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Based on random observation during the survey walk-through, staff interview and review of Life Safety Plans, the construction of the walls to provide the separation between the mobile MRI/CT dock and the hospital building is not provided to maintain separation of the different construction types to comply with 19.1.6.2 and NFPA 80A. This deficiency could affect all patients in the facility, as well as any staff and visitors present, because the lack of protection of the building structure from the effects of fire exposure can cause building collapse prior to evacuation.

Findings include:
A. A 2-hour barrier was not observed to be maintained between the hospital and the mobile MRI/CT unit. The dock vestibule exterior wall contained a non-rated exterior overhead door. Alternatively, the interior walls of the dock vestibule were not confirmed to be of minimum 2-hour rated construction including a 1 1/2-hour rated door assembly. The corridor wall was not constructed to the deck above. The vestibule was observed to be utilized as an equipment storage room at the time of the survey.
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Based on random observation during the survey walk-through, the construction type of the building is not maintained in accordance with, 19.1.6.2. This deficiency could affect all in-patients in the facility, as well as any staff and visitors present, because the lack of protection of the building structure from the effects of fire exposure can cause building collapse prior to evacuation.

Findings include:
A. Structural steel framing was observed in the Boiler room that was missing fireproofing. Observed location was primarily near the chiller equipment.
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Based on random observation during the survey walk-through, not all exit access corridors are separated from use areas in accordance with 19.3.6.1. These deficiencies could affect all beds in the smoke compartment, as well as any staff and visitors present, because the lack of smoke detectors could result in delayed activation of the fire alarm system and smoke compromising the facility's exit access corridors.

Findings include:
A. The nourishment alcove within the 2nd floor OB unit was observed to be open to the corridor and not protected with smoke detection in accordance with 19.3.6.1 Exception No. 1.

B. The Emergency Dept. contained treatment stations open to the corridor in non-compliance with 19.3.6.1. During staff interview and review of the Life Safety reference plans, the ED was not defined as a suite to allow the open stations.
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Based on random observation during the survey walk-through, not all doors in exit access corridors are in compliance with 19.3.6.3. This deficiency could affect all patients within the 3rd floor north smoke compartmentof the facility, as well as any staff and visitors present, by allowing smoke to pass from one side of the corridor wall to the other; either compromising the building's exit access corridors or the rooms occupied.

Findings include:
A. 3rd floor Patient room 333 door was equipped with only keyed dead bolt lock hardware which does not self-latch upon closing to comply with 19.3.6.3.2. The dead bolt lock can not be utilized in combination with a latchset which would constitute hardware requiring more than one operation to release the door in non-compliance with 7.2.1.5.4.

B. 2nd floor ICU Patient room #12 is equipped with a pair of doors which can not be maintained in a latched condition upon closing to comply with 19.3.6.3.2.

C. Horizontal sliding doors were not provided with positive latching to comply with 19.3.6.3.2. These doors were not otherwise defined as being located with suites on the Life Safety Reference plans. These door conditions were observed in the following areas:

1. OR Prep area
2. Chest Pain Clinic area
3. Emergency Dept. area
4. Imaging check-in area.
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Based on random observation during the survey walk-through, vertical openings between floors are not protected to comply with 19.3.1.1. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, because the lack of protection can allow smoke and fire to migrate from one floor to another.

Findings include:
A. The 3rd floor Electrical room adjacent Stair D was observed to have wiring thru a floor sleeve not completely sealed in accordance with fire/smoke rated tested design assemblies.

B. The ducts from the 2nd floor center large Mechanical room penetrated the floor near the southeast corner and could not be confirmed to be equipped with fire dampers to comply with 19.3.1.1 and NFPA 90A because access doors were not observed in the ducts in the Mechanical room.
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Based on random observation during the survey walk-through, not all doors in smoke barrier walls are confirmed to be in compliance with 19.3.7.6, 8.3.4.3 and 7.2.1.9.2. This deficiency could affect all patients on either side of the 1st floor smoke barrier between the compartments containing the OR/Recovery and the OR Prep areas, as well as any staff and visitors present, by allowing smoke to pass from one side of the smoke barrier wall to the other; compromising either smoke compartment.

Findings include:
A. The door in the smoke barrier between the OR Recovery room and the OR Prep area could not be confirmed to drop out during fire alarm activation to maintain the door in a closed position.
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Based on random observation during the survey walk-through on the morning of 1/31/12, not all hazardous areas are separated from the remainder of the building in accordance with 38.3.2.1 and 8.4.1. These deficiencies could affect all patients of the facility, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into the building's exit access.

