HospitalInspections.org

Based on observation and record review, the facility failed to provide building construction type per NFPA 101 19.1.6.1 for 6 of 7 floors in the facility having unprotected steel beams. This could potentially affect 301 of 301 patients in the facility at the time of survey on the event of a fire emergency.

Findings: 1)During tour of the facility on 7/27/10 between 7:30am and 5:00pm, the North wing of the building for floors 1,2,3,5,6,and 7 were observed to have unprotected steel beams at the end of the building. Floor 4 North Wing has been recently renovated and the steel beams have had fire proof spray applied.
2) A review of facility records ,on 7/28/10 at 1:30pm, of a previous Fire Safety Equivalency filled out in 1995 by an engineer revealed the same deficiency noted with the facility achieving an equivelancy to the code for Life Safety.

Based on observation, the facility failed to provide stairways and elevator shafts that are enclosed with construction having a fire resistance rating of at least one hour for 1 stairwell serving all 7 patient floors and for 5 elevator shafts that service all 7 patient floors. These deficiencies could potentially affect all 301 patients in the facility in the event of a smoke or fire emergency.

Findings:1) During tour of the facility on 7/27/09 and 7/28/10 between 7:30am and 5:00pm each day, the stairwell B4 that services floors 1 through 7, was observed to have large chiller and return water lines through from the main building to the facility mechanical/chiller room. These lines do not service the stairwell.
2) During a check of the elevator shafts on 7/28/10 between 9:00am and 11:00am, the elevator shafts 1&2; 3&4; 5&6 at the main building was observed to have numerous unsealed penetrations in the shaft wall and missing pieces of concrete block missing throughout the entire shaft.

3) During a check of the elevator shafts on 7/28/10 between 9:00am and 11:00am, the elevator shafts 11&12; and 14&15 was observed to have a piece of fire rated shaft board ,approximately 3 feet by 3 feet square in each shaft, missing from above the 7th floor elevator doors inside the shaft.

Based on observation, the facility failed to provide stairwells with doors that are a minimum fire resistance rating of at least 1 hour for 16 stairwells in the facility that connect all 8 occupiable floors. This could potentially affect 301 of 301 patients in the facility in the event of a fire or smoke emergency.

Findings: During a tour of the facility on 7/27/10 between 7:30am and 5:00pm, the following stairwells were observed to not have labels that showed the proper fire reistance rating on the doors:
1) Sairwell door D-13 at the rear of the laundry ,
2)Stairwell D-12 in the Cath Lab,
3) Stairwell B-4 2nd floor,
4) Stairwell B-5 2nd Floor,
5) Stairwell A-9 2nd floor,
6) Stairwell A-1 2nd floor,
7) Stairwell B-4 3rd Floor Dialysis,
8) Both stairwell doors at the rear of Pharmacy,
9) Stairwell A-1 3rd Floor ,
10) Stairwell Across from A-554,
11) Stairwell across from A571,
12) Stairwell A-2 6th floor,
13) Stairwell A-9 7th Floor,
14) Stairwell 8th floor Bio Medical Engineering.

Based on observation, the facility failed to provide exit access that is readily accessible at all times in accordance with section 7.1 for 1 stairwell door on the 6th floor Pediatric Intensive Care Unit (PICU). This could potentially affect the 5 patients in the Unit at the time of survey in the event of a non fire emergency. The facility also failed to provide means of egress with headroom height of 7 feet 6 inches with projects no less than 6 feet 8 inches throughout the facility. This deficiency could potentially affect 301 of 301 patients in the facility in the event of smoke or fire emergency or total evacuation of the building.

Findings:1) During tour of the facility on 7/27/10 at 10:00am, the stairwell door at the rear of the PICU was observed to have Delay Egress Locks installed on it. During test of the door, the Delay Egress did not function correctly by sounding an alarm after door is pushed for 3 second causing an irreversible process and opens freely after 15 seconds. The door failed to open as designed but does release on activation of the facility fire alarm system.

2) During a tour of the facility on 7/27/10 between 7:30am and 5:00pm, the corridors throughout the facility were observed to have ceiling heights of 7 feet 2 inches and less with projections of less than 6 feet 8 inches. This is an 8 story building with the original building being built in 1958. The height between floors was observed to be 10 feet from floor to bottom of the floor above without acoustical ceiling tiles being in place.

Based on observation, the facility failed to provide areas used to transfer liquid oxygen that are mechanically ventilated, and has ceramic or concrete flooring and has signs posted indicating that tranferring of oxygen is occuring and smoking is not permitted in accordance with NFPA 99. This could potentially affect Skilled Nursing Unit and the 12 patients on the floor in the event of an accident occuring with the transferring of the oxygen.

Findings: During a tour of the facility on 7/27/10 at 9:00am, a staff member was observed going into a room across from the 7th floor front nurses station with a portable liquid oxygen canister. While in the room the staff person was observed to transfer liquid oxygen from a large canister on wheels into the small canister. The room that was being used to transfer the oxygen was fully sprinklered with a 1 hour fire seperation was in place, but it had no mechanical ventiallation to ventilate any liquid oxygen vapors in the air. the room also was observed to have vinyl flooring on top of the concrete floor. The room also did not have a sign posted stating that Liquid Oxygen transferring was occuring.

