HospitalInspections.org

Based on interview and observation, the hospital failed to ensure that a vertical opening shaft was enclosed and sealed against the penetration of heat and smoke. Failure to enclose and seal vertical penetrations risks spread of fire and smoke from floor to floor in the building.

Findings include:

During a tour of the Lindeman Pavilion on 11/16/10, it was observed that three dumbwaiter shafts were located on the west side of the tower. These shafts were no longer in service according to hospital facilities management. The dumbwaiter doors had been sealed with metal plates, but a gap remained between the rubber gaskets on the doors, permitting the passage of small objects between the doors. This gap would allow heat and smoke to penetrate from floor to floor in the tower in the event of fire. Hospital facilities management confirmed the observation.



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Based on observation, the hospital failed to install a smoke detector in accordance with the manufacturer's specifications. Failure to install smoke detectors in accordance with manufacturer's specifications risk failure to the smoke detector to operate during a fire/smoke event and subsequent failure to alert building occupants.

Findings:

During a tour of the Buck building on 11/17/10, a smoke detector was observed installed 14 inches from an air supply diffuser. The detector must be installed 3 feet from air supply diffusers.


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Based on observation, the hospital failed to maintain ceiling tiles above sprinkler heads consistent with NFPA 25 for maintenance of the ceiling tiles. Failure to maintain sprinkler system heads consistent with NFPA 25 risks head passage above sprinkler heads and subsequent failure of the sprinkler head to operating during a fire event.

Findings:

During a tour of the Imaging Clinical Engineering work room on 11/17/10, several missing and damaged ceiling tiles were found next to a sprinkler head.

THIS WAS CORRECTED DURING THE SURVEY


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Based on observation, the hospital failed to limit trash collection receptacles over 32 gal storage in an exit corridor outside of a protected area. Failure to store trash collection receptacles over 32 gal out of the exit corridor risks smokey fires should ignition occur and subsequent occupant exiting.

Findings:

During a tour of the Buck building on 11/16/10, 2 - 50 gal shredded paper containers were found in the corridor outside medical records.


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Based on observation the facility failed to properly store oxygen cylinders to ensure the medical gases were protected in accordance with the NFPA 99 standards. Failure on the part of the facility to properly store oxygen cylinders puts patients, staff and visitors at risk for injury from unsecured oxygen cylinders and possible missile activity from a damaged cylinder nozzle.

Findings include:

1. On 11/17/2010 during the hospital tour the surveyor observed three "E" cylinders standing upright which was a tipping hazard. They were unsecured in the soiled utility room on the 8th floor of the hospital .

2. Also, the surveyor found an "E" cylinder lying on the floor and not secured in the equipment storage room on the the 7th floor of the hospital on 11/17/2010 .
After the surveyor brought the safety risk to the attention of the hospital staff, the four unrestrained oxygen E cylinders were immediately secured during the survey.


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Based on observation, interview, and review of hospital documents, the hospital failed to provide medical air compressor installation and maintenance consistent with NFPA 99, Chapter 4. Failure to install and maintain medical air compressors consistent with NFPA 99 risks potential patient exposure to medical air contaminated with toxic materials.

Findings:

During a tour of the Buck tower mechanical room containing medical air compressor on 11/16/10, outside air intake for medical air compressors was not found. The mechanical room location is subject to particulate matter, oil and grease vapors, potential combustion products, and odors. During and interview on this same tour Staff #S1 confirmed the air compressors use mechanical room air for medical air compressors.

During an interview on 11/18/10 Staff #S2 confirmed a continuously operational carbon monoxide alarm is installed for hospital medical air compressors. Review of hospital records showed no evidence the carbon monoxide alarm for the medical air compressors had been maintained or calibrated since installation approximately five years ago.

A review of hospital contractor testing documents [Medical Gas System Services LLC, 2/1/10] showed that the Buck tower medical air compressors are being used for dental air. NFPA 99 stipulates medical air compressors not be used for anything but patient respiration and calibration of respiratory equipment.