Findings include:
A. The unsprinklered fuel fired furnace rooms (two rooms) were observed not to be 1-hour enclosed with a minimum 3/4-hour fire rated self-closing door to comply with 8.4.1.2.

B. The unsprinklered Janitor room containing materials having a greater degree of hazard than that normal to the general occupancy of the building was observed not to be 1-hour enclosed with a minimum 3/4-hour fire rated self-closing door to comply with 8.4.1.2.

C. The unsprinklered Supply storage room containing materials having a greater degree of hazard than that normal to the general occupancy of the building was observed not to be 1-hour enclosed with a minimum 3/4-hour fire rated self-closing door to comply with 8.4.1.2.
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Based on random observation during the survey walk-through on the morning of 1/31/12, not all hazardous areas are separated from the remainder of the building in accordance with 39.3.2.1 and 8.4.1. These deficiencies could affect all patients of the facility, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into the building's exit access.

Findings include:
A. The unsprinklered electric furnace room is also utilized as the Janitor supply storage room containing materials having a greater degree of hazard than that normal to the general occupancy of the building and was observed not to be 1-hour enclosed with a minimum 3/4-hour fire rated self-closing door to comply with 8.4.1.2.

B. The unsprinklered Hydro Therapy room is also utilized as a general storage room containing materials having a greater degree of hazard than that normal to the general occupancy of the building and was observed not to be 1-hour enclosed with a minimum 3/4-hour fire rated self-closing door to comply with 8.4.1.2. This room was also observed to be the storage location for an E-size oxygen cylinder not separated from combustibles to comply with NFPA 99-1999, 8-3.1.11.2(c).

C. The unsprinklered southeast storage room containing materials having a greater degree of hazard than that normal to the general occupancy of the building was observed not to be 1-hour enclosed with a minimum 3/4-hour fire rated self-closing door to comply with 8.4.1.2.
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Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1 and 8.4.1. These deficiencies could affect all patients within the smoke compartment of the location, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into the building's exit access corridors in the event of a fire condition.

Findings include:
A. The 3rd floor Equipment storage room on the west corridor was observed to have a door which did not self-close to a latched condition.

B. The 2nd floor OB Soiled Food cart/Trash holding room near room 283 was observed not to have a self-closing door.

C. The 1st floor OR Janitor room storing combustibles was observed not to have a door which did not self-close to a latched condition.
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Based on random observation during the survey walk-through, not all exit or exit access doors are arranged so that exits are readily accessible at all times in accordance with 19.2.1 and Chapter 7. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the building.

Findings include:
A. Doors equipped with magnetic locking devices do not comply with all requirements of 19.2.2.2.4 and 7.2.1.6. Conditions and locations observed:

1. The single swing cross corridor doors between the main ED area and the "Team C" area are equipped with magnetic locking devices. Although the locks were not functioning at the time of the survey and their purpose was not known by staff, they were not installed in compliance with 7.2.1.6.1 or 7.2.1.6.2.

2. The north doors of the ED area are a pair of single swing doors swinging into the ED area. These doors were marked with exit signage on the ED side only. Compliance with 7.2.1.4.2 for the doors to swing in the direction of travel is not met.

3. The north doors of the ED area are a pair of single swing doors swinging into the ED area and are equipped with magnetic locking devices. These doors were marked with exit signage on the ED side only. The locking devices are released by key card activation only on either side and not installed in compliance with 7.2.1.6.1 or 7.2.1.6.2.

4. The linen closet adjacent X-ray room #4 was observed to be equipped with a keyed-both-sides dead bolt lock only in non-compliance with 7.2.1.5.1.

5. The east door from the Kitchen to the serving line was observed to be marked as an exit and was equipped with both a latchset and a dead bolt lock in non-compliance with 7.2.1.5.4.
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Based on random observation during the survey walk-through on the morning of 1/31/12, not all exit discharge locations are provided with illumination to comply with 38.2.8, 7.8 and 7.9. These deficiencies could affect all persons in the facility required to utilize the exit by preventing safe and unimpeded access to the public way.

Findings include:
A. The exit discharge lighting provided at the north exit discharge was one single-lamp fixture not in accordance with 7.8.1.4. Surveyor notes that lighting on an emergency power supply is not required per the requirements of 38.2.9.1.

