HospitalInspections.org

Egress doors are capable of being locked in a manner not permitted by the Code. Failure to provide locking systems for means of egress doors in accordance with Code requirements can compromise the safety of occupants during a fire/smoke emergency by not providing the safeguards afforded by the Code for exiting from a fire/smoke condition.

Findings include:

A. On 1/5/21 while in the company of the FM it was observed that Delayed Egress locking systems had been installed at the 1st floor Emergency Dept. which were not in full compliance with 19.2.2.2.4 and 7.2.1.6.1.

1. Delayed Egress Magnetically Locked doors did not include the signage required by 7.2.1.6.1.1(4). Locations observed include:

a. Doors observed at 1:40pm at the east exterior door from the Emergency Dept. (ED).

b. Doors observed at 1:45pm at the cross-corridor egress doors between the ED and the Stair K discharge corridor. (Staff indicated the doors were normally closed and locked but repairs to the operation of the doors had the system temporarily disengaged and held open.)

c. Doors observed at 1:48pm at the north doors of the ED.

d. Doors observed at 1:56pm at the southwest ED exit path to the east.

B. On 1/5/21 at 1:55pm while in the company of the FM it was observed that magnetic locking devices were installed at the ED Ambulance entry/exit horizontal sliding doors which did not fully comply with 19.2.2.2.4 and 7.2.1.6.2 for Access Controlled Egress Doors because the magnetically locked door was only operated by the card reader and lacked release of the magnet by the installed sensor device to comply with 7.2.1.6.2(1) and manual wall button to comply with 7.2.1.6.2(3). Full compliance with 7.2.1.6.2 was not confirmed. (The magnet also prevents the break-and-swing operation of the horizontal sliding door assembly when engaged.)

C. On 1/5/21 at 2:10pm while in the company of the FM it was observed that the Main Lobby Gift Shop (although not currently occupied due to COVID) was equipped with both a deadbolt lock and a latchset which does not comply with 7.2.1.5.10.2 or 7.2.1.5.10.6 when the calculated occupancy of the space exceeds 3.

Based upon observation, two exits are not provided from every story of the facility. This deficient practice could affect staff by not providing adequate paths of egress to evacuate in the event of an emergency.

Findings include:

On 1/5/21 at 9:47am, while in the company of the DAS, it was observed on the sixth floor of the original building, which serves as a mechanical and storage occupancy, that only one exit from the story is defined. As stated by 40.2.4.1.2 and 42.2.4.1(2), a single means of egress can be permitted if the exit can be reached within the distance permitted as a common path of travel, however, the distance to the defined exit well exceeds the allowable 100 feet maximum.

Based upon observation, Corridors were found to exceed the maximum 30 ft. dead-end length allowed as stated by 19.2.5.2. This deficient practice could affect the safety of patients, staff, and visitors by delaying an occupants ability to find an exit if an occupant enters the dead end thinking an exit is available and must retrace their path to find the exit.

The finding is:

A. On 1/5/21 at 10:24am while in the company of the DAS, it was observed on the fifth floor of the original building that the Northwest corridor has a dead-end length of 56' or longer.

B. On 1/5/21 at 10:43am while in the company of the DAS, it was observed on the fourth floor of the original building that the Northwest corridor has a dead-end length of 56' or longer.

C. On 1/5/21 at 11:21am while in the company of the DAS, it was observed on the second floor of the original building that the Northwest corridor has a dead-end length of 56' or longer.

Based on observation and staff interview, illumination of the exit discharge portion of the means of egress is not provided to maintain illumination of the means of egress in the event of failure of the lighting provided. Failure to maintain illumination of the means of egress can affect all persons in the facility required to utilize the exit(s) by preventing safe and unimpeded access to the public way.

Findings include:

A. On 1/5/21 while in the company of the FM it was observed that exit discharge lighting was not confirmed to be of the instant-on type to provide illumination within the required 10 second period to comply with 19.2.8, 19.2.9 and 7.8 & 7.9.1.3. Not all Exit discharge locations are provided with multiple fixtures or lamps or the lamp type was HID without quartz restrike which does not comply with 7.8.1.4. Locations observed:

1. At 1:35pm at the 1st floor Emergency Dept. Lobby discharge.

2. At 2:00pm at the 1st floor south corridor serving exit Stairs B & J discharge.

Battery powered emergency lighting is not provided at anesthetizing locations to comply with Code requirements. Failure to provide battery powered emergency lighting at anesthetizing locations can leave the location in total darkness until generator systems provide emergency lighting. Total darkness during critical surgical procedures can compromise the safety of patients if surgeons lacked lighting during the switch from normal power to emergency power.

Findings include:

On 1/4/21 at 2:00pm during record document review and staff interview it was noted that records for battery powered emergency lighting did not include battery powered emergency lighting at the Operating Rooms to comply with NFPA 99-2012, 6.3.2.2.11. Upon inspection of the 6th floor Operating rooms on 1/5/21 at 10:00am while in the company of the MT, it was confirmed that battery powered emergency lighting was not provided.

