HospitalInspections.org

A. Corrected 07/16/2014
B. Corrected 07/16/2014
C. Corrected 07/16/2014
D. Corrected 07/16/2014


16339


E. Corrected 07/16/2014


20224


Based on random observation during the survey walk through while accompanied by engineering staff, not all vertical openings are protected to comply with 19.3.1 and 8.2.5.2. This could contribute to the lack of containment during a fire event. These deficiencies could affect any patients, staff, or visitors in the building by permitting smoke and fire to pass between building stories.

Findings include:

F. CORRECTED 07/16/2014

G. 05/08/13 at 2:30 pm, a duct was observed above the ceiling of the 12th floor at the intersection of corridor 1236 D and 1201 G (as shown on the facility provided Life Safety plan dated 2/22/13), which penetrates the floor of the Penthouse above (near Passage P 014-as shown on the facility Life Safety plans dated 2/22/13). This penetration lacks the installation of a fire damper within the plane of the floor to comply with NFPA 90 A 1999 3-3.2.

A. Corrected 11/01/13
B. Corrected 07/15/2014
C. Corrected 11/01/13
D. Corrected 11/01/13
E. Corrected 07/15/2014
F. Corrected 07/15/2014
G. Corrected 07/15/2014
H. Corrected 07/15/2014
I. Corrected 07/15/2014
J. Corrected 07/15/2014
K. Corrected 07/15/2014


16339

L. Corrected 07/15/2014
M. Corrected 07/15/2014
N. Corrected 07/15/2014
O. Corrected 07/15/2014
P. Corrected 07/15/2014
Q. Corrected 07/15/2014


20224


Based on random observation during the survey walk-through while accompanied by engineering staff, 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, staff and visitors within the smoke compartment, by allowing smoke and fire to escape from hazardous rooms into the exit access corridor during a fire emergency.

Findings include:

R. Corrected 07/15/2014
S. Corrected 07/15/2014
T. Corrected 07/15/2014

U. 05/08/13 at 2:15 pm 1st floor Surgery Sterile Core contains numerous shelves and material storage and it is not designated as a hazardous area to comply with 8.4.1. It does not have perimeter smoke tight walls with doors with a means for maintaining a closed position to comply with 19.3.2.1, 8.4.1.2 and 8.2.4.3.5.

A. 11/01/13: After reviewing the currently cited deficiencies in the field and the current PoC for K033, K034 and K038, the surveyor finds that the provider lacks an exit study by floor which clearly identifies the exits for each floor and an evaluation of each exit for compliance with 7.7.1 and 7.7.2, based on the requirements for each floor.

B. Multiple floor plans available onsite identify the use of horizontal exits on multiple floors. Based on previous submittals, the surveyor observes that some of these horizontal exits are required exits. However, the fire barriers which define these designated horizontal exits are not shown continuously from foundation to roof in accordance with 7.2.4.3.1 (NFPA 101). Accordingly, under 7.2.4.3.1 (c) all exits must discharge directly to the outside and most or all of the required exit stairs may not use 7.7.2 for compliance (see "A" above).


13755


Based on observation during the survey walk-through, not all exits are enclosed with construction having a fire resistance rating to comply with 19.3.1.1 and 8.2.5.2 and 7.1.3.2. 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. Corrected 07/16/2014
B. Corrected 07/16/2014
C. Corrected 07/16/2014

D. At 9:30am on 5/9/13 it was observed that the exit passageway serving as the discharge for Stair #4 leads through Stair #14A.

1. Stair 14A contains elevator openings
(do not comply with 9.4.7) and has the
elevator machine room (considered a
normally unoccupied space) accessing
the stair in noncompliance with
7.1.3.2.1(d). Stair #13A also has these
conditions.

2. The exit passageway does not terminate
directly at a public way or at an exterior
exit discharge to comply with 7.7.1 and
7.1.3.2.2 (without going through Stair
14A).

