HospitalInspections.org

Based on observation and interview, the facility failed to maintain the communicating opening in the two hour fire-resistant common wall on two of four floors.

Findings include:

Observation on November 3, 2010, between 9:21 AM and 10:57 AM revealed the following unsealed 2-hour fire partition penetrations:
a. 9:21 AM Zero Level corridor between B&C towers around wires, conduit, pipes, etc. and where wall meets deck above.
b. 10:11 AM 1st floor corridor between Level 1 Stairwell door across from the men's room to the corridor fire partition doors around water pipes, MC cables, wires, etc.
c. 10:57 AM 1st floor above the double doors between the pump room and ER entrance around pipes and conduit, and where the wall meets the ceiling.

Interview with the Facility Manager November 3, 2010, at at the above times confirmed the fire partition deficiencies.

Based upon observation and interview, it was determined the doors protecting corridor openings in other than hazardous areas are not substantial, nor smoke resistant as per regulations in one area in the facility.

Findings include:

Observation on November 4, 2010 at 11:15 am revealed the following;

A) The door to classroom C was being held open with an unauthorized hold open device.
B) The door to classroom B was being held open with an unauthorized hold open device.
C) The Corridor door to classroom B was being blocked open with a copier machine that would not allow the door to close.

Interview with the Facility Management and CEO on the above date and times confirmed this condition exists.

Based on observation and interview, it was determined the facility failed to maintain the proper fire resistance rating of smoke barrier walls three of four floors.

Findings include:

1. Observation on November 3, 2010, between 9:25 AM and 1:17 PM revealed the following smoke barrier wall deficiencies:

a) 9:29 AM, there were unsealed penetrations around ducts, conduit and an I Beam in the 4th Floor Rehab Room, room 466, above the bed and inside the restroom.
b) 9:43 AM, there was an unsealed smokewall penetration in the 4th floor room 457 where the curtain meets the smokewall.
c) 10:41 AM, there was an unsealed smokewall penetration in the 3rd floor room 365 near the window around a sprinkler pipe.
d) 11:01 AM, there was mineral wool used to seal penetrations where the smokewall meets the ceiling above the 3rd floor corridor doors.
e) 12:21 PM, there was a 4-inch unsealed smokewall penetration in the 2nd floor men's locker room above the hand dryers.
f) 12:31 PM, there was a 4-inch unsealed smokewall penetration in the 2nd floor kitchen storage room above the freezer.
g) 12:43 PM, there were unsealed smokewall penetrations above the 2nd floor double doors leading to the Sterile Processing Decontamination Room.
h) 12:55 PM, there were unsealed smokewall penetrations in the 2nd floor men's locker room above the hand dryers.
i) 1:05 PM, there were unsealed smokewall penetrations at various locations in the 2nd floor smokewall as viewed inside of the pharmacy.
j) 1:17 PM, there were unsealed smokewall penetrations at various locations in the 2nd floor smokewall from the Storeroom alcove door to the outside wall in the Storeroom.

Interview with the Fire Safety Technician and the Craft Technician on November 3, 2010, at at the above times confirmed the smoke barrier wall deficiencies.


27496

Based upon observation and interview, the smoke barriers are constructed to provide at least a one half hour fire resistance rating in several areas throughout the building.

Findings include:

Observation on 11/3-4/2010 revealed the following:
a) On 11/3/2010 @ 1:00 p.m. the 3rd floor B-tower storage room had penetrations in the walls above the ceiling.
b) On 11/4/2010 @ 09:30 a.m. at 0 level Maternity there were smoke wall penetrations above the smoke doors by room 30.
c) On 11/4/2010 @ 10:30 a.m. at 0 level Pediatrics the smoke wall in room # 9 needs sealed to the deck above.
d) On 11/4/2010 @ 10:35 a.m. at 0 level Pediatrics the smoke wall in room # 7 needs sealed to the deck above
e) On 11/4/2010 @ 11:00 a.m. the storage room for flammable liquids by the lab had a penetration above the ceiling.

Interview with the Facility Management and CEO on the above date and times confirmed this condition exists.

Based upon observation and interview, the smoke barrier door assemblies do not comply with regulations on one of four floors.