Based on observation and record review, the facility failed to provide building construction type per NFPA 101 19.1.6.1 for 6 of 7 floors in the facility having unprotected steel beams. This could potentially affect 301 of 301 patients in the facility at the time of survey on the event of a fire emergency.

Findings: 1)During tour of the facility on 7/27/10 between 7:30am and 5:00pm, the North wing of the building for floors 1,2,3,5,6,and 7 were observed to have unprotected steel beams at the end of the building. Floor 4 North Wing has been recently renovated and the steel beams have had fire proof spray applied.
2) A review of facility records ,on 7/28/10 at 1:30pm, of a previous Fire Safety Equivalency filled out in 1995 by an engineer revealed the same deficiency noted with the facility achieving an equivelancy to the code for Life Safety.

Based on observation, the facility failed to provide stairways and elevator shafts that are enclosed with construction having a fire resistance rating of at least one hour for 1 stairwell serving all 7 patient floors and for 5 elevator shafts that service all 7 patient floors. These deficiencies could potentially affect all 301 patients in the facility in the event of a smoke or fire emergency.

Findings:1) During tour of the facility on 7/27/09 and 7/28/10 between 7:30am and 5:00pm each day, the stairwell B4 that services floors 1 through 7, was observed to have large chiller and return water lines through from the main building to the facility mechanical/chiller room. These lines do not service the stairwell.
2) During a check of the elevator shafts on 7/28/10 between 9:00am and 11:00am, the elevator shafts 1&2; 3&4; 5&6 at the main building was observed to have numerous unsealed penetrations in the shaft wall and missing pieces of concrete block missing throughout the entire shaft.

3) During a check of the elevator shafts on 7/28/10 between 9:00am and 11:00am, the elevator shafts 11&12; and 14&15 was observed to have a piece of fire rated shaft board ,approximately 3 feet by 3 feet square in each shaft, missing from above the 7th floor elevator doors inside the shaft.

Based on observation, the facility failed to provide stairwells with doors that are a minimum fire resistance rating of at least 1 hour for 16 stairwells in the facility that connect all 8 occupiable floors. This could potentially affect 301 of 301 patients in the facility in the event of a fire or smoke emergency.

Findings: During a tour of the facility on 7/27/10 between 7:30am and 5:00pm, the following stairwells were observed to not have labels that showed the proper fire reistance rating on the doors:
1) Sairwell door D-13 at the rear of the laundry ,
2)Stairwell D-12 in the Cath Lab,
3) Stairwell B-4 2nd floor,
4) Stairwell B-5 2nd Floor,
5) Stairwell A-9 2nd floor,
6) Stairwell A-1 2nd floor,
7) Stairwell B-4 3rd Floor Dialysis,
8) Both stairwell doors at the rear of Pharmacy,
9) Stairwell A-1 3rd Floor ,
10) Stairwell Across from A-554,
11) Stairwell across from A571,
12) Stairwell A-2 6th floor,
13) Stairwell A-9 7th Floor,
14) Stairwell 8th floor Bio Medical Engineering.

Based on observation, the facility failed to provide exit access that is readily accessible at all times in accordance with section 7.1 for 1 stairwell door on the 6th floor Pediatric Intensive Care Unit (PICU). This could potentially affect the 5 patients in the Unit at the time of survey in the event of a non fire emergency. The facility also failed to provide means of egress with headroom height of 7 feet 6 inches with projects no less than 6 feet 8 inches throughout the facility. This deficiency could potentially affect 301 of 301 patients in the facility in the event of smoke or fire emergency or total evacuation of the building.

Findings:1) During tour of the facility on 7/27/10 at 10:00am, the stairwell door at the rear of the PICU was observed to have Delay Egress Locks installed on it. During test of the door, the Delay Egress did not function correctly by sounding an alarm after door is pushed for 3 second causing an irreversible process and opens freely after 15 seconds. The door failed to open as designed but does release on activation of the facility fire alarm system.

2) During a tour of the facility on 7/27/10 between 7:30am and 5:00pm, the corridors throughout the facility were observed to have ceiling heights of 7 feet 2 inches and less with projections of less than 6 feet 8 inches. This is an 8 story building with the original building being built in 1958. The height between floors was observed to be 10 feet from floor to bottom of the floor above without acoustical ceiling tiles being in place.

Based on observation, the facility failed to provide areas used to transfer liquid oxygen that are mechanically ventilated, and has ceramic or concrete flooring and has signs posted indicating that tranferring of oxygen is occuring and smoking is not permitted in accordance with NFPA 99. This could potentially affect Skilled Nursing Unit and the 12 patients on the floor in the event of an accident occuring with the transferring of the oxygen.

Findings: During a tour of the facility on 7/27/10 at 9:00am, a staff member was observed going into a room across from the 7th floor front nurses station with a portable liquid oxygen canister. While in the room the staff person was observed to transfer liquid oxygen from a large canister on wheels into the small canister. The room that was being used to transfer the oxygen was fully sprinklered with a 1 hour fire seperation was in place, but it had no mechanical ventiallation to ventilate any liquid oxygen vapors in the air. the room also was observed to have vinyl flooring on top of the concrete floor. The room also did not have a sign posted stating that Liquid Oxygen transferring was occuring.