3. (Modified 11/01/13): The exit
passageway contains recessed medical
gas zone valves in the enclosing walls.
The provider lacks information which
demonstrates how fire rating for the
walls are maintained at these zone valve
boxes. This is not a deficiency if this
space is not an exit passageway.

4. The exit passageway has openings onto
it from normally unoccupied spaces
such as the Cath Lab storage rooms and
telecom/electrical rooms in
noncompliance with 7.1.3.2.1(d).


16339


E. Corrected 07/15/2014
F. Corrected 07/15/2014


20224

Based on random observation during the survey walk through, while accompanied by engineering staff, not all designated exit stair enclosures provide a protected means of egress to an exit discharge. This condition may affect patients, staff and visitors on the upper floors from a safe means of egress during a fire/smoke event.

G. 05/07/13, at 11:15 am The Life Safety plans indicate that Stair # 3 and Stair # 9 are both served by a 2-hour fire rated exit passageway on the 1st floor (North side). The exit passageway does not comply with 19.3.1.1 due to the following:

1. A Storage room opens into the exit
passageway which does not comply
with 7.1.3.2.1 (d) which limits openings
into an exit passageway for those
necessary for access from occupied
spaces.

2. Corrected 2/9/15


H. Corrected 2/9/15

A. Corrected 07/16/2014
B. Corrected 07/16/2014


13755


A. Corrected 07/16/2014


16339


B. Corrected 07/16/2014


20224


Based on random observation during the survey walk-through while accompanied by engineering staff, exit access was not readily accessible at all times in accordance with 7.1 and 19.2.1. 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 utilizing an available exit from the building during an event requiring such exiting.

Findings include:

C. Deleted 10/31/13

D. Corrected 07/15/2014

E. 05/08/13 10:15 am, 3rd floor LDR wing, Stair #5 and Stair #6 both contain magnetic locking devices and alarms. These doors do have a delayed egress device. However, the doors do not comply with 7.2.1.6.1 for identification signage.

F. Corrected 2/9/15

Based upon observation during the survey walk-through, not all exit access doors provide a minimum 32" clear width to comply with 19.2.3.5. Locations observed include:

Findings include:

A. 9:30am on 5/9/13 it was observed that the 1st floor level pair of doors leading to the southeast glass enclosed stair through the 2-hour rated wall were provided with a center mullion which reduced the clear width of each door leaf opening to less than 32".
(Modified 07/16/2014) One pair of doors are corrected, the other pair are not.


16339


B. Corrected 07/16/2014

From random observation during the survey walk-through while accompanied by the Facilities Representative not all designated suites comply with 19.2.5 concerning the remotely located exit access doors. This condition may affect patients, staff and visitors during a fire emergency by increasing the amount of time and travel distance required to reach an exit access corridor.

Findings include:

A. (Modified 11/01/13): 05/08/13 at 2:50 1st floor ICU was identified as a suite of approximately 4,500 square feet with two means of egress, which are both located on the West corridor wall, and do not comply with 19.2.5.2 and 7.5.1.4 for the minimum distance required (remoteness) between means of egress doors from this space.

B. Corrected 07/16/2014

Based on observation during the survey walk-through, exit signs were not provided, were not fully visible, or incorrectly identified paths of egress in accordance with 19.2.10.1. 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. Exit signs are not provided to identify the 2nd means of egress from corridors to comply with 19.2.5.9. Locations noted include the following:

1. It was observed at 2:30pm on 5/6/13 that the corridors north and south of the center meeting room at the Penthouse level lack exit signage on the corridor side of four doors to define the egress path to the other stair serving the floor level.

2. It was observed at 2:30pm on 5/7/13 that the 4th floor Paint Shop elevator lobby area lacked exit signage to define the available path of egress.

3. It was observed at 10:30am on 5/8/13 that the 4th floor corridors on each side of the smoke barrier doors near 411 lacked exit signage to identify the egress paths to a second exit.

