HospitalInspections.org

Based on observations during the survey walk of the facility on the morning of 9/22/2011, with the Director of Facility Maintenance, the facility failed to assure the integrity of the corridor. Second floor patient room 25 door ' s positive latching hardware was not operational.

Based on observations during the survey walk of the facility on the morning of 9/22/2011, with the Director of Facility Maintenance, the facility failed to assure the smoke compartments during construction. The smoke compartment walls had many penetrations in them and plastic barrier impeded the egress to the second set of stairs of the third floor. The third floor contains patients. Access to exits must remain in place during construction and this includes egress lighting powered from life safety branch in the construction area to get to the stairwell. The smoke compartment must remain intact and prevent ay smoke to migrate from one compartment to another.
NFPA 101, requires ..... Buildings or portions of buildings shall be permitted to be occupied during construction, repair, alterations, or additions only where required means of egress and required fire protection features are in place and continuously maintained for the portion occupied or where alternative life safety measures acceptable to the authority having jurisdiction are in place.

Based on observations during the survey walk of the facility on the morning of 9/22/2011, with the Director of Facility Maintenance, the facility failed to assure the doors in smoke barriers had the required smoke control amenities. Both sets of the second floor ' s opposite swing cross-corridor smoke doors did not have astragals installed to provide a smoke tight seal at the meeting edges of the doors when closed.

Based on observations during the survey walk of the facility on the morning of 9/22/2011, with the Director of Facility Maintenance, the facility failed to maintain a rated barrier. First floor emergency suite ' s soiled utility door closure was not operational. Additionally, second floor's stairwell door did not latch at the door frame when closed.


Based on observations during the survey walk of the facility on the morning of 9/22/2011, with the Director of Facility Maintenance, the facility failed to maintain a rated barrier. Imaging suite ' s door, leading to the egress corridor, did not latch at the door frame when the door was in a closed position. Additionally the operating suite ' s soiled utility (janitor closet) did not close completely because the door was not in alignment with the frame.

Based on observations during the survey walk of the facility on the morning of 9/22/2011, with the Director of Facility Maintenance, the facility failed to assure that the egress door was in compliance. The exit door from the dietary department suite to the egress corridor was equipped with two latching arrangements from the egress side. Door shall be operable with not more than one releasing operation.

Based on observations during the survey walk of the facility on the morning of 9/22/2011, with the Director of Facility Maintenance, the facility failed to provide an exit sign indicating the exit access door. An exit sign did not exist which would indicate the direction of egress out of the imaging suite. A sign shall be placed in every location where the direction of travel to reach the nearest egress corridor is not apparent.


Based on observations during the survey walk of the facility on the morning of 9/22/2011, with the Director of Facility Maintenance, the facility failed to provide an exit sign marking the egress path out the building. The egress corridor near the emergency room and lab had an exit sign which pointed to a corridor which did not lead to an exit. Additionally the surgical suite had an exit sign which pointed to the women ' s dressing room.


Based on observations during the survey walk of the facility on the morning of 9/22/2011, with the Director of Facility Maintenance, the facility failed to provide an exit sign indicating a second exit. No exit sign existed at either set of second floor control doors, which would lead through the behavioral unit to reach the exit stairwell. A sign shall be placed in every location where the direction of travel to reach the nearest egress corridor is not apparent.

Based on review of records during the survey of the facility on the morning of 9/22/2011, with the Director of Facility Maintenance, the facility failed to perform proper fire drills. The fire drill logs only recorded one daytime shift participating in the fire drills. The Director of Facility Maintenance noted that the facility has two 12 hour shifts. Drills shall be conducted quarterly on each shift to familiarize the facility personnel with the signals and emergency action required under various conditions.

Based on observations during the survey walk of the facility on the morning of 9/22/2011, with the Director of Facility Maintenance, the facility failed to assure correct cross labeling of the FACP and the electrical panel that provides the power for the FACP. The FACP panel and subpanels were not always labeled as to which electrical panel and breaker supplied the power for the FACP. Also the breakers shall be labeled at the panel that supplies power to the FACP. The label shall be placed immediately adjacent to the breaker and say " Fire Alarm Control Panel " and the breaker shall be colored red.

Based on observations during the survey walk of the facility on the morning of 9/22/2011, with the Director of Facility Maintenance, the facility failed to maintain sprinkler heads. Several sprinkler heads had foreign material (dust or paint) on them and must be replaced; such as in the medical records and administration area.