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Based on observation the hospital failed to seal penetrations of smoke barriers in accordance with 8.3.6. Failure to seal penetrations in smoke barriers risk the passage of smoke into the corridor during a fire event and thereby compromises building occupant safe egress.

Findings:

During a tour of the hospital on 11/17/10, a conduit fire seal pillow was found on the floor of the gastroenterology SE electrical room. On this same tour, the wall above the smoke barrier doors for the gastroenterology day surgery center was found to have and incomplete fire seal around a duct penetrating the barrier.

THESE WERE CORRECTED DURING THE SURVEY.


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Based on observation, the hospital failed to provide the two-hour hyperbaric facilities in compliance with NFPA 99 for 90 minutes connecting doors for the 2-hour noncombustible construction. Failure to provide for the 2 -hour noncombustible separation increases the risk for patients undergoing hyperbaric treatment from fire in the adjacent structure.

Findings:

During a tour of the hyperbaric facilities on 11/18/10, the gasket between two sets of 90 minute connecting doors were found to be deteriorated and/or missing due to deterioration.


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Based upon staff interviews, observations and record reviews, the facility was unable to verify that the Type One Essential Electrical System (EES) was divided into the critical branch, life safety branch and the emergency system in accordance with NFPA 99.

Failure to divide the EES in accordance with applicable codes risks failure of essential electrical systems during a power outage.

Findings include but are not limited to:

During a tour of the hospital on 11/16/10, it was found that 4 of 11 EES end-user panels inspected had services on the panels that are not permitted by the Code.

Examples include:
Panel 8SE2X (Lindeman Tower) was identified as a panel on the Life Safety branch, but had services for emergency receptacles, communication room, and data room.

Panel 5SE2Y (Lindeman Tower) was identified as a panel on the Critical branch, but had services for medical gas alarm.

Panel XG (Hospital 10th floor) was identified as a panel on the Life Safety branch, but had services for patient room and nursing station outlets, clocks, and night lights

Panel XL3 (Buck Pavillion) was identified as a panel on the Life Safety branch, but had services for receptacles and computer monitors

Hospital facilities management confirmed the observations.

Based on interview and observation, the hospital failed to ensure that a vertical opening shaft was enclosed and sealed against the penetration of heat and smoke. Failure to enclose and seal vertical penetrations risks spread of fire and smoke from floor to floor in the building.

Findings include:

During a tour of the Lindeman Pavilion on 11/16/10, it was observed that three dumbwaiter shafts were located on the west side of the tower. These shafts were no longer in service according to hospital facilities management. The dumbwaiter doors had been sealed with metal plates, but a gap remained between the rubber gaskets on the doors, permitting the passage of small objects between the doors. This gap would allow heat and smoke to penetrate from floor to floor in the tower in the event of fire. Hospital facilities management confirmed the observation.



.

Based on observation, the hospital failed to install a smoke detector in accordance with the manufacturer's specifications. Failure to install smoke detectors in accordance with manufacturer's specifications risk failure to the smoke detector to operate during a fire/smoke event and subsequent failure to alert building occupants.

Findings:

During a tour of the Buck building on 11/17/10, a smoke detector was observed installed 14 inches from an air supply diffuser. The detector must be installed 3 feet from air supply diffusers.


.

Based on observation, the hospital failed to maintain ceiling tiles above sprinkler heads consistent with NFPA 25 for maintenance of the ceiling tiles. Failure to maintain sprinkler system heads consistent with NFPA 25 risks head passage above sprinkler heads and subsequent failure of the sprinkler head to operating during a fire event.

Findings:

During a tour of the Imaging Clinical Engineering work room on 11/17/10, several missing and damaged ceiling tiles were found next to a sprinkler head.

THIS WAS CORRECTED DURING THE SURVEY


.

Based on observation, the hospital failed to limit trash collection receptacles over 32 gal storage in an exit corridor outside of a protected area. Failure to store trash collection receptacles over 32 gal out of the exit corridor risks smokey fires should ignition occur and subsequent occupant exiting.

Findings:

During a tour of the Buck building on 11/16/10, 2 - 50 gal shredded paper containers were found in the corridor outside medical records.


