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Tag No.: K0011
A. Based on random observation during the survey walk-through and document review on the afternoon of November 7, 2011, not all building occupancies are separated from health care occupancies to comply with 19.1.2. This condition may affect patients, staff and visitors direction of egress during a fire emergency in the north wing of the Main level.
The finding is:
1. There is no designated (on the facility Life Safety drawings) 2-hour fire barrier/separation wall, observed between the Ambulance bay garage and the hospital to comply with 19.1.2.1 (2). The pair of designated exit doors leading to the Ambulance garage lack a label to identify their fire resistance rating.
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Tag No.: K0018
Based on random observation on November 7-8, 2011 during the survey walkthrough, corridor doors were observed which did not maintain the integrity of the means of egress for safe passage during a fire emergency. This condition may affect all patients, staff and visitors within the facility.
Findings include:
A.. Doors in exit access corridors are not positive latching to comply with 19.3.6.3.2. Locations observed include:
1. Main Level pair of entry doors to the Surgery suite from the east/west corridor.
2. Main Level pair of entry doors to the ICU suite from the east/west corridor.
B. A door was held open by unapproved devices which does not comply with 19.3.6.3.2. Location observed:
1. Store room # 119 contains a self closing device with a hold open mechanism.
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Tag No.: K0020
Based on random observation during the survey walk-through on the morning of November 8, 2011, vertical openings between floors are not protected to comply with 19.3.1.1. These deficiencies could affect staff, patients and visitors in the East wing of the facility, due to the lack of protection which can prevent smoke and fire to migrate from one floor to another.
Findings include:
A. Lower Level bed storage # 022 is not separated from either a shaft above or the adjacent occupied room due to the lack of a fire damper within a duct that penetrates the south wall of this room and continues up a shaft located on the north end of the room. The duct contains an in-line exhaust fan and serves the Beautician shop located next door. This room is considered part of the shaft, therefore the shaft is open to the adjacent occupied room which does not comply with 19.3.1.1.
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Tag No.: K0025
Based on random observation during the survey walk-through on the afternoon of Nov. 7, 2011 , not all designated or required smoke barrier walls are constructed or maintained as fire rated assemblies to comply with 19.3.7.3. This may affect all patients staff and visitors within the facility from gaining access to a safe smoke free environment.
The finding is:
A. Main level facility designated smoke barrier for the south wing, housing the Med/Surg Unit, contains a pair of self closing cross corridor doors which do not comply with 19.3.7.5 due to the following:
1. The pair of doors both contain an astragal which is a continuous 2 by 4 screw-attached to the meeting stiles of these doors. This type of installation is non compliant and does not maintain the doors' designated fire resistance rating. Therefore there is an incomplete barrier between two smoke compartments which does not comply with 19.3.7.3. and 8.3.2.
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Tag No.: K0029
Based on random observation during the survey walk-through on the afternoon of November 7 and morning of the 8th, not all hazardous areas are separated from the remainder of the building to comply with 19.3.2.1, 39.3.2.1 and 8.4. This condition may prevent the use of an exit access corridor or path of egress by patients, staff and visitors during a fire emergency.
Findings include:
A. Equipment storage located in the Surgical suite contains numerous combustible items stored (stryofoam pads) along with equipment in an amout deemed hazardous. This room is approximately 112 square feet. This room lacks separation from a path of egress due to a self closing door which does not latch.
B. Clean linen located in the ICU suite contains numerous combustibles within a room that is approximately 100 square feet. This room does not maintain a resistant separation from the adjacent rooms due to the following:
1. The door does not latch.
2. The door is not self closing.
C. Linen chute room located in the Lower level Laundry room does not maintain a fire resistant separation from this adjacent room due to the following:
1. The Linen chute room's fire rated door displays decay across the bottom and at the latch side.
2. The door's finish is delaminated in areas and the interior core may be viewed.
D. Lower Level Environmental Services room # 005 contains numerous combustible paper products within a room that is approximately 100 square feet. This room does not maintain a resistant separation from the adjacent path of egress due to an entry door which is not self closing.
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Tag No.: K0034
Based on random observation during the survey walk-through on the morning of November 8, 2011, not all stair shafts used as exits are constructed in accordance with 7.2. This deficiency may affect all occupants of the building due to compromising their ability to exit the building and reach a public way.
Findings include:
A. The facilty has two stairs (one is a convenience stair and lacks an exit sign). The other stair is a designated exit stair located on the south Med/Surge wing. This stair discharges to the interior of the building without the use of a vestibule and does not comply with 7.7.2. This Hospital building has no stairs which discharge directly to the exterior of the building or to a vestibule.
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Tag No.: K0042
During the survey walk through, document review and staff interview, on afternoon of November 7, 2011 it was observed that not all facility designated suites are provided with exits to comply with 19.2.5.2. This condition may affect patients and staff on the North side of the main level for compliant travel routes during a fire emergency.
Findings include:
A. The deficiencies listed below were observed regarding the Main Level suite layout. Surveyor notes that the Life Safety floor plans did not clearly define the following areas as suites to comply with 19.2.5. The surveyor was informed by the facility representatives that the following locations constituted healthcare suites. The following deficiencies were identified:
1. Space were observed at which the egress path passes through at least 2 intervening spaces and is in excess of 50'-0" in length which does not comply with 19.2.5.8. Locations' observed:
a. Surgery suite Pack prep room
b. Radiology suite.