B. The main entry/exit discharge was not provided with lighting at the exterior to comply with 7.8.1.4.
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Based on random observation during the survey walk-through on the morning of 1/31/12, not all exit discharge locations are provided with illumination to comply with 39.2.8, 7.8 and 7.9. These deficiencies could affect all persons in the facility required to utilize the exit by preventing safe and unimpeded access to the public way.

Findings include:
A. The exit discharge lighting provided at the east exit discharges was one single-lamp fixture not in accordance with 7.8.1.4. Surveyor notes that lighting on an emergency power supply is not required per the requirements of 39.2.9.1.
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Based on random observation during the survey walk-through, exit signs were not fully visible to designate the path of egress in all cases in accordance with 18.2.10.1. and 7.10. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by preventing those occupants from readily identifying the path to an available exit from the building.

Findings include:
A. Egress paths were observed that are not identified by fully visible exit signs as required by 7.10.1. Locations observed include:

1. Exit signage was not provided at the east and west ends of the north corridor area of the 3rd floor Chest Pain Clinic area to identify exit paths.

2. Exit signage was not provided at northwest corner of the 1st floor OB unit to identify the second path.

3. Exit signage was not provided outside CT Scan 2 directing exiting to the east.

4. Exit signage was not provided at the Ambulance entry area to direct occupants to the second or other exits.
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Based on random observation during the survey walk-through, not all portions of the facility's fire alarm system are installed and maintained in accordance with NFPA 72 1999. These deficiencies can prevent the intiation of the fire alarm system designed to provide early detection of fire conditions.

Findings include:
A. The smoke detector located within the 2nd floor Electrical room adjacent Stair D was not mounted at the ceiling to comply with NFPA 72-1999, 2-3.4.3.1.

B. The shutter provided at the Imaging Center reception window had smoke detection designated for the operation of the door located within the Waiting area but not confirmed to be located within 5' of the opening to comply with NFPA 72-1999, 2-10.6.5.1.1.

.C. The corridor visual notification devices in the corridors are not synchronized as required by NFPA-72, Section 4-4.4.2.3.
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Based on random observation during the survey walk through, not all portions of the sprinkler system are installed in accordance with NFPA-13 (1999).

Findings include:
A. The 2nd floor Med Prep room remodel project has removed the ceiling as part of the project without relocation of the sprinkler heads to comply with NFPA 13. Although staff indicated that interim life safety measures were implemented, the area as observed is not separated from the above ceiling cavity of all adjacent areas. This condition compromises the effective operation of the sprinkler system.


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B. The fire pump remote alarm panel does not have the four alarm points required by NFPA 20-7-4.7. This could effect the safety of all occupants of the building if the sprinkler system did not operate as required during a fire.
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Based on document review and staff interview the surveyor finds the facility does not conduct a from the floor inspection of the installed sprinkler system annually. (NFPA 25, 1998, 2-2.1.1).
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Based on document review and staff interview it is not documented that the annual fire pump flow test was conducted under emergency power. (NFPA 25, 1998, 5-3.3.4)
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Based on random observation during the survey walk-through, not all means of egress are maintained free of obstructions which reduce the width of the corridors in non-compliance with 7.1.10. These deficiencies could affect all patients in the location of occurrence, as well as any staff and visitors present, by preventing or impeding those occupants from reaching an exit from the building.

Findings include:
A. Two stretchers were observed to be stored along the corridor outside X-ray room 2.

Based on random observation during the survey walk-through, not all portable medical gases are stored in accordance with NFPA 99.

Findings include:
A. Medical gas tanks were observed being stored with combustibles within 5'-0" not in compliance with NFPA 99 1999 8-3.1.11.2(c)(2). This deficiency could affect all occupants of the smoke compartment they are located in because the medical gas tanks could contribute to any combustion which might occur with the adjacent combustible materials. Locations observed include but are not necessarily limited to the following:

1. The 1st floor Clean storage room at the OR Prep area was observed to be storing oxygen cylinders within 5' of combustibles.

2. The 1st floor Respiratory Therapy storage room was observed to be storing 14 E-size oxygen cylinders within 5' of combustibles.

3. The unobserved 1st floor elevator lobby alcove open to the corridor near Imaging area was observed to be storing 5 E-size cylinders on the wheelchairs.