Based upon observation, vertical openings between floor levels are not protected in accordance with Code requirements. Failure to protect vertical openings between floor levels can permit the affects of a fire/smoke condition to migrate to other floors to compromise the safety of patients, staff and visitors.

Findings include:

A. On 1/5/21 while in the company of the MT it was observed that fire rated access doors located in the Soiled rooms adjacent the shaft enclosure adjacent Stair K in the 1980 Pavilion were not closed and latched to provide full enclosure and separation of the shaft to comply with 19.3.1.1 and NFPA 80. Locations observed include:

1. The access door on the 4th floor observed at 10:35am.

2. The access door on the 3rd floor observed at 10:50am.

Based upon observation, hazardous areas are not properly separated from the remainder of the occupancy and the means of egress. Failure to properly separate storage of combustible material (which represents a degree of hazard greater than that normal to the general occupancy due to quantity and density of materials) from required means of egress paths can compromise the safety of occupants if a fire were to originate at the stored material to compromise the use of the adjacnet corridor for exiting.

Findings include:

A. On 1/5/21 it was observed that sprinklered storage rooms containing combustibles were not provided with self-closing doors to comply with 19.3.2.1.3 and 19.3.6.3.5. Locations observed include:

1. The 1980 Pavilion building 6th floor Sterile Storage room corridor door observed at 10:15am in the company of the MT was not self-closing to a latched condition due to a loose hinge which prevented the door from closing completely in the frame.

2. The 1980 Pavilion building 5th floor supply storage room adjacent the ICU Lounge containing quantities of cardboard boxes and papaer supplies was observed in the company of the FM at 10:40am to lack a closer to comply with 19.3.2.1.2 and 8.4.3.5.

3. The 1980 Pavilion 1st floor Emergency Dept. Soiled room door was observed in the company of the FM at 1:48pm not to be self-closing to a latched condition.

4. The Original Building 2nd floor mechanical room adjacent to Stair G was observed at 11:13am to have double doors that failed to self-close and self-latch.

Based on observation the facility lacks complete sprinkler protection. Failure to install and maintain this installation could result in delayed response and fire suppression. This deficient practice could affect patients, staff and visitors during a fire event.

The finding is:

A. On 1/5/21 at 11:52am, while in the company of the DAS, it was observed in Storage Room 1B141 on the Basement floor of the original building, that ceiling tile was missing in the grid system to provide a separation from the above ceiling cavity to provide effective operation of the sprinkler head to comply with NFPA 13 2010, 8.6.4.1.1.

Based on observation, an obstruction exists which limits the coverage provided by the 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.

The finding is:

B. On 1/5/21 at 9:50am, while in the company of the DAS, it was observed that the walls constructing the toilet room and mechanical closet contiguous to it on the sixth floor of the original building, do not extend to roof deck above. The space above these rooms is not provided with complete fire suppression coverage by the heads in the rooms below as required by NFPA 13, 2010, 8.1.1


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Based on observation the facility lacks complete sprinkler protection. Failure to install and maintain this installation could result in delayed response and fire suppression. This deficient practice could affect patients, staff and visitors during a fire event.

The findings is:

C. On 1/5/21 at 10:35am accompanied by the FM in the basement sterile processing department, it was observed that ceiling tile was missing above the mechanical service section of the washer/disinfector equipment allowing heat and products of combustion to bypass the installed sprinkler head. This is not in compliance with NFPA 13, 2010, 8.6.4.1.

Based upon observation and staff interview, areas open to the corridor are not provided the protective features required to permit them to be open to the corridor. Failure to provide the required protective features can result in delayed response to a fire/smoke condition that can compromise the use of the corridor as a protected path of egress.

Findings include:

On 1/5/21 at 11:15am while in the company of the FM it was observed in the 1980 Pavilion building 2nd floor, that an unoccupied nurses station was not provided with smoke detection to comply with 19.3.6.1(1). Staff indicated that the outpatient surgery dept. located on this floor is not occupied on a 24/7 basis to qualify as being under continual observation to permit a nurse station to be open to the corridor without added protective features.

Corridor doors are held open by nonapproved means. Use of nonapproved hold-open devices can result in delay or inability to close the corridor door in the event of a fire/smoke condition which could compromise the corridor as a means of egress for patient, visitor or staff movement to safety.

Findings include:

On 1/5/21 while in the company of the FM it was observed that the 1980 Pavilion building 2nd floor Endo suite east corridor door was equipped with a closer and being held open by a rubber stop not in compliance with 19.3.6.3.10. The self-closing door was not otherwise provided with a releasing system in compliance with 7.2.1.8.2.

Based on observation, staff interview, and document review the facility failed to provide documentation of maintenance of fire stop protection appliances within the ventilation duct system. Failure to install and maintain these installations could result in the passage of fire and products of combustion from one fire compartment to another. This deficient practice could affect patients, staff and visitors during a fire event.

