HospitalInspections.org

Based upon observation, non-healthcare occupancies and/or defined building separations are not maintained in accordance with Code requirements. Failure to maintain the minimum 2-hour separation can result in the spread of fire/smoke conditions from one building to the other compromising the safety of occupants in both buildings.

Findings include:

A. On 4/7/21 at 1:15pm while in the company of the VPO it was observed that door #LL-S in the 2-hour barrier at the lower level of Building G which leads to the Service Building was not self-closing to a latched condition to comply with 19.1.3.3(2) and NFPA 80 due to a restriction created by a weatherstripping seal installed at the stop of the door frame.

B. On 4/7/21 at 1:30pm while in the company of the VPO it was observed that two doors (G148 & G149) in the 2-hour barrier at the 1st floor of Building G which separate the Lab Building from Building G lacked fire rating labels to comply with 19.1.3.3(2) and NFPA 80.

Based upon a facility staff interview, the facility failed to provide a building with an acceptable construction type. This deficient practice could affect patients, staff and visitors if the building did not maintain its structural integrity for the required length of time during a fire emergency.

The finding is:

On 4/6/21 at 11:00am it was confirmed by the VPO that Building A has a deficient construction type. The building is 7-stories with a Penthouse of construction type II(000) due to floor slabs being 2-1/2 inches thick which does not comply with Table 19.1.6.1.

Based on observation, the facility failed to provide a building with an acceptable construction type. This deficient practice could affect patients, staff and visitors if the building did not maintain its structural integrity for the required length of time during a fire emergency.

The finding is:

On 04/06/2021 at 10:30am during a discussion with the VPO it was determined that Building B is of Type II (000) construction. The concrete floor slabs are approximately 2 1/2"-3" thick, which does not comply with Table 19.1.6.2. Based on observation Floors 3 and 5 have spray on fire proofing in areas.

Based upon observation, stairs are not constructed to prevent fall hazards in accordance with permitted standards. Failure to provide protective guards can result in injuries due to a fall between the railings/guards.

The finding is:

On 4/6/21 at 11:55am while in the company of the VPO it was observed that the stair between the 7th floor level and the Penthouse was not provided with guard rails in accordance with 7.2.2.4.5.3. The horizontal distance between the stair runs exceeds 20"+/- which can permit a fall greater than a half story in height.

Based on observations and interviews, the facility failed to provide exit stairways enclosed with construction having the proper fire resistance rating to provide a continuous path of escape from exit discharge to public access way. This deficient practice could affect patients, staff and visitors if fire and smoke were to enter the exit enclosure and encumber evacuation of the facility during a fire emergency.

Findings include:

A. On 04/06/2021 at 10:40am during a discussion with the VPO, a series of exit stair enclosures within the Building B do not carry a minimum 2 hour fire resistance rating required by 19.3.1.1 and 8.6.5. Building B exit stair enclosures at which this condition was indicated include:

1. Exit Stair 2B at all levels.

2. Exit Stair 3B at all levels.

B. On 04/07/2021 at 9:15am while accompanied by the DDC, the surveyor observed an exit passageway which serves exit Stair #31B (based upon Life Safety floor plan revision date 03/25/2021) which contains a hole in the wall adjacent to Room #149A(Physician Learning). This condition does not comply with 7.1.3.2.1(3).

Based on observations and interviews, the facility failed to provide exit stairways enclosed with construction having the proper fire resistance rating and provide a continuous path of escape from exit discharge to public access way. This deficient practice could affect patients, staff and visitors if fire and smoke were to enter the exit enclosure and encumber evacuation of the facility during a fire emergency.

Findings include:

A. On 04/07/2021 at 1:10pm while accompanied by the DDC, the surveyor observed doors to exit stair enclosures that are not labeled to show their fire rating to comply with 8.3.3and NFPA 80, 2010. Example location:
3rd floor, door 63G leading to exit passageway for Stair 5G

B. On 04/07/2021 at 1:06pm, while accompanied by the DDC, the surveyor observed through floor conduits for telephone equipment passing through the floor and ceiling of the exit passageway that serves an exit stair. This condition does not comply with 7.1.3.2.1 (10). Location observed third floor Stair 5G.

C. On 04/07/2021 at 1:13pm while accompanied by the DDC, the surveyor observed door to exit stair enclosures that do not latch upon closing to comply with 8.3.3.1, NFPA 80, 2010. Example location:
3rd floor, Stair 5G entry door.

Based upon observation, not all floor levels have at least two means of egress identified. Failure to identify at least two means of egress can prevent occupants from reaching an exit if the primary exit is compromised or unavaialble during a fire/smoke event.

