HospitalInspections.org

K 012

Based on observation and interview, it was determined that the building construction type and height does not meet regulations on two of five building levels.

Findings include:

Observation on February 27, 2012 between 1:35 pm and 2:45 pm revealed the following floor/ceiling assemblies are not adequately sealed:
A. Deficiency #A was corrected at the time of the follow-up survey on January 8, 2013.
B. Second floor pipe chase 0242 has floor level exhaust vents that are not properly capped off (2:45 pm).

Interview with Chief Operating Officer on February 27, 2012 at 2:45 pm confirmed the unsealed floor penetrations.

Interview with Fire Marshal at the time of follow-up survey on January 8, 2013 confirmed the above deficiency is not corrected. Facility shall address all floor penetrations that may negate the 2-hour fire rated floor assembly.

K 017

Based upon observation and interview, the corridor walls do not meet the requirements of the regulations on one of five building levels.

Findings include:

Observation on February 27, 2012 at 1:15 pm revealed third floor corridor walls at Doctor Office Ward #3 has fusible link fire dampers installed throughout in the corridor walls above the ceiling tile. Facility is using corridors as a plenum-rated assembly. The fire dampers in the corridor walls would not resist the passage of smoke.

Interview with Chief Operating Officer on February 27, 2012 at 1:15 pm confirmed the corridor fire dampers do not maintain a smoke resistant corridor wall.

Interview with Fire Marshal at the time of follow-up survey on January 8, 2013 confirmed the above deficiency is not corrected. On this day, a fire safety evaluation survey was conducted by the surveyor in lieu of correction of this deficiency. Facility did not pass this evaluation survey option; therefore, the above deficiency shall stand and require correction.

K 020

Based upon observation and interview, it was determined that the vertical openings between floors are not enclosed with construction having a fire resistive rating of 1 hour on one of five building levels.

Findings include:

Observation on February 27, 2012 between 3:00 pm and 3:20 pm revealed the following vertical openings were deficient:
A. Deficiency #A was corrected at the time of the follow-up survey on January 8, 2013.
B. First floor main lobby stair tower 0100 doors (both sets) lack positive latching (3:20 pm).

Interview with Chief Operating Officer on February 27, 2012 at 3:20 pm confirmed the 2-hour fire rated shafts do not comply with regulations.

Interview with Fire Marshal at the time of follow-up survey on January 8, 2013 confirmed the above deficiency is not corrected. After the initial survey, facility chose to replace existing doors at this location. The newly purchased doors, hardware and vision panels within the doors, lack the correct fire rating for a 2-hour stair tower application.

K 144

Based on document review, observation and interview, generators are inspected weekly and exercised under load for 30 minutes per month and shall be in accordance with regulations for one of one emergency generator.

Findings include:

A. Observation on February 28, 2012 at 10:20 a.m. revealed the emergency generator remote annunciator panel lacks an audible sound when the test button is depressed. Facility shall verify the annunciator panel will sound an alarm if there are faults with the emergency generator.

Interview with Facility Maintenance Manager 1 on February 28, 2012 at 10:20 a.m. confirmed the audible sound on the remote annunciator panel did not activate when tested.

Interview with Fire Marshal at the time of follow-up survey on January 9, 2013 confirmed the above deficiency is not corrected.

B. Deficiency #B was corrected at the time of the follow-up survey on January 9, 2013.

K 144

Based upon documentation review and interview, it was determined that the facility failed to comply with regulations for one of one generator.

Findings include:

1. Deficiency #1 was corrected at the time of the follow-up survey on January 8, 2013.

2. Observation on February 28, 2012 at 11:30 am revealed that the facility lacks a remote annunciator with both audible and visual alarm signals outside of the generator area in a location readily observed by operation personal at a regular work station.

Interview with the Fire Marshal on February 28, 2012 at 11:30 am confirmed that the facility lacks a remote annunciator for the the emergency generator.

Interview with Fire Marshal at the time of follow-up survey on January 8, 2013 confirmed the above deficiency is not corrected.