HospitalInspections.org

Based on observation this portion of the building was constructed in 1996 and provides radiology services. The facility's Life Safety Code drawings indicated that it is separated from the main hospital by one hour rated fire resistive construction. NFPA 101 Chapter 19 Section 19.1.1.4.1 requires a 2 hour separation. This deficient practice could effect all building occupants as a result of a fire.

Findings include:

During the facility tour on 11-26-12 at 2:30 PM based on review of available documentation, i.e, in the facility's Life Safety Code drawings, it appears that this area used by radiology is only separated by one hour fire resistive construction, from the Main Hospital Building, and the standard requires a two hour fire rating. The services of a registered architect may be needed to provide additional documentation to support the rating of this separation.

This deficient practice was confirmed by (MM) Maintenance Manager at the time of exit.

Based on observation the facility failed to maintain a one hour fire resistive ceiling. This deficient practice could affect all residents, staff, and visitors.

Findings include:

During the facility tour on 11-26-12 at 2:30 PM , it was observed that the one hour fire resistive ceiling in the Doctor's Sleep Area, located on the 6th floor (shower area) may not have had the required one hour fire resistive rating as required by LSC(00) section(s) 19.1.6.1 and 8.2.3.3.4.2. Exposed plywood was observed in the ceiling assembly and it could not be determined if this was a component of the required ceiling fire rating.

This deficient practice was confirmed by (MM) Maintenance Manager at the time of exit.

Based on observation the rating of the exposed wood plywood sheeting in several locations could not be determined. This deficient practice could effect all occupants of the facility.

Findings include:

During the facility tour 11-26-12 thru 11-28-12 it was observed that the fire rating of exposed wood plywood, used in most cases for mounting equipment and wires could not be determined as required by LSC(00) 19.3.3.2. One example would be in the "fire extinguisher room" located in the basement. This was also observed in closets containing IT and communications equipment. Verify the rating, treat the plywood to at least a class "C" flame spread rating, remove the plywood, or cover with gypsum board where practical.

This deficient practice was confirmed by (MM) Maintenance Manager at the time of exit. at the time of exit.

Based on observation and interview, the facility failed to provide means of egress in accordance with the following requirements of LSC(00), Section 7.2.1.5.4. The deficient practice could affect all occupants.

Findings include:

During the facility tour and fire drill on 11-27-12 at 11:00 AM it was observed that the stairwell doors of the 4th Floor OB area, were equipped with a delayed egress devices. However, the doors were not properly signed to indicate that the door had a delayed egress devices installed.

This deficient practice was verified by (MM) Maintenance Manager at the time of the exit.

Based on observation and interview, the facility's fire alarm system is not maintained in conformance with NFPA 72. This deficient practice could affect all patients.

Findings include:

During the facility tour 11-26-12 thru 11-28-12, observation revealed that:

1. There were no smoke detectors connected to the building fire alarm system installed in the OR Personel On-call Rooms and 6th Floor Doctors Sleeping Room #614.

2. In was observed that are fire alarm system connected smoke detectors located within 3 feet of HVAC deflectors in the facility Conference Room and on the 6th Floor by rooms N23l 1D011 & N23L 1D004. The entire facility should be reviewed for smoke detectors the are loscated too close to air diffusers.

3. The secure stairwell doors on the 5th floor Mental Health Unit automatically re-lock upon re-set of the building fire alarm system. Minnsota StateFifre Code (MSFC) (07), Section 1008.1.11 requires the re-locking to be done manually at the door(s)..

These deficient practices were verified by (MM) Maintenance Manager at the time of exit.

Based on observations and interview, the automatic sprinkler system in not installed in accordance with NFPA 13, and being maintained in accordance with NFPA 25. This deficient practice could affect all patients.

Findings include:

During the facility tour 11-26-12 thru 11-28-12 observation revealed:

1. In the 6th Floor Boiler Room, the rack storage shelves (4 feet by 16 feet) are solid rack shelving.

2. There is no fire sprinkler system coverage in the Doctors Sleeping Area linen closet, the Lab Bio-storage room, and Fan Room #4, all located on the 6th floor, and there is no fire sprinkler head in the Surgery Suite Electrical Closet across from OR Room 11.

3. There are no fire srinkler system gages installed at the top of the risers on the 6th floor stairwells B, D, & E. This same observation was made on the 4th floor stairwell M.

4. Fire sprinkler eads throughout the building need to be inspected for damage, i.e., SPD room. Heads also need to be inspected for accumulation of dirt, grime, and dust, i.e. Histology room 1132.

