HospitalInspections.org

NEW 11/16/15:

A. In the afternoon of 11/16/15, on the office of the Director of the Plant Operations Based on document review and staff interview, with the Director of Plant Operations and facility Staff present, the Life Safety drawings have been modified and reviewed specific to area suites and boundaries. It was determined during staff interview that the sliding doors to the suite boundary do not comply with 19.3.6.3.2. Failure to maintain corridor doors could allow a fire to spread beyond the room of fire origin.

1. On the Fourth Floor of the designated Same Day Surgery and Endoscopy Holding Area Suite, the sliding doors to the suite boundary which are required to comply as corridor doors lack positive latching hardwares. This does not comply with 9.3.6.3.2, and doors must maintain a smoke-tighted separation between suite and corridor to comply with 19.3.6.3.1.

2. The sliding corridor doors do not have a break and swing capability to comply with 7.2.1.4.

Based on random observation during the survey walk through on the morning of 11/19/2014, while accompanied by the electrical technician, not all portions of the sprinkler system are installed in accordance with NFPA-13 (1999). This could effect the safety of all occupants of the building if the sprinkler system did not operate as required during a fire.

Findings include:


A. The fire pump remote alarm panel does not have the four alarm points required by NFPA 20-7-4.7.

B. The fire pump was not equipped with a transfer switch at the fire pump location and was not served from the emergency generator to comply with NFPA-20, Section 6.2.

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, while accompanied by the electrical technician, the surveyor observed the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised.

Findings include:

A. On the afternoon of 11/19/2014, the surveyor observed that the emergency power panels are not properly separated into the life safety, the critical and the equipment branches as required by NFPA-70, Section 517-31 thru 35. The system one line diagram was not up to date and it did not show all emergency panels or what branch each transfer switch served, and most panels were not labeled with the branch of emergency power they served. Examples include:

1. On the morning of 11/19/2014, the surveyor observed that panel E5PH is serving a mixture of all three branches, life safety, critical and equipment.

2. On the morning of 11/19/2014, the surveyor observed that panel ETS01-5 serves a mixture of life safety and critical, including room receptacles (critical) Section 517-33, and elevator cab lighting that shall be served from life safety in accordance with section 517-32.

3. On the morning of 11/19/2014, the surveyor observed that panels CP2 and CP3 are new critical panels in the remodeled northeast wings on the second and third floors, and they are serving med gas alarms and emergency lighting which shall be served by the life safety panel to comply with Section 517-32.

4. On the morning of 11/19/2014, the surveyor observed that panel E2PA did not have enough detail in the circuit description to determine if it was life safety or critical.

5. On the morning of 11/19/2014, the surveyor observed that panel EBPA serves a mixture of life safety and equipment.

6. On the morning of 11/19/2014, the surveyor observed that two panels in the tunnel off of mechanical room B, EBPN and EBPO were labeled as critical panels , but served mostly equipment loads.

Based on random observation during the survey walk-through while accompanied by the electrical technician the surveyor found that not all portions of the building systems are installed in accordance with NFPA 70 (1999).

Findings include:

A. On the morning of 11/19/2014, the surveyor observed that normal power receptacles were not provided in operating rooms on the fourth floor as required by NFPA-70, Section 517-19, and NFPA-99, Section 3-3.2.1.2(a)1. In the event of a transfer switch failure upon return to normal power, these rooms could be left with no power.

B. Corrected 06/10/2015

C. On the morning of 11/19/2014, the surveyor observed that patient bed location on the third floor in wing A were not equipped with emergency receptacles as required by NFPA-70, Section 517-18. This could effect any patient in this wing in the event of a power outage.

D. Corrected 04/15/2015

Based on random observation during the survey walk-through on the morning of 11/19/2014, while accompanied by the electrical technician the surveyor found that portions of the elevator control system are not installed in accordance with NFPA-70, and ASME A17.1. Any elevator user could be put in a dangerous situation without the proper safety devices installed.

Findings include:

A. On the morning of 11/19/2014, the surveyor observed that each elevator was not equipped with a single lockable disconnect or proper labeling for the emergency lighting, receptacle, and ventilation as required by NFPA-70, Section 620-53.

B. On the morning of 11/19/2014, the surveyor observed that the disconnect for the emergency lighting and controls for each elevator was not fed from the life safety panel in accordance with NFPA-70, Section 517-32(f).