HospitalInspections.org

A walk-through with the Maintenance Director, the Risk Manager, et al, August 2 through August 11, 2011, determined by observation that the separation between the Main Hospital and the leased clinic adjacent to the Main Hospital, as well as the communicating opening between the Main Hospital and the Administration Wing (the old hospital) do not conform respectively with the requirements contained in Sections 19.1.1.4.1 and 19.1.1.4.2 in the 2000 edition of the Life Safety Code, NFPA 101.

1] There were wall penetrations in the corridor wall separating the Main Hospital and the leased clinic facility adjacent to the Main Hospital (corrected during inspection).

2] The "Time Clock" door, which separates the corridor coming from the Main Hospital and corridor leading into the Administration Wing is not identified as having a 90-minute rating.

Section 19.1.1.4.1 of the Life Safety Code requires non-conformance rated additions be separated by a two-hour fire resistance rating

Section 19.1.1.4.2 of the Life Safety Code requires that communicating openings in fire barriers be protected by approved, self-closing fire doors. A two-hour fire resistance rated wall separation requires a minimum 90-minute rated fire door.

A walk-through with the Maintenance Director, the Risk Manager, et al, August 2 through August 11, 2011, determined by observation that the structure did not conform to the requirements of Section 19.1.6.2 in the 2000 edition of the Life Safety Code, NFPA 101.

Unprotected steel floor and structural members were identified in the following locations:

Third Floor
-The Electrical Room in 3-North, fire protection missing from the beams

Second Floor
-The North Staircase (#4 Stairwell), exposed steel structure
-OB Nursery Storage Room, exposed steel

First Floor
-The old CT Storage room has a sheet metal pipe approximately 8-inches in diameter penetrating the ceiling area
-Elevator Hydraulic Mechanical room, I-beam missing fire protection coating
Electrical room and Storage room in the Admission area have exposed steel

Provided the structure is protected by an automatic sprinkler system, Table 19.1.6.2, "Construction Type Limitations," in the 2000 edition of the Life Safety Code requires health care structures up to and including three-stories be a minimum Type II (111).

A walk-through with the Maintenance Director, the Risk Manager, et al, August 2 through August 11, 2011, determined by observation that the following corridor walls or doors did not conform to the requirements contained in Section 19.3.6 of the 2000 edition of the Life Safety Code, NFPA 101.

Main Hospital, 2nd Floor:
Pediatrics storage room door not positively latching into the frame

Administration Wing (old hospital):
Door to the Risk Manager's Office needs a smoke seal on the hinged-side of the door

Monte Vista Clinic:
The X-Ray door is dragging on the floor making it difficult to close

A walk-through with the Maintenance Director, the Risk Manager, et al, August 2 through August 11, 2011, determined by observation that the following elevator shaft walls did not conform to the requirements contained in Section 19.3.1.1 of the 2000 edition of the Life Safety Code, NFPA 101.

The elevator shaft for the "1992 elevator addition" is breached in several spots by hydraulic and electrical penetrations with unsealed openings about those penetrations. And, there is a hydraulic fluid lead about the hydraulic cylinder in the shaft of the 1992 elevator addition. This exposes areas outside the elevator shaft to the potential of burning hydraulic oil.

A walk-through with the Maintenance Director, the Risk Manager, et al, August 2 through August 11, 2011, determined by observation that egress paths were not identified or mis-identified contrary to the requirements contained in Section 7.10 of the 2000 edition of the Life Safety Code, NFPA 101.

Main Hospital, 3rd Floor:
1] The Exit sign on 3-North Stairwell is missing (corrected during inspection)
2] The Exit sign in the 3-North Waiting Room is missing (corrected during inspection)

Main Hospital, 2nd Floor:
1] The South horizontal exit on the mezzanine needs and Exit sign leading traffic South
2] The Exit Sign in the South MOB stairwell needs to be turned directing traffic to the stairwell

Main Hospital, 1st Floor:
1] ER, Stairway 4, remove the Exit sign over door #6 (corrected during inspection)
2] Exit sign near the Kitchen Supervisor's Office has only one bulb illuminated (corrected during inspection)

A walk-through with the Maintenance Director, the Risk Manager, et al, August 2 through August 11, 2011, determined by observation that smoke compartmentation and control did not conform to the requirements contained Section 19.3.7.3 of the 2000 edition of the Life Safety Code, NFPA 101.

Main Hospital, 2nd Floor:
The center smoke seal in door 18 in the OB area has a gap greater than one-eighth inch

Main Hospital, 1st Floor Business Unit:
Smoke door not positively latching into the frame between Pediatrics and OB and GYN

PS Building:
The one-hour, self-closing door, adjacent to the Staff bathroom and break room does not positively close and latch into the frame assembly.

A walk-through with the Maintenance Director, the Risk Manager, et al, August 2 through August 11, 2011, determined by observation that the following hazardous areas did not conform to the requirements contained in Section 19.3.2.1 of the 2000 edition of the Life Safety Code, NFPA 101.