Findings include:

Observation on 11/3/2010 at 13:45 p.m. revealed the smoke doors in the main store room did not fully close.

Interview with the Facility Management and CEO on the above date and times confirmed this condition exists.

Based upon observation and interview, it was determined the facility failed to maintain hazardous areas in compliance with regulations on one of four floors.

Findings include:

Observation on 11/3-4/2010 revealed the following:
a) At 14:00 p.m. on level 2 B-tower the abandoned nurse's station is not rated to be a storage location.
b) At 14:15 p.m. on level 2 B-tower Room 233 is not rated to be a storage area.

Interview with the Facility Management and CEO on the above date and times confirmed this condition exists.

Based on observation and interview, the facility failed to maintain the proper fire resistance rating of an exit component enclosure in one area on one of four floors.

Findings include:

Observation on November 3, 2010, at 9:57 AM revealed that there were unsealed penetrations inside the 4th floor Stairwell 6 above the north and east walls where the walls meet the ceiling. Additionally, the facility needs to verify the 2-hour construction of all four walls within the stairwell.

Interview with the Craft Technician on November 3, 2010, at at the above time confirmed the above deficiency exists.

Based upon observation and interview, it was determined the facility failed to maintain the exit access at at times in one area in the facility of four floors.

Findings include:

Observation on November 4, 2010 at 11:00 am revealed that the class rooms C and B where blocking the exits with tables and equipment.

Interview with the Facility Management and CEO on the above date and times confirmed this condition exists.

Based upon observation and interview, it was determined that the exit and directional signs are not in accordance with regulations in two locations of the entire facility.

Findings include:

Observation on November 3, 2010 revealed the following;

A) At 11:30 am, there is a directional exit sign missing in the corridor coming from the B tower elevator lobby.
B) At 11:45 am, there is a directional exit sign missing in the corridor coming from the A tower elevator lobby.


Interview with the Facility Management and CEO on the above date and times confirmed this condition exists.

Based upon observation and interview, it was determined the facility's automatic fire sprinkler system is not installed as per NFPA 13 on one of four floors.

Findings include:

Observation on November 4, 2010 at 1:00 pm revealed that the sprinkler heads in the A tower elevator equipment room had downward facing sprinkler heads that would not cover the open space above.

Interview with the Facility Management and CEO on the above date and times confirmed this condition exists.

Based on observation and interview it was determined the facility failed to provide medical gas storage and administration areas in accordance with NFPA 101, 19.3.2.4 and NFPA 99, 1999 edition in two locations.

Findings include:

Observation of medical gas storage and/or cylinders on 11/3-4/10 revealed the following:

A) At 11/3/10 at 10:00 am, The medical gas piping in the overhead on 4th floor near the transcription office did not have proper labels.
B) At 11/3/10 at 10:15 am, The zone valve shut-off labeled b-430 through c-449, needs to have proper labels corresponding to the correct room numbers.

Interview with the Facility Management and CEO on the above date and times confirmed this condition exists.






27496

Based on observation and interview it was determined the facility failed to provide medical gas storage and administration areas in accordance with NFPA 101, 19.3.2.4 and NFPA 99, 1999 edition in one locations.

Findings include:

Observation of medical gas storage and/or cylinders on 11/4/10 revealed the following:

A) At 11/4/10 at 0900 am, There was an unsecured oxygen cylinder in the med room at the nurse's station in the Labor & Delivery area.

Interview with the Facility Management and CEO on the above date and times confirmed this condition exists.

Based on observation and interview, the facility failed to maintain electrical wiring and equipment in accordance with NFPA 70, National Electrical Code. 9.1.2 in three areas on two of four floors.

Findings include:

Observation on November 3, 2010, between 10:17 AM and 12:27 PM revealed the following deficiencies:
a) 10:17 AM, roof Cart Lift Room near C Tower has an uncovered 12-inch by 18-inch electrical panel.
b) 10:53 AM, 3rd floor Resident room 356 has an uncovered 4-inch by 4-inch electrical box above the computer.
c) 12:27 PM, 2nd floor men's locker room has an uncovered 4-inch by 4-inch electrical box above the first wooden bench.

Interview with the Fire Safety Technician and the Craft Technician on November 3, 2010, at at the above times confirmed the above deficiencies exist.

