM: The door to IT Work Room a135.
2. 12:30 PM: The door to Staff Locker Room a048.

B. 9:31 AM: The inactive leaf at the pair of doors to Electrical Closet b021 was observed to be equipped with throw bolts, and not manual flush bolts as required by Exception 4. to 18.2.3.5.

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Based on random observation during the survey walk-through and staff interview, not all designated or required smoke barrier walls are constructed or maintained as minimum 1 hour fire rated assemblies in accordance with 18.3.7.3. These deficiencies could affect any patients, staff, or visitors in the two adjacent smoke compartments by permitting smoke to cross the smoke barrier.

Findings include:

A. 9:25 AM: The following conditions were observed above the cross-corridor doors (located in a designated smoke barrier wall) at the south end of Corridor b017:

1. During an interview held at the site, the provider's Support Services Director was not able to confirm that the space directly above the top surface of the original precast concrete roof panel and the underside of the new roof deck is sealed against the passage of smoke as required by 18.3.7.3. and 8.3.6.1.

B. Pipe or other penetrations were observed in the smoke barrier wall that are not sealed against the passage of smoke as required by 18.3.7.3. and 8.3.6.1.

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Based on random observation during the survey walk-through, not all doors in smoke barrier walls are resistant to the passage of smoke in accordance with 18.3.7.5., 18.3.7.6., and 18.3.7.7.

Findings include:

A. 12:48 AM: During the survey, the south wall of the Physical Therapy Unit was considered as part of a smoke barrier wall. The pair of doors to the Unit was observed to lack:
1. Vision panels required by 18.3.7.7. This deficiency could affect any patients, staff or visitors in the two smoke compartments by making it difficult to open the smoke barrier doors if there are unseen obstructions on the opposite side.

2. An astragal required by 18.3.7.8. This deficiency could affect any patients, staff, or visitors in the two smoke compartments by permitting smoke to cross the smoke barrier.

B. 12:50 PM: The pair of doors in the smoke barrier wall between the Emergency Department and the Surgical Department was observed to lack an astragal required by 18.3.7.8. This deficiency could affect any patients, staff, or visitors in the two smoke compartments by permitting smoke to cross the smoke barrier.

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Based on staff interview, fire drills are not held in accordance with 18.7.1.2.

Findings include:

A. During an interview held in the Administrative Conference Room at 11:06 AM on February 22, 2012, the provider's Support Services Director confirmed that fire drills do not include the transmission of a fire alarm signal as required by 18.7.1.2. This deficiency could affect any patients, staff, or visitors in the building because the connection between the building fire alarm system and the fire alarm monitoring service is not tested periodically to ensure its operation.

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Based on random observation during the survey walk-through, not all portions of the building fire alarm system are installed in accordance with 18.3.4.

Findings include:

A. 9:41 AM: The smoke detector in Pharmacy IV Storage Room a089 was observed to be located within 3'-0" of a supply air diffuser as prohibited by NFPA 72 1999 2-3.5.1. this deficiency could affect any patients, staff, or visitors in the immediate area by preventing the timely activation of the smoke detector.

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Based on document review and staff interview, the facility's fire alarm system is not inspected, tested, and maintained in accordance with 9.6.

Findings include:

A. Through document review, it was determined that the facility does not test fire alarm system components on a periodic basis as required by NFPA 72 1999 Table 7-3.2. During an interview held in the Administrative Conference Room at 12:38 PM on February 22, 2012, the provider's Support Services Director confirmed that the building fire alarm system had not been inspected by an outside agency since 2009. This deficiency could affect any patients, staff, or visitors in the building because the fire alarm system may not be in working order.

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Based on random observation during the survey walk-through, not all portions of the facility's automatic sprinkler system are installed and maintained in accordance with NFPA 13 1999. These deficiencies could affect any patients, staff, or visitors in the immediate area by preventing the timely activation of the sprinkler heads.

