HospitalInspections.org

Bldg A-1 - Memorial Hospital Central - Central Tower

Through observation during the survey July 27 through August 19, 2010 it was determined that the facility failed to maintain the fire resistance rating of the corridor walls.

During the walk through of the facility with the Maintenance Director, the corridor wall, outside of room #1418C, contained a two inch (2") hole in the corridor wall to an adjacent room. The hole was utilized for electrical conduit during remodel of the area. 2000 Edition NFPA 101 Section 19.3.6.2.1

Note: This item was corrected during the survey.

Bldg A-1 - Memorial Hospital Central - Central Tower

Through observation during the survey July 27 through August 19, 2010 it was determined the facility failed to maintain the doors to the corridor.

During the walk through of the facility with the Maintenance Director:

1) Seven (7) patient room doors contained excessive gaps in excess of 1/2 inch between the door and the frame or the door and the stop and would not resist the passage of smoke per section 19.3.6.1.
a. #7532
b. #7512
c. #6646
d. #6620
e. #5640
f. #5649
g. #4526

2) Corridor doors would not positively latch into the frame when closed. 19.3.6.3.2
a) Nine (9) corridor doors would not latch into the frame when closed.
1. Room #7524 - door would not latch into the frame
2. Room #7504 - door would not latch into the frame
3. Room #7530 - door was tight on frame and would not latch
4. Room #7508 - door was tight in the frame and would not latch
5. Room #6540 - door would not latch into the frame
6. One (1) door on the Therapy room, located on the seventh (7th) floor, would not latch into the frame
7. Room #5642 - would not latch into the frame
8. Room #5526 - door would not shut into the frame
9. Room #4530 - door would not latch into the frame
b) Three (3) 70/30 double doors were not considered to be positive latching (due to a thumb bolt lock) on the "30 side", when in the closed position. The following doors contained slide locks on the "30 side" of the door for locking:
1. Room #465, which is located off of the corridor, contains a 70/30 door. The 30 portion of the door contains a thumb lock and does not positively latch into the frame.
2. Room #4654, which is located off of the corridor, contains a 70/30 door. The 30 portion of the door contains a thumb lock and does not positively latch into the frame.
3. Room #2621 A and B contained a double door that opened into the corridor. One (1) side of the double door contained a thumb lock and would not positively lock into the frame.

Note: All deficiencies were corrected during the survey by Maintenance Staff.

Building A2 - Memorial Hospital Central - East Tower

Through observation during the survey July 27 through August 19, 2010 it was determined the facility failed to maintain the doors to the corridor.

During the walk through of the facility with the Maintenance Director:

1) Corridor doors would not positively latch into the frame when closed 19.3.6.3.2
a) Two (2) corridor doors would not latch into the frame when closed
1) East wing room #4206, door threshold was hitting on the bottom of the door causing the door to not latch into the frame
2) East wing door #4209 would not latch into the frame
b) Four (4) sets of double doors were not considered to be positive latching (due to a thumb bolt lock), on the left side of the door, when in the closed position
1) Room #BNB118A
2) Room #BNB117A
3) Room #BNB102A
4) Room #BSB302A

Bldg A-1 - Memorial Hospital Central - Central Tower

Through observation during the survey July 27 through August 19, 2010 it was determined the facility failed to maintain the fire resistive rating of the vertical opening.

During the walk through of the facility with the Maintenance Director, the facility contained a vertical opening, in the Central Tower, from the first floor to the second floor at section 1L-2D. This area contained an egress corridor located in the vertical opening that was unprotected. Sections 19.3.1 and 8.2.5.

Building #1 - Memorial Hospital North - 4050 Brairgate Parkway

Through observation during the survey July 27 through August 19, 2010 it was determined the facility failed to maintain the fire resistive rating of the vertical opening.

During the walk through of the facility with the Maintenance Director, the facility contained a vertical opening, in the North Facility from the first floor kitchen/dining area to the second floor at the entrance. This area contained an egress corridor located at the main entrance level, in the vertical opening that was unprotected. This area must be protected per section 18.3.1.1 and section 8.2.5.

Building A2 - Memorial Hospital Central - East Tower

Through observation during the survey July 27 through August 19, 2010 it was determined the facility failed to maintain the fire resistive rating of the vertical opening.

During the walk through of the facility with the Maintenance Director, the facility contained a vertical opening in the East Tower. The vertical opening contained a gasketed system glass wall with sprinklers on each side of the glass. The glass did not contain a wired glass, laminated glass or a stamp indicating the glass was tempered. The facility determined, by investigation, that the glass installed was non-tempered. The glass must be of tempered type per section 8.2.5.6 exception No. 2.

Bldg A-1 - Memorial Hospital Central - Central Tower

Through observation during the survey July 27 through August 19, 2010 it was determined the facility failed to maintain the smoke barrier doors.

During the walk through of the facility with the Maintenance Director, two (2) fire barrier doors would not latch into the frame when closed;
1) #4685A smoke door, one (1) side would not latch into the frame
2) #1740A smoke door would not shut completely, this was due to an auto closure device that would not close the door

Note: All cross corridor deficiencies were corrected during the survey.

Bldg A-1 - Memorial Hospital Central - Central Tower

Through observation during the survey July 27 through August 19, 2010 it was determined the facility failed to maintain the doors to the hazardous areas.

