HospitalInspections.org

Egress doors are not maintained to provide exiting of the building. Failure to maintain doors can result in failure of occupants being able to readily exit the building.

Findings include:

A. On 12/17/20 at 9:45am while in the company of the DF it was observed that the right side door of the northeast exit from the building was not easily opened due to the door being held by weatherstriping on the adjacent door. Both doors were equipped with panic hardware. The force requirements of 7.2.1.4.5 could not be confirmed to be met.

B. On 12/17/20 at 10:00am while in the company of the DF it was observed that the west exit access door from the Infusion room did not swing in the direction of travel to comply with 7.2.1.4.2. Exit signage from the original building area directed exiting to this door and the exit through the healing garden. The occupant load for these exit doors was not determined at the time of the survey.

Based upon observation and review of fire safety reference plans, corridors are not provided with two separate means of egress in compliance with Code requirements. Failure to provide required compliant means of egress for building occupants can compromise the safety of occupants if protected paths of travel are not provided as permitted by the Code.

Findings include:

A. On 12/16/20 at 9:30am while in the company of the DF it was observed that the East wing 5th floor corridors of the Surgery Dept. are directed by exit signs through the OR area which is defined as a suite on the fire safety reference plan to provide access to the east exit stair. The corridors outside the suite cannot be directed through the suite to remain in compliance with 19.2.5.4. The corridors outside the designated suite are dead end corridors not in compliance with 19.2.5.2.

B. On 12/16/20 at 10:00am while in the company of the DF it was observed that the 4th floor East wing corridor is directed through the ICU which is designated as a suite on the fire safety reference plans. The Corridors outside the suite cannot be directed through the suite to remain in compliance with 19.2.5.4. The Corridors outside the designated suite constitute a dead end condition not in compliance with 19.2.5.2.

C. On 12/16/20 at 10:05am while in the company of the DF it was observed that the 4th floor corridor is directed through the South wing Accounting offices area which is designated as a suite on the fire safety reference plans. The Corridor outside the suite cannot be directed through the suite to remain in compliance with 19.2.5.4. The Corridor outside the designated suite constitutes a dead end condition not in compliance with 19.2.5.2 because exit access through the OB Dept. is restricted access. The single-swing cross-corridor doors at the entrance to the Acounting area suite swing against egress travel from the non-suite side in non-compliance with 7.2.1.4.2.

Based upon observation and review of the fire safety reference plan, suites are not in compliance with Code requirements. Failure to properly identify and maintain suites can compromise occupant safety by reducing features designed to limit the spread of fire and smoke conditions.

Findings include:

On 12/16/20 at 2:20pm while in the company of the DF it was observed that the ED Step-down area adjacent the defined ED suite was not separated from the ED suite in accordance with 19.2.5.7.1.2 because no doors were provided at the corridor joining the two areas as shown on the fire safety reference plan. The combined areas appeared to exceed the allowable 10,000 square foot area permitted by 19.2.5.7.3.3 to consider it as a single suite. Other cross-corridor doors in the area were not positive latching to qualify as equivalent to corridor door meeting the requirements of 19.3.6.3.5.

Exit discharge is not maintained in accordance with Code requirements. Failure to maintain exit components can result in occupants failure to safely exit the building and gain access to the public way as a place of refuge.

Finding include:

A. On 12/17/20 at 10:00am while in the company of the DF it was observed that the west exterior exit door discharged to a concrete pad but did not extend a maintainable path up the grass slope to the public way to comply with 19.2.7 and 7.1.6.

B. On 12/17/20 at 9:45am while in the company of the DF it was observed that the path from the exterior exit door through the healing garden was not maintained free of snow/ice accummulation to comply with 7.1.6.4.

Based on observation and staff interview, illumination of the exit discharge portion of the means of egress is not provided to maintain illumination of the means of egress in the event of failure of the lighting provided. Failure to maintain illumination of the means of egress can affect all persons in the facility required to utilize the exit(s) by preventing safe and unimpeded access to the public way.

