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Based on random observation during the survey walk-through, not all portions of the building are of fire resistive construction in accordance with 19.1.6.2. These deficiencies could affect any patients, staff, or visitors in the building by permitting the building structure to be compromised during fire conditions.

Findings include:

A. At 2:11 PM on April 23, 2013, the roof of the east portion of the East Elevator Penthouse was observed to consist of unprotected metal roof panels, which are not consistent with the building's designated construction type.

Based on random observation during the survey walk-through, not all wall and ceiling finishes in rooms or spaces could be verified as carrying a flame spread rating of Class A or B or less in accordance with 19.3.3.1. These deficiencies could affect any patients, staff, or visitors in the building by permitting smoke to develop in occupied portions of the building.

Findings include:

A. Finish materials which do not carry a Class A or B flame spread rating, as required by 19.3.3.2.(1), were observed. Locations and finish materials observed include:

1. 9:47 AM April 24, 2013: Administrative Assistant's Office, wood paneling.

2. 9:49 AM April 24, 2013: Chief Executive's Officer's Office, wood paneling.

Based on random observation during the survey walk-through, not all doors in exit access corridors are in compliance with 19.3.6.3. These deficiencies could affect any patients, staff, or visitors in the building by allowing smoke or fire to enter the egress corridor.

Findings include:

A. At 9:41 AM on April 24, 2013, the door to the First Floor Dental Lab was observed to not be positive latching as required by 19.3.6.3.2.
B. During a test of the building fire alarm system conducted at 1:20 PM on April 24, 2013, the door to the Fourth Floor ICU Suite was observed to not be positive latching as required by 19.3.6.3.2.

Based on random observation during the survey walk-through and staff interview, not all designated or required smoke barrier walls are constructed or maintained as minimum 30 minute fire rated assemblies in accordance with 19.3.7.3. These deficiencies could affect any patients, staff, or visitors in the building by allowing smoke to pass between smoke compartments.

Findings include:

A. During an interview conducted at 2:30 PM on April 23, 2013, the provider's Director of Plant Operations stated that an abandoned duct which passes through the Fourth Floor smoke barrier wall is not sealed against the passage of smoke as required by 19.3.7.3. and 8.3.2.

Based on random observation during the survey walk-through, not all exit stair shafts are constructed or maintained as fire resistive assemblies in accordance with 19.3.1.1. This deficiency could affect any patients, staff, or visitors in the building by preventing them from evacuating the building under fire conditions.

Findings include:

A. At 3:08 PM on April 23, 2013, an opening that is not sealed against the passage of fire was observed in the wall of the West Exit Stair, between the First and Second Floors, as prohibited by 8.2.2. and 8.2.3.2.4.2.

Based on random observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from reaching an exit under fire conditions.

Findings include:

A. At 10:06 AM on April 24, 2013, the following deficiencies were observed at the First Floor Northwest Exit Stair (designated as Exit Stair B):
1. Based on the placement of an exit sign above the east (interior) door from the Exit Stair, the Exit Stair discharges interior to the building as prohibited by 7.7.1.

2. The door marked by the exit sign swings against the direction of egress as prohibited by 7.2.1.4.3.

3. the east (Corridor) face of the door has a painted sign which reads "EMERGENCY EXIT," thus directing building occupants away from the designated exit as prohibited by 7.10.

B. At 9:50 AM on April 24, 2013, the door to the First Floor Pharmacy was observed to be a dutch door at which both the upper and lower leaf latch to the door frame independently of each other, thus requiring 2 operations to exit the room as prohibited by 7.2.1.5.4.

C. At 10:26 AM on April 24, 2013, the door to the First Floor Air Handling Unit Room, across from the Radiology Reception Room, was observed to reduce the Corridor to less than half its required width, and to obstruct a cross-corridor egress door, as prohibited by 7.2.1.4.4.

Based on random observation during the survey walk-through, not all designated or required horizontal exits or fire barriers are constructed or maintained as fire resistive assemblies. These deficiencies could affect any patients, staff, or visitors in the cited area by allowing smoke or fire to pass between fire compartments.

Findings include:

A. During a test of the building fire alarm system conducted at 1:20 PM on April 24, 2013, fire rated door FDL15 was observed to not close to latch as required by 8.2.3.2.3.1(1).

Based on random observation during the survey walk-through and staff interview, not all exterior egress paths are illuminated in such a manner that the failure of one fixture will not leave the area in darkness as prohibited by 19.2.8. These deficiencies could affect any patients, staff, or visitors in the building because the failure of the emergency lighting could prevent them from safely exiting the building under fire conditions.

Findings include:

A. During an interview conducted, at 10:01 AM on April 24, 2013, at the exterior side of the exit door for the West Exit Stair, the provider's Director of Plant Operations stated that emergency lighting is not provided at the exterior sides of egress doors from the building. This condition exists at exterior exit doors including, but not limited to:
1. The Main Entrance.

2. The exit door for the East Exit Stair.
3. The Emergency Department Entrance.

4. The west exit door from the Emergency Department.
5. The Center Alley in which 2 Exit Stairs discharge.

6. The northwest exit door near the Freight Elevator.

7. The exit door for the West Exit Stair.

Based on document review, fire drills are not held at varying times and varying conditions in accordance with 19.7.1.2. These deficiencies could affect any patients, staff, or visitors in the building because staffmay not be properly prepared to respond to a fire emergency.