During the walk through of the facility with the Maintenance Director, the room adjacent to room #1482A contained a high amount of combustible material. The doors contained a self-closing device, however it was disconnected from the door. Per 19.3.2.1 high hazard areas must contain a self-closing device on the door.

Note: This item was corrected during the survey.

Building #1 - Memorial Hospital North - 4050 Brairgate Parkway

Through observation during the survey July 27 through August 19, 2010 it was determined the facility failed to maintain the doors to the hazardous areas.

During the walk through of the facility with the Maintenance Director, the North facility contained two (2) elevator equipment rooms on the fifth (5th) floor mechanical space. The areas did not contain sprinkler protection, however were separated from adjacent spaces by a two-hour (2) wall separation. The doors to the area were rated at forty five minute doors (3/4 hour). The areas must contain sprinkler protection or contain a fully separated area by two-hour separation, including doors per section 18.3.5.1.

Bldg A-1 - Memorial Hospital Central - Central Tower

Through observation during the survey conducted July 27 through August 19, 2010 it was determined the facility did not maintain the fire exit hardware on exit doors.

During the walk through of the facility with the Maintenance Director, the fire exit hardware located at seven areas (7) on exit and fire-rated doors were not UL rated as fire-rated hardware.
1) Seventh (7th) floor fire door exit
2) Two (2) sets of smoke doors, located on the seventh floor Central Tower 7C
3) Fifth floor (5th) fire exit door
4) Two sets of smoke doors, located on the fifth floor Central Tower 5C
5) Fourth floor (4th) fire exit door
6) Two sets of smoke doors, located on the fifth floor Central Tower 4C
7) Smoke door #0405, located in the basement

Bldg A-1 - Memorial Hospital Central - Central Tower

Through observation during the survey July 27 through August 19, 2010 it was determined the facility failed to arrange the exit access so that exits are readily accessible at all times.

During the walk through of the facility with the Maintenance Director, the facility failed to contain an egress path from the exit door to a public way. This area was located at the north egress (1J) which contained a small four foot by four foot (4'x4') concrete pad only. The exit discharge did not contain a hard packed surface to a public means per section 19.2.7 and 7.7.1.

Building A2 - Memorial Hospital Central - East Tower

Through observation during the survey July 27 through August 19, 2010 it was determined the facility failed to arrange the exit access so that exits are readily accessible at all times.

During the walk through of the facility with the Maintenance Director, the facility contained two (2) delayed egress doors within the same path. The doors were located in the East Tower emergency waiting room. One (1) door was located in the emergency waiting room and the second was located in the egress corridor to the exterior of the building. Per 18.2.2.2.4 exception No. 2.

Note: Delayed egress from the egress corridor was removed during the survey, so there was only One (1) delayed egress in the exit path.

Bldg A-1 - Memorial Hospital Central - Central Tower

Through observation during the survey conducted July 27 through August 19, 2010 it was determined that the facility failed to install and maintain the fire alarm system with approved components, devices or equipment in accordance with NFPA 72.

During the walk through of the facility with the Maintenance Director, the operating room suite contained a fire alarm system that included strobes and alarms in the corridors. The operating rooms contained blinds or window coverings that obscured the visual notification of the alarm devices from the corridor side. Per 19.3.4.3.1, 9.6.3 and 9.6.3.6 exception #2.

Building #1 - Memorial Hospital North - 4050 Brairgate Parkway

Through observation during the survey conducted July 27 through August 19, 2010 it was determined the facility failed to install and maintain the fire alarm system with approved components, devices or equipment in accordance with NFPA 72

During the walk through of the facility with the Maintenance Director, three (3) areas contained smoke detectors spaced closer than four feet (4') from an air duct. Per 18.3.4.5.1, 9.6, 9.6.1.4 and NFPA 72 section 2-3.5.1 and A-2-3.5.1 "Detectors should not be located in a direct airflow nor closer than 3 ft (1 m) from an air supply diffuser or return air opening."

1) Physician sleeping room on second (2nd) floor
2) GI Lab 1
3) Laboratory on second (2nd) floor, in the hallway portion of the laboratory

Note: This smoke detectors were relocated by staff during the survey.

Building A2 - Memorial Hospital Central - East Tower

Through observation during the survey conducted July 27 through August 19, 2010 it was determined the facility failed to install and maintain the fire alarm system with approved components, devices or equipment in accordance with NFPA 72

During the walk through of the facility with the Maintenance Director, smoke detectors were spaced further than thirty feet (30') apart from one another in corridors in two (2) areas. The manufacturer sheets of the detectors stated the spacing should not be more than thirty feet (30'). Per NFPA 72.

1) East wing third floor (3rd) staff corridor detectors were spaced at thirty four feet (34')
2) East wing second floor corridor pod #2222 through 2225 detectors were spaced at thirty four feet (34')

Bldg A-1 - Memorial Hospital Central - Central Tower

Through observation during the survey conducted July 27 through August 19, 2010 it was determined the facility failed to provide a complete automatic sprinkler system in accordance with NFPA 13.

During the walk through of the facility with the Maintenance Director:

1) The East Tower basement elevator room, which was located off of the egress corridor, did not contain sprinkler protection per section 19.3.6.1. The room was separated by a one-hour wall only.