4. It was observed at 10:45am on 5/8/13 that the 4th floor rooftop court utilized by patients is not provided with exit signage to identify the required egress paths.

5. Corrected 07/16/2014

6. It was observed at 11:00am on 5/8/13 that the exit signage at the 2nd floor cafeteria cashier area is not directional to make clear the path to the Stairs and may inadvertently direct occupants into the serving line room.

7. It was observed at 1:30pm on 5/8/13 that the corridors north and south of the 1st floor Emergency Dept. lack exit signage to identify two compliant available paths of egress when cross corridor doors close.

8. It was observed at 1:35pm on 5/8/13 that the corridors outside the 1st floor G.I. Procedure room lack exit signage to identify two compliant available paths of egress when cross corridor doors close.

9. It was observed at 1:40pm on 5/8/13 that the corridor outside the Blood Bank on the 1st floor lacks exit signage to identify two compliant available paths of egress when cross corridor doors close.

10. It was observed at 2:00pm on 5/8/13 that the corridor west of the 1st floor Cashier suite lacks exit signage to identify two compliant available paths of egress when cross corridor doors close.

11. It was observed at 2:15pm on 5/8/13 that the Main Lobby lacks exit signage to identify a 2nd path of exit.

12. It was observed at 2:45pm on 5/8/13 that the corridor west of the Ear Nose & Throat Center lacks exit signage to identify two compliant available paths of egress when cross corridor doors close.

11/01/13: A 6/30/2015 correction date is proposed. What specfic interim life safety measures for location are proposed until correction?

B. Exit signs are inappropriately placed to define available exit paths. Locations observed include the following:

1. Corrected 07/15/2014
2. Corrected 07/15/2014

3. It was observed at 10:15am on 5/9/13 that the Basement Mezzanine level (identified as an Exit Passageway) is provided with exit signage at the entrance to the Stair #5 exit stair. The door at this level swings against the direction of egress travel identified by the exit signage in noncompliance with 7.2.1.4.3. The 1st floor level of Stair #5 is marked within the stair with exit signage to identify the 1st floor as the level of exit discharge but the swing of the door at this level does not swing in the direction of egress travel to comply with 7.2.1.4.3. An interrupter gate is not provided at a discharge level to comply with 7.7.3 to prevent travel beyond the discharge level. The exit signage and the door swings did not match to determine which level was the intended discharge level.

4. It was observed at 10:30am on 5/9/13 that directional exit signage provided at the west end of the Basement Mezzanine level exit passageway directs the exit path to both Stair #7 and Stair #8. Stair #8 serves as an exit for the Basement level and discharges to the Basement Mezzanine level exit passageway which leads to Stair #7. Stair #8 is not an exit for the Basement Mezzanine level exit passageway.

5. It was observed at 11:30am on 5/9/13 that directional exit signage provided at the west end door of the Basement level material management storage area directs the exit path north and south prior to proceeding through the door which leads to the corridor leading to exit Stair #8. The directional exit sign at this location is not appropriate.

11/01/13: A 6/30/2015 correction date is proposed. What specfic interim life safety measures for location are proposed until correction?


16339

Based on random observation during the survey walk-through on 05/08/13, exit signs did not identify available paths of egress in all cases in accordance with 19.2.5.9, 19.2.10.1. and 7.10. These deficiencies could affect all patients in the smoke compartment, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the smoke compartment or building.

Findings include:

C. Corrected 07/15/2014

D. On the afternoon of 05/07/13, Building - 01, Fifth Floor-Rehabilitation Floor: The east exit access corridor near Room 512 was not provided with fully visible exit signage from all points in the corridor.

E. Corrected 07/15/2014

11/01/13: A 6/30/2015 correction date is proposed. What specfic interim life safety measures for location are proposed until correction?

