HospitalInspections.org

1. Portions of the building were found to have unprotected structural steel. The surveyor finds that portions of structural beams have missing fire proofing. Example locations include:

a) Fourth Floor - Outpatient: Toilet Room in NW Doctor's Office west corridor.

2. Certain areas have spray on fireproofing on the underside of the concrete pan for the waffle slab. During an interview held in the building on the morning of July 14, 2010, the provider ' s Supervisor of Construction was not able to identify the UL Designs used to obtain the necessary construction type throughout the building. " Documentation for the construction assemblies to comply with 19.1.6.2 and NFPA 220 1999 was not available on site (No UL Design Numbers).

Based on random observation during the survey walk-through, not all exit access corridors are separated from use areas in accordance with 19.3.6.1.

Findings include:

A. The Second Floor Surgical Department Holding Bays were observed to constitute patient treatment rooms which are not separated from exit access corridors as required by 19.3.6.1.

B. Corrected 12/28/10.
C. Corrected 12/28/10.

Based on random observation during the survey walk-through, not all exit access corridors are separated from use areas in accordance with 19.3.6.1.

Findings include:

A. Corrected 12/28/10.

B. The 4th Floor Outpatient Unit exit access corridor has a nursing station that is open to the corridor. The nurse's station lacks 24 hour supervision. The nursing station is smoke detected but not sprinklered in accordance with the exceptions under 19.3.6.1.

UPDATE 12/28/10: The plan of correction indicated that this nurse station qualified under Exception No. 3 of 19.3.6.1 as a nurse station. However, this exception implies that the nurse station is staffed or otherwise supervised in accordance with the NFPA 101 Handbook commentary which states "Staff supervision is important; it allows staff to see, hear or smell a developing fire or to prevent the ignition of a fire by virtue of their presence." Since this staff supervision is not available on a 24 hour basis, the space does not qualify as a nurse station under Exception No. 3. Since this building has construction type and vertical opening deficiencies, a fire developing on this floor can directly affect patients on other floors. Surveyor notes that Exception No. 6 may be an alternative to separation of the space from the corridor if the space and the corridors onto which the space opens onto located in the same smoke compartment are provided with smoke detection and the space is provided with sprinkler protection.

C. Corrected 12/28/10.
D. Corrected 12/28/10.

Based on random observation during the survey walk-through, not all ventilation shafts or floor/ceiling assemblies are constructed or maintained as fire resistive assemblies in accordance with 19.3.1.1.

Findings include:

A. Seventh Floor (Penthouse): A floor access panel was observed to not carry a minimum fire resistance rating of 1-1/2 hours as required by 8.2.3.2.3.1(1).

UPDATE 12/28/10: Although smaller floor access penetrations have been sealed with concrete in accordance with the plan of correction, a 2-leaf steel access door located adjacent the elevator machinery was observed that did not afford a minimum 1 1/2-hour rating.

B. Corrected 12/28/10.

C. Sixth Floor: The ventilation shaft that connects 4 stories or more by Stair #2 was observed to not carry 2 hour rated enclosure as required by 19.3.1.1.

UPDATE 12/28/10: Surveyor notes the correction date for this deficiency to be 6/11/11.

D. Corrected 12/28/10.
E. Corrected 12/28/10.

Based on random observation during the survey walk-through, not all designated or required smoke barrier walls are constructed or maintained as minimum 30 minute fire rated assemblies in accordance with 19.3.7.3.

Findings include:

A. Fifth Floor: Cable wirings near the EMS Office were observed that pass through a required smoke barrier wall that are not sealed against smoke to comply with 8.3.6.1.

UPDATE 12/28/10: Although the noted wiring pentration has been sealed, the duct penetration in this barrier does not contain a smoke damper to comply with Exception No. 2 under 19.3.7.3. Both smoke compartments on each side of the smoke barrier are not fully sprinkler protected.

Based on random observation during the survey walk-through, not all exit stair shafts are constructed or maintained as fire resistive assemblies in accordance with 19.3.1.1.

Findings include:

A. An exit passageway was observed with duct penetrations that appear to be tied in to the main ventilation system. The provider was unable to identify when these ducts were installed and how they are permitted under 7.1.3.2.1.(e). Ground Floor exit passageway extending from Stair #2.