2) The facility contained quick response sprinkler heads and standard response heads installed and located in the same compartment. Per 19.3.5.1, 9.7.1, and 2000 Edition NFPA 13 Section 5-3.1.5.2 "When existing light hazard systems are converted to use quick-response or residential sprinklers, all sprinklers in a compartmented space shall be changed."

a) Third floor executive office corridor contains four (4) standard response heads and all others are quick response heads
b) Three (3) quick response heads in the corridor outside room #3129 and all other heads are standard response heads
c) One (1) quick response and one (1) standard response in suite #3119
d) One (1) quick response and One (1) standard response in room #3393
e) Six (6) standard response and ten (10) quick response heads located in the same compartment of the oncology corridor

3) The facility contained one (1) painted sprinkler head in the Clinical Engineering office located on the second (2nd) floor.

4) One (1) sprinkler head, located at the smoke door #1722A, was installed within three inches (3") from the smoke door. Per NFPA 13, section 5-6.3.3 "Sprinklers shall be located a minimum of 4 in. (102 mm) from a wall."

5) The pharmacy contained a sprinkler riser with two (2) OS&Y valves that were not supervised by electronic supervision. The OS&Y valves were locked open by use of a chain and lock. The air compressor for the pre-action system on zone six (6) would cycle every forty (40) seconds, which indicated a leak on the system.

Note: Item (5) and item (4) were corrected during the survey.

Building #1 - Memorial Hospital North - 4050 Brairgate Parkway

Through observation during the survey July 27 through August 19, 2010 it was determined the facility failed to install an automatic sprinkler system per NFPA 13.

During the walk through of the facility with the Maintenance Director;
1) Sprinkler equipment room #BG202 did not contain sprinkler protection.
2) An awning, located outside of the ambulance entrance of the emergency department, contained a fabric awning on a metal frame structure. The awning protruded more than four feet (4') from the structure. Documentation could not be located to indicate the awning was fire resistive and sprinkler protection was not provided for the awning.

Building A2 - Memorial Hospital Central - East Tower

Through observation during the survey July 27 through August 19, 2010 it was determined the facility failed to install sprinkler protection coverage to all areas.

During the walk through of the facility with the Maintenance Director, the Eat Tower basement elevator room did not contain sprinkler protection. The room also did not contain a two-hour separation between the room and the corridor. Per section 18.3.5.1.

Bldg A-1 - Memorial Hospital Central - Central Tower

Through observation during the survey July 27 through August 19, 2010 it was determined the facility failed to maintain the automatic sprinkler system in reliable operating condition.

During the walk through of the facility with the Maintenance Director:

1) Sprinkler gauges were outdated and documentation could not be located to indicate a calibration had occurred within the past five years (5) per NFPA 25, Chapter 5, section 5.3.2. "Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced."

a) Pre-action valve for surgery rooms 8&9, contained one (1) gauge dated 2004
b) Pre-Action valve zone 4, MRI, contained one (1) gauge dated 2003
c) Pre-Action valve zone 4, radiology, contained one (1) gauge dated 2004

2) Escutcheon plates were loose or missing from the sprinkler heads in six (6) locations;
a) Room #6630-escutcheon plate missing
b) Nurse station on fifth (5th) floor (adjacent to room #5626) - gap around escutcheon plate and ceiling
c) Fire extinguisher was not fully charged
d) In the corridor outside of room #4568, charge indicator was in the red, non-charged, area
e) North facility room #3304
f) North facility sterile processing room

Note: All items corrected during the survey

Bldg A-1 - Memorial Hospital Central - Central Tower

Through observation during the survey conducted July 27 through August 19, 2010 it was determined the facility allowed the use of flammable decorations.

During the walk through of the facility with the Maintenance Director, the facility displayed a five foot (5') tall Christmas tree in the Radiology Nursing Unit. Documentation could not be provided to indicate the tree was flame retardant.

Note: The tree was removed immediately by staff.

Bldg A-1 - Memorial Hospital Central - Central Tower

Through observation and record review during the survey conducted on July 27 through August 19, 2010 it was determined the facility failed to provide curtains that comply with NFPA 701 in all areas.

During record review and walk through of the facility with the Maintenance Director, curtains located throughout the facility did not contain tags or markings showing they met NFPA 701 requirements.
1) Blood bank office #2410B contained sheer type draperies on the window
2) Pink curtains were located in the OR overflow rooms
3) Room #1776 contained draperies that were not labeled

Note: Curtains were removed by staff during the survey.

Bldg A-1 - Memorial Hospital Central - Central Tower

Through observation during the survey July 27 through August 19, 2010 it was determined the facility failed to provide a separation between service valves as required by NFPA 99.

During the walk through of the facility with the Maintenance Director, the facility contained emergency oxygen shutoff valves in two (2) areas. These emergency valves controlled oxygen valves in two rooms that were without separation between the beds it controls and the shut off valve. Per NFPA 99 section 4-3.1.2.3(d) "Zone Valve. Station outlets shall not be supplied directly from a riser unless a manual shutoff valve located in the same story is installed between the riser and the outlet with a wall intervening between the valve and the outlet."

1) Respiratory Care area contains One (1) med gas valve not separated by a wall.

2) Hat Team Unit, room #3142, contains one (1) med gas shutoff valve.

Note: The above areas are currently office space and do contain patients; however the valves were active during the survey. The facility disconnected the valves from service during the survey.

