HospitalInspections.org

Based upon observation, Non-Healthcare occupancy separations are not maintained as 2-hour rated assemblies. Failure to maintain required 2-hour separations can compromise the safety of Healthcare occupants if a fire/smoke condition were to develop in the adjacent occupancy and not be contained by the required barrier.

Findings include:

A. On March 13, 2019 at 8:50am while in the company of the DFM & MM it was observed that the 4th floor 2-hour barrier doors between the Healthcare occupancy building and the Business Occupancy building did not close to a latched condition to comply with 19.1.1.4 and NFPA 80-2010.

B. On March 13, 2019 at 9:40am while in the company of the DFM & MM it was observed that the 3rd floor 2-hour barrier doors between the Healthcare occupancy building and the Business Occupancy building did not close to a latched condition to comply with 19.1.1.4 and NFPA 80-2010.

C. On March 13, 2019 at 10:50am while in the company of the DFM & MM it was observed that the 2nd floor 2-hour barrier doors between the Healthcare occupancy building and the Business Occupancy building did not close to a latched condition to comply with 19.1.1.4 and NFPA 80-2010.

Based upon observation, the building construction type is not maintained in accordance with Code requirements. Failure to maintain the required protection of structural members can lead to premature failure and building collapse during a fire emergency and affect all occupants.

Findings include:

On March 13, 2019 at 2:50pm while in the company of the DFM & MM it was observed that fireproofing was missing on a structural beam at the Boiler room. Thus not meeting the requirements of 19.1.6.1.

Based upon observation, doors are not maintained to provide means of egress in accordance with Code requirements. Failure to provide means of egress can compromise occupant safety if they are unable to exit an area during an emergency condition.

Findings include:

A. On March 13, 2019 at 10:05am while in the company of the DFM & MM it was observed at the 3rd floor LDR unit that neither of the doors in the smoke barrier wall (one providing exit access to the NE stair through the C-section area and the other providing egress for the corridor at the doors to the west near the Soiled Utility room) are not marked as a required exit access and are provided with locking hardware controlled by an infant abduction system. It was not determined whether the locking system was installed in accordance with any of the provisions of 19.2.2.2.4 because Delayed Egress (7.2.1.6.1), Access Controlled Egress (7.2.1.6.2) or the full compliance with 19.2.2.2.5.2 could not be determined.

B. On March 13, 2019 at 10:30am while in the company of the DFM & MM it was observed at the 3rd floor C-section area that the door providing required exit access to the LDR area was not marked as a required exit access and is provided with locking hardware controlled by an infant abduction system. It was not determined whether the locking system was installed in accordance with any of the provisions of 19.2.2.2.4 because Delayed Egress (7.2.1.6.1), Access Controlled Egress (7.2.1.6.2) or the full compliance with 19.2.2.2.5.2 could not be determined.

C. On March 13, 2019 at 10:55am while in the company of the DFM & MM it was observed at the 2nd floor of the Business occupancy buildings that magnetic locking devices were installed on egress doors which did not have Delayed Egress function in accordance with 39.2.2.2.5 and 7.2.1.6.1. The locks were not functional at the time of the survey, but could not be confirmed to be permanently disabled to prevent their use to restrict egress.

D. On March 13, 2019 at 3:05pm while in the company of the DFM & MM it was observed that the corridors outside the Lower level Central Sterile Processing Dept. were being used for the storage/staging of supplies in non-compliance with 19.2.1 & 7.1.10.1.

Based upon observation, Exit stairs are not maintained in accordance with Code requirements. Failure to maintain Exit stairs can compromise the ability for occupants to use the stairs during a fire event or emergency evacuation.

Findings include:

On March 14, 2019 at 9:05am while in the company of the DFM, MM & OSA it was observed that the exit stair serving the 2nd floor tenant space was used for storage of equipment and materials in non-compliance with 7.1.3.2.3.

Based upon observation, Exits are not maintained to provide a protected path for egress from the building in the event of a fire/smoke emergency. Failure to maintain exits can compromise the safety of any occupants required to exit the building during a fire/smoke condition.

Findings include:

A. On March 13, 2019 at 1:10pm while in the company of the DFM & MM it was observed that the Exit Passageway provided for the 1956 building Exit Stair at the 1st floor is not maintained clear of stored materials including ladders and the enclosure is not separated from adjacent spaces in compliance with 7.1.3.2.1(9)(c) because an access panel is not fire rated, rated doors to rooms are not self-closing and the fuel-fired generator is accessed directly from the Exit Passageway.