UPDATE 12/28/10: This deficiency was not reviewed during this on-site survey. It is not clear how the duct penetrations may comply with the requirements of 7.1.3.2.1(e), Exception No. 1 for existing penetrations when not protected by fire dampers. It is not clear from the original drawings provided as part of the plan of correction explanation where the enclosure of the exit passageway is maintained. (Is the "chase" containing the fan coil and ducts within the rated enclosure or outside the enclosure which would require the duct penetrations to be provided with fire dampers?)

B. Corrected 12/28/10.

Based on random observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1.

Findings include:

A. Corrected 12/28/10.
B. Corrected 12/28/10.
C. Corrected 12/28/10.
D. Corrected 12/28/10.

E. Chairs were observed, at Corridor work stations, which obstruct the Corridor in a manner prohibited by 19.2.3.3. and 7.1.10.2.1.

1. Third Floor 1961/1929 Building CVU, all Corridors.
2. Corrected 12/28/10.

F. Corrected 12/28/10.

G. NEW 12/28/10: The discharge level for Stair #2 is not provided with an interrupter gate or other effective means to prevent continued travel beyond the level of discharge to comply with 7.7.3.

Based on random observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1.

Findings include:

A. Corrected 12/28/10.

B. Common path of travel was observed to exceed 75 feet as required by 39.2.5.3.
Locations observed include:

1. First Floor, Old Recovery Room corridor leading to the old OR's.

UPDATE 12/28/10: The plan of correction for this deficiency relies upon an FSES. However, it does not appear that the FSES will pass if the construction type (K012), vertical opening (K020) and lack of a building separation (K044)deficiencies that would apply to this building area are not corrected. An explanation of how the parameter values were assigned was not provided with the FSES.

Based on random observation during the survey walk-through and document review, not all designated or required horizontal exits or fire barriers are constructed or maintained as fire resistive assemblies.

Findings include:

A. Designated 2 hour rated fire separation walls at the First Floor Level near the Old Day Surgery Waiting have double egress doors that are not labeled as to their fire resistance rating.

UPDATE 12/28/10: The labels on these doors specifically indicate that the doors do not carry a rating due to the manner in which they were constructed and installed but are labeled as "fire door". Without certification of a minimum 1 1/2-hour fire resistance rating, credit can not be given to the installation as a 2-hour barrier.

Based on random observation during the survey walk-through not all exterior egress paths are illuminated in such a manner that the failure of one fixture will not leave the area in darkness as prohibited by 19.2.8.

Findings include:

A. Numerous exterior egress paths were observed that are not provided with lighting, on emergency power, that are equipped so that the failure of 1 fixture (bulb) will not leave the area in darkness. Example locations include:

1. First Floor - Stair # 1 (G)

2. First Floor - Exterior exit by the Blessing Foundation

3. Ground Floor - Stair #3 Exit C

4. Ground Floor - Exit D

UPDATE 12/28/10: New lighting has been installed which utilizes a 2-lamp fixture. However, the lamp type is not of the incandescent, fluorescent, LED, quartz or otherwise of a type which is of the instant-on type to meet the requirement for continuous illumination. The lamps provided have a restrike time which can leave the area in darkness longer than the 10 seconds allowed.

Based on random observation during the survey walk-through, exit signs did not illuminate a continuous path of egress in all cases in accordance with 19.2.10.1. and 7.10.

Findings include:

A. Egress paths were observed that are not identified by exit signs as required by 7.10.1.1. Locations observed include (all First Floor):

1. Corrected 12/28/10.

2. The north end of the 1929 Building (former Administration) Corridor.
UPDATE 12/28/10: Although exit signage was indicated to be added at the far north end of the corridor, the only path of egress marked by visible exit signage at the corridor intersection near the entrance to Stair #7 was for Stair #7. A second path was not identified to direct the second path through at least one of the three self-closing cross corridor doors at this location. Signage on both sides of these doors may be required to provide the required designation of exit paths.

Based on random observation during the survey walk-through, exit signs did not illuminate a continuous path of egress in all cases in accordance with 19.2.10.1. and 7.10.