Bldg A-1 - Memorial Hospital Central - Central Tower

Through observation during the survey July 27 through August 19, 2010 it was determined the facility failed to maintain the anesthetizing locations per NFPA 99.

During the walk through and discussions with the maintenance staff and Maintenance Director;

1) Anesthetizing operating rooms did not contain ground fault or line isolation electrical protection. Per the 2000 Edition of NFPA 99, Section 3-3.2.1.2 these locations are considered "wet" locations and must be protected by either GFCI (ground fault circuit interruption) or LIM (line isolation monitors).

a) Room #1653, located in the MSCA area, utilized as a pediatric procedure room. Per conversations with the nurse staff, inhaled anesthesia is utilized in the room during procedures.
b) 2nd floor Central tower Zone 1 Surgery A,B, and C.

2) The facility failed to provide a means by which to exhaust the windowless anesthetizing operating rooms in the event that smoke or the products of combustion are detected, as required by NFPA 99, 5-4.1.2. Per discussions with Maintenance staff, it appears the AHU (air handling unit) shuts down on ducts detector activation in some cases or the air handling system is operated by duct detection only in all cases and does not exhaust products of combustion of smoke per NFPA 99 5-4.1.2 and 5-4.1.3.

a) Room #1653, located in the MSCA area, utilized as a pediatric procedure room.
b) Cath lab
c) 2nd floor Central tower Zone 1 Surgery A,B, and C. This area is setup to shut down on activation of a duct detector only. Smoke detectors are equipped in the operating rooms, however they are not interfaced with the HVAC system.
d) Operating rooms one through five (1-5) in the Central Tower. This area is setup to shut down on activation of a duct detector only. Smoke detectors are equipped in the operating rooms, however they are not interfaced with the HVAC system.
e) Operating rooms seven through eleven (7-11) contain an AHU (air handling unit) that controls only operating rooms seven through eleven (7-11) and no other areas. Duct detection operates the exhaust fan function only. Smoke detection does not activate the exhaust function of the AHU unit.
f) Operating Room six (6) contains an AHU (air handling unit) that operates only operating room #6 and no other areas. Duct detection operates an exhaust fan - smoke detection in rooms do not activate the fan mode.

Building #1 - Memorial Hospital North - 4050 Brairgate Parkway

Through observation during the survey July 27 through August 19, 2010 it was determined the facility failed to maintain the anesthetizing locations per NFPA 99.

During the walk through of the facility and staff interviews with the Maintenance Director, the ventilation system, located in eight (8) anesthetizing locations, could not be determined as to how they operate in case of a fire. The Maintenance Director of the hospital stated that the ventilation "shuts down" during a fire alarm situation. Per NFPA 99 1999 Edition, chapter 5, section 5-4.1.2 "Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically vent smoke and products of combustion." And section 5-4.1.3 "Ventilating systems for anesthetizing locations shall be provided that automatically (a) prevent recirculation of smoke originating within the surgical suite and (b) prevent the circulation of smoke entering the system intake, without in either case interfering with the exhaust function of the system."

1) Two (2) "C-Section" rooms located on the second floor.

2) Six (6) operating rooms located on the ground floor.

Building A2 - Memorial Hospital Central - East Tower

Through observation during the survey July 27 through August 19, 2010 it was determined that the facility failed to maintain the anesthetizing locations per NFPA 99.

During the walk through of the facility and staff interviews with the Maintenance Director, the ventilation system, located in two (2) OB/GYN rooms in the East tower, utilized inhaled anesthetizing agents for procedures. The exhaust system could not be tested during the survey due to procedures being conducted as to how they operate in case of a fire. The Maintenance Director of the hospital stated they believe the ventilation "shuts down" during a fire alarm situation. Per NFPA 99 1999 Edition, chapter 5, section 5-4.1.2 "Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically vent smoke and products of combustion." And section 5-4.1.3 "Ventilating systems for anesthetizing locations shall be provided that automatically (a) prevent recirculation of smoke originating within the surgical suite and (b) prevent the circulation of smoke entering the system intake, without in either case interfering with the exhaust function of the system."

Bldg A-1 - Memorial Hospital Central - Central Tower

Through record review, observation, and testing during the survey July 27 through August 19, 2010 it was determined the facility failed to maintain the emergency generator transfer time at less than ten (10) seconds.

During the review of the facility's records, maintenance presented documentation indicating the transfer time between loss of power and generator transfer was greater than ten (10) seconds on the transfer switches for the Life Safety Branch of the emergency power system. 19.2.9.1 and 7.9.1.2.

Note: This deficiency was corrected during the survey by maintenance by adjusting the transfer switches affected to properly transfer within ten (10) seconds.

Building #1 - Memorial Hospital North - 4050 Brairgate Parkway

Through record review, observation, and testing during the survey July 27 through August 19, 2010 it was determined the facility failed to maintain the emergency generator transfer time at less than ten (10) seconds.

During the review of the facility's records, maintenance presented documentation indicating the transfer time between loss of power and generator transfer was greater than ten (10) seconds on the transfer switches for the Life Safety Branch of the emergency power system. 19.2.9.1 and 7.9.1.2.

Note: This deficiency was corrected during the survey by maintenance by adjusting the transfer switches that were affected to properly transfer within ten (10) seconds.

