HospitalInspections.org

Based on observation, not all enclosures for hazardous areas are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors if smoke and fire could pass from the hazardous areas to the remainder of the building in the event of a fire emergency.

Findings include: On 10/02/18 while accompanied by the VPO, the following hazardous areas are not in accordance with 39.3.2.1 and 8.7.1.1.

Locations and conditions as follows:

1. At 10:10AM, the entry door to the Main Storage room lacks a means to keep the door closed in order to resist the passage of smoke.
2. At 10:21AM, the Mechanical/boiler room walls contain gaps between the wall and the ceiling's metal deck flutes.
3. At 10:35AM, the Medical record room contains penetrations that were not sealed smoke tight.
4. At 10:50AM, the fire rated walls of the Elevator machine room have gaps between the walls and metal deck flutes which are not fire resistant.

Based on observation, not all enclosures for hazardous areas are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building if smoke and fire could pass from the hazardous areas to the remainder of the building in the event of a fire emergency.

Findings include: On 10/01/18 at 12:40AM, while accompanied by the VPO, it was observed that the large loading dock located in the Lower Level was not installed with a door to resist the passage of smoke/fire. The dock is not separated from the rest of the facility to comply with 19.3.2.1, 19.3.5.9 and 8.7.1.1.

Based on observation, not all fire alarm control functions are installed or operate as required. This deficient practice could affect patients, staff, and visitors in the building if the fire alarm system would fail to operate and was not installed properly and do not function as required.

Findings include: On 10/02/18, at 9:15AM while accompanied by the VPO, observation determined that the breaker serving the Fire Alarm Control Unit does not comply with NFPA 72 2010, 10.5.5.2 and 10.5.5.3 due to the following:

1. Is not labeled "FIRE ALARM".
2. The breaker serving the Fire Alarm Control Unit is not marked in red.
3. The breaker is not mechanically secured.

Based on observation, the facility failed to protect hazardous areas. This deficient practice could affect patients, staff, and visitors in the building because the automatic sprinkler system was not provided may fail to extinguish a fire if it is not properly installed.

Findings include: On 10/02/18 at 2:10PM while accompanied by the VPO, observation determined that the southwest Storage room was not protected with an automatic sprinkler system as required per 39.3.2.1 and 8.7.1.1.

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: On 10/01/18 accompanied by the DEM, it was observed that sprinkler protection is not provided at the following locations. This is in non-compliance with NFPA 13, 2010, 8.1.

1. at 1:45 PM in the 1st Floor Emergency Department Triage South Bay (T1043)
2. at 3:00 PM in the Basement Engineering Department Bullpen (TL037) North printer alcove

Based on observation, not all fire alarm initiation devices are installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building, the fire alarm could fail to activate under emergency conditions.

Findings include:

A. On 10/02/18 at 10:10AM while accompanied by the VPO, observation determined that fire alarm initiating devices (smoke detectors) do not comply with NFPA 72-2010, 17.7.4.1 due to the proximity of HVAC diffusers within 3'-0". Location observed, the door to the Medical Oncology suite.

B. On 10/02/18 at 9:50AM while accompanied by the VPO, observation determined that the Classroom/Conference Room/Training Room, open to a corridor lacks smoke detection to comply with NFPA 72-2010, 17.6.3.1 and 17.6.3.2.

Based upon observation the facility failed to provide complete smoke detection. This deficient practice could result in the untimely notification of fire which may affect patients, staff and visitors.

Findings include: On 10/02/2018 at 10:45 AM accompanied by the MFS, areas open to the means of egress corridor lack smoke detection to comply with 19.3.6.1(c). Locations observed:

1. 1st Floor Wheel chair storage open to Reception #T1216.
2. 1st Floor Family Lounge #T1189 with a corridor door which remains in the open position.

Based upon observation, corridor doors are not positive latching. Failure to provide positive latching corridor doors may compromise the effectiveness of the door to remain closed to prevent the passage of smoke from one side of the corridor wall to the other.

Findings include:

A. While in the company of the MFS, it was observed that the corridor doors were not equipped with a means to provide positive latching in order to comply with 19.3.6.3.5. Locations observed:

1. On 10/02/2018 at 9:25AM 1st Floor pair of doors from Cath Lab suite to corridor # T1177( designated on Facility life safety floor plan).

2. On 10/01/2018 at 2:10 PM 2nd Floor pair of doors from ICU to corridor # T2111.

3. On 10/01/2018 at 3:00PM 2nd Floor pair of doors from ICU to corridor #T20191.

4. On 10/01/2018 at 2:45PM 2nd Floor pair of doors from PACU Phase 1 Recovery to corridor #T2084.

B. While in the company of the MFS, it was observed that corridor doors contain roller latches which do not comply with 19.3.6.3.5. Locations observed:

1. On 10/01/2018 at 3:15PM 2nd Floor pairs of corridor doors to Storage Closets #T2214 and #T2215

2. On 10/02/2018 at 1:00PM Lower Level Floor pairs of corridor doors to Storage Closets # TL122, #TL121, #TL120, #TL119, #TL118 and #TL117.

Based upon review of record documentation of door inspections, doors are not being maintained in fully functional condition to afford the protection they are intended to provide. Failure to maintain doors can compromise adjacent spaces during a fire condition.

Findings include: On 10/02/2018 at 2:45PM while in the company of the MFS and DEM, documentation for fire rated doors was reviewed to comply with NFPA 80 2010, 5.2.1. Documents were incomplete due to the following:

1. One document appeared to be a proposed work order. Documents did not indicate the actual repair or maintenance provided for each each door's condition. No document contained the signature of the individual who inspected/tested each door.

Based upon observation, the facility failed to provide properly ventilated hazardous areas for medical gas storage. The condition of oxidizing gas in a confined area, may lead to an acceleration of a fire event. This deficient practice could affect patients, staff and visitors in the area.

Findings include: On 10/03/2018 8:30AM in the company of the MFS and DEM, medical gas "E" sized tanks (approximately 25 c.f.) are not allowed to be stored within the means of egress corridor which does not comply with 19.3.2.4, 8.7.1.1(1), NFPA 99 2012, 5.1.3..2. Locations of storage racks labeled "empty tanks" were observed on the 1st and 2nd Floors near unoccupied Reception counters.