B. On March 13, 2019 at 1:15pm while in the company of the DFM & MM it was observed that the 1912/1938/1956/1965 building area upper floors are served by four exits. One exit access is provided to the 1977 building and three others are stairs which discharge at the 1st floor level. Two stairs have been indicated to have Exit Passageways to the exterior to attempt to comply with 7.7.2. These two stairs do not comply with 7.7.2 because one is the Exit Passageway noted as deficient in "A." above and the other is an Exit Passageway which has an elevator opening into it in non-compliance with 9.4.7. The Exits serving the upper stories do not comply with 7.7.2.

Based on observation, the designated 2-hour barriers are not maintained to afford the assigned 2-hour rated construction. Failure to maintain the assigned rated construction can compromise the safety of occupants during a fire/smoke condition.

Findings include:

A. On March 13, 2019 at 9:05am while in the company of the DFM & MM it was observed that the 4th floor designated 2-hour barrier wall between the 1912 building and the 1965 building was not complete above the ceiling and the old Operating Room corridor door was not self-closing or labeled as minimum 1 1/2-hour rated to comply with 8.3.1 thru 8.3.4. The old OR was also used for miscellaneous storage which also require the door to be self-closing to comply with 39.3.2.1, 7.1.10 and 7.5.1.6.

B. On March 13, 2019 at 9:35am while in the company of the DFM & MM it was observed that the 3rd floor designated 2-hour barrier wall between the 1912 building and the 1965 building near the time clock contained unsealed penetrations above the ceiling not in compliance with 8.3.5.

Based on observation, illumination of the means of egress is not provided in accordance with the Code. Failure to provide illumination of the means of egress can compromise the safety of occupants during exiting of the building.

Findings include:

On March 14, 2019 while in the company of the DFM & MM it was observed that exit discharge lighting at the entry vestibule of the building consisted of a single lamp fixture which cannot provide lighting in accordance with 39.2.8 and 7.8.1.4 if it were to fail.

Based upon observation, illumination of means of egress lighting is not provided in accordance with Code requirements. Failure to provide lighting can compromise the safety of building occupants while exiting the building.

Findings include:

On March 13, 2019 2:00pm while in the company of the DFM & MM it was observed that lighting was not provided at the exit discharge path along the exterior of the MRI building which provides access to the public way to comply with 19.2.8 & 7.8.

Based upon observation and record document review, testing of the battery powered emergency lighting systems was not completed and accurately documented. Failure to properly record maintenance activities can result in failure of the lighting systems due to lack of periodic inspection and maintenance affecting all occupants during an emergency event.

Findings include:

On March 12, 2019 at 1:00pm while in the company of the DFM & MM, it was indicated that record documents for the testing & maintenance of battery powered emergency lighting systems used at anesthetizing locations (Operating rooms) was not available to indicate the lighting was capable of providing lighting for 1 1/2-hours, and being tested monthly for 30 seconds and annually for 30 minutes to comply with NFPA 99-2012, 6.3.2.2.11.

Based upon observation, EXIT signs are not placed appropriately to identify available exit paths. Failure to correctly identify exit paths can result in occupants not being able to identify and reach available exit paths during a fire/smoke emergency.

Findings include:

On March 14, 2019 at 8:50am while in the company of DFM, MM & OSA it was observed that EXIT signage in accordance with 7.10.6 or 7.10.7 is not provided in the hall containing the ramp to identify two means of egress to comply with 39.2.4.1, 39.2.10 and 7.10.

Based upon observation, exit signs are not placed appropriately to identify available exit paths. Failure to correctly identify exit paths can result in occupants not being able to identify and reach available exit paths during a fire/smoke emergency.

Findings include:

A. On March 13, 2019 while in the company of DFM & MM it was observed that EXIT signage is not provided, obscured from view, or incorrectly identifies the means of egress in non-compliance with 19.2.10.1, 39.2.10 and 7.10.

Locations include:

1. At 9:15am it was observed that the 1938 building 3rd floor lacks exit signage at the newer cross corridor door to identify the 2nd means of egress (for the 1956 building area) to comply with 39.2.4.1, 39.2.10 and 7.10.

2. At 9:45am at the 3rd floor of the 1977 building near room 350 an inappropriate directional exit sign was observed which could misdirect exiting in non-compliance with 19.2.10.1 and 7.10.