Based on observation and interview, the facility failed to maintain the communicating opening in the two hour fire-resistant common wall on two of four floors.

Findings include:

Observation on November 3, 2010, between 9:21 AM and 10:57 AM revealed the following unsealed 2-hour fire partition penetrations:
a. 9:21 AM Zero Level corridor between B&C towers around wires, conduit, pipes, etc. and where wall meets deck above.
b. 10:11 AM 1st floor corridor between Level 1 Stairwell door across from the men's room to the corridor fire partition doors around water pipes, MC cables, wires, etc.
c. 10:57 AM 1st floor above the double doors between the pump room and ER entrance around pipes and conduit, and where the wall meets the ceiling.

Interview with the Facility Manager November 3, 2010, at at the above times confirmed the fire partition deficiencies.

Based upon observation and interview, it was determined the doors protecting corridor openings in other than hazardous areas are not substantial, nor smoke resistant as per regulations in one area in the facility.

Findings include:

Observation on November 4, 2010 at 11:15 am revealed the following;

A) The door to classroom C was being held open with an unauthorized hold open device.
B) The door to classroom B was being held open with an unauthorized hold open device.
C) The Corridor door to classroom B was being blocked open with a copier machine that would not allow the door to close.

Interview with the Facility Management and CEO on the above date and times confirmed this condition exists.

Based on observation and interview, it was determined the facility failed to maintain the proper fire resistance rating of smoke barrier walls three of four floors.

Findings include:

1. Observation on November 3, 2010, between 9:25 AM and 1:17 PM revealed the following smoke barrier wall deficiencies:

a) 9:29 AM, there were unsealed penetrations around ducts, conduit and an I Beam in the 4th Floor Rehab Room, room 466, above the bed and inside the restroom.
b) 9:43 AM, there was an unsealed smokewall penetration in the 4th floor room 457 where the curtain meets the smokewall.
c) 10:41 AM, there was an unsealed smokewall penetration in the 3rd floor room 365 near the window around a sprinkler pipe.
d) 11:01 AM, there was mineral wool used to seal penetrations where the smokewall meets the ceiling above the 3rd floor corridor doors.
e) 12:21 PM, there was a 4-inch unsealed smokewall penetration in the 2nd floor men's locker room above the hand dryers.
f) 12:31 PM, there was a 4-inch unsealed smokewall penetration in the 2nd floor kitchen storage room above the freezer.
g) 12:43 PM, there were unsealed smokewall penetrations above the 2nd floor double doors leading to the Sterile Processing Decontamination Room.
h) 12:55 PM, there were unsealed smokewall penetrations in the 2nd floor men's locker room above the hand dryers.
i) 1:05 PM, there were unsealed smokewall penetrations at various locations in the 2nd floor smokewall as viewed inside of the pharmacy.
j) 1:17 PM, there were unsealed smokewall penetrations at various locations in the 2nd floor smokewall from the Storeroom alcove door to the outside wall in the Storeroom.

Interview with the Fire Safety Technician and the Craft Technician on November 3, 2010, at at the above times confirmed the smoke barrier wall deficiencies.


27496

Based upon observation and interview, the smoke barriers are constructed to provide at least a one half hour fire resistance rating in several areas throughout the building.

Findings include:

Observation on 11/3-4/2010 revealed the following:
a) On 11/3/2010 @ 1:00 p.m. the 3rd floor B-tower storage room had penetrations in the walls above the ceiling.
b) On 11/4/2010 @ 09:30 a.m. at 0 level Maternity there were smoke wall penetrations above the smoke doors by room 30.
c) On 11/4/2010 @ 10:30 a.m. at 0 level Pediatrics the smoke wall in room # 9 needs sealed to the deck above.
d) On 11/4/2010 @ 10:35 a.m. at 0 level Pediatrics the smoke wall in room # 7 needs sealed to the deck above
e) On 11/4/2010 @ 11:00 a.m. the storage room for flammable liquids by the lab had a penetration above the ceiling.

Interview with the Facility Management and CEO on the above date and times confirmed this condition exists.

Based upon observation and interview, the smoke barrier door assemblies do not comply with regulations on one of four floors.