Findings include:

A. On 12/17/20 at 9:15am while in the company of the FD it was observed that exit discharge lighting was not was not of the instant-on type to provide illumination within the required 10 second period to comply with 39.2.8, 39.2.9 and 7.8 & 7.9. Not all Exit discharge locations are provided with multiple fixtures or lamps or the lamp type appeared to be HID without quartz restrike which does not comply with 7.8.1.4.

B. On 12/17/20 at 9:15am while in the company of the FD it was indicated by the FD that the alternate power source required by 7.9.1.3 for the exit discharge lighting was a generator system which was currently non-functional and in the process of replacement. Interim life safety measures were relied upon until the permanent generator installation was complete.

Exits are not properly identified to provide safe exiting from the building. Failure to properly identify exits can result in mis-direction of occupants to an unprotected path from the building.

Finding include:

A. On 12/16/20 at 3:45pm while in the company of the DF it was observed that Stair #6 was considered a convenience stair and marked as "Not an Exit" on all floors except the Basement. An illuminated exit sign between the hall door and the stair door at the Basement level can allow the stair door to be mistaken as the required exit. The stair cannot be a convenience stair and a required exit at the same time to remain in compliance with 7.1.3.2.1.

B. On 12/16/20 at 3:05pm while in the company of the DF it was observed that exiting for the roof mounted Helipad is directed through the second floor Mechanical room and not provided with exit signage to Stair #7. This arrangement for exiting the roof does not comply with 7.5.1.6 and 7.1.6.

Based upon observation, vertical openings between floor levels are not protected in accordance with Code requirements. Failure to protect vertical openings between floor levels can permit the effects of a fire/smoke condition to migrate to other floors to compromise the safety of patients, staff and visitors.

Findings include:

On 12/16/20 at 9:00am while in the company of the FD it was observed that the west wing contained an abandoned linen or trash chute which lacked proper 2-hour rated enclosure to comply with 19.3.1 and NFPA 82-2009, 5.2.3.1.2. Conditi9ons observed:

a. The facility life safety reference plans did not indicate the chute enclosure to be rated.

b. Access doors on at least the 5th and 3rd floors were observed to be non-rated assemblies.

c. One wall of the enclosure at some floors (2nd) had non-rated metal lockers penetrating the enclosure.

d. The abandoned metal chute could not otherwise be confirmed to be filled with rated floor construction at each floor level to close the floor penetration.

Based upon observation, hazardous areas are not separated from the remainder of the occupancy and the means of egress. Failure to properly separate storage of combustible material (which represents a degree of hazard greater than that normal to the general occupancy due to quantity and density of materials) from required means of egress paths can compromise the safety of occupants if a fire were to originate at the stored material to block exiting.

Findings include:

A. On 12/16/20 at 9:10am while in the company of the FD it was ovserved that the 5th floor Janitor 5278 room storing quantities of combustible paper products lacked a self-closing door assembly to comply with 19.3.2.1.3.

B. On 12/16/20 at 9:15am while in the company of the FD it was ovserved that the 5th floor Respiratory Storage room 5005 lacked a self-closing door assembly to comply with 19.3.2.1.3 because the closer was equipped with a hold-open feature not in accordance with 7.2.1.8.2.

C. On 12/16/20 at 9:15am while in the company of the FD it was ovserved that the 5th floor South wing old OR used for storage had a small door which was not a self-closing door assembly to comply with 19.3.2.1.3.

D. On 12/16/20 at 11:05am while in the company of the FD it was ovserved that the 2nd floor Data/Com room in the east wing used for storage of combustible material lacked a self-closing door assembly to comply with 19.3.2.1.3.

E. On 12/16/20 at 9:10am while in the company of the FD it was ovserved that lacked a self-closing door assembly to comply with 19.3.2.1.3.