Main Hospital, 2nd Floor:
-Gap or hole in the North wall across from room #217 (OB Clean Utility Room), which violates the smoke-seal integrity of the room
-OB Nursery Storage Room-wall to deck needs to be smoke-sealed
-OB Nursery Storage Room-door needs self-closing or automatic closing mechanism

Main Hospital, 1st Floor:
-The door for the Old CT Room Storage needs a self-closer or automatic closing mechanism
-The Bio-Hazard door, across from the PACU, has no latching mechanism and no self-closing mechanism
-Hydraulic oil storage area on the first floor is a hazardous area and needs to be enclosed in a smoke resistive enclosure. This door must be self-closing or automatic closing
-Kitchen doors opening directly to the back corridor, near the elevators, do not latch

Administration Wing (Old Hospital):
-Housekeeping storage door needs self-closing or automatic-closing mechanism

Administration Wing Medical or Hospital Records Office
-Sprinklers do not cover the entire area
-Door needs self-closing or automatic-closing mechanism

Administration Wing Physicians' Records and Physicians' Records Release Room
-Door does not have self-closing or automatic-closing mechanism
-Door binds and does not positively latch into its frame

Item A:
A walk-through with the Maintenance Director, the Risk Manager, et al, August 2 through August 11, 2011, determined by observation that the Access-controlled egress doors did not conform to the requirements of Section 7.2.1.6.2 (a) through (e) of the 2000 edition of the Life Safety Code, NFPA 101.

Main Hospital, 3rd Floor---Access into the third-floor ICU from the stairwell adjacent to room #322 is controlled, but there is no sensor provided on the egress side to detect and unlock the doors if an occupant approaches from the egress side.

Item B:
A walk-through with the Maintenance Director, the Risk Manager, et al, August 2 through August 11, 2011, determined by observation that doors #17 and #19 for the OB Area did not conform to the requirements of Section 7.2.1.5 of the 2000 edition of the Life Safety Code, NFPA 101.

Main Hospital, 2nd Floor---Egress doors from the OB Nursery Area found locked against egress.

Item C:
A walk-through with the Maintenance Director, the Risk Manager, et al, August 2 through August 11, 2011, determined by observation that door to Stair #1 in the egress path from the OB Area did not conform to the requirements of Section 7.2.1.5 of the 2000 edition of the Life Safety Code, NFPA 101.

Main Hospital, 2nd Floor---The door to Stair #1 found locked with a key-operated magnetic locking device.

Item D:
A walk-through with the Maintenance Director, the Risk Manager, et al, August 2 through August 11, 2011, determined by observation that Exit door in Stair #5 in the egress path from the OB Area did not conform to the requirements of Section 7.2.1.5.4 of the 2000 edition of the Life Safety Code, NFPA 101.

Main Hospital, 1st Floor---The door to Stair #5 requires two separate and distinct actions to open the door.

Item E:
A walk-through with the Maintenance Director, the Risk Manager, et al, August 2 through August 11, 2011, determined by observation that several doors in the basement area of the Administrative Wing (Old Hospital) did not conform to the requirements of Section 7.2.1.5.1 of the 2000 edition of the Life Safety Code, NFPA 101.

Several doors in the basement area of the Administrative Wing were found to have been secured closed with hasp and lock type mechanisms. (Corrected during inspection.)

Item F:
A walk-through with the Maintenance Director, the Risk Manager, et al, August 2 through August 11, 2011, determined by observation that sliding-glass doors in the Main Hospital Entrance, the South Tower, and the Emergency Room do not conform to the requirements of Section 7.2.1.5.1 of the 2000 edition of the Life Safety Code, NFPA 101.

Sliding-glass doors at the Main Hospital Entrance, the South Tower, and the Emergency Room no longer have the "break-away" opening feature with the mechanical center lock engaged, and the doors are unable to be opened from the egress side without the use of a key and/or special knowledge.

Item G:
A walk-through with the Maintenance Director, the Risk Manager, et al, August 2 through August 11, 2011, determined by observation that bathroom or storage room door for HR does not conform to the requirements of Section 7.2.1.5.1 of the 2000 edition of the Life Safety Code, NFPA 101.

The door was found to be equipped with sliding-bolt locking mechanisms.

Item H:
A walk-through with the Maintenance Director, the Risk Manager, et al, August 2 through August 11, 2011, determined by observation that the sliding-glass main entrance and exit doors in the Physicians' Services (PS) Building do not conform to the requirements of Section 39.2.2.2 and the subsequently referenced Section 7.2.1.5.1 of the 2000 edition of the Life Safety Code, NFPA 101.

The sliding-glass main entrance doors in the Physicians' Services (PS) Building were found to be equipped with sliding-bolt locking mechanisms.

A walk-through with the Maintenance Director, the Risk Manager, et al, August 2 through August 11, 2011, determined by observation that illumination of the Exit signs in the Monte Vista Clinic do not conform to the requirements of the 1999 edition of NFPA 72, the National Fire Alarm Code.

1. The Exit sign over the Southwest door of the Waiting Room did not illuminate with the test button depressed.
2. The Exit sign over the West door to the Lobby (at the Nurses' Station) did not illuminate with the test button depressed.