Findings include:

A. Egress paths were observed that are not identified by exit signs as required by 7.10.1.1. Locations observed include:

1. Ground Floor - Kitchen.
2. First Floor Account Offices.

UPDATE 12/28/10: Although the plan of correction indicated that new exit signage would be installed, verification of the installed signage was inadvertantly missed during this follow-up survey. Verification will be required at the next on-site visit.

Based on document review, the facility's written plan for the protection of patients is not complete as required by 19.7.1.1.

Findings include:

A. During a review of the facility's fire protection plan documents, 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 not shown accurately on the facility's Life Safety Master Plans include:

1. Not all existing Ventilation shaft are identified on the Life Safety master Plan. Example: Sixth Floor-Ventilation Shafts on the West Side.

UPDATE 12/28/10: This specific deficiency location was not reviewed during this follow-up survey. Surveyor notes that the correction noted for deficiency K067.A.2 indicated that a shaft had been removed by rerouting exhaust ductwork horizontally and slab penetrations sealed with concrete. However, the reference plans indicated that a shaft still existed.

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 sensitivity of smoke detectors is not calibrated at least every other year as required by NFPA 72 1999 7-3.2.1. During an interview, held in the Office of the Administrative Director of Facility Support Services and Safety on the morning of July 15, 2010, the provider's Compliance Specialist confirmed this finding.

UPDATE 12/28/10: The Plan of Correction indicated that documentation of the sensitivity testing of the smoke detectors was completed. However review of the documentation was not done on this survey date. Review will be required during a subsequent follow-up survey.

A. Annual fire pump testing documents do not indicate test was performed on emergency power. (NFPA 25, 1998, 5-3.3.4)

UPDATE 12/28/10: The Plan of Correction indicated that documentation of the annual fire pump testing was completed. However review of the documentation was not done on this survey date. Review will be required during a subsequent follow-up survey.

A. Corrected 12/28/10.

B. Annual fire pump testing documents do not indicate test was performed on emergency power. (NFPA 25, 1998, 5-3.3.4)

UPDATE 12/28/10: The Plan of Correction indicated that documentation of the annual fire pump testing was completed. However review of the documentation was not done on this survey date. Review will be required during a subsequent follow-up survey.

Based on document review and staff interview, not all portable fire extinguishers in the facility are installed and maintained in accordance with 19.3.5.6., 9.7.4.1., and NFPA 10.

Findings include:

A. Based on document review, it could not be determined that portable fire extinguishers are inspected and tested annually in accordance with NFPA 10 1998 4-4.1. because no records of such tests had been provided by the vendor responsible for the tests. During an interview, held in the Office of the Administrative Director of Facility Support Services and Safety on the morning of July 15, 2010, the provider's Compliance Specialist confirmed this finding.

UPDATE 12/28/10: The Plan of Correction indicated that documentation of the annual inspection and testing of the fire extinguishers was completed. However review of the documentation was not done on this survey date. Review will be required during a subsequent follow-up survey.

Based on random observation during the survey walk-through, not all portions of the facility's air conditioning and ventilating systems are installed in accordance with NFPA 90A.

Findings include:

A. The deficiencies listed below were observed at a series of toilet exhaust ducts throughout the 1970 Building. Surveyor 14290 notes that it appears that the cited conditions exist in at least 8 locations on the Sixth through Second Floors. Deficiencies observed include:
1. The toilet exhaust ducts were observed to not be enclosed in shafts which which carry a minimum 2 hour fire resistance rating, as required by NFPA 90A 1999 3-3.4.1., because the enclosures for the ducts consist of drywall or plaster on the outside of metal studs only and because they do not extend from the ceiling to the underside of the deck above.

2. No fire dampers, required by NFPA 90A 1999 3-3.4.4., were observed where the toilet exhaust ducts penetrate the enclosure walls.

A. Designated ventilation shafts were observed with duct penetrations that are not provided with fire dampers. Locations include:

1. Corrected 12/28/10.

2. Second Floor: A ductwork penetration through a ventilation shaft in Men's Room southeast side by Stair #4.

UPDATE 12/28/10: see also K048. Surveyor notes that the correction noted for this deficiency indicated that a shaft had been removed by rerouting exhaust ductwork horizontally and slab penetrations sealed with concrete. However, the reference plans indicated that a shaft still existed. Wall penetrations were noted to be unsealed if the shaft still existed on this floor and other floors as shown on the plans.