3. At 9:50am at the 3rd floor 1977 building smoke barrier door near Stair #1, it was observed that exit signage was not provided to comply with 19.2.10.1 and 7.10.

4. At 10:30am at the 3rd floor C-section semi-restricted area, which is not a defined suite, only one means of egress (to the Stair) is defined. A second exit from the area to the LDR area is not defined to comply with 19.2.4.3, 19.2.10.1 and 7.10. See also K211.

5. At 10:40am at the 3rd floor Corridor near Stair #1, a second exit access was not identified to comply with 19.2.4.3, 19.2.10.1 and 7.10.

6. At 1:45pm at the 1965 addition main entry lobby, a second exit access was not identified to comply with 39.2.4.1, 39.2.10 and 7.10.

7. At 2:30pm at the 1st floor Emergency Dept. an exit sign is not visible to identify the west exit door when viewed from the east side of the nurse station to identify a second exit access to comply with 19.2.4.3, 19.2.10.1 and 7.10.

Based upon observation, areas deemed to be hazardous areas due to storage of combustibles to a degree greater than normal to the remainder of the occupancy are not separated from the remainder of the occupancy. Failure to separate and/or contain such areas can compromise the safety of occupants if a fire were to develop and not be separated from the means of egress.

Findings include:

A. On March 14, 2019 while in the company of the DFM, MM, & OSA, it was observed that sprinklered storage rooms did not have self-closing doors to comply with 39.3.2.1, 8.7.1, & 8.4.3. Locations observed include:

1. At 8:50am the Occupational Therapy storage room doors.

2. At 8:55am the door at the 2nd floor Utility room containing soiled laundry and waste containers exceeding 64 gal. capacity.

Based upon observation, hazardous areas are not separated from the remainder of the occupancy and the means of egress. Failure to properly separate hazardous areas from required means of egress paths can compromise the safety of occupants during a fire emergency.

Findings include:

A. On March 13, 2019 while in the company of the DFM & MM sprinklered rooms or spaces used for storage were observed that are not separated by construction capable of resisting the passage of smoke including self-closing door assemblies to comply with 19.3.2.1, 39.3.2.1, 8.7.1, & 8.4.3.

Locations observed include:

1. At 8:55am, both corridor doors at the 1965 building 4th floor Auxiliary room (Gift Shop) storage room were not self-closing and positive latching to comply with 39.3.2.1.

2. At 9:00am, the corridors of the 1912 building 4th floor are utilized for the storage of equipment and supplies in non-compliance with 39.3.2.1, 7.1.10 and 7.5.1.6.

3. At 9:00am, the 1912 building 4th floor Print Room corridor door was not self-closing to comply with 39.3.2.1, 8.7.1, & 8.4.3.

4. At 11:20am, the 1977 building 2nd floor old ICU Soiled Utility room (now used for storage) corridor door is not positive latching to comply with 19.3.2.1 and 19.3.6.3.5.

5. At 3:30pm, the Lower level Bio-med shop two corridor doors were not self-closing to comply with 19.3.2.1, 8.7.1 & 8.4.3.

6. At 3:50pm, the Lower level Miscellaneous user Storage room (west of Pharmacy) lacked a self-closing door (either at the corridor or the inner door) to comply with 19.3.2.1, 8.7.1 & 8.4.3.

Based upon observation, fire alarm systems are not installed in accordance with Code requirements. Failure to install the fire alarm system in accordance with Code requirements can result in disruption of the system to not function as required affecting all occupants during emergency situations.

Findings include:

On March 13, 2019 at 3:35pm while in the company of the DFM & MM it was observed at the Lower Level room containing the BLS electrical panel with the circuits that provide power to the fire alarm system was not provided with red markings and mechanical lock-on devices to comply with NFPA 72-2010, 10.5.5.2.3 and 10.5.5.3.

Based upon observation, fire alarm systems are not installed in accordance with Code requirements. Failure to install the fire alarm system in accordance with Code requirements can result in disruption of the system to not function as required.

Findings include:

A. On March 14, 2019 at 8:15am while in the company of the DFM & MM it was observed that the electrical panel containing the circuit providing power to the fire alarm system was not provided with red markings and mechanical lock-on devices to comply with NFPA 72-2010, 10.5.5.2.3 and 10.5.5.3.