4. The Emergency Dept. Pixys machine room was observed to be storing 6 E-size oxygen cylinders within 5' of combustibles.
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Based on random observation during the survey walk-through, not all portions of the facility's piped medical gas system are installed in accordance with NFPA 99-1999.

Findings include:
A. During the survey of the 1st floor OB unit, the medical gas piping observed above the ceiling in room 101 and in the corridor outside rooms 101 & 102 was observed without labeling to identify the medical gas in accordance with 4-3.1.2.14 (a). The extent of the condition was not determined and may be typical throughout.
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Based on random observationduring the survey walk-through the generator equipment does not meet all requirements of NFPA-110. These deficiencies could affect building occupants because generators would not be able to be shut down remotely in the event of a catastophic failure which may allow damage to extend beyond the generator enclosure.

Findings include:
A. The building emergency generators did not have remote shut down switches to comply with NFPA-110, Section 3-5.5.6.
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Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

B. Water stained ceiling tile was observed in the Chest Pain Clinic east of the nurse station. The stained tile has the potential for mold growth and is an infection control risk.

C. Floor/wall base was observed to be missing at room 219 where a replacement fan coil unit had been installed. Cracks & crevices at the floor and wall are not cleanable and l have the potential to harbor bacterial growth.


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D. By direct observation the surveyor finds the use of portable dialysis machines are not connected to the water supply and discharge drainage system in compliance with the requirements from recognized sanitation and plumbing codes. It was not obvious that a reduced pressure principle backflow preventer is installed on the water supply inlet of the machine. The water supply tubing for the machine was connected to the shower head and to the lavatory spout in the patient bath room. The machine discharge was not provided with an individual indirect waste connection to the sanitary drainage system. The discharge tubing from the machine was coiled into the bowl of the water closet. This installation could cause possible contamination of the potable water supply and the dialysis machine compromising the care and safety of the patient and the facility.

A. Based upon direct observation during the survey walk-through, eye wash devices in the OR area are installed on the sink faucet spout and do not appear to have water tempering and pressure reducing devices as required by the recognized plumbing code and ANSI Z358.1-1998.


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B. By direct observation the eye wash devices in the Laboratory are installed on the sink faucet spout and do not appear to have water tempering and pressure reducing devices as required by the recognized plumbing code and ANSI Z358.1-1998.
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Based on random observation during the survey walk-through the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised by the loss of a single transfer switch.

Findings include:
A. Life safety panels EBE2 in the mechanical room near the generator room, EMBN1 in the fire pump room, and other life safety panels throughout the main building are serving loads other than those specifically allowed by NFPA70, Section 517-32.

B. Some of the critical panels were serving loads other than those allowed on the critical power system. Critical panel MRIEM1 had a circuit feeding the fire alarm system, (which should be on the life safety panel), and several circuits feeding hot water pumps, (which should be served by the equipment system). This does not meet the requirements of NFPA70, Section 517-33.

C. The fire alarm circuit breakers in the Life Safety Panels are not marked red and do not have a locking device on the breakers to comply with NFPA-72, Section 1-5.2.5.
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Based on random observation during the survey walk-through not all portions of the building systems are installed in accordance with NFPA 70 (1999).

Findings include:
A. Normal power receptacles were not provided in C-section rooms, operating rooms, chest pain clinic rooms, the nurseries, and ICU rooms as required by NFPA-70, Section 517-19, and NFPA-99, Section 3-3.2.1.2(a)1. In the event of a transfer switch failure upon return to normal power, these rooms could be left with no power.
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Based on random observation during the survey walk through, portions of the elevator control system are not installed in accordance with ASME A17.1. Any elevator user could be put in a dangerous situation without the proper safety devices installed.

Findings include:
A. The surveyor observed that the elevator machine rooms were equipped with sprinklers, but there was not a heat detector within 2' of each sprinkler head to initiate a shunt trip device to automatically disconnect the main power supply prior to the application of water in the machine room or shaft as required by ASME A17.1-102.2.c.3.

B. The surveyor did not find a single lockable disconnect for each elevator's emergency lighting, receptacle, and ventilation as required by NFPA-70, Section 620-53.

C. The surveyor did not find that the disconnect for the emergency lighting and controls for the hydraulic elevators were properly labeled in accordance with NFPA-70, Section 620-53.