Based on observations during the survey walk of the facility on the morning of 9/22/2011, with the Director of Facility Maintenance, the facility failed to provide a sprinklered smoke compartment. The entire smoke compartment was sprinklered except for the vault in the administration area and the haz-mat room in the emergency department. Both rooms appeared to be greater than 100 square feet and the vault contained combustible paper files. The vault door did not have a closure and was kept open. Both of these rooms will required either a fire sprinkler system or a fire rated door with self-closing device.

Based on observations during the survey walk of the facility on the morning of 9/22/2011, with the Director of Facility Maintenance, the facility failed to maintain continuous maintenance on the automatic sprinkler system. The existing sprinkler head storage box shall provide six spare sprinkler heads of each type and a sprinkler wrench.


Based on review of records during the survey of the facility on the morning of 9/22/2011, with the Director of Facility Maintenance, the facility failed to provide documentation that the sprinkler system had been inspected on an annual basis. Facility must initiate a log to retain these records.

Based on observations during the survey walk of the facility on the morning of 9/22/2011, with the Director of Facility Maintenance, the facility failed to maintain access to fire extinguishers. Behavior health ward ' s fire extinguishers were locked in a cabinet and none of the staff on duty had a key to the cabinet.


Based on observations during the survey walk of the facility on the morning of 9/22/2011, with the Director of Facility Maintenance, the facility failed to maintain the fire extinguisher. Operating suite ' s fire extinguisher ' s tag indicated it was last inspected during 2008. Annual inspections and maintenance must be provided in accordance with NFPA requirements.

Based on observations during the survey walk of the facility on the morning of 9/22/2011, with the Director of Facility Maintenance, the facility failed to secure many med gas cylinders located in the first floor med gas room and a cylinder in the workroom in the maintenance building.
NFPA 99 requires ..... Locations for central supply systems and the storage of medical gases shall meet the following requirements: (7) Be provided with racks, chains, or other fastenings to individually secure all cylinders, whether connected, unconnected, full, or empty, from falling.


Based on observations during the survey walk of the facility on the morning of 9/22/2011, with the Director of Facility Maintenance, the facility failed to segregate med gas cylinders. It could not be determined which cylinders were full and empty in the first floor med gas room had empty.
NFPA 99 requires ..... If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly.

Based on observations during the survey walk of the facility on the morning of 9/22/2011, with the Director of Facility Maintenance, the facility failed to provide a distinctive color at the generator's emergency system electrical receptacle. This receptacle is required to be red with the circuit and panel board numbers on the receptacle ' s plate. Per NFPA 99 ..... The cover plates for the electrical receptacles or the electrical receptacles themselves supplied from the emergency system shall have a distinctive color or marking so as to be readily identifiable. This receptacle must be powered from the electrical Type 1 EES panel board.
The existing electrical receptacle at the emergency generator was white in color at the older generator in the basement and the newer generator outside had no receptacle.


Based on observations during the survey walk of the facility on the morning of 9/22/2011, with the Director of Facility Maintenance, the facility failed to provide a remote generator annuciator for both generators.

Based on observations during the survey walk of the facility on the morning of 9/22/2011, with the Director of Facility Maintenance, the facility failed to assure that the essential electrical system was in full compliance. Computer and printer and towel warmer were supplied with power from the life safety branch of the essential electrical system for the smaller, newer generator. This equipment should be powered from the critical or equipment branch panel. The life safety branch of the emergency system shall supply power for the following lighting, receptacles and equipment: 1. Illumination of means of egress as required in NFPA 101, Life Safety Code; 2. Exit signs and exit direction signs required in NFPA 101, Life safety Code; 3. Alarm and alerting systems including the following: a. Fire Alarms, b. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, "Gas and Vacuum Systems;" 4. (Hospital or ASC) communication systems, where used for issuing instruction during emergency conditions; 5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location; 6. Elevator ... 7. Automatically opened doors used for building egress. No functions other than those listed above in items 1 through 7 shall be connected to the life safety branch


Based on observations during the survey walk of the facility on the morning of 9/22/2011, with the Director of Facility Maintenance, the facility failed to assure that the essential electrical system was in full compliance. The existing Type 1 EES was not divided into separate branches (critical branch, life safety branch and the equipment branch) per NFPA 99. Please identify if any of the new construction ties back into any one of the existing three panel boards located in the dietary electrical closet.