.

Based on observation the facility failed to properly store oxygen cylinders to ensure the medical gases were protected in accordance with the NFPA 99 standards. Failure on the part of the facility to properly store oxygen cylinders puts patients, staff and visitors at risk for injury from unsecured oxygen cylinders and possible missile activity from a damaged cylinder nozzle.

Findings include:

1. On 11/17/2010 during the hospital tour the surveyor observed three "E" cylinders standing upright which was a tipping hazard. They were unsecured in the soiled utility room on the 8th floor of the hospital .

2. Also, the surveyor found an "E" cylinder lying on the floor and not secured in the equipment storage room on the the 7th floor of the hospital on 11/17/2010 .
After the surveyor brought the safety risk to the attention of the hospital staff, the four unrestrained oxygen E cylinders were immediately secured during the survey.


.

Based on observation, interview, and review of hospital documents, the hospital failed to provide medical air compressor installation and maintenance consistent with NFPA 99, Chapter 4. Failure to install and maintain medical air compressors consistent with NFPA 99 risks potential patient exposure to medical air contaminated with toxic materials.

Findings:

During a tour of the Buck tower mechanical room containing medical air compressor on 11/16/10, outside air intake for medical air compressors was not found. The mechanical room location is subject to particulate matter, oil and grease vapors, potential combustion products, and odors. During and interview on this same tour Staff #S1 confirmed the air compressors use mechanical room air for medical air compressors.

During an interview on 11/18/10 Staff #S2 confirmed a continuously operational carbon monoxide alarm is installed for hospital medical air compressors. Review of hospital records showed no evidence the carbon monoxide alarm for the medical air compressors had been maintained or calibrated since installation approximately five years ago.

A review of hospital contractor testing documents [Medical Gas System Services LLC, 2/1/10] showed that the Buck tower medical air compressors are being used for dental air. NFPA 99 stipulates medical air compressors not be used for anything but patient respiration and calibration of respiratory equipment.


.

Based on observation the hospital failed to seal penetrations of smoke barriers in accordance with 8.3.6. Failure to seal penetrations in smoke barriers risk the passage of smoke into the corridor during a fire event and thereby compromises building occupant safe egress.

Findings:

During a tour of the hospital on 11/17/10, a conduit fire seal pillow was found on the floor of the gastroenterology SE electrical room. On this same tour, the wall above the smoke barrier doors for the gastroenterology day surgery center was found to have and incomplete fire seal around a duct penetrating the barrier.

THESE WERE CORRECTED DURING THE SURVEY.


.

Based on observation, the hospital failed to provide the two-hour hyperbaric facilities in compliance with NFPA 99 for 90 minutes connecting doors for the 2-hour noncombustible construction. Failure to provide for the 2 -hour noncombustible separation increases the risk for patients undergoing hyperbaric treatment from fire in the adjacent structure.

Findings:

During a tour of the hyperbaric facilities on 11/18/10, the gasket between two sets of 90 minute connecting doors were found to be deteriorated and/or missing due to deterioration.


.

Based upon staff interviews, observations and record reviews, the facility was unable to verify that the Type One Essential Electrical System (EES) was divided into the critical branch, life safety branch and the emergency system in accordance with NFPA 99.

Failure to divide the EES in accordance with applicable codes risks failure of essential electrical systems during a power outage.

Findings include but are not limited to:

During a tour of the hospital on 11/16/10, it was found that 4 of 11 EES end-user panels inspected had services on the panels that are not permitted by the Code.

Examples include:
Panel 8SE2X (Lindeman Tower) was identified as a panel on the Life Safety branch, but had services for emergency receptacles, communication room, and data room.

Panel 5SE2Y (Lindeman Tower) was identified as a panel on the Critical branch, but had services for medical gas alarm.

Panel XG (Hospital 10th floor) was identified as a panel on the Life Safety branch, but had services for patient room and nursing station outlets, clocks, and night lights

Panel XL3 (Buck Pavillion) was identified as a panel on the Life Safety branch, but had services for receptacles and computer monitors

Hospital facilities management confirmed the observations.