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The facility failed to maintain the two-hour fire resistive rating of the floor/ceiling assemblies throughout the building.

Observation determined the two-hour fire rated floor/ceiling assemblies had multiple unsealed spaces throughout the basement, first floor and second floor.

Failure to maintain the two-hour fire resistive rating of floor/ceiling assemblies increases the risk of death or injury due to fire.

The deficiency affected two (2) of two (2) floors in the facility.

The facility failed to provide corridors that were separated from use areas by walls with at least one-half hour fire resistance rating.

Observation determined there was an unsealed space above the duct to the corridor from the sewage pump room in the basement.

Failure to maintain the one-half hour fire resistance rating of corridor walls increases the risk of death or injury due to fire.

The deficiency affected one (1) of numerous corridor walls in the facility.

The facility failed to ensure the corridor doors latched into their frames and resisted the passage of smoke.

Observation determined the door to Patient Room #232 failed to latch into the frame.

Failure to ensure corridor doors were latched properly increases the risk of death or injury due to fire.

The deficiency affected one (1) of numerous corridor doors in the facility.

1) The facility failed to provide two-hour fire resistive construction for stairways.

Observation determined the second floor center stairway door did not self-close and latch into the door frame.

The deficiency affected one (1) of four (4) stairways in the facility.

2) The facility failed to maintain the two-hour fire resistive rating of elevator shaft enclosures.

Observation determined there was an open pipe penetration from the main elevator shaft into the elevator equipment room.

Failure to maintain vertical openings as required increases the risk of death or injury due to fire.

The deficiency affected one (1) of two (2) elevator shafts.

The facility failed to ensure smoke barriers were at least one-half hour fire resistant and smoke resistant.

Observation determined the second floor north smoke barrier had an unsealed cable penetration on both sides above the cross-corridor smoke barrier doors.

Failure to maintain smoke barriers as required increases the risk of death or injury due to fire.

The deficiency affected two (2) of six (6) smoke compartments in the facility.

The facility failed to ensure doors located in smoke barrier walls resisted the passage of smoke.

Observation determined:

1) The second floor south smoke barrier cross-corridor doors would not close into the door frame.

2) The second floor smoke barrier door from the Nourishment Station to Conference Room #230 had a hole from a door knob that had been removed.

Failure to maintain smoke barrier doors increases the risk of death or injury due to fire.

The deficiency affected two (2) of six (6) smoke compartments in the facility.

The facility failed to separate hazardous areas from other spaces with one-hour fire resistive rated partitions and self-closing fire-rated door assemblies.

Observation determined:

1) The Cardiac Rehab Storage Room did not have one-hour fire rated construction.

a) The wall between the Cardiac Rehab Room and the Cardiac Rehab Storage Room did not extend to the floor/ceiling assembly.

b) The door to the Cardiac Rehab Storage Room did not have a ?-hour fire rated door and frame assembly with a self-closing device.

2) The door to the Storage Room #3 did not self-close and latch into the door frame.

3) The door to the Laundry Drying Room did not self-close and latch into the door frame.

4) The door to the second floor South Wing Linen Room (exceeding fifty (50) sq feet with a combustible load) did not have a self-closing device.

Failure to separate hazardous areas increases the risk of death or injury due to fire.

The deficiency affected four (4) of seventeen (17) hazardous areas in the facility.

Keyed locks, dead bolt locks and multi-latching devices create an impediment to egress from habitable spaces. Doors shall be operable with not more than one releasing operation. 7.2.1.5.4

The facility failed to ensure exit access was readily accessible at all times.

Observation determined the corridor door to the Mammogram Room was equipped with a lever latch, slide-bolt latch and thumb latch.

Failure to maintain the means of egress as required increases the risk of death or injury due to fire.

The deficiency affected one (1) of numerous habitable spaces in the facility.

The facility failed to ensure exits were marked by approved signage that was readily visible from any direction of exit access and that obviously and clearly identified the exit. 7.10.1.2

Observation determined:

1) The exit sign on the west side of the second floor north smoke barrier cross-corridor doors was not illuminated.

2) No directional exit sign was provided on the south side of the north cross-corridor doors on the second floor to identify the direction of travel to the north stairway from the south.

Failure to provide exit signage as required increases the risk of death or injury due to fire.

The deficiency affected exiting on the second floor of the facility.

The facility failed to provide a fire safety plan as required.

Observation and policy review determined the fire safety plan did not provide for evacuation of smoke compartments as required.

Failure to provide a fire plan as required increases the risk of death or injury due to fire.

The deficiency affected one (1) of eight (8) required fire safety plan provisions for the facility.