Findings include:

A. 9:09 AM: Auxiliary Storage Room d084 was observed to lack a ceiling assembly, thus permitting heat or flames to enter the ceiling cavity as prohibited by NFPA 13 1999 5-6.4.1.1.
B. 10:22 AM: Ceiling tiles were observed to be missing in Purchasing Room a144, which compromises sprinkler coverage as prohibited by NFPA 13 1999 5-6.4.1.1.

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26665


Based on random observation during the survey walk-through during the morning on February 22, 2012, not all portions of the facility's sprinkler system are installed in accordance with NFPA 13, 1999.

Findings include:

A. During the survey of the old kitchen (area currently used for storage) the range hood obstructed the sprinkler head from fully developing its pattern, thus not in accordance with 5-5.5.3.

This deficiency could cause injury to staff and patients by allowing a fire in the unprotected area to continue to burn.

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Based on random observation during the survey walk-through, not all portable medical gases are stored in accordance with NFPA 99.

Findings include:

A. Medical gas tanks were observed being stored that are less than 5'-0" from combustibles as prohibited by NFPA 99 1999 8-3.1.11.2(c)(2). These deficiencies could affect any patients, staff, or visitors in the immediate area because the oxygen could contribute to an ongoing fire. locations observed include:
1. 1009 AM: Physical Therapy Open Gym a124, 1 tank.

2. 10:12 AM, Cardiac Rehab Room a127, 1 tank.

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Based on random observation during the survey walk-through during the morning on February 22, 2012, not all portions of the facility's piped medical gas system are in accordance with NFPA 99 1999.

Findings include:

A. During the survey of the mechanical room, the medical air system dew point monitor appeared to have a trouble code reading and not the dew point in accordance with 4-3.1.2.2.

B. During the building walk-through area alarm panels were not labeled as to the area it monitored in accordance with 4-3.1.2.2 (a) 3.

C. During the building walk-through zone boxes was not correctly labeled with corresponding room numbers in accordance with 4-3.1.2.14.

Deficiency A could cause patient injury due to excess moisture in the air they are breathing.

Deficiency B and C could cause injury to patients by accidental shutting off of the wrong gas valves.

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Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

A. 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.

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Based on random observation during the survey walk-through of the Laboratory area on the morning of February 22, 2012, not all portions of the Laboratory are in accordance with NFPA 99 1999.

Findings include:

A. The eye wash station was observed without a pressure reducing and tempering valves in accordance with 10-6.

This deficiency could cause injury the staff due to excessive pressures and temperatures.

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Based on random observation during the document review process on February 22, 2012, not all portions of the emergency generator testing are in accordance with NFPA 110 1999.

Findings include:

A. During the review of monthly generator load testing the amperage readings were less than name plate full load and not in accordance with 6-4.2.

B. During the review records were not available for annual load bank testing in accordance with 6-4.2.2.

C. During the record review monthly testing of the three transfer switches were not available in accordance with 6-4.1.

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Based on random observation during the survey walk-through on February 22, 2012, not all portions of the facility's emergency electrical panels were observed to be in accordance with NFPA 70 1999.

Findings include:

A. During the survey walk-through of the main electrical room, emergency electrical panels were observed to have different panel designations on the same branch and were labeled consistently for each branch in accordance with 700-9.

This deficiency could cause injury to patients and staff due to the wrong circuit being turned off.

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Based on random observation during the survey walk-through, not all exit access corridors are separated from use areas in accordance with 18.3.6.1. These deficiencies could affect any patients, staff, or visitors in the immediate area by permitting smoke to pass from the cited rooms into the building's corridors.

Findings include:

A. 9:11 AM: Business Office d077, which was observed to be open to the adjacent corridor, was observed to lack smoke detectors required by Subpart (c) of Exception 1. to 18.3.6.1.
B. 9:40 AM: The corridor window at Pharmacy a086 was observed to be provided with a smoke detector on the Corridor side only, and not at both sides of the window as required by 18.3.6.3.2.