Based on observations during the survey walk of the facility on the morning of 9/22/2011, with the Director of Facility Maintenance, the facility failed to assure the integrity of the corridor. Second floor patient room 25 door ' s positive latching hardware was not operational.

Based on observations during the survey walk of the facility on the morning of 9/22/2011, with the Director of Facility Maintenance, the facility failed to assure the smoke compartments during construction. The smoke compartment walls had many penetrations in them and plastic barrier impeded the egress to the second set of stairs of the third floor. The third floor contains patients. Access to exits must remain in place during construction and this includes egress lighting powered from life safety branch in the construction area to get to the stairwell. The smoke compartment must remain intact and prevent ay smoke to migrate from one compartment to another.
NFPA 101, requires ..... Buildings or portions of buildings shall be permitted to be occupied during construction, repair, alterations, or additions only where required means of egress and required fire protection features are in place and continuously maintained for the portion occupied or where alternative life safety measures acceptable to the authority having jurisdiction are in place.

Based on observations during the survey walk of the facility on the morning of 9/22/2011, with the Director of Facility Maintenance, the facility failed to assure the doors in smoke barriers had the required smoke control amenities. Both sets of the second floor ' s opposite swing cross-corridor smoke doors did not have astragals installed to provide a smoke tight seal at the meeting edges of the doors when closed.

Based on observations during the survey walk of the facility on the morning of 9/22/2011, with the Director of Facility Maintenance, the facility failed to maintain a rated barrier. First floor emergency suite ' s soiled utility door closure was not operational. Additionally, second floor's stairwell door did not latch at the door frame when closed.


Based on observations during the survey walk of the facility on the morning of 9/22/2011, with the Director of Facility Maintenance, the facility failed to maintain a rated barrier. Imaging suite ' s door, leading to the egress corridor, did not latch at the door frame when the door was in a closed position. Additionally the operating suite ' s soiled utility (janitor closet) did not close completely because the door was not in alignment with the frame.

Based on observations during the survey walk of the facility on the morning of 9/22/2011, with the Director of Facility Maintenance, the facility failed to assure that the egress door was in compliance. The exit door from the dietary department suite to the egress corridor was equipped with two latching arrangements from the egress side. Door shall be operable with not more than one releasing operation.

Based on observations during the survey walk of the facility on the morning of 9/22/2011, with the Director of Facility Maintenance, the facility failed to provide an exit sign indicating the exit access door. An exit sign did not exist which would indicate the direction of egress out of the imaging suite. A sign shall be placed in every location where the direction of travel to reach the nearest egress corridor is not apparent.


Based on observations during the survey walk of the facility on the morning of 9/22/2011, with the Director of Facility Maintenance, the facility failed to provide an exit sign marking the egress path out the building. The egress corridor near the emergency room and lab had an exit sign which pointed to a corridor which did not lead to an exit. Additionally the surgical suite had an exit sign which pointed to the women ' s dressing room.


Based on observations during the survey walk of the facility on the morning of 9/22/2011, with the Director of Facility Maintenance, the facility failed to provide an exit sign indicating a second exit. No exit sign existed at either set of second floor control doors, which would lead through the behavioral unit to reach the exit stairwell. A sign shall be placed in every location where the direction of travel to reach the nearest egress corridor is not apparent.

Based on review of records during the survey of the facility on the morning of 9/22/2011, with the Director of Facility Maintenance, the facility failed to perform proper fire drills. The fire drill logs only recorded one daytime shift participating in the fire drills. The Director of Facility Maintenance noted that the facility has two 12 hour shifts. Drills shall be conducted quarterly on each shift to familiarize the facility personnel with the signals and emergency action required under various conditions.

Based on observations during the survey walk of the facility on the morning of 9/22/2011, with the Director of Facility Maintenance, the facility failed to assure correct cross labeling of the FACP and the electrical panel that provides the power for the FACP. The FACP panel and subpanels were not always labeled as to which electrical panel and breaker supplied the power for the FACP. Also the breakers shall be labeled at the panel that supplies power to the FACP. The label shall be placed immediately adjacent to the breaker and say " Fire Alarm Control Panel " and the breaker shall be colored red.

Based on observations during the survey walk of the facility on the morning of 9/22/2011, with the Director of Facility Maintenance, the facility failed to maintain sprinkler heads. Several sprinkler heads had foreign material (dust or paint) on them and must be replaced; such as in the medical records and administration area.


