HospitalInspections.org

Based on observations the facility failed to provide the required 1 hour fire protection rating for structural steel.

Findings Include:

While inspecting the 5th floor center core unit in the 1951 addition on May 5, 2010 at 11:00 A.M. The surveyor observed 6 unrated access panels in the 1 hour fire rated ceiling assembly located in the exit access corridor.

This deficient practice has the potential of affecting the 10 patient rooms in the 5th floor center core unit. The administrator and the maintenance director were notified during the survey and in the exit conference.

Based on observations the facility failed to provide the required 2 hour fire rating for vertical shafts in a building 5 stories in height.

While inspecting vertical shafts on May 11, 2010 at 10: 45 am., the surveyor observed the following vertical shafts with penetrations throughout.
1. 2nd floor 2 east dumbwaiter system.
2. Service elevator shaft #11.
3. Elevator shafts 9 and 10.
4. Elevator shaft #6.
5. Elevator shafts 3 and 4.
6. Elevator shafts 12 and 13.

This deficient practice has the potential of affecting the entire facility. The administrator and the maintenance director were notified during the survey and in the exit conference.

Based on observations the facility failed to provide the required 1 hour fire protection rating for hazardous areas in non-sprinkled portions of the facility.

While inspecting hazardous areas on May 11-13, 2009, the surveyor observed the following hazardous areas without 1 hour fire rated walls.
1. On May 11, 2010 at 12:15 p.m., the surveyor observed the 5th floor 5 east sub acute soiled/bio-hazard room without the required 1 hour fire rating.
2. On May 12, 2010 at 2:50 p.m., the surveyor observed the 3rd floor 3 east post-partum unit bio-hazard/soiled room without the required 1 hour fire rating.
3. On May 12, 2010 at 3:45 p.m., the surveyor observed the 2nd floor ICU unit bio-hazard/soiled room without the required 1 hour fire rating.
4. On May 12, 2010 at 4:30 p.m., the surveyor observed the 2nd floor east unit bio-hazard/soiled room without the required 1 hour fire rating.

This deficient practice has the potential of affecting 4 of 12 nursing units. The administrator and the maintenance director were notified during the survey and in the exit conference.

Based on observations the facility failed to provide approved audio and visual notification devices for the fire alarm system in accordance with NFPA 72.

While inspecting the fire alarm system on May 13, 2010 at 10:30 a.m., the surveyor observed the following exit access corridors without audio or visual fire alarm notification devices.
1. 4th floor center core wing
2. Revenue management unit
3. 3rd floor inner core unit
4. 3rd floor elevator lobby
5. 3rd floor labor and delivery unit
6. Endoscopy unit
7. Cardiology unit
8. LTACH unit
9. 2nd floor center core unit
10. 2nd floor surgery unit
11. 2nd floor 2 east unit
12. 2nd floor ICU unit
13. Wound care unit
14. I.S. Unit
15. Central sterile unit
16. Kitchen corridor
17. Cafeteria corridor
18. Cafeteria
19. E.R. unit
20. Radiology unit
21. Admissions unit
22. Dialysis unit
This deficient practice has the potential of affecting the entire facility. The administrator and the maintenance director were notified during the survey and in the exit conference.

Based on observations the facility failed to provide the required 1 hour fire protection rating for structural steel.

Findings Include:

While inspecting the 5th floor center core unit in the 1951 addition on May 5, 2010 at 11:00 A.M. The surveyor observed 6 unrated access panels in the 1 hour fire rated ceiling assembly located in the exit access corridor.

This deficient practice has the potential of affecting the 10 patient rooms in the 5th floor center core unit. The administrator and the maintenance director were notified during the survey and in the exit conference.

Based on observations the facility failed to provide the required 2 hour fire rating for vertical shafts in a building 5 stories in height.

While inspecting vertical shafts on May 11, 2010 at 10: 45 am., the surveyor observed the following vertical shafts with penetrations throughout.
1. 2nd floor 2 east dumbwaiter system.
2. Service elevator shaft #11.
3. Elevator shafts 9 and 10.
4. Elevator shaft #6.
5. Elevator shafts 3 and 4.
6. Elevator shafts 12 and 13.

This deficient practice has the potential of affecting the entire facility. The administrator and the maintenance director were notified during the survey and in the exit conference.

Based on observations the facility failed to provide the required 1 hour fire protection rating for hazardous areas in non-sprinkled portions of the facility.

While inspecting hazardous areas on May 11-13, 2009, the surveyor observed the following hazardous areas without 1 hour fire rated walls.
1. On May 11, 2010 at 12:15 p.m., the surveyor observed the 5th floor 5 east sub acute soiled/bio-hazard room without the required 1 hour fire rating.
2. On May 12, 2010 at 2:50 p.m., the surveyor observed the 3rd floor 3 east post-partum unit bio-hazard/soiled room without the required 1 hour fire rating.
3. On May 12, 2010 at 3:45 p.m., the surveyor observed the 2nd floor ICU unit bio-hazard/soiled room without the required 1 hour fire rating.
4. On May 12, 2010 at 4:30 p.m., the surveyor observed the 2nd floor east unit bio-hazard/soiled room without the required 1 hour fire rating.

This deficient practice has the potential of affecting 4 of 12 nursing units. The administrator and the maintenance director were notified during the survey and in the exit conference.

Based on observations the facility failed to provide approved audio and visual notification devices for the fire alarm system in accordance with NFPA 72.

While inspecting the fire alarm system on May 13, 2010 at 10:30 a.m., the surveyor observed the following exit access corridors without audio or visual fire alarm notification devices.
1. 4th floor center core wing
2. Revenue management unit
3. 3rd floor inner core unit
4. 3rd floor elevator lobby
5. 3rd floor labor and delivery unit
6. Endoscopy unit
7. Cardiology unit
8. LTACH unit
9. 2nd floor center core unit
10. 2nd floor surgery unit
11. 2nd floor 2 east unit
12. 2nd floor ICU unit
13. Wound care unit
14. I.S. Unit
15. Central sterile unit
16. Kitchen corridor
17. Cafeteria corridor
18. Cafeteria
19. E.R. unit
20. Radiology unit
21. Admissions unit
22. Dialysis unit
This deficient practice has the potential of affecting the entire facility. The administrator and the maintenance director were notified during the survey and in the exit conference.