B. On March 14, 2019 at 8:15am while in the company of the DFM & MM it was observed that the Fire Alarm Control Panel (FACP) was not labeled to identify the electrical panel and circuit from which it was fed to comply with NFPA 72-2010, 10.5.5.2.1.

Based upon observation, fire alarm systems are not installed in accordance with Code requirements. Failure to install the fire alarm system in accordance with Code requirements can result in disruption of the system to not function as required.

Findings include:

On March 14, 2019 at 9:10am while in the company of the DFM & MM it was observed that the electrical panel containing the circuit providing power to the fire alarm system was not provided with red markings and mechanical lock-on devices to comply with NFPA 72-2010, 10.5.5.2.3 and 10.5.5.3.

Based on observation, the facility failed to install a complete building fire suppression system. This deficient practice could result in the delayed response and suppression during a fire event, which may affect patients, staff and visitors.

Findings include:

A. On March 13, 2019 at 8:30am while in the company of the DFM & MM, it was observed at the 4th floor Mechanical room of the 2011 addition that closely spaced ducts with a combined width greater than 4'-0" and observed to have combustible storage beneath were not provided with sprinkler coverage under the duct to comply with NFPA 13-2010, 8.6.5.3.3.

B. On March 13, 2019 at 8:50am while in the company of the DFM & MM, it was observed that the 4th floor Women's Toilet room in the 1965 addition was not provided with sprinkler protection to comply with NFPA 13-2010, 4.1.

C. On March 13, 2019 at 3:40pm while in the company of the DFM & MM it was observed that the Telephone terminal board room at the Lower level storage room in the old PT area did not have a ceiling to provide containment of the space to provide effective activation of the sprinkler system provided to comply with NFPA 13-2010, 4.1 & 3..3.6.

D. On March 13, 2019 at 3:45pm while in the company of the DFM & MM it was observed that the Electrical Equipment room at the north side of the Lower level Pharmacy did not have a ceiling or full height wall to separate this space from the above ceiling area of the adjacent Pharmacy area to provide containment of the space to provide effective activation of the sprinkler system to comply with NFPA 13-2010, 4.1 & 3.3.6. This space was also not provided with adequate sprinkler heads to reach all areas of the 'L' shaped room to comply with 8.6.5. This room was also noted on the Life Safety Reference plans to be separated by 2-hour construction but the wall constructed was not full height and contained numerous transfer air louvers.

Based upon observation and staff interview, the building is identified as being fully sprinkler protected. Failure to provide sprinkler protection for all areas of the building in accordance with Code requirements can compromise the safety of occupants during a fire event.

Findings include:

On March 14, 2019 at 8:30am while in the company of the DFM & MM it was observed that the entry vestibule of the facility was not provided with sprinkler protection to comply with NFPA 13-2010, 4.1.

Portable fire extinguishers are not being maintained in accordance with Code requirements. Failure to inspect portable extinguishers can result failure to control a fire event in its initial stages and cause occupant injury if they were to fail to operate as intended during such a fire event.

Findings include:

On March 14, 2019 at 8:45am while in the company of the DFM & MM it was observed that the portable fire extinguisher inspection tags had not documented the monthly visual inspections required by NFPA 10-2010, 7.2.1.2.

Based upon observation, corridor doors are not positive latching. Failure to provide postive latching for corridor doors can permit fire/smoke conditions to enter the corridor from areas required to be separated from the corridor and compromise the use of the corridors as a means of egress for any occupants.

Findings include:

A. On March 13, 2019 at 11:15am while in the company of the DFM & MM it was observed that the 1977 addition 2nd floor old ICU suite (now used as Joint Replacement Education suite) corridor door was not positive latching to comply with 19.3.6.3.5.

B. On March 13, 2019 at 3:25pm while in the company of the DFM & MM it was observed that the Lower level Pain Clinic suite corridor doors are provided with dogged panic hardware to permit operation of the power door opening hardware. The doors are not positive latching to comply with 19.3.6.3.5 upon activation of the fire alarm when the power opening hardware ceases to function.

C. On March 13, 2019 at 2:15pm while in the company of the DFM & MM it was observed that the cross corridor double egress doors between the Radiology suite and the Emergency Department suite which is also the designated smoke barrier are not resistant to the passage of smoke to comply with 19.2.5.7.1.2 and 8.5.4.1 due to the 1/4"+/- gap between the doors.