The finding is:

On 04/07/2021 at 8:45am while in the company of the VPO it was observed that the Penthouse level mechanical room had only one exit identified in non-compliance with 7.4.1.1 and 40.2.4.1.2. The single exit identified is indicated by the life safety plans available for reference as having a common path of travel distance exceeding the 100' permitted by Table 40.2.5.

Based upon observation, not all floor levels have at least two means of egress identified. Failure to identify at least two means of egress can prevent occupants from reaching an exit if the primary exit is compromised or unavailable during a fire/smoke event.

The finding is:

On 4/6/21 at 11:57am while in the company of the VPO it was observed that the Penthouse level mechanical room had only one exit identified in non-compliance with 7.4.1.1 and 40.2.4.1.2. The single exit identified is indicated by the life safety plans made available for reference as having a common path of travel distance exceeding the 100' permitted by Table 40.2.5.

Based upon observation not all corridors are provided with exit signage to identify two means of egress from the exit access corridor. Failure to provide identification of a second means of egress can confuse occupants in finding an exit if the primary exit is compromised or unavailable for use.

Findings include:

A. On 4/6/21 at 11:35am while in the company of the VPO it was observed that the 7th floor south corridor section between the Peds unit and the Waiting room which provides access to the south Stair of Building A lacked the identification of the second means of egress from the corridor to comply with 19.2.5.4.

B. On 4/6/21 at 2:20pm while in the company of the VPO it was observed that the 2nd floor corridor intersection near Elevator A4 lacked the identification of the second means of egress from the corridors leading to this intersection to comply with 19.2.5.4.

Based on observation, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency. This deficient practice may compromise the prompt care and movement of patients, visitors and staff during a fire/smoke emergency.

Findings include:

A. On 04/07/2021at 10:10am while accompanied by the DDC, means of egress were observed containing numerous materials blocking part of the egress path including cardboard boxes which form tripping hazards, the walls are lined with shelving containing stored materials. This condition does not comply with 19.2.3.3.
Locations observed: Basement level Servery area.

B. On 04/06/2021 at 1:45pm while in the company of the DDC, the surveyor observed a gurney and crib not "in-use" were in front of a pair of opposite swinging cross corridor doors. Further, they were obstructing the necessary door within the direction of egress. This condition does not comply with 19.2.3.5. Location observed: 6th floor corridor leading to "C" Building across from elevators.

C. On 04/06/2021 at 11:43am while in the company of the DDC, the surveyor observed two carts not "in-use" located in front of the egress door from the C-Section suite to the corridor. This condition does not comply with 19.2.3.5. Location observed: 7th floor C-Section Scrub area to corridor.

Sleeping suites are larger than permitted. Failure to limit the size of sleeping suites can compromise the safety of patients and staff with regard to exit access travel distances and compartmentalization in the event of a fire/smoke event.

The finding is:

On 04/07/2021 while in the company of the VPO during review of the facility Life Safety Plans the surveyor observed that sprinklered sleeping suites are noted to be larger than the permitted 7500 sf when not provided with total coverage of a smoke detection system to comply with 19.2.5.7.2.3(C).
Example locations of Suites include:

1. At 10:45am the 9648 sf 3rd floor ICU suite
2. At 11:00am the 8053 sf 1st floor Admissions & Testing suite

Based on observation the facility failed to provide properly arranged lighting to provide continuous operation without manual intervention. This condition may affect visitors staff and patients within the exit stair during an emergency evacuation.

The finding is:

On 04/07/2021 at 9:10am while in the company of the DDC, the surveyor observed a light switch within an exit stair that controlled lighting levels within the stair enclosure. This condition does not comply with 19.2.8 and 19.2.9. Location observed: 1st floor Stair 21B

Based on observation, exit signs were not provided, were not fully visible, or incorrectly identified paths of egress. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by preventing those occupants from readily identifying the path to an available exit from the building.

The finding is:

On 04/007/2021 at 10:05am while accompanied by the DDC, means of egress areas lack exit signage to comply with 7.8.1.2 and 19.2.8.
Location observed: Lower Level Kitchen Servery leading to the Dining area

Based upon observation, vertical openings are not protected to maintain separation of floor levels. Failure to maintain separation of floor levels can result in the spread of fire/smoke conditions from one floor to another.

Findings include:

A. On 4/6/21 at 11:30am while in the company of the VPO it was observed at Janitor room A779 that vertical conduits extending through the ceiling had been removed and the ceiling was not resealed (to match all other conduit penetrations). This condition does not prevent the passage of fire/smoke to above in order to comply with 19.3.1.1.