D. The soiled elevator was not equipped with elevator recall system as required by ASME A17.1-211.3.
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Based on random observation during the survey walk-through, staff interview and review of Life Safety Plans, the construction of the walls to provide the separation between the mobile MRI/CT dock and the hospital building is not provided to maintain separation of the different construction types to comply with 19.1.6.2 and NFPA 80A. This deficiency could affect all patients in the facility, as well as any staff and visitors present, because the lack of protection of the building structure from the effects of fire exposure can cause building collapse prior to evacuation.

Findings include:
A. A 2-hour barrier was not observed to be maintained between the hospital and the mobile MRI/CT unit. The dock vestibule exterior wall contained a non-rated exterior overhead door. Alternatively, the interior walls of the dock vestibule were not confirmed to be of minimum 2-hour rated construction including a 1 1/2-hour rated door assembly. The corridor wall was not constructed to the deck above. The vestibule was observed to be utilized as an equipment storage room at the time of the survey.
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Based on random observation during the survey walk-through, the construction type of the building is not maintained in accordance with, 19.1.6.2. This deficiency could affect all in-patients in the facility, as well as any staff and visitors present, because the lack of protection of the building structure from the effects of fire exposure can cause building collapse prior to evacuation.

Findings include:
A. Structural steel framing was observed in the Boiler room that was missing fireproofing. Observed location was primarily near the chiller equipment.
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Based on random observation during the survey walk-through, not all exit access corridors are separated from use areas in accordance with 19.3.6.1. These deficiencies could affect all beds in the smoke compartment, as well as any staff and visitors present, because the lack of smoke detectors could result in delayed activation of the fire alarm system and smoke compromising the facility's exit access corridors.

Findings include:
A. The nourishment alcove within the 2nd floor OB unit was observed to be open to the corridor and not protected with smoke detection in accordance with 19.3.6.1 Exception No. 1.

B. The Emergency Dept. contained treatment stations open to the corridor in non-compliance with 19.3.6.1. During staff interview and review of the Life Safety reference plans, the ED was not defined as a suite to allow the open stations.
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Based on random observation during the survey walk-through, not all doors in exit access corridors are in compliance with 19.3.6.3. This deficiency could affect all patients within the 3rd floor north smoke compartmentof the facility, as well as any staff and visitors present, by allowing smoke to pass from one side of the corridor wall to the other; either compromising the building's exit access corridors or the rooms occupied.

Findings include:
A. 3rd floor Patient room 333 door was equipped with only keyed dead bolt lock hardware which does not self-latch upon closing to comply with 19.3.6.3.2. The dead bolt lock can not be utilized in combination with a latchset which would constitute hardware requiring more than one operation to release the door in non-compliance with 7.2.1.5.4.

B. 2nd floor ICU Patient room #12 is equipped with a pair of doors which can not be maintained in a latched condition upon closing to comply with 19.3.6.3.2.

C. Horizontal sliding doors were not provided with positive latching to comply with 19.3.6.3.2. These doors were not otherwise defined as being located with suites on the Life Safety Reference plans. These door conditions were observed in the following areas:

1. OR Prep area
2. Chest Pain Clinic area
3. Emergency Dept. area
4. Imaging check-in area.
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Based on random observation during the survey walk-through, vertical openings between floors are not protected to comply with 19.3.1.1. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, because the lack of protection can allow smoke and fire to migrate from one floor to another.

Findings include:
A. The 3rd floor Electrical room adjacent Stair D was observed to have wiring thru a floor sleeve not completely sealed in accordance with fire/smoke rated tested design assemblies.

B. The ducts from the 2nd floor center large Mechanical room penetrated the floor near the southeast corner and could not be confirmed to be equipped with fire dampers to comply with 19.3.1.1 and NFPA 90A because access doors were not observed in the ducts in the Mechanical room.
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Based on random observation during the survey walk-through, not all doors in smoke barrier walls are confirmed to be in compliance with 19.3.7.6, 8.3.4.3 and 7.2.1.9.2. This deficiency could affect all patients on either side of the 1st floor smoke barrier between the compartments containing the OR/Recovery and the OR Prep areas, as well as any staff and visitors present, by allowing smoke to pass from one side of the smoke barrier wall to the other; compromising either smoke compartment.

Findings include:
A. The door in the smoke barrier between the OR Recovery room and the OR Prep area could not be confirmed to drop out during fire alarm activation to maintain the door in a closed position.
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Based on random observation during the survey walk-through on the morning of 1/31/12, not all hazardous areas are separated from the remainder of the building in accordance with 38.3.2.1 and 8.4.1. These deficiencies could affect all patients of the facility, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into the building's exit access.