A walk-through with the Maintenance Director, the Risk Manager, et al, August 2 through August 11, 2011, determined by observation that the Manual Fire Alarm Pull Station (MP) in the Emergency Room (ER) does not conform to the requirements of Section 9.6.2.3 of the 2000 edition of the Life Safety Code, NFPA 101.

The MP in the ER is not mounted in the natural exit access path.

Item A:
A walk-through with the Maintenance Director, the Risk Manager, et al, August 2 through August 11, 2011, determined by observation that visual notification devices in the older section of the Main Hospital do not conform to the requirements of Section 4-4.4.1.1 of the 1999 edition of NFPA 72, the National Fire Alarm Code.

It was observed that the strobe lights in the older section of the Main Hospital were not flashing in a synchronized manner. This includes the Emergency Room area and the hall leading to it, the area between the Lobby and the Cafeteria, the OB-GYN Hall, the Infant Hall, the area by the elevators outside the waiting room on the 2nd floor, and the 3rd floor Specialty Clinic Check-In area.

Section 4-4.4.1.1, of the 1999 edition of NFPA 72 states, in part, "...Visible notification appliances shall be installed in accordance with Table 4-4.4.1.1(a), using one of the following: ...(4) More than two visible notification appliances in the same room or adjacent space within the field of view that flash in synchronization. This requirement shall not preclude synchronization of appliances that are not within the same field of view."

Item B:
A walk-through with the Maintenance Director, the Risk Manager, et al, August 2 through August 11, 2011, determined by observation that visual notification devices in the older section of the Main Hospital do not conform to the requirements of the 1999 edition of NFPA 72, the National Fire Alarm Code.

The strobe lights on the 3rd floor, by the Stairway 5, in the 3rd floor waiting room, in the 3rd floor Cardiopulmonary area, in the Respiratory area, and in the OT/PT area not illuminating (firing).

Item C:
A walk-through with the Maintenance Director, the Risk Manager, et al, August 2 through August 11, 2011, determined by observation that visual notification devices in the older section of the Main Hospital do not conform to the requirements of the 1999 edition of NFPA 72, the National Fire Alarm Code.

There were no audio-visual notification devices in the area of the elevator by the X-Ray Department area.

A walk-through with the Maintenance Director, the Risk Manager, et al, August 2 through August 11, 2011, determined by observation that the door for the horizontal protection between the Administrative Wing (Old Hospital) and the Main Hospital did not operate in conformance with the requirements of the 1999 edition of NFPA 72, the National Fire Alarm Code.

The "Time Clock" door, which is held open with an automatic hold-open device and separates the corridors between the Main Hospital and the Administration Wing, did not release when the Main Hospital Fire Alarm system was activated.

A walk-through with the Maintenance Director, the Risk Manager, et al, August 2 through August 11, 2011, determined by observation that sprinkler protection of the hydraulically operated 1992 Elevator does not conform to the requirements of Section 19.3.5.1 of the 2000 edition of the Life Safety Code, NFPA 101.

Sprinkler protection could not be identified at the base of the shaft of the hydraulically operated 1992 Elevator.

NFPA 101, Section 19.3.5.1 states, "Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7."

Item A:
A walk-through with the Maintenance Director, the Risk Manager, et al, August 2 through August 11, 2011, determined by observation that sprinkler heads installed in various areas of the hospital do not conform to requirements for thermal sensitivity in Section 5-3.1.5 of the 1999 edition of NFPA 13, the Standard for the Installation of Sprinkler Systems.

There is a mixture of sprinkler heads having different thermal response characteristics in the following areas:

1. OB Lobby area, adjacent to the elevators
2. Radiology and Nuclear Medicine Corridors

According to Section 5-3.1.5.2 of the 1999 edition of NFPA 13, the Standard for the Installation of Sprinkler Systems, "When existing light hazard systems are converted to use quick-response or residential sprinklers, all sprinklers in a compartmented space shall be changed."

Item B:
A walk-through with the Maintenance Director, the Risk Manager, et al, August 2 through August 11, 2011, determined by observation that sprinkler heads installed in the following areas had their spray patterns obstructed due to the installation of the sprinkler heads, or the installation of structural components or appurtenances after the sprinklers had been installed. These situations do not conform to requirements of the 1999 edition of NFPA 13, the Standard for the Installation of Sprinkler Systems.

The pendent head sprinkler in room #217 is obstructed by cabinets, and the pendent head sprinkler in the corridor outside of room #217 is too close to the corridor wall.

Item C:
A walk-through with the Maintenance Director, the Risk Manager, et al, August 2 through August 11, 2011, determined by observation that thermal characteristics of the sprinkler heads installed in the storage room area of the kitchen do not conform to requirements for thermal sensitivity contained in the 1999 edition of NFPA 13, the Standard for the Installation of Sprinkler Systems.

The upright sprinkler heads in the storage room area of the kitchen (an ordinary hazard area) are high-temperature frangible-bulb sprinklers.

A walk-through with the Maintenance Director, the Risk Manager, et al, August 2 through August 11, 2011, determined by observation that documentation of monthly maintenance inspections for the portable fire suppression devices does not conform to the requirements of the 1998 edition of NFPA 10, the Standard for Portable Fire Extinguishers.

The facility failed to document the monthly inspection of the fire extinguisher in the Gift Shop.