3. Corrected 12/28/10.

A. Based on direct observation, record review and interview, the facility failed to provide for the Tea Room grease hood system:

1. A connection between the hood suppression system and the fire alarm system. (NFPA 96, 1999, 7-6.2)

2. Monthly system inspections of the hood suppression system as required. (NFPA 17, 1998, 9-2 & 17A, 5-2)

UPDATE 12/28/10: The Plan of Correction indicated that documentation of the correction of the above deficiencies was available. However review of the documentation was not done on this survey date. Review will be required during a subsequent follow-up survey.

Based on random observation during the survey walk-through, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency in accordance with 19.2.3.3.

Findings include:

A. Carts and equipment were observed in exit access corridors that obstruct egress as prohibited by 19.2.3.3. and 7.1.10.2.1. Locations and items observed include (all Third Floor Surgery Center):

1. Corrected 12/28/10.

2. The Surgical Prep/Stage I Recovery Corridors.

UPDATE 12/28/10: Although the carts and equipment were observed not to be located to obstruct the required egress aisles, they were observed to be stored in patient prep/recovery bays as to constitute a degree of hazard greater than normal to the general occupancy. Although the use of the patient bays would not be prohibited for storage of such equipment, they were not enclosed to meet the requirements of 8.4.1.2. The number of recovery bays can not be reduced since they are required to meet the recovery count for the number of OR being served.

3. Corrected 12/28/10.
4. Corrected 12/28/10.

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, in sprinklered portions of the building, that are less than 5'-0" from combustibles as prohibited by NFPA 99 1999 8-3.1.11.2(c)(2). Locations observed include:

1. Sixth Floor:
a. Corrected 12/28/10.
b. 1961 Building Storage Room, 6 tanks.
UPDATE 12/28/10: The plan of correction indicated that the oxygen storage would be removed from this storage room and discontinued. However, signage on the door indicated that oxygen was stored in this room and tanks were observed to be stored in non-compliance with applicable requirements.

2. Corrected 12/28/10.

Based on random observation during the survey walk-through, not all piped-in medical gas systems are installed and maintained in accordance with NFPA 99.

Findings include:

A. Manual medical gas shutoff (zone) valves were observed that are located in the same room as the station outlets they serve, as prohibited by NFPA 99 1999 4.3.1.2.3(d). Locations observed include (all Second Floor 1982 Building Surgical Department):
1. Surgical Prep/Holding Bays.

2. Corrected 12/28/10.

Based on random observation during the survey walk-through, not all designated or required smoke barrier walls are constructed or maintained as minimum 30 minute fire rated assemblies in accordance with 19.3.7.3.

Findings include:

A. Corrected 12/28/10.

B. First Floor: Designated smoke barrier wall leading to Patient Account Offices was observed with a duct penetration that is not smoke dampered (adjacent compartment of the Patient Account Offices is not sprinklered).

UPDATE 12/28/10: A duct entering the Patient Account Offices suite from the adjacent west office on the south side of the designated smoke barrier wall could not be confirmed to be provided with a smoke damper.

D. Corrected 12/28/10.

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, not all portions of the building electrical system are installed in accordance with NFPA 70 1999.

Findings include:

A. Corrected 12/28/10. However the electrical panel EEU located in the west end of the Sixth floor in a small closet was not provided with a directory as required by NFPA 70 1999 384-13.

B. Corrected 12/28/10.
C. Corrected 12/28/10.

A. 1970 Building Ninth Floor Elevator Penthouse

1. By direct observation the surveyor finds sprinkler protection provided within the elevator equipment room, however heat detectors are not provided or install within 2 feet of each sprinkler head as a means to automatically disconnect the main power supply to elevators prior to the application of water from the activation of sprinklers. (A17.1, 102.2.c.3)

2. By direct observation and staff interview the above condition exists within the remainder of the facilty's elevator equipment rooms.

UPDATE 12/28/10: Heat detectors were observed to be installed at the 9th floor penthouse in accordance with the plan of correction. However, observation of the heat detection for other sprinklered elevator equipment rooms was not done during this survey. Confirmation of installations will be required during a subsequent follow-up survey.