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Tag No.: K0017
The facility did not ensure that corridors were separated from use areas by walls constructed with at least a 30 minutes rating as required by section 19.3.6.1 of the LSC.
On 05/03/11 at 09:45 AM the surveyor, accompanied by the Director of Support Services observed disabled multiple " Amsco Warming cabinets " installed within the corridor walls of the Endoscopy wing of the facility, negating the corridor walls ability to resist the passage of smoke as required by section 19.3.6.1 of the LSC.
Tag No.: K0018
The facility did not ensure doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas are substantial doors, such as those constructed of 1? inch sold-bonded core wood, capable of resisting fire for at least 20 minutes. Doors in sprinklered buildings are only required to resist the passage of smoke. There is no impediment to the closing of the doors.
1. On 05/03/11 at 10:45 AM the surveyor, accompanied by the Director of Support Services observed that patient room #671 was warped and split, negating the assembly ' s ability to resist the passage of smoke as required by section 19.3.6.3.6 of the LSC.
2. On 05/03/11 at 09:05 AM, the surveyor while accompanied by the Manager of Engineering & Facilities Management, observed that a transfer grille was installed in the corridor wall, outside the telecommunications room, Liscomb/West Wing-9th Floor; i.e. transfer grilles not permitted in corridor walls
Tag No.: K0029
The facility did not ensure that hazardous areas were either separated by construction providing at least a one-hour fire resistance rating as required by 19.3.2.1
On 05/02/11 at 2:00 PM, the surveyor while accompanied by the Manager of Engineering & Facilities Management and the Supervisor of Engineering & Facilities Management, observed that Mechanical Room # 115 at the Reach Facility at 305 Boston Avenue was not separated from all other parts of the building by construction having at least a one-hour fire resistance rating as required by Section 39.3.2.1 (Business Occupancy chapter); i.e. voids and gaps around penetrations (copper piping and red, cables) in the wall above the door that were not properly sealed with fire rated materials.
Tag No.: K0130
The facility did not ensure that patient electrical devices were being inspected at least annually as required in NFPA 99 " Health Care Facility ' s " Section 7-6.2.1.2, and as part of the facility ' s preventive maintenance program.
a. On 05/02/11 at 10:20 AM and at other times throughout the day, the surveyor while accompanied by the Manager of Engineering & Facilities Management, observed that patient, electric beds throughout the facility lacked valid, current & non-expired preventive maintenance stickers and the facility failed to provide documentation that all patient care electrical devices are inspected as required in NFPA 99, Section 7-5.1.3, 7-5.2.2.1 and 7-6.2.1.2 and as part of the facility ' s preventive maintenance program; i.e. expired stickers and no documentation to indicate pm ' s or electrical safety checks (see field notes for types, times & locations) had been conducted within the last year.
b. On 05/04/11 at 10:20 AM, the surveyor was not provided with documentation from the Manager of Engineering & Facilities Management, to indicate that either longer or shorter intervals of electrical safety inspections/testing of patient care appliances was warranted; i.e Bio-Med contractor (Nova Med) provided no documentation or justification based on previous safety testing records for the equipment in question, unusually light or heavy utilization, or similar considerations as required by NFPA 99, Section 7-6.2.1.1, Exception No.1
Tag No.: K0147
The facility did not ensure that electrical wiring and equipment is in accordance with NFPA 70, National Electrical Code. 9.1.2
On 05/02/11 at 9:20 AM and at other times throughout the day, the surveyor while accompanied by the Manager of Engineering & Facilities Management, observed that power strips and residential style, surge protectors with multiple receptacles were in use and connected to patient care appliances throughout the Operating Rooms/Surgical suites; i.e. widespread use of power strips and residential style, surge protectors with multiple receptacles located in operating suites toured and in stock rooms with patient care appliance storage.