Based on observations during the survey walk of the facility on the morning of 9/22/2011, with the Director of Facility Maintenance, the facility failed to provide a sprinklered smoke compartment. The entire smoke compartment was sprinklered except for the vault in the administration area and the haz-mat room in the emergency department. Both rooms appeared to be greater than 100 square feet and the vault contained combustible paper files. The vault door did not have a closure and was kept open. Both of these rooms will required either a fire sprinkler system or a fire rated door with self-closing device.

Based on observations during the survey walk of the facility on the morning of 9/22/2011, with the Director of Facility Maintenance, the facility failed to maintain continuous maintenance on the automatic sprinkler system. The existing sprinkler head storage box shall provide six spare sprinkler heads of each type and a sprinkler wrench.


Based on review of records during the survey of the facility on the morning of 9/22/2011, with the Director of Facility Maintenance, the facility failed to provide documentation that the sprinkler system had been inspected on an annual basis. Facility must initiate a log to retain these records.

Based on observations during the survey walk of the facility on the morning of 9/22/2011, with the Director of Facility Maintenance, the facility failed to maintain access to fire extinguishers. Behavior health ward ' s fire extinguishers were locked in a cabinet and none of the staff on duty had a key to the cabinet.


Based on observations during the survey walk of the facility on the morning of 9/22/2011, with the Director of Facility Maintenance, the facility failed to maintain the fire extinguisher. Operating suite ' s fire extinguisher ' s tag indicated it was last inspected during 2008. Annual inspections and maintenance must be provided in accordance with NFPA requirements.

Based on observations during the survey walk of the facility on the morning of 9/22/2011, with the Director of Facility Maintenance, the facility failed to secure many med gas cylinders located in the first floor med gas room and a cylinder in the workroom in the maintenance building.
NFPA 99 requires ..... Locations for central supply systems and the storage of medical gases shall meet the following requirements: (7) Be provided with racks, chains, or other fastenings to individually secure all cylinders, whether connected, unconnected, full, or empty, from falling.


Based on observations during the survey walk of the facility on the morning of 9/22/2011, with the Director of Facility Maintenance, the facility failed to segregate med gas cylinders. It could not be determined which cylinders were full and empty in the first floor med gas room had empty.
NFPA 99 requires ..... If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly.

Based on observations during the survey walk of the facility on the morning of 9/22/2011, with the Director of Facility Maintenance, the facility failed to provide a distinctive color at the generator's emergency system electrical receptacle. This receptacle is required to be red with the circuit and panel board numbers on the receptacle ' s plate. Per NFPA 99 ..... The cover plates for the electrical receptacles or the electrical receptacles themselves supplied from the emergency system shall have a distinctive color or marking so as to be readily identifiable. This receptacle must be powered from the electrical Type 1 EES panel board.
The existing electrical receptacle at the emergency generator was white in color at the older generator in the basement and the newer generator outside had no receptacle.


Based on observations during the survey walk of the facility on the morning of 9/22/2011, with the Director of Facility Maintenance, the facility failed to provide a remote generator annuciator for both generators.

Based on observations during the survey walk of the facility on the morning of 9/22/2011, with the Director of Facility Maintenance, the facility failed to assure that the essential electrical system was in full compliance. Computer and printer and towel warmer were supplied with power from the life safety branch of the essential electrical system for the smaller, newer generator. This equipment should be powered from the critical or equipment branch panel. The life safety branch of the emergency system shall supply power for the following lighting, receptacles and equipment: 1. Illumination of means of egress as required in NFPA 101, Life Safety Code; 2. Exit signs and exit direction signs required in NFPA 101, Life safety Code; 3. Alarm and alerting systems including the following: a. Fire Alarms, b. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, "Gas and Vacuum Systems;" 4. (Hospital or ASC) communication systems, where used for issuing instruction during emergency conditions; 5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location; 6. Elevator ... 7. Automatically opened doors used for building egress. No functions other than those listed above in items 1 through 7 shall be connected to the life safety branch


Based on observations during the survey walk of the facility on the morning of 9/22/2011, with the Director of Facility Maintenance, the facility failed to assure that the essential electrical system was in full compliance. The existing Type 1 EES was not divided into separate branches (critical branch, life safety branch and the equipment branch) per NFPA 99. Please identify if any of the new construction ties back into any one of the existing three panel boards located in the dietary electrical closet.