5. A spare supply of fire sprinkler heads shall be maintained in the sprinkler box for each of the different heads located in the facility.

6. The garage and lawn care area should be revived for proper coverage and installation.



These deficient practices was verified by (MM) Maitnenace Manager at the time of exit.

Based on observation the exhaust hood system located in the kitchen is not properly protected in accordance with LSC(00) Section 19-3.2.5 and NFPA 96. This deficient practice could effect all building occupants in the event of a fire under the hood.

Findings include:

During the facility tour and fire drill on 11-27-12 at 11:00 AM, it was reveled:

1. The general fire alarm signal was sounded during the a drill. Upon fire alarm activation the exhaust fan on the hood system automatically shut down. This exhaust fan shall remain operational upon general fire alarm activation.

2. The gas supply to the appliances under the hood did shut down as required. However, it could not be determined if the electrical supply also shut down upon fire alarm activation.

3. It was observed that one of the required baffles was missing. It was also observed that the accumulation of grease was excessive in the hood.

This deficient practice was confirmed by (MM) Maintenance Manager at the time of exit.

Observations and an interview with staff revealed that the 2 Operating Rooms do not have isolation monitors on their electrical systems in accordance with NFPA 99 (1999 edition) section 3-3.2.1.2. This deficient practice could affect all patients and staff within the operating room if the floor is wet during normal use.

Findings Include:
An interview with staff and observations during the facility tour on November 27, 2012 between 1:45 pm and 3:00 pm, with Master Electrician (TP), revealed that the two operating rooms do not have isolation monitors nor do they use GFI outlets and are considered wet location (General surgery is done on-site)

The Master Electrician (TP) verified this finding during the facility tour.

An isolation electrical panel and GFI protected outlet are not provided in the OB operating rooms on the 4th floor. This deficient practice could effect all occupants of the area.

Findings include:

During the facility tour on 11-27-12 at approximately 10:00 AM, and based on interview and observation, the OB Operating Rooms on the 4th floor (considered to be wet locations) have no isolation panel and/or GFI protected electrical outlets installed as required by NFPA 99 (99 Edition).

This deficient practice was confirmed by (MM) Maintenance Manager at the time of exit.

Based on observation this portion of the building was constructed in 1996 and provides radiology services. The facility's Life Safety Code drawings indicated that it is separated from the main hospital by one hour rated fire resistive construction. NFPA 101 Chapter 19 Section 19.1.1.4.1 requires a 2 hour separation. This deficient practice could effect all building occupants as a result of a fire.

Findings include:

During the facility tour on 11-26-12 at 2:30 PM based on review of available documentation, i.e, in the facility's Life Safety Code drawings, it appears that this area used by radiology is only separated by one hour fire resistive construction, from the Main Hospital Building, and the standard requires a two hour fire rating. The services of a registered architect may be needed to provide additional documentation to support the rating of this separation.

This deficient practice was confirmed by (MM) Maintenance Manager at the time of exit.

Based on observation the facility failed to maintain a one hour fire resistive ceiling. This deficient practice could affect all residents, staff, and visitors.

Findings include:

During the facility tour on 11-26-12 at 2:30 PM , it was observed that the one hour fire resistive ceiling in the Doctor's Sleep Area, located on the 6th floor (shower area) may not have had the required one hour fire resistive rating as required by LSC(00) section(s) 19.1.6.1 and 8.2.3.3.4.2. Exposed plywood was observed in the ceiling assembly and it could not be determined if this was a component of the required ceiling fire rating.

This deficient practice was confirmed by (MM) Maintenance Manager at the time of exit.

Based on observation the rating of the exposed wood plywood sheeting in several locations could not be determined. This deficient practice could effect all occupants of the facility.

Findings include:

During the facility tour 11-26-12 thru 11-28-12 it was observed that the fire rating of exposed wood plywood, used in most cases for mounting equipment and wires could not be determined as required by LSC(00) 19.3.3.2. One example would be in the "fire extinguisher room" located in the basement. This was also observed in closets containing IT and communications equipment. Verify the rating, treat the plywood to at least a class "C" flame spread rating, remove the plywood, or cover with gypsum board where practical.

This deficient practice was confirmed by (MM) Maintenance Manager at the time of exit. at the time of exit.

Based on observation and interview, the facility failed to provide means of egress in accordance with the following requirements of LSC(00), Section 7.2.1.5.4. The deficient practice could affect all occupants.