C. 10:45 AM: Pipe or other penetrations were observed, in the east wall of Mechanical Room d039, that are not sealed against the passage of smoke as required by 18.3.6.2. and 8.2.4.4.1.

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Based on random observation during the survey walk-through, not all doors in exit access corridors are in compliance with 18.3.6.3. These deficiencies could affect any patients, staff, or visitors in the immediate area by permitting smoke to pass from the cited rooms to the building's corridors.

Findings include:

A. Doors in exit access corridors were observed that are not positive latching as required by 18.3.6.3.2. Locations observed include:
1. 10:20 AM: The door to IT Work Room a135.
2. 12:30 PM: The door to Staff Locker Room a048.

B. 9:31 AM: The inactive leaf at the pair of doors to Electrical Closet b021 was observed to be equipped with throw bolts, and not manual flush bolts as required by Exception 4. to 18.2.3.5.

.

Based on random observation during the survey walk-through and staff interview, not all designated or required smoke barrier walls are constructed or maintained as minimum 1 hour fire rated assemblies in accordance with 18.3.7.3. These deficiencies could affect any patients, staff, or visitors in the two adjacent smoke compartments by permitting smoke to cross the smoke barrier.

Findings include:

A. 9:25 AM: The following conditions were observed above the cross-corridor doors (located in a designated smoke barrier wall) at the south end of Corridor b017:

1. During an interview held at the site, the provider's Support Services Director was not able to confirm that the space directly above the top surface of the original precast concrete roof panel and the underside of the new roof deck is sealed against the passage of smoke as required by 18.3.7.3. and 8.3.6.1.

B. Pipe or other penetrations were observed in the smoke barrier wall that are not sealed against the passage of smoke as required by 18.3.7.3. and 8.3.6.1.

.

Based on random observation during the survey walk-through, not all doors in smoke barrier walls are resistant to the passage of smoke in accordance with 18.3.7.5., 18.3.7.6., and 18.3.7.7.

Findings include:

A. 12:48 AM: During the survey, the south wall of the Physical Therapy Unit was considered as part of a smoke barrier wall. The pair of doors to the Unit was observed to lack:
1. Vision panels required by 18.3.7.7. This deficiency could affect any patients, staff or visitors in the two smoke compartments by making it difficult to open the smoke barrier doors if there are unseen obstructions on the opposite side.

2. An astragal required by 18.3.7.8. This deficiency could affect any patients, staff, or visitors in the two smoke compartments by permitting smoke to cross the smoke barrier.

B. 12:50 PM: The pair of doors in the smoke barrier wall between the Emergency Department and the Surgical Department was observed to lack an astragal required by 18.3.7.8. This deficiency could affect any patients, staff, or visitors in the two smoke compartments by permitting smoke to cross the smoke barrier.

.

Based on staff interview, fire drills are not held in accordance with 18.7.1.2.

Findings include:

A. During an interview held in the Administrative Conference Room at 11:06 AM on February 22, 2012, the provider's Support Services Director confirmed that fire drills do not include the transmission of a fire alarm signal as required by 18.7.1.2. This deficiency could affect any patients, staff, or visitors in the building because the connection between the building fire alarm system and the fire alarm monitoring service is not tested periodically to ensure its operation.

.

Based on random observation during the survey walk-through, not all portions of the building fire alarm system are installed in accordance with 18.3.4.

Findings include:

A. 9:41 AM: The smoke detector in Pharmacy IV Storage Room a089 was observed to be located within 3'-0" of a supply air diffuser as prohibited by NFPA 72 1999 2-3.5.1. this deficiency could affect any patients, staff, or visitors in the immediate area by preventing the timely activation of the smoke detector.

.

Based on document review and staff interview, the facility's fire alarm system is not inspected, tested, and maintained in accordance with 9.6.