Findings include:
A. The unsprinklered fuel fired furnace rooms (two rooms) were observed not to be 1-hour enclosed with a minimum 3/4-hour fire rated self-closing door to comply with 8.4.1.2.

B. The unsprinklered Janitor room containing materials having a greater degree of hazard than that normal to the general occupancy of the building was observed not to be 1-hour enclosed with a minimum 3/4-hour fire rated self-closing door to comply with 8.4.1.2.

C. The unsprinklered Supply storage room containing materials having a greater degree of hazard than that normal to the general occupancy of the building was observed not to be 1-hour enclosed with a minimum 3/4-hour fire rated self-closing door to comply with 8.4.1.2.
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Based on random observation during the survey walk-through on the morning of 1/31/12, not all hazardous areas are separated from the remainder of the building in accordance with 39.3.2.1 and 8.4.1. These deficiencies could affect all patients of the facility, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into the building's exit access.

Findings include:
A. The unsprinklered electric furnace room is also utilized as the Janitor supply storage room containing materials having a greater degree of hazard than that normal to the general occupancy of the building and was observed not to be 1-hour enclosed with a minimum 3/4-hour fire rated self-closing door to comply with 8.4.1.2.

B. The unsprinklered Hydro Therapy room is also utilized as a general storage room containing materials having a greater degree of hazard than that normal to the general occupancy of the building and was observed not to be 1-hour enclosed with a minimum 3/4-hour fire rated self-closing door to comply with 8.4.1.2. This room was also observed to be the storage location for an E-size oxygen cylinder not separated from combustibles to comply with NFPA 99-1999, 8-3.1.11.2(c).

C. The unsprinklered southeast storage room containing materials having a greater degree of hazard than that normal to the general occupancy of the building was observed not to be 1-hour enclosed with a minimum 3/4-hour fire rated self-closing door to comply with 8.4.1.2.
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Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1 and 8.4.1. These deficiencies could affect all patients within the smoke compartment of the location, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into the building's exit access corridors in the event of a fire condition.

Findings include:
A. The 3rd floor Equipment storage room on the west corridor was observed to have a door which did not self-close to a latched condition.

B. The 2nd floor OB Soiled Food cart/Trash holding room near room 283 was observed not to have a self-closing door.

C. The 1st floor OR Janitor room storing combustibles was observed not to have a door which did not self-close to a latched condition.
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Based on random observation during the survey walk-through, not all exit or exit access doors are arranged so that exits are readily accessible at all times in accordance with 19.2.1 and Chapter 7. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the building.

Findings include:
A. Doors equipped with magnetic locking devices do not comply with all requirements of 19.2.2.2.4 and 7.2.1.6. Conditions and locations observed:

1. The single swing cross corridor doors between the main ED area and the "Team C" area are equipped with magnetic locking devices. Although the locks were not functioning at the time of the survey and their purpose was not known by staff, they were not installed in compliance with 7.2.1.6.1 or 7.2.1.6.2.

2. The north doors of the ED area are a pair of single swing doors swinging into the ED area. These doors were marked with exit signage on the ED side only. Compliance with 7.2.1.4.2 for the doors to swing in the direction of travel is not met.

3. The north doors of the ED area are a pair of single swing doors swinging into the ED area and are equipped with magnetic locking devices. These doors were marked with exit signage on the ED side only. The locking devices are released by key card activation only on either side and not installed in compliance with 7.2.1.6.1 or 7.2.1.6.2.

4. The linen closet adjacent X-ray room #4 was observed to be equipped with a keyed-both-sides dead bolt lock only in non-compliance with 7.2.1.5.1.

5. The east door from the Kitchen to the serving line was observed to be marked as an exit and was equipped with both a latchset and a dead bolt lock in non-compliance with 7.2.1.5.4.
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Based on random observation during the survey walk-through on the morning of 1/31/12, not all exit discharge locations are provided with illumination to comply with 38.2.8, 7.8 and 7.9. These deficiencies could affect all persons in the facility required to utilize the exit by preventing safe and unimpeded access to the public way.

Findings include:
A. The exit discharge lighting provided at the north exit discharge was one single-lamp fixture not in accordance with 7.8.1.4. Surveyor notes that lighting on an emergency power supply is not required per the requirements of 38.2.9.1.