B. On 04/06/2021 at 11:40am while in the company of the VPO, shaft enclosures within Building A do not carry a minimum 2 hour fire resistance rating required by 19.3.1.1 and 8.2.5.4. This was confirmed by discussions with the facility representative along with the life safety floor plans dated 03/25/2021.

Based on observations and interviews the facility failed to maintain properly rated shaft enclosures. This deficient practice could affect patients, staff and visitor if smoke and fire were allowed to expand from other areas of the facility through deficient shaft enclosures.

Findings include:

On 04/06/2021 at 10:30am, during a discussion with the VPO, shaft enclosures within Building B do not carry a minimum 2 hour fire resistance rating required by 19.3.1.1 and 8.6.5. This was confirmed by the life safety floor plans dated 03/25/2021.
Example locations:

1. Elevator shafts

2. Linen chute shaft

3. Trash chute shaft

4. A series of ventilation shafts, which are at least 4 stories in height, lack a minimum 2 hour fire resistance rating. Ventilation shafts identified as carrying less than a 2 hour fire rating include:
i.The ventilation shaft at the southwest side of Exit Stair 3B at all levels.
ii. The ventilation shaft approximately 10 feet northeast of Exit Stair 3B at all levels.
iii. The center ventilation shaft.
iv. Approximately 15 ventilation shafts which serve the induction units installed at the exterior walls of the Building B.

5. Due to the construction type of the building floor slabs being 1-hour rated and serving as top of certain shafts ie linen and trash chute shafts. The ninth floor Building B segment of the linen and trash chutes, located within the elevator penthouse, lack shaft enclosures to comply with 8.6.5 (1).

6. The doors to the elevators at the northeast end of the Building B could not be determined to carry a minimum 1-1/2 hour fire resistance rating, as required by 19.3.1, table 8.3.4.2, 8.6.5(1) due to the fire resistance rating labels not being legible.

Based on observation, hazardous areas are not separated from the remainder of the occupancy and the means of egress. This deficient practice could affect the safety of patients, staff and visitors during a fire event.

The finding is:

On 04/06/2021 at 2:51pm, while in the company of the SDS, in the lower level of Building D, it was observed that the double doors serving the electrical room near stair A, which is designated a hazardous area on the provided life safety plan, do not properly self-close and self-latch to comply with 19.3.2.1.3 and 19.3.6.3.5.

Based on observation not all enclosures of hazardous areas are constructed and mantained as required. This deficient practice could affect patients, staff, and visitors in the buidling due to smoke and fire passing from the hazardous area th the remainder of hte builidng.

Findings include:

A. On 04/07/2021 at 9:15am while in the company of the DDC, the surveyor observed that there was no separation between dry storage and the remainder of the kitchen. The dry storage area is deemed as hazardous 19.3.2.1.5 (7) and the separation between the kitchen and storage does not comply with 19.3.2.1, 8.7 and 8.4. Location observed: Basement Kitchen

B. On 04/07/2021 at 9:05am while in the company of the DDC, the surveyor observed that the chute room for Laundry ( Room # B018) does not comply with the following:

1. The life safety floor plan indicates the chute room is not the required fire resistant to comply with NFPA 82, 2009 5.2.4.1.1, 19.3.1, 8.6.5(1).

2. The door to the room lacks a label to indicate the fire rating in order to comply with NDPA 80, 2010 5.2.4.

3. The door is damaged and delaminated which compromises the fire resistance integrity for that door. This condition does not comply with NFPA 80, 2010, 5.2.4.2 (1).

C. On 04/06/2021 at 1:20pm while in the company of the DDC, the surveyor observed that a room contains numerous shelves on all walls and into the room with cardboard boxes, plastic containers and plastic coverings so that this area is deemed as hazardous 19.3.2.1.5 (7). The entry door does not comply with 19.3.2.1.3 for a self closing door. Location observed: 6th floor Pharmacy

Based on observation the facility failed to regularly inspect fire extinguishing devises. This deficient practice could affect patients, staff and visitors.

The finding is:

On 04/07/2021 at 9:25am accompanied by the DDC, in the basement level Kitchen Dry Goods Storage and Servery, it was observed that the wet chemical grease hood fire suppression system was not inspected on a monthly basis, (NFPA 17A 2009, 7.2)

Based on observation, the fire alarm system is not installed in accordance with Code requirements. Failure to install the fire alarm system in accordance with Code requirements can result in delayed activation and notification of occupants of a fire/smoke condition present in the building.