A walk-through with the Maintenance Director, the Risk Manager, et al, August 2 through August 11, 2011, determined by observation that storage items were being maintained in the corridor of the PS Building, which does not comply with Section 7.1.10 of the 2000 edition of the Life Safety Code, NFPA 101.

The exit corridor of the Old Surgery Suite of the PS Building contains storage items in the egress path.

A walk-through with the Maintenance Director, the Risk Manager, et al, August 2 through August 11, 2011, determined by observation that storage of an oxygen cylinder in the PACU Soiled Utility Closet did not comply with the requirements of the 1999 edition of NFPA 99, Standard for Health Care Facilities.

An oxygen cylinder was found lying on the floor in the PACU Soiled Utility Closet.

According to NFPA 99 medical gas storage shall be protected. NFPA 99, Section 4-3.1.1.2 (a) 3 states, "Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation."

A walk-through with the Maintenance Director, the Risk Manager, et al, August 2 through August 11, 2011, determined by observation that storage of an oxygen cylinder in the PACU Soiled Utility Closet did not comply with the requirements of the 1999 edition of NFPA 99, Standard for Health Care Facilities.

An oxygen cylinder was found lying on the floor in the PACU Soiled Utility Closet.

According to NFPA 99, medical gas storage shall be protected. NFPA 99, Section 4-3.1.1.2 (a) 3 states, "Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation."

Item A:
A walk-through with the Maintenance Director, the Risk Manager, et al, August 2 through August 11, 2011, determined by observation that the smoke evacuation system in the Operating Room (OR) suites did not conform to the requirements of the 1999 edition of Health Care Facilities, NFPA 99.

Neither a review of the records, nor a walk-through of the facility confirmed that the smoke control system conformed to the requirements of the 2000 edition of NFPA 101, Sections 18.3.2.3 and 19.3.2.3, and the 1999 edition of NFPA 99, Section 5-4.1.3.

The facility could not provide documentation nor physically demonstrate that the air handling system for the new and old OR suites work to prevent the recirculation of smoke originating within the surgical suites, or prevent the circulation of smoke entering the system intake of the new OR suite, without interfering with the exhaust function of the system on the new OR suite.

According to the 1999 edition of NFPA 99, Section 5-4.1.3, "Ventilating systems for anesthetizing locations shall be provided that automatically (a) prevent recirculation of smoke originating within the surgical suite and (b) prevent the circulation of smoke entering the system intake, without in either case interfering with the exhaust function of the system."

Item B:
A walk-through with the Maintenance Director, the Risk Manager, et al, August 2 through August 11, 2011, determined, through observation that the electrical installation in the Operating Suite (OR) Suite 1 and OR Suite 2 did not conform to the requirements of the 2000 edition of NFPA 101, Life Safety Code, Section 19.3.2.3.

The OR suites do not utilize Line Isolation Monitors or Ground Fault Circuit Interrupter protection for the protection of electrical outlets in the OR suites as required by NFPA 99, Section 3-3.2.1.2, "All Patient Care Areas" (f) Wet Locations 1.

According to the 1999 edition of NFPA 99, Section 3-3.2.1.2, All Patient Care Areas (f) Wet Locations 1, "Wet location patient care areas shall be provided with special protection against electric shock. This special protection shall be provided by a power distribution system that inherently limits the possible ground-fault current due to a first fault to a low value, without interrupting the power supply; or by a power distribution system in which the power supply is interrupted if the ground-fault current does, in fact, exceed a value of 6 mA."

Wet Location. A patient care area that is normally subject to wet conditions while patients are present. This includes standing fluids on the floor or drenching of the work area, either of which condition is intimate to the patient or staff. Routine housekeeping procedures and incidental spillage of liquids do not define a wet location (ADM).

Item C:
A walk-through with the Maintenance Director, the Risk Manager, et al, August 2 through August 11, 2011, determined by observation that the Nurse-Servers (pull-down platforms for the nurses' computers) do not conform to the requirements of the 2000 edition of the Life Safety Code, NFPA 101.

The pull-down platforms for the nurses' computers are not automatically retractable, thereby impinging on the corridor width.

A walk-through with the Maintenance Director, the Risk Manager, et al, August 2 through August 11, 2011, determined by observation that the electrical system or constituent components so not conform to the requirements of the 1999 edition of the National Electrical Code, NFPA 70.

Main Hospital:
-GFCI receptacles in the kitchen do not trip with the test button depressed.
-Power strip connected in series (Daisy-Chained) with an extension cord in the Physicians' Consulting Room.
-Power strip improperly mounted behind the television in the Physicians' Consulting Room---the power strip is hanging by the attachment plug.
-An electrical junction box is missing its cover in the Physicians' Consulting Room.

PS Building:
-Extension Cord used to replace permanent wiring in the 2nd Floor Mechanical Room.
-Power strip connected in series (Daisy-Chained) with an extension cord in the 2nd Floor Mechanical Room.
-Power strip connected in series (Daisy-Chained) with an extension cord in the Home Health Office.

Monte Vista Clinic:
-Extension Cord used to replace permanent wiring in the Monte Vista Doctors' Office-extension cord is serving a portable fan.