B. The main entry/exit discharge was not provided with lighting at the exterior to comply with 7.8.1.4.
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Based on random observation during the survey walk-through on the morning of 1/31/12, not all exit discharge locations are provided with illumination to comply with 39.2.8, 7.8 and 7.9. These deficiencies could affect all persons in the facility required to utilize the exit by preventing safe and unimpeded access to the public way.

Findings include:
A. The exit discharge lighting provided at the east exit discharges was one single-lamp fixture not in accordance with 7.8.1.4. Surveyor notes that lighting on an emergency power supply is not required per the requirements of 39.2.9.1.
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Based on random observation during the survey walk-through, exit signs were not fully visible to designate the path of egress in all cases in accordance with 18.2.10.1. and 7.10. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by preventing those occupants from readily identifying the path to an available exit from the building.

Findings include:
A. Egress paths were observed that are not identified by fully visible exit signs as required by 7.10.1. Locations observed include:

1. Exit signage was not provided at the east and west ends of the north corridor area of the 3rd floor Chest Pain Clinic area to identify exit paths.

2. Exit signage was not provided at northwest corner of the 1st floor OB unit to identify the second path.

3. Exit signage was not provided outside CT Scan 2 directing exiting to the east.

4. Exit signage was not provided at the Ambulance entry area to direct occupants to the second or other exits.
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Based on random observation during the survey walk-through, not all portions of the facility's fire alarm system are installed and maintained in accordance with NFPA 72 1999. These deficiencies can prevent the intiation of the fire alarm system designed to provide early detection of fire conditions.

Findings include:
A. The smoke detector located within the 2nd floor Electrical room adjacent Stair D was not mounted at the ceiling to comply with NFPA 72-1999, 2-3.4.3.1.

B. The shutter provided at the Imaging Center reception window had smoke detection designated for the operation of the door located within the Waiting area but not confirmed to be located within 5' of the opening to comply with NFPA 72-1999, 2-10.6.5.1.1.

.C. The corridor visual notification devices in the corridors are not synchronized as required by NFPA-72, Section 4-4.4.2.3.
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Based on random observation during the survey walk through, not all portions of the sprinkler system are installed in accordance with NFPA-13 (1999).

Findings include:
A. The 2nd floor Med Prep room remodel project has removed the ceiling as part of the project without relocation of the sprinkler heads to comply with NFPA 13. Although staff indicated that interim life safety measures were implemented, the area as observed is not separated from the above ceiling cavity of all adjacent areas. This condition compromises the effective operation of the sprinkler system.


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B. The fire pump remote alarm panel does not have the four alarm points required by NFPA 20-7-4.7. This could effect the safety of all occupants of the building if the sprinkler system did not operate as required during a fire.
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Based on document review and staff interview the surveyor finds the facility does not conduct a from the floor inspection of the installed sprinkler system annually. (NFPA 25, 1998, 2-2.1.1).
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Based on document review and staff interview it is not documented that the annual fire pump flow test was conducted under emergency power. (NFPA 25, 1998, 5-3.3.4)
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Based on random observation during the survey walk-through, not all means of egress are maintained free of obstructions which reduce the width of the corridors in non-compliance with 7.1.10. These deficiencies could affect all patients in the location of occurrence, as well as any staff and visitors present, by preventing or impeding those occupants from reaching an exit from the building.

Findings include:
A. Two stretchers were observed to be stored along the corridor outside X-ray room 2.

Based on random observation during the survey walk-through, not all portable medical gases are stored in accordance with NFPA 99.

Findings include:
A. Medical gas tanks were observed being stored with combustibles within 5'-0" not in compliance with NFPA 99 1999 8-3.1.11.2(c)(2). This deficiency could affect all occupants of the smoke compartment they are located in because the medical gas tanks could contribute to any combustion which might occur with the adjacent combustible materials. Locations observed include but are not necessarily limited to the following:

1. The 1st floor Clean storage room at the OR Prep area was observed to be storing oxygen cylinders within 5' of combustibles.

2. The 1st floor Respiratory Therapy storage room was observed to be storing 14 E-size oxygen cylinders within 5' of combustibles.

3. The unobserved 1st floor elevator lobby alcove open to the corridor near Imaging area was observed to be storing 5 E-size cylinders on the wheelchairs.