The finding is:

On 04/07/2021 at 11:15am, while in the company of the SDS, in the Lower Level of Building E it was observed that a fire alarm manual pull station was not installed within 5' of the East exit doors to comply with NFPA 72, 2010, 17.14.6.

Based on observations and interviews, the facility failed to provide properly installed fire alarm components related to exit locations. This deficient practice could affect patients, staff and visitors by encumbering evacuation during a fire event.

The finding is:

On 04/07/2021 at 1:11pm while accompanied by the DDC, the surveyor observed a manual pull station greater than 5 feet from the exit stair entry door which does not comply with 9.6.2, NFPA 72 2010, 17.14. Location observed 2nd floor Exit Stair 5.

Based on observation, the fire alarm system is not installed in accordance with Code requirements. Failure to install the fire alarm system in accordance with Code requirements can result in delayed activation and notification of occupants of a fire/smoke condition present in the building.

The finding is:

On 04/07/2021 at 12:40am, while in the company of the SDS, in the Wound Healing Center it was observed that a fire alarm manual pull station was not installed within 5' of the South exit doors to comply with NFPA 72, 2010, 17.14.6.

Based on observation the facility failed to provide a complete installation of the fire alarm system. System components are to be installed such that visitors, staff and patients are notified from all required locations.

The finding is:

On 04/07/2021 at 11:45am while accompanied by the DDS, the surveyor observed a visitor waiting room open to the corridor without staff supervision. During an interview with staff, the corridor door to the waiting room is always in the open position, therefore, this condition does not comply with 19.3.6.1 and 19.3.4.5.2 for detection in spaces open to the corridor. Location observed: G464 Visitor's Lounge

Based on observation the facility lacks complete sprinkler protection. Failure to install and maintain this installation could result in delayed response and fire suppression. This deficient practice could affect patients, staff and visitors during a fire event.

Findings include:

A. On 04/07/21 at 8.30am, while in the company of the SHP in the lower level Pharmacy it was observed that the two robotic picking machine enclosures with storage spaces of combustibles are not provided with sprinkler fire protection. The picking machine enclosures obstruct the provided sprinkler protection NFPA 13, 2010.8.1.1.


20224


B. On 04/07/2021 at 10:33am while in the company of the DDC, the surveyor observed an exit stair between the 1st floor and Basement levels is not sprinkler protected at the intermediate landing. This does not comply with NFPA 13 2010 8.1, 8.9.5.3. Location observed: Landing between the First floor and Basement of Building C, Stair 1 LLC (stair discharges to an exit passageway at the Basement level.

Based on observation the facility lacks complete sprinkler protection. Failure to install and maintain this installation could result in delayed response and fire suppression. This deficient practice could affect patients, staff and visitors during a fire event.

The finding is:

On 04/07/2021 at 9:10am while in the company of the DDC, the surveyor observed the 1st floor level for the exit Stair (which discharges to the interior) is not sprinkler protected below the intermediate landing. This does not comply with NFPA 13 2010 8.1, 8.9.5.3. Location observed: First floor Building B Stair 21B.

Based on observation the facility lacks complete sprinkler protection. Failure to install and maintain this installation could result in delayed response and fire suppression. This deficient practice could affect the safety of patients, staff and visitors during a fire event.

The finding is:

On 04/07/2021 at 9:00am, while in the company of the SDS, in the 6th floor IT closet of Building E it was observed that penetrations for low voltage electrical systems were open to the ceiling space in the adjacent corridor. These penetrations would allow heat and products of combustion to bypass the installed sprinkler head and therefore does not comply with NFPA 13, 2010, 8.6.4.1

Based on staff interview and observation the facility lacks complete protection of ventilation ducts through fire rated barriers. Failure to install and maintain this installation could result in the passage of fire and products of combustion from one fire compartment to another. This deficient practice could affect patients, staff and visitors during a fire event.

The findings are:

A. On 04/06/2021 at 11:00am, while in the company of the VPO in the first floor conference room it was confirmed that a series of ventilation duct shafts serving room induction units lack fire dampers as the individual ducts serving the induction units penetrates the shaft enclosure or floor above. NFPA 90A, 5.3.4

B. On 04/06/2021 at 11:30am, while in the company of the SHP in the penthouse mechanical room it was observed that the through the floor high pressure duct penetrations serving the induction units on floors below lack fire damper. NFPA 90A, 5.3.2

Based on staff interview the facility lacks complete protection of ventilation ducts through fire rated barriers. Failure to install and maintain this installation could result in the passage of fire and products of combustion from one fire compartment to another. This deficient practice could affect patients, staff and visitors during a fire event.