Based upon observation, the facility failed to provide documentation of monthly inspections for Kitchen hood suppression systems. Failure to perform and document monthly inspections can result in failure to observe deficiencies during periodic inspections of the system that could prevent proper operation of the system when needed.

Findings include:

On 12/16/20 at 2:45pm while in the company of the DF it was observed that inspection tags for the Kitchen hood Ansul fire suppression systems were not filled out to indicate the date and initials of the inspector to indicate monthly inspections to comply with NFPA 17-2009, 11.2.1 & 11.2.4 (Dry Chemical systems) or NFPA 17A-2009, 7.2.1 & 7.2.5 (Wet Chemical systems).

Based upon observation, the fire alarm system is not installed in accordance with Code requirements. Failure to properly install the fire alarm system can result in failure of the system to operate.

Findings include:

A. On 12/17/20 at 9:30am while in the company of the FD, it was observed that fire alarm system labeling was not provided in accordance with NFPA 72-2011, 10.5.5.2.

1. The Fire Alarm Control Panel (FACP) was not labeled to identify the electrical panel and circuit from which it was fed. (10.5.5.2.1)

2. The circuit located in the P1A panel serving the FACP was not provided with red markings to readily identify the fire alarm circuit to comply with 10.5.5.2.3.

3. Although the P1A panel was locked to restrict access to only authorized personnel to comply with 10.5.5.2.4, the breaker serving the FACP was not provided with a listed breaker locking device to comply with 10.5.5.3.

4. The P1A panel was not identified on the exterior to readily identify the location of the fire alarm circuit which is referenced and labeled at the FACP.

Based upon observation, waiting areas open to the corridor are not provided with supervision or smoke detection system. Failure to provide supervision or smoke detection devices may prevent the building's occupants from being alerted to a fire related emergency. This deficient practice could affect the safety of patients, staff, and visitors.

The finding is:

A. On 12/16/20 at 1:55pm while in the company of the DF, it was observed that the MRI Waiting area is open to the corridor and lacks a 24/7 supervisory station or smoke detection devices to comply with 19.3.6.1(2).

B. On 12/16/20 at 2:15pm while in the company of the DF, it was observed that the Expanded ED Waiting area nearest the "Atrium" located along the corridor lacks 24/7 supervision or a smoke detection device to comply with 19.3.6.1(2). Other seating along this corridor is covered by detection but the far north end is not.

Based upon document review, written policies regarding fire drills may result in drills not being conducted in accordance with Code requirements. Failure to conduct drills properly may fail to properly train staff to respond appropriately in a fire/smoke condition.

Findings include:

On 12/15/20 at 3:45pm during document review in the company of the DF, it was observed that the Fire Plan policy indicated that "At least 50% of the fire drills are to be unannounced." This policy allows fire drills to be announced, which does not meet the requirements of 19.7.1.6 for staff to be tested periodically under varied conditions.

Based upon observation and staff interview, not all patient rooms are provided with emergency power in accordance with Code requirements. Failure to provide emergency power at patient bed locations can disrupt use of bedside equipment used by patients.

Findings include:

A. On 12/16/20 while in the company of the DF it was observed that Med/Surg patient rooms lacked emergency power receptacles to comply with NFPA 70-2011, 517-18(A). Observed conditions may exist at other locations not specifically named.

1. Condition was observed on the 3rd floor North unit at 10:50am.

2. Condition was observed on the 2nd floor North unit at 11:40am.

B. On 12/16/20 at 2:40pm while in the company of the DF it was observed that red receptacles in the Cath Lab suite were not labeled to indicate the panel and circuit from which they were fed to comply with NFPA 70-2011, 408.4.

C. On 12/16/20 at 11:15am while in the company of the DF it was observed in the 2nd floor East Mechanical room that Panel LS4-21 believed to be a Life Safety branch panel had mixed loads of exit/means of egress lighting etc. with pumps/equipment loads. Not all loads could be verified to be Life Safety branch loads as permitted by NFPA 99-2012, 6.4.2.2.3.2.