Bldg A-1 - Memorial Hospital Central - Central Tower

Through observation during the survey July 27 through August 19, 2010 it was determined that the facility failed to maintain the fire resistance rating of the corridor walls.

During the walk through of the facility with the Maintenance Director, the corridor wall, outside of room #1418C, contained a two inch (2") hole in the corridor wall to an adjacent room. The hole was utilized for electrical conduit during remodel of the area. 2000 Edition NFPA 101 Section 19.3.6.2.1

Note: This item was corrected during the survey.

Bldg A-1 - Memorial Hospital Central - Central Tower

Through observation during the survey July 27 through August 19, 2010 it was determined the facility failed to maintain the doors to the corridor.

During the walk through of the facility with the Maintenance Director:

1) Seven (7) patient room doors contained excessive gaps in excess of 1/2 inch between the door and the frame or the door and the stop and would not resist the passage of smoke per section 19.3.6.1.
a. #7532
b. #7512
c. #6646
d. #6620
e. #5640
f. #5649
g. #4526

2) Corridor doors would not positively latch into the frame when closed. 19.3.6.3.2
a) Nine (9) corridor doors would not latch into the frame when closed.
1. Room #7524 - door would not latch into the frame
2. Room #7504 - door would not latch into the frame
3. Room #7530 - door was tight on frame and would not latch
4. Room #7508 - door was tight in the frame and would not latch
5. Room #6540 - door would not latch into the frame
6. One (1) door on the Therapy room, located on the seventh (7th) floor, would not latch into the frame
7. Room #5642 - would not latch into the frame
8. Room #5526 - door would not shut into the frame
9. Room #4530 - door would not latch into the frame
b) Three (3) 70/30 double doors were not considered to be positive latching (due to a thumb bolt lock) on the "30 side", when in the closed position. The following doors contained slide locks on the "30 side" of the door for locking:
1. Room #465, which is located off of the corridor, contains a 70/30 door. The 30 portion of the door contains a thumb lock and does not positively latch into the frame.
2. Room #4654, which is located off of the corridor, contains a 70/30 door. The 30 portion of the door contains a thumb lock and does not positively latch into the frame.
3. Room #2621 A and B contained a double door that opened into the corridor. One (1) side of the double door contained a thumb lock and would not positively lock into the frame.

Note: All deficiencies were corrected during the survey by Maintenance Staff.

Building A2 - Memorial Hospital Central - East Tower

Through observation during the survey July 27 through August 19, 2010 it was determined the facility failed to maintain the doors to the corridor.

During the walk through of the facility with the Maintenance Director:

1) Corridor doors would not positively latch into the frame when closed 19.3.6.3.2
a) Two (2) corridor doors would not latch into the frame when closed
1) East wing room #4206, door threshold was hitting on the bottom of the door causing the door to not latch into the frame
2) East wing door #4209 would not latch into the frame
b) Four (4) sets of double doors were not considered to be positive latching (due to a thumb bolt lock), on the left side of the door, when in the closed position
1) Room #BNB118A
2) Room #BNB117A
3) Room #BNB102A
4) Room #BSB302A

Bldg A-1 - Memorial Hospital Central - Central Tower

Through observation during the survey July 27 through August 19, 2010 it was determined the facility failed to maintain the fire resistive rating of the vertical opening.

During the walk through of the facility with the Maintenance Director, the facility contained a vertical opening, in the Central Tower, from the first floor to the second floor at section 1L-2D. This area contained an egress corridor located in the vertical opening that was unprotected. Sections 19.3.1 and 8.2.5.

Building #1 - Memorial Hospital North - 4050 Brairgate Parkway

Through observation during the survey July 27 through August 19, 2010 it was determined the facility failed to maintain the fire resistive rating of the vertical opening.

During the walk through of the facility with the Maintenance Director, the facility contained a vertical opening, in the North Facility from the first floor kitchen/dining area to the second floor at the entrance. This area contained an egress corridor located at the main entrance level, in the vertical opening that was unprotected. This area must be protected per section 18.3.1.1 and section 8.2.5.

Building A2 - Memorial Hospital Central - East Tower

Through observation during the survey July 27 through August 19, 2010 it was determined the facility failed to maintain the fire resistive rating of the vertical opening.

During the walk through of the facility with the Maintenance Director, the facility contained a vertical opening in the East Tower. The vertical opening contained a gasketed system glass wall with sprinklers on each side of the glass. The glass did not contain a wired glass, laminated glass or a stamp indicating the glass was tempered. The facility determined, by investigation, that the glass installed was non-tempered. The glass must be of tempered type per section 8.2.5.6 exception No. 2.

Bldg A-1 - Memorial Hospital Central - Central Tower

Through observation during the survey July 27 through August 19, 2010 it was determined the facility failed to maintain the smoke barrier doors.

During the walk through of the facility with the Maintenance Director, two (2) fire barrier doors would not latch into the frame when closed;
1) #4685A smoke door, one (1) side would not latch into the frame
2) #1740A smoke door would not shut completely, this was due to an auto closure device that would not close the door

Note: All cross corridor deficiencies were corrected during the survey.

Bldg A-1 - Memorial Hospital Central - Central Tower

Through observation during the survey July 27 through August 19, 2010 it was determined the facility failed to maintain the doors to the hazardous areas.