Based upon observation, hydraulic Elevator Machine rooms are not maintained as separated enclosures in accordance with Code requirements. Failure to maintain enclosure/separation of the Machine room can compromise the safety of occupants if a fire/smoke condition would develop with the elevator equipment.

Findings include:

On March 14, 2019 at 9:00am while in the company of the DFM, MM & OSA it was observed that the Elevator Machine room serving the tenant area was not enclosed/separated to comply with ASME 17.1-2007, 3.7.1 and 2.7.1. Penetrations between the Machine room and the hoistway were not sealed and the door was not self-closing.

Based upon record review and staff interview, fire drills are not conducted at varying times. Failure to conduct fire drills at varying times does not train staff to respond to a fire condition under varying circumstances.

Findings include:

A. On March 2, 2019 at 1:30pm while in the company of DFM & MM it was observed that fire drills for the 3rd shift personnel (12am to 7am) have consistently been conducted within the same 1-hour period between 5:00am & 5:50am which is approximately during the later part of the shift which does not comply with 19.7.1.6 for varied times & conditions. No drills were conducted at the beginning and middle portions of the shift as evidenced by the following drills recorded:

3/12/19 at 5:12am
2/22/19 at 5:35am
1/11/19 at 5:35am
12/19/18 at 5:00am
11/21/18 at 5:30am
10/28/18 at 5:30am
10/4/18 at 5:50am
8/9/18 at 5:38am
6/29/18 at 5:30am
5/29/18 at 5:20am
3/23/18 at 5:30am

B. On March 12, 2019 at 1:30pm while in the company of DFM & MM it was observed that fire drills for the 1st shift personnel (7am to 4pm) have consistently been conducted within the same 1-hour period between 10:00am & 11:00am which is approximately during the later beginning and mid-shift period which does not comply with 19.7.1.6 for varied times & conditions. No drills were conducted at the beginning and later portions of the shift as evidenced by the following drills recorded:

2/21/19 at 10:55am
10/4/18 at 10:30am
8/8/18 at 10:30am
7/31/18 at 11:00am
5/27/18 at 10:30am
4/6/18 at 10:45am
2/7/18 at 10:00am
1/3/18 at 10:10am

Based upon observation, documentation of fire door inspections was not available for review. Failure to conduct and document annual fire door inspections and maintenance can compromise the safety of any building occupants if the door assemblies are not maintained as intended to restrict the spread of fire & smoke during a fire emergency.

Findings include:

On March 12, 2019 at 1:45am while in the company of DFM & MM, documentation of a fire door inspection program to comply with 19.7.6, 8.3.3.1 and 7.2.1.15 was not available.

Based on observation, not all portions of the building's medical gas system are installed as required. This deficient practice could affect any patients, staff, and visitors in the building if emergency conditions warranted shut-off of portions of the medical gas system and proper identification of the valves controlling affected areas could not be readily identified.

Findings include:

A. On March 13, 2019 at 10:00am while in the company of the DFM & MM it was observed that the medical gas shutoff valves near the Nursery labeled as serving rooms 344 & 344B were not identified by room signage. The DFM & MM indicated that medical gas valves may be utilizing construction drawing room identification numbers and not the room numbering system posted and this condition may be typical throughout the hospital. The valve labeling does not match the room labeling to comply with 19.3.2.4 and NFPA 99-2012, 5.1.11.2.1(2).

B. On March 13, 2019 at 11:20am while in the company of the DFM & MM it was observed that the medical gas shut-off valves and inlet/outlets serving the 1977 addition old ICU suite rooms had the valve handles removed. The DFM & MM indicated the system has been abandoned but labeling was not provided to indicate the system to be abandoned to comply with NFPA 99-2012, 5.1.11.2.1.

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.

Findings include:

A. On March 13, 2019 at 11:30am while in the company of the DFM & MM it was observed that Operating Rooms #5, #6, & #7 lacked electrical receptacles served by normal power system as required by NFPA 70-2011, 517-19(A). It could not otherwise be determined that the red receptacles in the room were served by two separate transfer switches in accordance with Exception No. 2.

B. On March 13, 2019 at 2:15pm while in the company of the DFM & MM it was observed that the Emergency Dept. critical care bed stations #1 & #2 lacked electrical receptacles served by normal power system as required by NFPA 70-2011, 517-19(A). It could not otherwise be determined that the red receptacles in the room were served by two separate transfer switches in accordance with Exception No. 2.