A walk-through with the Maintenance Director, the Risk Manager, et al, August 2 through August 11, 2011, determined by observation that the separation between the Main Hospital and the leased clinic adjacent to the Main Hospital, as well as the communicating opening between the Main Hospital and the Administration Wing (the old hospital) do not conform respectively with the requirements contained in Sections 19.1.1.4.1 and 19.1.1.4.2 in the 2000 edition of the Life Safety Code, NFPA 101.

1] There were wall penetrations in the corridor wall separating the Main Hospital and the leased clinic facility adjacent to the Main Hospital (corrected during inspection).

2] The "Time Clock" door, which separates the corridor coming from the Main Hospital and corridor leading into the Administration Wing is not identified as having a 90-minute rating.

Section 19.1.1.4.1 of the Life Safety Code requires non-conformance rated additions be separated by a two-hour fire resistance rating

Section 19.1.1.4.2 of the Life Safety Code requires that communicating openings in fire barriers be protected by approved, self-closing fire doors. A two-hour fire resistance rated wall separation requires a minimum 90-minute rated fire door.

A walk-through with the Maintenance Director, the Risk Manager, et al, August 2 through August 11, 2011, determined by observation that the structure did not conform to the requirements of Section 19.1.6.2 in the 2000 edition of the Life Safety Code, NFPA 101.

Unprotected steel floor and structural members were identified in the following locations:

Third Floor
-The Electrical Room in 3-North, fire protection missing from the beams

Second Floor
-The North Staircase (#4 Stairwell), exposed steel structure
-OB Nursery Storage Room, exposed steel

First Floor
-The old CT Storage room has a sheet metal pipe approximately 8-inches in diameter penetrating the ceiling area
-Elevator Hydraulic Mechanical room, I-beam missing fire protection coating
Electrical room and Storage room in the Admission area have exposed steel

Provided the structure is protected by an automatic sprinkler system, Table 19.1.6.2, "Construction Type Limitations," in the 2000 edition of the Life Safety Code requires health care structures up to and including three-stories be a minimum Type II (111).

A walk-through with the Maintenance Director, the Risk Manager, et al, August 2 through August 11, 2011, determined by observation that the following corridor walls or doors did not conform to the requirements contained in Section 19.3.6 of the 2000 edition of the Life Safety Code, NFPA 101.

Main Hospital, 2nd Floor:
Pediatrics storage room door not positively latching into the frame

Administration Wing (old hospital):
Door to the Risk Manager's Office needs a smoke seal on the hinged-side of the door

Monte Vista Clinic:
The X-Ray door is dragging on the floor making it difficult to close

A walk-through with the Maintenance Director, the Risk Manager, et al, August 2 through August 11, 2011, determined by observation that the following elevator shaft walls did not conform to the requirements contained in Section 19.3.1.1 of the 2000 edition of the Life Safety Code, NFPA 101.

The elevator shaft for the "1992 elevator addition" is breached in several spots by hydraulic and electrical penetrations with unsealed openings about those penetrations. And, there is a hydraulic fluid lead about the hydraulic cylinder in the shaft of the 1992 elevator addition. This exposes areas outside the elevator shaft to the potential of burning hydraulic oil.

A walk-through with the Maintenance Director, the Risk Manager, et al, August 2 through August 11, 2011, determined by observation that egress paths were not identified or mis-identified contrary to the requirements contained in Section 7.10 of the 2000 edition of the Life Safety Code, NFPA 101.

Main Hospital, 3rd Floor:
1] The Exit sign on 3-North Stairwell is missing (corrected during inspection)
2] The Exit sign in the 3-North Waiting Room is missing (corrected during inspection)

Main Hospital, 2nd Floor:
1] The South horizontal exit on the mezzanine needs and Exit sign leading traffic South
2] The Exit Sign in the South MOB stairwell needs to be turned directing traffic to the stairwell

Main Hospital, 1st Floor:
1] ER, Stairway 4, remove the Exit sign over door #6 (corrected during inspection)
2] Exit sign near the Kitchen Supervisor's Office has only one bulb illuminated (corrected during inspection)

A walk-through with the Maintenance Director, the Risk Manager, et al, August 2 through August 11, 2011, determined by observation that smoke compartmentation and control did not conform to the requirements contained Section 19.3.7.3 of the 2000 edition of the Life Safety Code, NFPA 101.

Main Hospital, 2nd Floor:
The center smoke seal in door 18 in the OB area has a gap greater than one-eighth inch

Main Hospital, 1st Floor Business Unit:
Smoke door not positively latching into the frame between Pediatrics and OB and GYN

PS Building:
The one-hour, self-closing door, adjacent to the Staff bathroom and break room does not positively close and latch into the frame assembly.

A walk-through with the Maintenance Director, the Risk Manager, et al, August 2 through August 11, 2011, determined by observation that the following hazardous areas did not conform to the requirements contained in Section 19.3.2.1 of the 2000 edition of the Life Safety Code, NFPA 101.