Ref: 2000 NFPA 101 Section 19.7.1.1, 19.7.2.2

The facility failed to test and maintain the fire alarm system as required by NFPA 72, National Fire Alarm Code.

Observation and review of fire alarm system test records determined:

1) The last annual test of the fire alarm system was conducted on 04/26/2013, exceeding the required annual testing requirement.

2) There was no record of the semiannual load voltage tests of the fire alarm system sealed lead acid batteries.

3) There were missing ceiling tiles throughout the building that could delay the activation of heat detectors.

Failure to test and maintain the fire alarm system as required increases the risk of death or injury due to fire.

The deficiency affected one (1) of one (1) fire alarm system. The fire alarm system serves the entire facility.

The facility failed to install and inspect fire extinguishers in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

Observation determined:

1) The inspection tag on the Penthouse fire extinguisher had not been initialed to indicate a monthly inspection during July 2014.

2) The fire extinguisher in the X-ray Office was sitting on the floor rather than mounted on the wall with an approved wall hanger.

Failure to ensure portable fire extinguishers comply with NFPA 10 increases the risk of death or injury due to fire.

The deficiency affected two (2) of numerous portable fire extinguishers in the facility.

The facility failed to prevent the use of portable space heating devices in patient sleeping areas.

Observation determined electric portable space heaters were being used in Patient Rooms #210 and #211.

Failure to prevent the use of portable space heating devices in patient sleeping areas increases the risk of death or injury due to fire.

The deficiency affected two (2) of numerous areas of the facility.

The facility failed to maintain exit corridors free of all obstructions or impediments to exiting.

Observation determined:

1) Two (2) patient scales were stored in the corridor across from Clinic Exam Room #1.

2) A stool and two (2) chairs were stored in the first floor west exit corridor.

Failure to maintain corridors free of obstructions increases the risk of death or injury due to fire.

This deficiency affected two (2) of eight (8) exit corridors.

The facility failed to ensure the oxygen supply system and all components were in accordance with the requirements for a Type I Gas System.

Observation determined:

1) The medical gas system alarm was not connected to the oxygen supply system.

2) The oxygen supply piping had no markings or labels applied every 20 feet to the piping to indicate the content of the gas line.

3) There was no emergency oxygen supply connection located on the main building.

4) There were eight (8) oxygen cylinders for the oxygen supply system that were not secured and located to prevent them from falling or being knocked over.

Failure to ensure oxygen supply systems comply with NFPA 99 increases the risk of death or injury due to fire.

The deficiency affected the entire facility.

Fire damper testing must be performed as required by NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems at least every six (6) years and records of the testing made available for review.

Review of records and staff interview determined that five (5) fire dampers in the Mechanical Penthouse had not been inspected and tested in the past six (6) years.

Failure to maintain fire dampers increases the risk of death or injury due to fire.

This deficiency affected five (5) of numerous fire dampers throughout the facility.

The facility failed to ensure the emergency generator was in compliance with NFPA 110, Standard for Emergency and Standby Power Systems.

Observation and record review determined:

1) All Level 1 and Level 2 installations of an emergency generator shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building.

For Level 1 and Level 2 systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified. NFPA 110, Standard for Emergency and Standby Power Systems.

There was no remote stop switch for the generator located outside of the generator room.

2) There was no record that weekly inspections of the emergency generator were being conducted.

3) The specific gravity and water levels of the emergency generator battery were not checked at seven (7) day intervals as required.

Failure to inspect and maintain the emergency generators in accordance with NFPA 99 and NFPA 110 increases the risk of death or injury due to fire.

The deficiency affected one (1) of one (1) emergency generator which provides all emergency power to the facility.

Flexible cords and cables must not be used as a substitute for fixed wiring of a structure. NFPA 70, National Electrical Code, 400-8

The facility failed to ensure electrical wiring and electrical equipment met NFPA 70 requirements.

Observation determined:

1) A multiplug adapter was in use in place of permanent wiring to provide electricity to the paging system in the Admissions Office.

2) A multiplug adapter was in use in place of permanent wiring to provide electricity to the RO system in the Autoclave Room.

3) The cover for the electrical panel in the basement South Storage Room was removed and sitting on the floor below the panel.

4) There was an open electrical junction box on the ceiling of the Cardiac Rehab Storage Room.

5) There was an open electrical junction box on the ceiling of the UPS Backup Room in the basement.

6) Numerous power strips were in use in place of permanent wiring to provide electricity to pagers, refrigerators, microwave ovens, radios, lamps and fans throughout the facility.

Failure to ensure electrical wiring is in accordance with NFPA 70 requirements increases the risk of death or injury due to fire.

The deficiency affected components of the electrical system in the facility.