During the walk through of the facility with the Maintenance Director, the room adjacent to room #1482A contained a high amount of combustible material. The doors contained a self-closing device, however it was disconnected from the door. Per 19.3.2.1 high hazard areas must contain a self-closing device on the door.

Note: This item was corrected during the survey.

Building #1 - Memorial Hospital North - 4050 Brairgate Parkway

Through observation during the survey July 27 through August 19, 2010 it was determined the facility failed to maintain the doors to the hazardous areas.

During the walk through of the facility with the Maintenance Director, the North facility contained two (2) elevator equipment rooms on the fifth (5th) floor mechanical space. The areas did not contain sprinkler protection, however were separated from adjacent spaces by a two-hour (2) wall separation. The doors to the area were rated at forty five minute doors (3/4 hour). The areas must contain sprinkler protection or contain a fully separated area by two-hour separation, including doors per section 18.3.5.1.

Bldg A-1 - Memorial Hospital Central - Central Tower

Through observation during the survey conducted July 27 through August 19, 2010 it was determined the facility did not maintain the fire exit hardware on exit doors.

During the walk through of the facility with the Maintenance Director, the fire exit hardware located at seven areas (7) on exit and fire-rated doors were not UL rated as fire-rated hardware.
1) Seventh (7th) floor fire door exit
2) Two (2) sets of smoke doors, located on the seventh floor Central Tower 7C
3) Fifth floor (5th) fire exit door
4) Two sets of smoke doors, located on the fifth floor Central Tower 5C
5) Fourth floor (4th) fire exit door
6) Two sets of smoke doors, located on the fifth floor Central Tower 4C
7) Smoke door #0405, located in the basement

Bldg A-1 - Memorial Hospital Central - Central Tower

Through observation during the survey July 27 through August 19, 2010 it was determined the facility failed to arrange the exit access so that exits are readily accessible at all times.

During the walk through of the facility with the Maintenance Director, the facility failed to contain an egress path from the exit door to a public way. This area was located at the north egress (1J) which contained a small four foot by four foot (4'x4') concrete pad only. The exit discharge did not contain a hard packed surface to a public means per section 19.2.7 and 7.7.1.

Building A2 - Memorial Hospital Central - East Tower

Through observation during the survey July 27 through August 19, 2010 it was determined the facility failed to arrange the exit access so that exits are readily accessible at all times.

During the walk through of the facility with the Maintenance Director, the facility contained two (2) delayed egress doors within the same path. The doors were located in the East Tower emergency waiting room. One (1) door was located in the emergency waiting room and the second was located in the egress corridor to the exterior of the building. Per 18.2.2.2.4 exception No. 2.

Note: Delayed egress from the egress corridor was removed during the survey, so there was only One (1) delayed egress in the exit path.

Bldg A-1 - Memorial Hospital Central - Central Tower

Through observation during the survey conducted July 27 through August 19, 2010 it was determined that the facility failed to install and maintain the fire alarm system with approved components, devices or equipment in accordance with NFPA 72.

During the walk through of the facility with the Maintenance Director, the operating room suite contained a fire alarm system that included strobes and alarms in the corridors. The operating rooms contained blinds or window coverings that obscured the visual notification of the alarm devices from the corridor side. Per 19.3.4.3.1, 9.6.3 and 9.6.3.6 exception #2.

Building #1 - Memorial Hospital North - 4050 Brairgate Parkway

Through observation during the survey conducted July 27 through August 19, 2010 it was determined the facility failed to install and maintain the fire alarm system with approved components, devices or equipment in accordance with NFPA 72

During the walk through of the facility with the Maintenance Director, three (3) areas contained smoke detectors spaced closer than four feet (4') from an air duct. Per 18.3.4.5.1, 9.6, 9.6.1.4 and NFPA 72 section 2-3.5.1 and A-2-3.5.1 "Detectors should not be located in a direct airflow nor closer than 3 ft (1 m) from an air supply diffuser or return air opening."

1) Physician sleeping room on second (2nd) floor
2) GI Lab 1
3) Laboratory on second (2nd) floor, in the hallway portion of the laboratory

Note: This smoke detectors were relocated by staff during the survey.

Building A2 - Memorial Hospital Central - East Tower

Through observation during the survey conducted July 27 through August 19, 2010 it was determined the facility failed to install and maintain the fire alarm system with approved components, devices or equipment in accordance with NFPA 72

During the walk through of the facility with the Maintenance Director, smoke detectors were spaced further than thirty feet (30') apart from one another in corridors in two (2) areas. The manufacturer sheets of the detectors stated the spacing should not be more than thirty feet (30'). Per NFPA 72.

1) East wing third floor (3rd) staff corridor detectors were spaced at thirty four feet (34')
2) East wing second floor corridor pod #2222 through 2225 detectors were spaced at thirty four feet (34')

Bldg A-1 - Memorial Hospital Central - Central Tower

Through observation during the survey conducted July 27 through August 19, 2010 it was determined the facility failed to provide a complete automatic sprinkler system in accordance with NFPA 13.

During the walk through of the facility with the Maintenance Director:

1) The East Tower basement elevator room, which was located off of the egress corridor, did not contain sprinkler protection per section 19.3.6.1. The room was separated by a one-hour wall only.