Main Hospital, 2nd Floor:
-Gap or hole in the North wall across from room #217 (OB Clean Utility Room), which violates the smoke-seal integrity of the room
-OB Nursery Storage Room-wall to deck needs to be smoke-sealed
-OB Nursery Storage Room-door needs self-closing or automatic closing mechanism

Main Hospital, 1st Floor:
-The door for the Old CT Room Storage needs a self-closer or automatic closing mechanism
-The Bio-Hazard door, across from the PACU, has no latching mechanism and no self-closing mechanism
-Hydraulic oil storage area on the first floor is a hazardous area and needs to be enclosed in a smoke resistive enclosure. This door must be self-closing or automatic closing
-Kitchen doors opening directly to the back corridor, near the elevators, do not latch

Administration Wing (Old Hospital):
-Housekeeping storage door needs self-closing or automatic-closing mechanism

Administration Wing Medical or Hospital Records Office
-Sprinklers do not cover the entire area
-Door needs self-closing or automatic-closing mechanism

Administration Wing Physicians' Records and Physicians' Records Release Room
-Door does not have self-closing or automatic-closing mechanism
-Door binds and does not positively latch into its frame

Item A:
A walk-through with the Maintenance Director, the Risk Manager, et al, August 2 through August 11, 2011, determined by observation that the Access-controlled egress doors did not conform to the requirements of Section 7.2.1.6.2 (a) through (e) of the 2000 edition of the Life Safety Code, NFPA 101.

Main Hospital, 3rd Floor---Access into the third-floor ICU from the stairwell adjacent to room #322 is controlled, but there is no sensor provided on the egress side to detect and unlock the doors if an occupant approaches from the egress side.

Item B:
A walk-through with the Maintenance Director, the Risk Manager, et al, August 2 through August 11, 2011, determined by observation that doors #17 and #19 for the OB Area did not conform to the requirements of Section 7.2.1.5 of the 2000 edition of the Life Safety Code, NFPA 101.

Main Hospital, 2nd Floor---Egress doors from the OB Nursery Area found locked against egress.

Item C:
A walk-through with the Maintenance Director, the Risk Manager, et al, August 2 through August 11, 2011, determined by observation that door to Stair #1 in the egress path from the OB Area did not conform to the requirements of Section 7.2.1.5 of the 2000 edition of the Life Safety Code, NFPA 101.

Main Hospital, 2nd Floor---The door to Stair #1 found locked with a key-operated magnetic locking device.

Item D:
A walk-through with the Maintenance Director, the Risk Manager, et al, August 2 through August 11, 2011, determined by observation that Exit door in Stair #5 in the egress path from the OB Area did not conform to the requirements of Section 7.2.1.5.4 of the 2000 edition of the Life Safety Code, NFPA 101.

Main Hospital, 1st Floor---The door to Stair #5 requires two separate and distinct actions to open the door.

Item E:
A walk-through with the Maintenance Director, the Risk Manager, et al, August 2 through August 11, 2011, determined by observation that several doors in the basement area of the Administrative Wing (Old Hospital) did not conform to the requirements of Section 7.2.1.5.1 of the 2000 edition of the Life Safety Code, NFPA 101.

Several doors in the basement area of the Administrative Wing were found to have been secured closed with hasp and lock type mechanisms. (Corrected during inspection.)

Item F:
A walk-through with the Maintenance Director, the Risk Manager, et al, August 2 through August 11, 2011, determined by observation that sliding-glass doors in the Main Hospital Entrance, the South Tower, and the Emergency Room do not conform to the requirements of Section 7.2.1.5.1 of the 2000 edition of the Life Safety Code, NFPA 101.

Sliding-glass doors at the Main Hospital Entrance, the South Tower, and the Emergency Room no longer have the "break-away" opening feature with the mechanical center lock engaged, and the doors are unable to be opened from the egress side without the use of a key and/or special knowledge.

Item G:
A walk-through with the Maintenance Director, the Risk Manager, et al, August 2 through August 11, 2011, determined by observation that bathroom or storage room door for HR does not conform to the requirements of Section 7.2.1.5.1 of the 2000 edition of the Life Safety Code, NFPA 101.

The door was found to be equipped with sliding-bolt locking mechanisms.

Item H:
A walk-through with the Maintenance Director, the Risk Manager, et al, August 2 through August 11, 2011, determined by observation that the sliding-glass main entrance and exit doors in the Physicians' Services (PS) Building do not conform to the requirements of Section 39.2.2.2 and the subsequently referenced Section 7.2.1.5.1 of the 2000 edition of the Life Safety Code, NFPA 101.

The sliding-glass main entrance doors in the Physicians' Services (PS) Building were found to be equipped with sliding-bolt locking mechanisms.

A walk-through with the Maintenance Director, the Risk Manager, et al, August 2 through August 11, 2011, determined by observation that illumination of the Exit signs in the Monte Vista Clinic do not conform to the requirements of the 1999 edition of NFPA 72, the National Fire Alarm Code.

1. The Exit sign over the Southwest door of the Waiting Room did not illuminate with the test button depressed.
2. The Exit sign over the West door to the Lobby (at the Nurses' Station) did not illuminate with the test button depressed.