Findings include:

On 1/4/21 at 2:00pm while in the company of the FM and DAS, the fire damper inspection completed 2/3/16 thru 3/3/16 indicated failed or deficient devices requiring repair or replacement. No subsequent documentation was available at the time of the survey to indicate corrective actions had been made to comply with NFPA 90A - 2012, 5.4.8 and NFPA 80 - 2010, 19.4.9.1.

Based upon observation, not all linen chutes are maintained in accordance with Code requirements. Failure to maintain the required enclosure of linen chutes can permit the affects of a fire/smoke condition to migrate to other floor levels and defeat the intent to compartmentalize the building for fire safety.

Findings include:

On 1/5/21 at 10:50am while in the company of the MT, it was observed in the 1980 Pavilion building that the linen chute door on the 3rd floor lacked a strike plate to secure the latching mechanism to comply with 19.3.1.1, 19.5.4 and NFPA 82-2009, 5.2.3.3.1.1.

Based upon observation, not all horizontally sliding fire door assemblies are maintained as required. This deficient practice could affect patients, staff, and visitors in the building because horizontally sliding fire door assemblies could fail to operate properly when needed if they are not properly installed and maintained.

Findings include:

On 1/5/21 at 2:00pm, while in the company of the FM, it was observed that the horizontally sliding fire door assembly in front of the non-operational elevator shaft adjacent to Stair D was not plumb or aligned to provide proper closure of the assembly, and is therefore not in compliance with NFPA 80 2010, 5.2.5.2

Based on observation and staff interview the facility lacks complete electrical bonding of the medical gas piping system. Failure to install and maintain this installation could result in the piping system to become electrically energized. This deficient practice could affect patients, staff and visitors.

The finding is:

On 1/5/21 at 10:15am accompanied by the FM at the nitrous oxide manifold room, it could not be confirmed through observation and staff interview that electrical bonding of the facility's medical gas piping system has been completed. This is not in compliance with NFPA 70 - 2011, 250.104 (B).

Based upon observation, not all portions of the electrical system are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because the electrical systems could fail to operate properly when needed if they are not properly installed

Findings include:

On 1/5/21 at 10:31am, while in the company of the DAS, it was observed that a coverplate was missing on an exposed electrical wall box in Electrical Closet T4074 on the fourth floor of the original building and is therefore not in compliance with NFPA 70-2011, 314.28(C).

Based upon observation, ground fault circuit interruption (GFCI) is not provided in accordance with code requirements. If GFCI protection is not provided, the circuit remains an electrical shock hazard to occupants. This deficient practice could affect the safety of patients, staff, and visitors.

The finding is:

A. On 1/5/21 at 10:12am while in the company of the DAS, it was observed on the fifth floor of the original building in Therapy Gym #1 and Therapy Gym #2 that receptacles are within 6'-0" of a sink fixture and are not provided with GFCI protection to comply with NFPA 70 2011, 210.8(B)(5).

B. On 1/5/21 at 1:39pm while in the company of the DAS, it was observed on the first floor of the original building in Urinalysis Lab, Coagulation Lab, Work Room, and Blood Bank that surface mounted raceways with multiple receptacles are within 6'-0" of sink fixtures and are not provided with GFCI protection to comply with NFPA 70 2011, 210.8(B)(5).

C. On 1/5/21 at 2:30pm while in the company of the DAS, it was observed on the basement floor of the original building in Biomedical that a receptacle is within 6'-0" of a sink fixture and is not provided with GFCI protection to comply with NFPA 70 2011, 210.8(B)(5).

Based upon observation and staff interview, not all patient bed locations are provided with electrical power in accordance with Code requirements. Failure to provide electrical power at patient bed locations can disrupt use of bedside equipment used by patients.

Findings include:

A. On 1/5/21 while in the company of the MT it was observed that the 1980 Pavilion 6th floor Critical Care Operating Rooms where not served by both normal power and emergency power to comply with NFPA 70-2011, 517-19(A) because no normal power receptacles were observed to be provided. It could not be determined by observation or document review that all Operating Rooms were otherwise served by two separate transfer switches in accordance with NFPA 70-2011, 517-19(A) Exception No. 2 Locations observed include the following, but may exist at all other Operating room locations not specifically named or able to be observed due to use.

1. At the 6th floor Ortho Operating room #5B at 10:00am.

2. At the 6th floor Operatiing room #6 at 10:05am.

B. On 1/5/21 while in the company of the MT it was observed that not all General Care Patient Bed locations where served by both normal power and emergency power to comply with NFPA 70-2011, 517.18(A) because no emergency power receptacles where observed and confirmed by staff to exist at all General Care patient bed locations. Locations observed include the following, but the condition may exist at all General Care Patient Bed locations not specifically observed or named.

1. The 5th floor original building Med/Surg patient rooms observed at 10:00am.

2. The 4th floor 1980 Pavilion Med/Surg patient rooms observed at 10:45am.

3. The 3rd floor 1980 Pavilion east side Med/Surg patient rooms observed at 10:55am.

4. The 2nd floor 1980 Pavilion Stage II recovery patient rooms at 11:10am.