2) The facility contained quick response sprinkler heads and standard response heads installed and located in the same compartment. Per 19.3.5.1, 9.7.1, and 2000 Edition NFPA 13 Section 5-3.1.5.2 "When existing light hazard systems are converted to use quick-response or residential sprinklers, all sprinklers in a compartmented space shall be changed."

a) Third floor executive office corridor contains four (4) standard response heads and all others are quick response heads
b) Three (3) quick response heads in the corridor outside room #3129 and all other heads are standard response heads
c) One (1) quick response and one (1) standard response in suite #3119
d) One (1) quick response and One (1) standard response in room #3393
e) Six (6) standard response and ten (10) quick response heads located in the same compartment of the oncology corridor

3) The facility contained one (1) painted sprinkler head in the Clinical Engineering office located on the second (2nd) floor.

4) One (1) sprinkler head, located at the smoke door #1722A, was installed within three inches (3") from the smoke door. Per NFPA 13, section 5-6.3.3 "Sprinklers shall be located a minimum of 4 in. (102 mm) from a wall."

5) The pharmacy contained a sprinkler riser with two (2) OS&Y valves that were not supervised by electronic supervision. The OS&Y valves were locked open by use of a chain and lock. The air compressor for the pre-action system on zone six (6) would cycle every forty (40) seconds, which indicated a leak on the system.

Note: Item (5) and item (4) were corrected during the survey.

Building #1 - Memorial Hospital North - 4050 Brairgate Parkway

Through observation during the survey July 27 through August 19, 2010 it was determined the facility failed to install an automatic sprinkler system per NFPA 13.

During the walk through of the facility with the Maintenance Director;
1) Sprinkler equipment room #BG202 did not contain sprinkler protection.
2) An awning, located outside of the ambulance entrance of the emergency department, contained a fabric awning on a metal frame structure. The awning protruded more than four feet (4') from the structure. Documentation could not be located to indicate the awning was fire resistive and sprinkler protection was not provided for the awning.

Building A2 - Memorial Hospital Central - East Tower

Through observation during the survey July 27 through August 19, 2010 it was determined the facility failed to install sprinkler protection coverage to all areas.

During the walk through of the facility with the Maintenance Director, the Eat Tower basement elevator room did not contain sprinkler protection. The room also did not contain a two-hour separation between the room and the corridor. Per section 18.3.5.1.

Bldg A-1 - Memorial Hospital Central - Central Tower

Through observation during the survey July 27 through August 19, 2010 it was determined the facility failed to maintain the automatic sprinkler system in reliable operating condition.

During the walk through of the facility with the Maintenance Director:

1) Sprinkler gauges were outdated and documentation could not be located to indicate a calibration had occurred within the past five years (5) per NFPA 25, Chapter 5, section 5.3.2. "Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced."

a) Pre-action valve for surgery rooms 8&9, contained one (1) gauge dated 2004
b) Pre-Action valve zone 4, MRI, contained one (1) gauge dated 2003
c) Pre-Action valve zone 4, radiology, contained one (1) gauge dated 2004

2) Escutcheon plates were loose or missing from the sprinkler heads in six (6) locations;
a) Room #6630-escutcheon plate missing
b) Nurse station on fifth (5th) floor (adjacent to room #5626) - gap around escutcheon plate and ceiling
c) Fire extinguisher was not fully charged
d) In the corridor outside of room #4568, charge indicator was in the red, non-charged, area
e) North facility room #3304
f) North facility sterile processing room

Note: All items corrected during the survey

Bldg A-1 - Memorial Hospital Central - Central Tower

Through observation during the survey conducted July 27 through August 19, 2010 it was determined the facility allowed the use of flammable decorations.

During the walk through of the facility with the Maintenance Director, the facility displayed a five foot (5') tall Christmas tree in the Radiology Nursing Unit. Documentation could not be provided to indicate the tree was flame retardant.

Note: The tree was removed immediately by staff.

Bldg A-1 - Memorial Hospital Central - Central Tower

Through observation and record review during the survey conducted on July 27 through August 19, 2010 it was determined the facility failed to provide curtains that comply with NFPA 701 in all areas.

During record review and walk through of the facility with the Maintenance Director, curtains located throughout the facility did not contain tags or markings showing they met NFPA 701 requirements.
1) Blood bank office #2410B contained sheer type draperies on the window
2) Pink curtains were located in the OR overflow rooms
3) Room #1776 contained draperies that were not labeled

Note: Curtains were removed by staff during the survey.

Bldg A-1 - Memorial Hospital Central - Central Tower

Through observation during the survey July 27 through August 19, 2010 it was determined the facility failed to provide a separation between service valves as required by NFPA 99.

During the walk through of the facility with the Maintenance Director, the facility contained emergency oxygen shutoff valves in two (2) areas. These emergency valves controlled oxygen valves in two rooms that were without separation between the beds it controls and the shut off valve. Per NFPA 99 section 4-3.1.2.3(d) "Zone Valve. Station outlets shall not be supplied directly from a riser unless a manual shutoff valve located in the same story is installed between the riser and the outlet with a wall intervening between the valve and the outlet."

1) Respiratory Care area contains One (1) med gas valve not separated by a wall.

2) Hat Team Unit, room #3142, contains one (1) med gas shutoff valve.

Note: The above areas are currently office space and do contain patients; however the valves were active during the survey. The facility disconnected the valves from service during the survey.