A walk-through with the Maintenance Director, the Risk Manager, et al, August 2 through August 11, 2011, determined by observation that the Manual Fire Alarm Pull Station (MP) in the Emergency Room (ER) does not conform to the requirements of Section 9.6.2.3 of the 2000 edition of the Life Safety Code, NFPA 101.

The MP in the ER is not mounted in the natural exit access path.

Item A:
A walk-through with the Maintenance Director, the Risk Manager, et al, August 2 through August 11, 2011, determined by observation that visual notification devices in the older section of the Main Hospital do not conform to the requirements of Section 4-4.4.1.1 of the 1999 edition of NFPA 72, the National Fire Alarm Code.

It was observed that the strobe lights in the older section of the Main Hospital were not flashing in a synchronized manner. This includes the Emergency Room area and the hall leading to it, the area between the Lobby and the Cafeteria, the OB-GYN Hall, the Infant Hall, the area by the elevators outside the waiting room on the 2nd floor, and the 3rd floor Specialty Clinic Check-In area.

Section 4-4.4.1.1, of the 1999 edition of NFPA 72 states, in part, "...Visible notification appliances shall be installed in accordance with Table 4-4.4.1.1(a), using one of the following: ...(4) More than two visible notification appliances in the same room or adjacent space within the field of view that flash in synchronization. This requirement shall not preclude synchronization of appliances that are not within the same field of view."

Item B:
A walk-through with the Maintenance Director, the Risk Manager, et al, August 2 through August 11, 2011, determined by observation that visual notification devices in the older section of the Main Hospital do not conform to the requirements of the 1999 edition of NFPA 72, the National Fire Alarm Code.

The strobe lights on the 3rd floor, by the Stairway 5, in the 3rd floor waiting room, in the 3rd floor Cardiopulmonary area, in the Respiratory area, and in the OT/PT area not illuminating (firing).

Item C:
A walk-through with the Maintenance Director, the Risk Manager, et al, August 2 through August 11, 2011, determined by observation that visual notification devices in the older section of the Main Hospital do not conform to the requirements of the 1999 edition of NFPA 72, the National Fire Alarm Code.

There were no audio-visual notification devices in the area of the elevator by the X-Ray Department area.

A walk-through with the Maintenance Director, the Risk Manager, et al, August 2 through August 11, 2011, determined by observation that the door for the horizontal protection between the Administrative Wing (Old Hospital) and the Main Hospital did not operate in conformance with the requirements of the 1999 edition of NFPA 72, the National Fire Alarm Code.

The "Time Clock" door, which is held open with an automatic hold-open device and separates the corridors between the Main Hospital and the Administration Wing, did not release when the Main Hospital Fire Alarm system was activated.

A walk-through with the Maintenance Director, the Risk Manager, et al, August 2 through August 11, 2011, determined by observation that sprinkler protection of the hydraulically operated 1992 Elevator does not conform to the requirements of Section 19.3.5.1 of the 2000 edition of the Life Safety Code, NFPA 101.

Sprinkler protection could not be identified at the base of the shaft of the hydraulically operated 1992 Elevator.

NFPA 101, Section 19.3.5.1 states, "Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7."

Item A:
A walk-through with the Maintenance Director, the Risk Manager, et al, August 2 through August 11, 2011, determined by observation that sprinkler heads installed in various areas of the hospital do not conform to requirements for thermal sensitivity in Section 5-3.1.5 of the 1999 edition of NFPA 13, the Standard for the Installation of Sprinkler Systems.

There is a mixture of sprinkler heads having different thermal response characteristics in the following areas:

1. OB Lobby area, adjacent to the elevators
2. Radiology and Nuclear Medicine Corridors

According to Section 5-3.1.5.2 of the 1999 edition of NFPA 13, the Standard for the Installation of Sprinkler Systems, "When existing light hazard systems are converted to use quick-response or residential sprinklers, all sprinklers in a compartmented space shall be changed."

Item B:
A walk-through with the Maintenance Director, the Risk Manager, et al, August 2 through August 11, 2011, determined by observation that sprinkler heads installed in the following areas had their spray patterns obstructed due to the installation of the sprinkler heads, or the installation of structural components or appurtenances after the sprinklers had been installed. These situations do not conform to requirements of the 1999 edition of NFPA 13, the Standard for the Installation of Sprinkler Systems.

The pendent head sprinkler in room #217 is obstructed by cabinets, and the pendent head sprinkler in the corridor outside of room #217 is too close to the corridor wall.

Item C:
A walk-through with the Maintenance Director, the Risk Manager, et al, August 2 through August 11, 2011, determined by observation that thermal characteristics of the sprinkler heads installed in the storage room area of the kitchen do not conform to requirements for thermal sensitivity contained in the 1999 edition of NFPA 13, the Standard for the Installation of Sprinkler Systems.

The upright sprinkler heads in the storage room area of the kitchen (an ordinary hazard area) are high-temperature frangible-bulb sprinklers.

A walk-through with the Maintenance Director, the Risk Manager, et al, August 2 through August 11, 2011, determined by observation that documentation of monthly maintenance inspections for the portable fire suppression devices does not conform to the requirements of the 1998 edition of NFPA 10, the Standard for Portable Fire Extinguishers.

The facility failed to document the monthly inspection of the fire extinguisher in the Gift Shop.