Findings include:

A. Based on document review conducted at 11:20 AM on April 24, 2013, fire drills are not conducted at varying times as required by 19.7.1.2. During the calendar years 2012 and 2013, fire drills for the following quarters/shifts were conducted at the similar times listed:

1. Second Shift:

a. February 27, 2012: 5:00 PM.

b. May 17, 2012: 4:30 PM.

c. August 28, 2012: 4:30 PM.

d. November 27, 2012: 5:00 PM.

e. February 21, 2013: 5:30 PM.

2. Third Shift:

a. March 20, 2012: 5:30 AM.

b. June 25, 2012: 5:00 AM.

c. September 25, 2012: 5:30 AM.

d. December 28, 2012: 5:30 AM.

e. March 12, 2013: 6:00 AM.

Based on random observation during the survey walk-through, not all portions of the building fire alarm system are installed in accordance with 19.3.4. These deficiencies could affect any patients, staff, or visitors in the building because the activation of the building fire alarm system could be delayed under fire emergency conditions.

Findings include:

A. Exit doors from building stories or fire compartments were observed that lack fire alarm pull manual stations within 5'-0" of the door as required by 9.6.2.3. and NFPA 72 1999 2-8.2.2. Locations observed include:

1. 2:45 PM April 23, 2012: Third Floor West Exit Stair.

2. 3:06 PM April 23, 2013: Second Floor West Exit Stair.

3. 9:38 AM April 24, 2013: First Floor Emergency Department Entrance (manual pull station was observed to be located adjacent to door to Dental Lab, out of the path of egress).


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B. The fire alarm panels were in areas that were not continuously occupied and did not have a smoke detector above the panel as required by NFPA-72, Section 1-5.6.

Based on document review and staff interview, not all portions of the facility's air conditioning and ventilating systems are installed or maintained in accordance with NFPA 90A. This deficiency could affect any patients, staff, or visitors in the building because fire or smoke dampers could fail under fire conditions.

Findings include:

A. During the document review process, it was determined that smoke and fire dampers are not tested every 4 years as required by NFPA 90A 1999 3-4.7. During an interview held in a Third Floor Conference Room at 11:25 AM on April 24, 2013, the provider's Director of Plant Operations confirmed this observation.

Based on random observation during the survey walk-through, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency in accordance with 19.2.3.3. These deficiencies could affect any patients, staff, or visitors in the areas cited because they could be prevented from reaching exits.

Findings include:

A. Carts, furnishings, and equipment were observed in exit access corridors that obstruct egress as prohibited by 19.2.3.3. and 7.1.10.2.1. Locations and items observed include:

1. 2:26 PM April 23, 2012: Fourth Floor Corridor, gurneys and equipment.

2. 3:05 PM April 23, 2013: Second Floor Corridor, linen hampers, equipment, and a scale.

Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

Based on random observation during the survey walk-through the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised.

Findings include:

A. Life Safety Panel EM1 was serving loads other than those allowed by NFPA-70, Section 517-32. Panel-EM2 was serving HW pump.

B. The transfer switches and panelboards serving by the emergency power system were not labeled with the branch of the emergency power system they served.

Based on random observation during the survey walk-through not all portions of the building systems are installed in accordance with NFPA 70 (1999).

Findings include:

A. Normal power receptacles were not provided in ICU rooms, operating rooms, and emergency treatment rooms as required by NFPA-70, Section 517-19, and NFPA-99, Section 3-3.2.1.2(a)1. In the event of a transfer switch failure upon return to normal power, these rooms could be left with no power.

B. Receptacles fed from the critical branch of emergency power were not provided at patient bed locations on the second and third floor and at the nurses stations as required by NFPA-70, Section 517-18 and 517-33.

C. The nurse call system was not served from the critical branch of emergency power in accordance with NFPA-70, Section 517-33(a)5.

D. By staff interview it could not be determined that the med gas alarms were served from the life safety branch of emergency power as required by NFPA-70, Section 517-32(c)(2).

E. Panels EM1 and EM2, and the isolation panels in the ER area were not equipped with panel scheduled as required by NFPA-70, Section 110-22 and 384-13. EM1 and EM2 are serving the life safety branch of emergency power, and without a panel directory the surveyor was unable to determine if the proper loads were served by the life safety branch panels in accordance with NFPA-70, Section 517-32.

F. The operating rooms were not equipped with battery powered emergency lights to meet the requirements of NFPA-99, Section 3-3.2.1.2(a)5.e.

G. The receptacles in the small kitchen areas near sinks were not GFCI protected in accordance with NFPA-70, Section 210-8.

Based on random observation during the survey walk through, portions of the elevator control system are not installed in accordance with ASME A17.1.

Findings include:

A. The surveyor did not find a single disconnect for each elevator's emergency lighting, receptacle, and ventilation, or proper signage identifying the source feeding these disconnects as required by NFPA-70, Section 620-53. . To prevent panic if people are in the elevator during a power outage, cab lighting, control, communications and signal systems shall be served by the life safety branch of emergency power in accordance with NFPA-99, Section 3-4.2.2.2(b)6.