Findings include:

During the facility tour and fire drill on 11-27-12 at 11:00 AM it was observed that the stairwell doors of the 4th Floor OB area, were equipped with a delayed egress devices. However, the doors were not properly signed to indicate that the door had a delayed egress devices installed.

This deficient practice was verified by (MM) Maintenance Manager at the time of the exit.

Based on observation and interview, the facility's fire alarm system is not maintained in conformance with NFPA 72. This deficient practice could affect all patients.

Findings include:

During the facility tour 11-26-12 thru 11-28-12, observation revealed that:

1. There were no smoke detectors connected to the building fire alarm system installed in the OR Personel On-call Rooms and 6th Floor Doctors Sleeping Room #614.

2. In was observed that are fire alarm system connected smoke detectors located within 3 feet of HVAC deflectors in the facility Conference Room and on the 6th Floor by rooms N23l 1D011 & N23L 1D004. The entire facility should be reviewed for smoke detectors the are loscated too close to air diffusers.

3. The secure stairwell doors on the 5th floor Mental Health Unit automatically re-lock upon re-set of the building fire alarm system. Minnsota StateFifre Code (MSFC) (07), Section 1008.1.11 requires the re-locking to be done manually at the door(s)..

These deficient practices were verified by (MM) Maintenance Manager at the time of exit.

Based on observations and interview, the automatic sprinkler system in not installed in accordance with NFPA 13, and being maintained in accordance with NFPA 25. This deficient practice could affect all patients.

Findings include:

During the facility tour 11-26-12 thru 11-28-12 observation revealed:

1. In the 6th Floor Boiler Room, the rack storage shelves (4 feet by 16 feet) are solid rack shelving.

2. There is no fire sprinkler system coverage in the Doctors Sleeping Area linen closet, the Lab Bio-storage room, and Fan Room #4, all located on the 6th floor, and there is no fire sprinkler head in the Surgery Suite Electrical Closet across from OR Room 11.

3. There are no fire srinkler system gages installed at the top of the risers on the 6th floor stairwells B, D, & E. This same observation was made on the 4th floor stairwell M.

4. Fire sprinkler eads throughout the building need to be inspected for damage, i.e., SPD room. Heads also need to be inspected for accumulation of dirt, grime, and dust, i.e. Histology room 1132.

5. A spare supply of fire sprinkler heads shall be maintained in the sprinkler box for each of the different heads located in the facility.

6. The garage and lawn care area should be revived for proper coverage and installation.



These deficient practices was verified by (MM) Maitnenace Manager at the time of exit.

Based on observation the exhaust hood system located in the kitchen is not properly protected in accordance with LSC(00) Section 19-3.2.5 and NFPA 96. This deficient practice could effect all building occupants in the event of a fire under the hood.

Findings include:

During the facility tour and fire drill on 11-27-12 at 11:00 AM, it was reveled:

1. The general fire alarm signal was sounded during the a drill. Upon fire alarm activation the exhaust fan on the hood system automatically shut down. This exhaust fan shall remain operational upon general fire alarm activation.

2. The gas supply to the appliances under the hood did shut down as required. However, it could not be determined if the electrical supply also shut down upon fire alarm activation.

3. It was observed that one of the required baffles was missing. It was also observed that the accumulation of grease was excessive in the hood.

This deficient practice was confirmed by (MM) Maintenance Manager at the time of exit.

Observations and an interview with staff revealed that the 2 Operating Rooms do not have isolation monitors on their electrical systems in accordance with NFPA 99 (1999 edition) section 3-3.2.1.2. This deficient practice could affect all patients and staff within the operating room if the floor is wet during normal use.

Findings Include:
An interview with staff and observations during the facility tour on November 27, 2012 between 1:45 pm and 3:00 pm, with Master Electrician (TP), revealed that the two operating rooms do not have isolation monitors nor do they use GFI outlets and are considered wet location (General surgery is done on-site)

The Master Electrician (TP) verified this finding during the facility tour.

An isolation electrical panel and GFI protected outlet are not provided in the OB operating rooms on the 4th floor. This deficient practice could effect all occupants of the area.

Findings include:

During the facility tour on 11-27-12 at approximately 10:00 AM, and based on interview and observation, the OB Operating Rooms on the 4th floor (considered to be wet locations) have no isolation panel and/or GFI protected electrical outlets installed as required by NFPA 99 (99 Edition).

This deficient practice was confirmed by (MM) Maintenance Manager at the time of exit.