Bldg A-1 - Memorial Hospital Central - Central Tower

Through observation during the survey July 27 through August 19, 2010 it was determined the facility failed to maintain the anesthetizing locations per NFPA 99.

During the walk through and discussions with the maintenance staff and Maintenance Director;

1) Anesthetizing operating rooms did not contain ground fault or line isolation electrical protection. Per the 2000 Edition of NFPA 99, Section 3-3.2.1.2 these locations are considered "wet" locations and must be protected by either GFCI (ground fault circuit interruption) or LIM (line isolation monitors).

a) Room #1653, located in the MSCA area, utilized as a pediatric procedure room. Per conversations with the nurse staff, inhaled anesthesia is utilized in the room during procedures.
b) 2nd floor Central tower Zone 1 Surgery A,B, and C.

2) The facility failed to provide a means by which to exhaust the windowless anesthetizing operating rooms in the event that smoke or the products of combustion are detected, as required by NFPA 99, 5-4.1.2. Per discussions with Maintenance staff, it appears the AHU (air handling unit) shuts down on ducts detector activation in some cases or the air handling system is operated by duct detection only in all cases and does not exhaust products of combustion of smoke per NFPA 99 5-4.1.2 and 5-4.1.3.

a) Room #1653, located in the MSCA area, utilized as a pediatric procedure room.
b) Cath lab
c) 2nd floor Central tower Zone 1 Surgery A,B, and C. This area is setup to shut down on activation of a duct detector only. Smoke detectors are equipped in the operating rooms, however they are not interfaced with the HVAC system.
d) Operating rooms one through five (1-5) in the Central Tower. This area is setup to shut down on activation of a duct detector only. Smoke detectors are equipped in the operating rooms, however they are not interfaced with the HVAC system.
e) Operating rooms seven through eleven (7-11) contain an AHU (air handling unit) that controls only operating rooms seven through eleven (7-11) and no other areas. Duct detection operates the exhaust fan function only. Smoke detection does not activate the exhaust function of the AHU unit.
f) Operating Room six (6) contains an AHU (air handling unit) that operates only operating room #6 and no other areas. Duct detection operates an exhaust fan - smoke detection in rooms do not activate the fan mode.

Building #1 - Memorial Hospital North - 4050 Brairgate Parkway

Through observation during the survey July 27 through August 19, 2010 it was determined the facility failed to maintain the anesthetizing locations per NFPA 99.

During the walk through of the facility and staff interviews with the Maintenance Director, the ventilation system, located in eight (8) anesthetizing locations, could not be determined as to how they operate in case of a fire. The Maintenance Director of the hospital stated that the ventilation "shuts down" during a fire alarm situation. Per NFPA 99 1999 Edition, chapter 5, section 5-4.1.2 "Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically vent smoke and products of combustion." And section 5-4.1.3 "Ventilating systems for anesthetizing locations shall be provided that automatically (a) prevent recirculation of smoke originating within the surgical suite and (b) prevent the circulation of smoke entering the system intake, without in either case interfering with the exhaust function of the system."

1) Two (2) "C-Section" rooms located on the second floor.

2) Six (6) operating rooms located on the ground floor.

Building A2 - Memorial Hospital Central - East Tower

Through observation during the survey July 27 through August 19, 2010 it was determined that the facility failed to maintain the anesthetizing locations per NFPA 99.

During the walk through of the facility and staff interviews with the Maintenance Director, the ventilation system, located in two (2) OB/GYN rooms in the East tower, utilized inhaled anesthetizing agents for procedures. The exhaust system could not be tested during the survey due to procedures being conducted as to how they operate in case of a fire. The Maintenance Director of the hospital stated they believe the ventilation "shuts down" during a fire alarm situation. Per NFPA 99 1999 Edition, chapter 5, section 5-4.1.2 "Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically vent smoke and products of combustion." And section 5-4.1.3 "Ventilating systems for anesthetizing locations shall be provided that automatically (a) prevent recirculation of smoke originating within the surgical suite and (b) prevent the circulation of smoke entering the system intake, without in either case interfering with the exhaust function of the system."

Bldg A-1 - Memorial Hospital Central - Central Tower

Through record review, observation, and testing during the survey July 27 through August 19, 2010 it was determined the facility failed to maintain the emergency generator transfer time at less than ten (10) seconds.

During the review of the facility's records, maintenance presented documentation indicating the transfer time between loss of power and generator transfer was greater than ten (10) seconds on the transfer switches for the Life Safety Branch of the emergency power system. 19.2.9.1 and 7.9.1.2.

Note: This deficiency was corrected during the survey by maintenance by adjusting the transfer switches affected to properly transfer within ten (10) seconds.

Building #1 - Memorial Hospital North - 4050 Brairgate Parkway

Through record review, observation, and testing during the survey July 27 through August 19, 2010 it was determined the facility failed to maintain the emergency generator transfer time at less than ten (10) seconds.

During the review of the facility's records, maintenance presented documentation indicating the transfer time between loss of power and generator transfer was greater than ten (10) seconds on the transfer switches for the Life Safety Branch of the emergency power system. 19.2.9.1 and 7.9.1.2.

Note: This deficiency was corrected during the survey by maintenance by adjusting the transfer switches that were affected to properly transfer within ten (10) seconds.