Findings include:

A. Through document review, it was determined that the facility does not test fire alarm system components on a periodic basis as required by NFPA 72 1999 Table 7-3.2. During an interview held in the Administrative Conference Room at 12:38 PM on February 22, 2012, the provider's Support Services Director confirmed that the building fire alarm system had not been inspected by an outside agency since 2009. This deficiency could affect any patients, staff, or visitors in the building because the fire alarm system may not be in working order.

.

Based on random observation during the survey walk-through, not all portions of the facility's automatic sprinkler system are installed and maintained in accordance with NFPA 13 1999. These deficiencies could affect any patients, staff, or visitors in the immediate area by preventing the timely activation of the sprinkler heads.

Findings include:

A. 9:09 AM: Auxiliary Storage Room d084 was observed to lack a ceiling assembly, thus permitting heat or flames to enter the ceiling cavity as prohibited by NFPA 13 1999 5-6.4.1.1.
B. 10:22 AM: Ceiling tiles were observed to be missing in Purchasing Room a144, which compromises sprinkler coverage as prohibited by NFPA 13 1999 5-6.4.1.1.

.


26665


Based on random observation during the survey walk-through during the morning on February 22, 2012, not all portions of the facility's sprinkler system are installed in accordance with NFPA 13, 1999.

Findings include:

A. During the survey of the old kitchen (area currently used for storage) the range hood obstructed the sprinkler head from fully developing its pattern, thus not in accordance with 5-5.5.3.

This deficiency could cause injury to staff and patients by allowing a fire in the unprotected area to continue to burn.

.

Based on random observation during the survey walk-through, not all portable medical gases are stored in accordance with NFPA 99.

Findings include:

A. Medical gas tanks were observed being stored that are less than 5'-0" from combustibles as prohibited by NFPA 99 1999 8-3.1.11.2(c)(2). These deficiencies could affect any patients, staff, or visitors in the immediate area because the oxygen could contribute to an ongoing fire. locations observed include:
1. 1009 AM: Physical Therapy Open Gym a124, 1 tank.

2. 10:12 AM, Cardiac Rehab Room a127, 1 tank.

.

Based on random observation during the survey walk-through during the morning on February 22, 2012, not all portions of the facility's piped medical gas system are in accordance with NFPA 99 1999.

Findings include:

A. During the survey of the mechanical room, the medical air system dew point monitor appeared to have a trouble code reading and not the dew point in accordance with 4-3.1.2.2.

B. During the building walk-through area alarm panels were not labeled as to the area it monitored in accordance with 4-3.1.2.2 (a) 3.

C. During the building walk-through zone boxes was not correctly labeled with corresponding room numbers in accordance with 4-3.1.2.14.

Deficiency A could cause patient injury due to excess moisture in the air they are breathing.

Deficiency B and C could cause injury to patients by accidental shutting off of the wrong gas valves.

.

Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

A. 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.

.

Based on random observation during the survey walk-through of the Laboratory area on the morning of February 22, 2012, not all portions of the Laboratory are in accordance with NFPA 99 1999.

Findings include:

A. The eye wash station was observed without a pressure reducing and tempering valves in accordance with 10-6.

This deficiency could cause injury the staff due to excessive pressures and temperatures.

.

Based on random observation during the document review process on February 22, 2012, not all portions of the emergency generator testing are in accordance with NFPA 110 1999.

Findings include:

A. During the review of monthly generator load testing the amperage readings were less than name plate full load and not in accordance with 6-4.2.

B. During the review records were not available for annual load bank testing in accordance with 6-4.2.2.

C. During the record review monthly testing of the three transfer switches were not available in accordance with 6-4.1.

.

Based on random observation during the survey walk-through on February 22, 2012, not all portions of the facility's emergency electrical panels were observed to be in accordance with NFPA 70 1999.

Findings include:

A. During the survey walk-through of the main electrical room, emergency electrical panels were observed to have different panel designations on the same branch and were labeled consistently for each branch in accordance with 700-9.

This deficiency could cause injury to patients and staff due to the wrong circuit being turned off.

.