The facility failed to maintain the two-hour fire resistive rating of the floor/ceiling assemblies throughout the building.

Observation determined the two-hour fire rated floor/ceiling assemblies had multiple unsealed spaces throughout the basement, first floor and second floor.

Failure to maintain the two-hour fire resistive rating of floor/ceiling assemblies increases the risk of death or injury due to fire.

The deficiency affected two (2) of two (2) floors in the facility.

The facility failed to provide corridors that were separated from use areas by walls with at least one-half hour fire resistance rating.

Observation determined there was an unsealed space above the duct to the corridor from the sewage pump room in the basement.

Failure to maintain the one-half hour fire resistance rating of corridor walls increases the risk of death or injury due to fire.

The deficiency affected one (1) of numerous corridor walls in the facility.

The facility failed to ensure the corridor doors latched into their frames and resisted the passage of smoke.

Observation determined the door to Patient Room #232 failed to latch into the frame.

Failure to ensure corridor doors were latched properly increases the risk of death or injury due to fire.

The deficiency affected one (1) of numerous corridor doors in the facility.

1) The facility failed to provide two-hour fire resistive construction for stairways.

Observation determined the second floor center stairway door did not self-close and latch into the door frame.

The deficiency affected one (1) of four (4) stairways in the facility.

2) The facility failed to maintain the two-hour fire resistive rating of elevator shaft enclosures.

Observation determined there was an open pipe penetration from the main elevator shaft into the elevator equipment room.

Failure to maintain vertical openings as required increases the risk of death or injury due to fire.

The deficiency affected one (1) of two (2) elevator shafts.

The facility failed to ensure smoke barriers were at least one-half hour fire resistant and smoke resistant.

Observation determined the second floor north smoke barrier had an unsealed cable penetration on both sides above the cross-corridor smoke barrier doors.

Failure to maintain smoke barriers as required increases the risk of death or injury due to fire.

The deficiency affected two (2) of six (6) smoke compartments in the facility.

The facility failed to ensure doors located in smoke barrier walls resisted the passage of smoke.

Observation determined:

1) The second floor south smoke barrier cross-corridor doors would not close into the door frame.

2) The second floor smoke barrier door from the Nourishment Station to Conference Room #230 had a hole from a door knob that had been removed.

Failure to maintain smoke barrier doors increases the risk of death or injury due to fire.

The deficiency affected two (2) of six (6) smoke compartments in the facility.

The facility failed to separate hazardous areas from other spaces with one-hour fire resistive rated partitions and self-closing fire-rated door assemblies.

Observation determined:

1) The Cardiac Rehab Storage Room did not have one-hour fire rated construction.

a) The wall between the Cardiac Rehab Room and the Cardiac Rehab Storage Room did not extend to the floor/ceiling assembly.

b) The door to the Cardiac Rehab Storage Room did not have a ?-hour fire rated door and frame assembly with a self-closing device.

2) The door to the Storage Room #3 did not self-close and latch into the door frame.

3) The door to the Laundry Drying Room did not self-close and latch into the door frame.

4) The door to the second floor South Wing Linen Room (exceeding fifty (50) sq feet with a combustible load) did not have a self-closing device.

Failure to separate hazardous areas increases the risk of death or injury due to fire.

The deficiency affected four (4) of seventeen (17) hazardous areas in the facility.

Keyed locks, dead bolt locks and multi-latching devices create an impediment to egress from habitable spaces. Doors shall be operable with not more than one releasing operation. 7.2.1.5.4

The facility failed to ensure exit access was readily accessible at all times.

Observation determined the corridor door to the Mammogram Room was equipped with a lever latch, slide-bolt latch and thumb latch.

Failure to maintain the means of egress as required increases the risk of death or injury due to fire.

The deficiency affected one (1) of numerous habitable spaces in the facility.

The facility failed to ensure exits were marked by approved signage that was readily visible from any direction of exit access and that obviously and clearly identified the exit. 7.10.1.2

Observation determined:

1) The exit sign on the west side of the second floor north smoke barrier cross-corridor doors was not illuminated.

2) No directional exit sign was provided on the south side of the north cross-corridor doors on the second floor to identify the direction of travel to the north stairway from the south.

Failure to provide exit signage as required increases the risk of death or injury due to fire.

The deficiency affected exiting on the second floor of the facility.

The facility failed to provide a fire safety plan as required.

Observation and policy review determined the fire safety plan did not provide for evacuation of smoke compartments as required.

Failure to provide a fire plan as required increases the risk of death or injury due to fire.

The deficiency affected one (1) of eight (8) required fire safety plan provisions for the facility.