A walk-through with the Maintenance Director, the Risk Manager, et al, August 2 through August 11, 2011, determined by observation that storage items were being maintained in the corridor of the PS Building, which does not comply with Section 7.1.10 of the 2000 edition of the Life Safety Code, NFPA 101.

The exit corridor of the Old Surgery Suite of the PS Building contains storage items in the egress path.

A walk-through with the Maintenance Director, the Risk Manager, et al, August 2 through August 11, 2011, determined by observation that storage of an oxygen cylinder in the PACU Soiled Utility Closet did not comply with the requirements of the 1999 edition of NFPA 99, Standard for Health Care Facilities.

An oxygen cylinder was found lying on the floor in the PACU Soiled Utility Closet.

According to NFPA 99 medical gas storage shall be protected. NFPA 99, Section 4-3.1.1.2 (a) 3 states, "Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation."

A walk-through with the Maintenance Director, the Risk Manager, et al, August 2 through August 11, 2011, determined by observation that storage of an oxygen cylinder in the PACU Soiled Utility Closet did not comply with the requirements of the 1999 edition of NFPA 99, Standard for Health Care Facilities.

An oxygen cylinder was found lying on the floor in the PACU Soiled Utility Closet.

According to NFPA 99, medical gas storage shall be protected. NFPA 99, Section 4-3.1.1.2 (a) 3 states, "Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation."

Item A:
A walk-through with the Maintenance Director, the Risk Manager, et al, August 2 through August 11, 2011, determined by observation that the smoke evacuation system in the Operating Room (OR) suites did not conform to the requirements of the 1999 edition of Health Care Facilities, NFPA 99.

Neither a review of the records, nor a walk-through of the facility confirmed that the smoke control system conformed to the requirements of the 2000 edition of NFPA 101, Sections 18.3.2.3 and 19.3.2.3, and the 1999 edition of NFPA 99, Section 5-4.1.3.

The facility could not provide documentation nor physically demonstrate that the air handling system for the new and old OR suites work to prevent the recirculation of smoke originating within the surgical suites, or prevent the circulation of smoke entering the system intake of the new OR suite, without interfering with the exhaust function of the system on the new OR suite.

According to the 1999 edition of NFPA 99, Section 5-4.1.3, "Ventilating systems for anesthetizing locations shall be provided that automatically (a) prevent recirculation of smoke originating within the surgical suite and (b) prevent the circulation of smoke entering the system intake, without in either case interfering with the exhaust function of the system."

Item B:
A walk-through with the Maintenance Director, the Risk Manager, et al, August 2 through August 11, 2011, determined, through observation that the electrical installation in the Operating Suite (OR) Suite 1 and OR Suite 2 did not conform to the requirements of the 2000 edition of NFPA 101, Life Safety Code, Section 19.3.2.3.

The OR suites do not utilize Line Isolation Monitors or Ground Fault Circuit Interrupter protection for the protection of electrical outlets in the OR suites as required by NFPA 99, Section 3-3.2.1.2, "All Patient Care Areas" (f) Wet Locations 1.

According to the 1999 edition of NFPA 99, Section 3-3.2.1.2, All Patient Care Areas (f) Wet Locations 1, "Wet location patient care areas shall be provided with special protection against electric shock. This special protection shall be provided by a power distribution system that inherently limits the possible ground-fault current due to a first fault to a low value, without interrupting the power supply; or by a power distribution system in which the power supply is interrupted if the ground-fault current does, in fact, exceed a value of 6 mA."

Wet Location. A patient care area that is normally subject to wet conditions while patients are present. This includes standing fluids on the floor or drenching of the work area, either of which condition is intimate to the patient or staff. Routine housekeeping procedures and incidental spillage of liquids do not define a wet location (ADM).

Item C:
A walk-through with the Maintenance Director, the Risk Manager, et al, August 2 through August 11, 2011, determined by observation that the Nurse-Servers (pull-down platforms for the nurses' computers) do not conform to the requirements of the 2000 edition of the Life Safety Code, NFPA 101.

The pull-down platforms for the nurses' computers are not automatically retractable, thereby impinging on the corridor width.

A walk-through with the Maintenance Director, the Risk Manager, et al, August 2 through August 11, 2011, determined by observation that the electrical system or constituent components so not conform to the requirements of the 1999 edition of the National Electrical Code, NFPA 70.

Main Hospital:
-GFCI receptacles in the kitchen do not trip with the test button depressed.
-Power strip connected in series (Daisy-Chained) with an extension cord in the Physicians' Consulting Room.
-Power strip improperly mounted behind the television in the Physicians' Consulting Room---the power strip is hanging by the attachment plug.
-An electrical junction box is missing its cover in the Physicians' Consulting Room.

PS Building:
-Extension Cord used to replace permanent wiring in the 2nd Floor Mechanical Room.
-Power strip connected in series (Daisy-Chained) with an extension cord in the 2nd Floor Mechanical Room.
-Power strip connected in series (Daisy-Chained) with an extension cord in the Home Health Office.

Monte Vista Clinic:
-Extension Cord used to replace permanent wiring in the Monte Vista Doctors' Office-extension cord is serving a portable fan.