Based on random observation during the survey walk-through while accompanied by facility staff, patient sleeping rooms do not have visual access to the outside to comply with 19.3.8. These deficiencies could affect all patients within the area of the facility, as well as any staff and visitors present, by allowing those occupants to be trapped in a smokey fire incident.

The finding is:

A. 05/08/13 at 2:55 pm, 1st floor ICU patient rooms located along an interior wall of the building, on the South side of the suite do not have an outside window.

11/01/13: The 1st Floor ICU is cited for multiple deficiencies, not limited to K018, K029, K038 and K055. The PoC includes a 7/31/14 correction date but does not include a phasing schedule which identifies:

1. The submittal date for construction documents for a project or multiple projects to correct the above

2. Start date for construction project(s)

A. Corrected 07/15/2014


14416

B. Mechanical room #248: The surveyor did not find the installation of fire dampers for the duct penetration to the floor below or to the floor above from this second floor mechanical room. Through staff interview it was determined that fire dampers and protections are not provided for the duct penetrations of supply and return/exhaust ventilation systems originating in this second floor mechanical space. (NFPA 90A, 1999, 3-3.2)

C. On review of the fire and smoke damper inspection dated December 2008 there was no evidence to indicate deficiencies cited in that inspection have been corrected. The 4 year inspection has not been competed at this time. The facility indicated they would opt for the 6 year CMS Categorical Waiver for damper inspection and maintenance. However, correction of the 2008 deficiencies need to be completed.

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.

11/01/13: Adequate interim life safety measures were not implemented. See each K-tag; a response is required where cited under each K-tag.

Based on random observation during the survey walk-through while accompanied by a member of the building engineering staff, the surveyor found that 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. Corrected 07/16/2014

B. Critical panels PHCLA, PHCLB, BCLC (in loading dock area), and 2CLF are designated as critical panels, but they are serving mostly equipment and do not meet the requirements of NFPA-70, Section 517-33 and 517-34.

A. Corrected 11/01/13
B. Corrected 07/16/2014
C. Corrected 11/01/13
D. Corrected 11/01/13
E. Corrected 07/16/2014
F. Corrected 07/16/2014


17659


Based on random observation during the survey walk-through while accompanied by a member of the building engineering staff, the surveyor found that not all portions of the building systems are installed in accordance with NFPA 70 (1999).

Findings include:

G. Normal power receptacles were not provided in the first floor endoscopy room, cystoscopy room, and in pediatrics rooms 629 and 630, treatment rooms in same day surgery 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.

H. Corrected 07/16/2014
I. Corrected 07/16/2014
J. Corrected 07/16/2014
K. Corrected 07/16/2014


20224


Based on random observation during the survey walk-through, while accompanied by engineering staff, electrical wiring and equipment was not installed and maintained in accordance with NFPA 70 National Electric Code and NFPA 101, 9.1.2. This deficiency could result in exposure of occupants to electrical shock.

Finding is:

L. Corrected 07/16/2014

M. 05/07/13 at 2:00 pm Through direct observation Normal power receptacles were not provided in the following locations to comply with NFPA-70, Section 517-19, and NFPA-99, Section 3-3.2.1.2(a)1:

1. 1st floor Operating rooms
2. 1st floor Stage I Recovery room
3. 3 rd floor Delivery rooms
4. Corrected 07/16/2014

N. Corrected 07/16/2014

Based on random observation during the survey walk-through while accompanied by a member of the building engineering staff, the surveyor found that 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. Corrected 07/16/2014
B. Corrected 07/16/2014
C. Corrected 07/16/2014

D. Based on personnel interview, including the CEO and the Director of Engineering, on 11/01/13, the provider indicates that eleven of eleven traction elevators in their facility do not comply with the automatic recall requirements to a primary floor and to an alternate floor in accordance with the requirements of ASME A17.1.
The extent of this condition was not determine by the surveyor. The surveyor also did not attempt to determine whether this condition applies to multiple hydraulic elevators.
A phasing schedule for the correction of each deficient elevator was not available.