Findings include:

Observation on 11/3/2010 at 13:45 p.m. revealed the smoke doors in the main store room did not fully close.

Interview with the Facility Management and CEO on the above date and times confirmed this condition exists.

Based upon observation and interview, it was determined the facility failed to maintain hazardous areas in compliance with regulations on one of four floors.

Findings include:

Observation on 11/3-4/2010 revealed the following:
a) At 14:00 p.m. on level 2 B-tower the abandoned nurse's station is not rated to be a storage location.
b) At 14:15 p.m. on level 2 B-tower Room 233 is not rated to be a storage area.

Interview with the Facility Management and CEO on the above date and times confirmed this condition exists.

Based on observation and interview, the facility failed to maintain the proper fire resistance rating of an exit component enclosure in one area on one of four floors.

Findings include:

Observation on November 3, 2010, at 9:57 AM revealed that there were unsealed penetrations inside the 4th floor Stairwell 6 above the north and east walls where the walls meet the ceiling. Additionally, the facility needs to verify the 2-hour construction of all four walls within the stairwell.

Interview with the Craft Technician on November 3, 2010, at at the above time confirmed the above deficiency exists.

Based upon observation and interview, it was determined the facility failed to maintain the exit access at at times in one area in the facility of four floors.

Findings include:

Observation on November 4, 2010 at 11:00 am revealed that the class rooms C and B where blocking the exits with tables and equipment.

Interview with the Facility Management and CEO on the above date and times confirmed this condition exists.

Based upon observation and interview, it was determined that the exit and directional signs are not in accordance with regulations in two locations of the entire facility.

Findings include:

Observation on November 3, 2010 revealed the following;

A) At 11:30 am, there is a directional exit sign missing in the corridor coming from the B tower elevator lobby.
B) At 11:45 am, there is a directional exit sign missing in the corridor coming from the A tower elevator lobby.


Interview with the Facility Management and CEO on the above date and times confirmed this condition exists.

Based upon observation and interview, it was determined the facility's automatic fire sprinkler system is not installed as per NFPA 13 on one of four floors.

Findings include:

Observation on November 4, 2010 at 1:00 pm revealed that the sprinkler heads in the A tower elevator equipment room had downward facing sprinkler heads that would not cover the open space above.

Interview with the Facility Management and CEO on the above date and times confirmed this condition exists.

Based on observation and interview it was determined the facility failed to provide medical gas storage and administration areas in accordance with NFPA 101, 19.3.2.4 and NFPA 99, 1999 edition in two locations.

Findings include:

Observation of medical gas storage and/or cylinders on 11/3-4/10 revealed the following:

A) At 11/3/10 at 10:00 am, The medical gas piping in the overhead on 4th floor near the transcription office did not have proper labels.
B) At 11/3/10 at 10:15 am, The zone valve shut-off labeled b-430 through c-449, needs to have proper labels corresponding to the correct room numbers.

Interview with the Facility Management and CEO on the above date and times confirmed this condition exists.






27496

Based on observation and interview it was determined the facility failed to provide medical gas storage and administration areas in accordance with NFPA 101, 19.3.2.4 and NFPA 99, 1999 edition in one locations.

Findings include:

Observation of medical gas storage and/or cylinders on 11/4/10 revealed the following:

A) At 11/4/10 at 0900 am, There was an unsecured oxygen cylinder in the med room at the nurse's station in the Labor & Delivery area.

Interview with the Facility Management and CEO on the above date and times confirmed this condition exists.

Based on observation and interview, the facility failed to maintain electrical wiring and equipment in accordance with NFPA 70, National Electrical Code. 9.1.2 in three areas on two of four floors.

Findings include:

Observation on November 3, 2010, between 10:17 AM and 12:27 PM revealed the following deficiencies:
a) 10:17 AM, roof Cart Lift Room near C Tower has an uncovered 12-inch by 18-inch electrical panel.
b) 10:53 AM, 3rd floor Resident room 356 has an uncovered 4-inch by 4-inch electrical box above the computer.
c) 12:27 PM, 2nd floor men's locker room has an uncovered 4-inch by 4-inch electrical box above the first wooden bench.

Interview with the Fire Safety Technician and the Craft Technician on November 3, 2010, at at the above times confirmed the above deficiencies exist.