Ref: 2000 NFPA 101 Section 19.7.1.1, 19.7.2.2

The facility failed to test and maintain the fire alarm system as required by NFPA 72, National Fire Alarm Code.

Observation and review of fire alarm system test records determined:

1) The last annual test of the fire alarm system was conducted on 04/26/2013, exceeding the required annual testing requirement.

2) There was no record of the semiannual load voltage tests of the fire alarm system sealed lead acid batteries.

3) There were missing ceiling tiles throughout the building that could delay the activation of heat detectors.

Failure to test and maintain the fire alarm system as required increases the risk of death or injury due to fire.

The deficiency affected one (1) of one (1) fire alarm system. The fire alarm system serves the entire facility.

The facility failed to install and inspect fire extinguishers in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

Observation determined:

1) The inspection tag on the Penthouse fire extinguisher had not been initialed to indicate a monthly inspection during July 2014.

2) The fire extinguisher in the X-ray Office was sitting on the floor rather than mounted on the wall with an approved wall hanger.

Failure to ensure portable fire extinguishers comply with NFPA 10 increases the risk of death or injury due to fire.

The deficiency affected two (2) of numerous portable fire extinguishers in the facility.

The facility failed to prevent the use of portable space heating devices in patient sleeping areas.

Observation determined electric portable space heaters were being used in Patient Rooms #210 and #211.

Failure to prevent the use of portable space heating devices in patient sleeping areas increases the risk of death or injury due to fire.

The deficiency affected two (2) of numerous areas of the facility.

The facility failed to maintain exit corridors free of all obstructions or impediments to exiting.

Observation determined:

1) Two (2) patient scales were stored in the corridor across from Clinic Exam Room #1.

2) A stool and two (2) chairs were stored in the first floor west exit corridor.

Failure to maintain corridors free of obstructions increases the risk of death or injury due to fire.

This deficiency affected two (2) of eight (8) exit corridors.

The facility failed to ensure the oxygen supply system and all components were in accordance with the requirements for a Type I Gas System.

Observation determined:

1) The medical gas system alarm was not connected to the oxygen supply system.

2) The oxygen supply piping had no markings or labels applied every 20 feet to the piping to indicate the content of the gas line.

3) There was no emergency oxygen supply connection located on the main building.

4) There were eight (8) oxygen cylinders for the oxygen supply system that were not secured and located to prevent them from falling or being knocked over.

Failure to ensure oxygen supply systems comply with NFPA 99 increases the risk of death or injury due to fire.

The deficiency affected the entire facility.

Fire damper testing must be performed as required by NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems at least every six (6) years and records of the testing made available for review.

Review of records and staff interview determined that five (5) fire dampers in the Mechanical Penthouse had not been inspected and tested in the past six (6) years.

Failure to maintain fire dampers increases the risk of death or injury due to fire.

This deficiency affected five (5) of numerous fire dampers throughout the facility.

The facility failed to ensure the emergency generator was in compliance with NFPA 110, Standard for Emergency and Standby Power Systems.

Observation and record review determined:

1) All Level 1 and Level 2 installations of an emergency generator shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building.

For Level 1 and Level 2 systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified. NFPA 110, Standard for Emergency and Standby Power Systems.

There was no remote stop switch for the generator located outside of the generator room.

2) There was no record that weekly inspections of the emergency generator were being conducted.

3) The specific gravity and water levels of the emergency generator battery were not checked at seven (7) day intervals as required.

Failure to inspect and maintain the emergency generators in accordance with NFPA 99 and NFPA 110 increases the risk of death or injury due to fire.

The deficiency affected one (1) of one (1) emergency generator which provides all emergency power to the facility.

Flexible cords and cables must not be used as a substitute for fixed wiring of a structure. NFPA 70, National Electrical Code, 400-8

The facility failed to ensure electrical wiring and electrical equipment met NFPA 70 requirements.

Observation determined:

1) A multiplug adapter was in use in place of permanent wiring to provide electricity to the paging system in the Admissions Office.

2) A multiplug adapter was in use in place of permanent wiring to provide electricity to the RO system in the Autoclave Room.

3) The cover for the electrical panel in the basement South Storage Room was removed and sitting on the floor below the panel.

4) There was an open electrical junction box on the ceiling of the Cardiac Rehab Storage Room.

5) There was an open electrical junction box on the ceiling of the UPS Backup Room in the basement.

6) Numerous power strips were in use in place of permanent wiring to provide electricity to pagers, refrigerators, microwave ovens, radios, lamps and fans throughout the facility.

Failure to ensure electrical wiring is in accordance with NFPA 70 requirements increases the risk of death or injury due to fire.

The deficiency affected components of the electrical system in the facility.