4. The Emergency Dept. Pixys machine room was observed to be storing 6 E-size oxygen cylinders within 5' of combustibles.
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Based on random observation during the survey walk-through, not all portions of the facility's piped medical gas system are installed in accordance with NFPA 99-1999.

Findings include:
A. During the survey of the 1st floor OB unit, the medical gas piping observed above the ceiling in room 101 and in the corridor outside rooms 101 & 102 was observed without labeling to identify the medical gas in accordance with 4-3.1.2.14 (a). The extent of the condition was not determined and may be typical throughout.
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Based on random observationduring the survey walk-through the generator equipment does not meet all requirements of NFPA-110. These deficiencies could affect building occupants because generators would not be able to be shut down remotely in the event of a catastophic failure which may allow damage to extend beyond the generator enclosure.

Findings include:
A. The building emergency generators did not have remote shut down switches to comply with NFPA-110, Section 3-5.5.6.
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Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

B. Water stained ceiling tile was observed in the Chest Pain Clinic east of the nurse station. The stained tile has the potential for mold growth and is an infection control risk.

C. Floor/wall base was observed to be missing at room 219 where a replacement fan coil unit had been installed. Cracks & crevices at the floor and wall are not cleanable and l have the potential to harbor bacterial growth.


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D. By direct observation the surveyor finds the use of portable dialysis machines are not connected to the water supply and discharge drainage system in compliance with the requirements from recognized sanitation and plumbing codes. It was not obvious that a reduced pressure principle backflow preventer is installed on the water supply inlet of the machine. The water supply tubing for the machine was connected to the shower head and to the lavatory spout in the patient bath room. The machine discharge was not provided with an individual indirect waste connection to the sanitary drainage system. The discharge tubing from the machine was coiled into the bowl of the water closet. This installation could cause possible contamination of the potable water supply and the dialysis machine compromising the care and safety of the patient and the facility.

A. Based upon direct observation during the survey walk-through, eye wash devices in the OR area are installed on the sink faucet spout and do not appear to have water tempering and pressure reducing devices as required by the recognized plumbing code and ANSI Z358.1-1998.


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B. By direct observation the eye wash devices in the Laboratory are installed on the sink faucet spout and do not appear to have water tempering and pressure reducing devices as required by the recognized plumbing code and ANSI Z358.1-1998.
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Based on random observation during the survey walk-through the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised by the loss of a single transfer switch.

Findings include:
A. Life safety panels EBE2 in the mechanical room near the generator room, EMBN1 in the fire pump room, and other life safety panels throughout the main building are serving loads other than those specifically allowed by NFPA70, Section 517-32.

B. Some of the critical panels were serving loads other than those allowed on the critical power system. Critical panel MRIEM1 had a circuit feeding the fire alarm system, (which should be on the life safety panel), and several circuits feeding hot water pumps, (which should be served by the equipment system). This does not meet the requirements of NFPA70, Section 517-33.

C. The fire alarm circuit breakers in the Life Safety Panels are not marked red and do not have a locking device on the breakers to comply with NFPA-72, Section 1-5.2.5.
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Based on random observation during the survey walk-through not all portions of the building systems are installed in accordance with NFPA 70 (1999).

Findings include:
A. Normal power receptacles were not provided in C-section rooms, operating rooms, chest pain clinic rooms, the nurseries, and ICU rooms as required by NFPA-70, Section 517-19, and NFPA-99, Section 3-3.2.1.2(a)1. In the event of a transfer switch failure upon return to normal power, these rooms could be left with no power.
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Based on random observation during the survey walk through, portions of the elevator control system are not installed in accordance with ASME A17.1. Any elevator user could be put in a dangerous situation without the proper safety devices installed.

Findings include:
A. The surveyor observed that the elevator machine rooms were equipped with sprinklers, but there was not a heat detector within 2' of each sprinkler head to initiate a shunt trip device to automatically disconnect the main power supply prior to the application of water in the machine room or shaft as required by ASME A17.1-102.2.c.3.

B. The surveyor did not find a single lockable disconnect for each elevator's emergency lighting, receptacle, and ventilation as required by NFPA-70, Section 620-53.

C. The surveyor did not find that the disconnect for the emergency lighting and controls for the hydraulic elevators were properly labeled in accordance with NFPA-70, Section 620-53.

D. The soiled elevator was not equipped with elevator recall system as required by ASME A17.1-211.3.
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