The finding is:

On 04/06/2021 at 11:00am, while in the company of the VPO in the first floor conference room it was confirmed that a series of ventilation duct shafts serving room induction units lack fire dampers as the individual ducts serving the induction units penetrates the shaft enclosure or floor above. NFPA 90A, 5.3.4

Based on observation the facility failed to install a compliant Category 1 Medical Gas System. This deficient practice could result in the failure / response which may affect patients, staff and visitors during a fire event.

The finding is:

On 04/07/2021 at 9:05am in the company of the SHP it was observed in the Lower Level ER1 that zone valves are installed within the same space for the outlets/inlets they control and not placed on an intervening wall. The zone valves are in the corridor however exam rooms 1 & 2 only have cubicle curtains separating the medical gas outlets/inlets from the valves that control them. NFPA 99, 2012, 5.1.4.8

Based on observation, not all electrical receptacles are installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the rooms because electrical equipment required for their care may fail to operate under emergency conditions if the electrical receptacles are not properly installed and maintained.

The finding is:

On 04/06/2012 at1:15pm while accompanied by the DDC, the surveyor observed that critical care patient beds lack electrical receptacles served by normal power to comply with NFPA 70 2011 517-19(A).
Location observed: C-Section Room

Based on observation, not all electrical receptacles are installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the rooms because electrical equipment required for their care may fail to operate under emergency conditions if the electrical receptacles are not properly installed and maintained.

The finding is:

On 04/07/2012 at 11:15am while accompanied by the DDC, the surveyor observed that critical care patient beds lack electrical receptacles served by normal power to comply with NFPA 70 2011 517-19(A).
Location observed: C-Section Room 7th floor Building G

Based upon observation, ground fault circuit interruption (GFCI) is not provided in accordance with code requirements. If GFCI protection is not provided, the circuit remains an electrical shock hazard to occupants. This deficient practice could affect the safety of patients, staff, and visitors.

The finding is:

On 04/07/2021 at 10:50am while in the company of the VPO, it was observed at the 2nd floor SICU that normal power receptacles at the cabinetry adjacent the sinks in the patient rooms are within 6'-0" of a sink fixture and are not provided with GFCI protection to comply with NFPA 70 2011, 210.8(B)(5).

The Type 1 Essential Electrical System (EES) is not arranged in compliance with Code requirements. Failure to distribute EES power in accordance with Code requirements can result in loss of emergency power to select functions designed to remain functional for evacuation puposes.

Findings include:

A. On 04/07/2021 while in the company of the VPO it was observed at several Life Safety electrical panels that loads identified as supplying "receptacles" not associated with the generator location, communication systems, or fire alarm auxilary functions were being fed from the Life Safety branch of the Essential Electrical System in non-compliance with NFPA 99-2012, 6.4.2.2.3.2. Receptacles appeared to be general use receptacles. Panels observed include:

1. C5-EL-1 on the 5th floor at 10:00am
2. C4-EL-1 on the 4th floor at 10:20am
3. C3-EL-1 on the 3rd floor at 10:45am
4. C1-EL-1 on the 1st floor at 11:10am

B. On 04/07/2021 at 11:10am while in the company of the VPO it was observed that the panel directory did not appear to match the circuit arrangement in Panel C1-EL-1: Circuit #14 has red markings but no lock-on device as required by NFPA 72-2010, 10.5.5.2; Circuit #4 is not marked with red markings and has lock-on device and is identified as serving the fire alarm.

Essential Electrical System receptacles are not labeled to identify the source from which they are fed. Failure to identify the location of the disconnecting breaker for the receptacles can delay the return of emergency power to critical functions in the event of momentary circuit breaker disconnection.

The finding is:

On 04/07/2021 at 9:45am while in the company of the VPO it was observed that red emergency receptacles are only labeled with a circuit number and lack the identification of the panel in which the circuit resides. The panel and circuit is required to be identified to comply with NFPA 70-2011, 517.19(A).
Example location: Cath Lab #1 (was the only lab available for review).

Based on observation, critical power receptacles are not labeled in compliance with Code requirements. This condition does not allow the ability to readily and accurately identify circuits to maintain critical power for patients if disconnection or maintenance is required.

The finding is:

On 04/07/2021 at 8:54am, while in the company of the SDS, it was observed that the labeling of the red outlets in typical Cardiology Patient rooms on the 6th floor of Building E had deteriorated to a point such that personnel cannot identify the panel and circuit from which they are fed, and therefore does not comply with NFPA 70, 2011, 517-19(A).