2. Several spaces were observed which lack two remote exits leading to exit access corridors. For example - Surveyor noted exits from the Radiology Dept, Recovery and the Emergency Dept. areas pass through a "connecting corridor which runs north/south and leads to the Clinic. The Life Safety drawings indicate that this corridor is part of the Recovery, Radiology and Emergency Dept. suite. This layout forms a "dead end" suite condition which does not comply with 19.2.5.1 for habitable rooms. None of the above listed suites have direct access to an exit access corridor.
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Tag No.: K0045
Based on random observation during the survey walk-through on the afternoon of November 7, 2011 not all exterior egress paths are illuminated in such a manner that the failure of one fixture will not leave the area in darkness to comply with 19.2.8. This condition may affect the safe egress to a public way for patients, staff and visitors.
The finding is:
A. Exterior discharges were observed that are not provided with lighting, on emergency power, that is equipped so that the failure of 1 fixture (bulb) will not leave the area in darkness. Locations observed:
1. Lower Level- south wing discharge for Med/surg.
2. Main Level - discharge from Surgery suite area (across from room # 150 family waiting).
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Tag No.: K0050
A. During document review on the morning of November 7, 2011, the Fire Drill documentation was reviewed. The surveyor finds that the provider conducts periodic fire drills; however, the documentation does not demonstrate compliance with 19.7.2.1 as follows. This condition may contribute to a delay in action for staff patients and visitors under a fire emergency.
1. The fire drill report forms do not identify the participation of all areas. There is no reference to the mobile MRI unit which is present on site two days each week.
2. The fire drill dates and times are all near the end of the month and roughly the same time of day which does not demonstrate the use of varying conditions and unexpected times.
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Tag No.: K0051
Based on random observation during the survey walk through on November 8, 2011, not all portions of the building fire alarm system are installed to comply with 19.3.4. The absence of a fire alarm notification device within the means of egress may serve to delay response in an emergency. This condition may affect patients, staff and visitors on the main level in the North wing leading to the Clinic.
Findings include:
A. Fire alarm pull stations were observed which are not located within 5'-0" of the door to comply with NFPA 72 1999 2-8.2.2. Location observed:
1. Main Level designated discharge door north of Ambulance bay.
26665
Based on random observation during the survey walk-through, not all components of the facility's fire alarm system are installed in accordance with NFPA 72 1999.
Findings include:
B. During the walk-through of the lower level in the corridor outside the engineering offices on the afternoon of November 7, 2011, 2 smoke detectors were observed within 3' of supply diffusers and not in accordance with 2-3.5.1.
The air from the diffuser could cause injury to patients and staff by a delay in detecting smoke.
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Tag No.: K0056
Based on random observation and staff interview, during the survey walk-through on the afternoon of November 7, 2011, not all portions of the facility's automatic sprinkler system are installed and maintained in accordance with NFPA 13 1999.
Finding is:
A. The Emergency Department Ambulance Bay, under which a vehicle was observed being stored, was observed to lack sprinkler heads required by NFPA 13 1999 5-13.8.2. During an interview held at the site on the afternoon of November 8, 2011, the provider's Safety and Risk Manager and the Maintenance Engineer confirmed that the parking of ambulances within the Bay is a common occurrence.
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Tag No.: K0077
Based on random observation during the survey walk-through, not all portions of the facility's piped medical gas system are installed in accordance with NFPA 99 1999.
Findings include:
A. During the walk-through of the mechanical room in the lower level on the afternoon of November 7, 2011 the medical vacuum pumps were observed with a manifold exhaust to a single pipe exiting to the outside without a check, manual valve or other arrangement to isolate the malfunctioning pump so the other pump could provide suction for patient needs in accordance with 4-3.2.1.9.
B. During the walk-through the medical vacuum system was observed with additional valves in the source line without identification tags to indicate the areas served by these valves in accordance with 4-3.2.2.4.
These deficiencies could cause injury to patients requiring medical vacuum for treatment.
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Tag No.: K0106
Based on random observation during the survey walk-through the generator equipment does not meet all requirements of NFPA-110. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised.
Findings include:
A. The caterpillar generator was not equipped with remote emergency shut-down switch to comply with NFPA-110, Section 3-5.5.6.
B. Both generators are using maintenance free batteries. Weekly records show N/A for battery inspections. Even though the batteries are the maintenance free type, later versions of NFPA-110 that allow maintenance free batteries require electrolyte levels or battery voltage to be checked weekly and maintained in accordance with manufacturer's specifications.
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Tag No.: K0130
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.
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Tag No.: K0145
Based on random observation during the survey walk-through 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. The following Life Safety Panels are serving loads other than those allowed by NFPA-70, Section 517-32 and NFPA-99, Section 3-4.2.2.2(b) .
a. Life Safety panel LE is feeding receptacles and equipment that should be served by other branches of the emergency power system.
b. Panel LE -2 is serving circuits other than those allowed on the life safety branch.
B. Equipment panel QE has a three pole circuit breaker serving critical panel PA. NFPA-70, Section 517-30(c)(1), requires the separation of life safety and critical branch wiring from each other and any other systems.
C. All power serving the emergency department and the operating and procedure rooms is fed through a single transfer switch. There are no normal power circuits that do not feed these areas through the transfer switch. This creates a single point of failure that could leave these areas completely out of power during a critical procedure, and does not meet the intent of NFPA-70, Section 517-30 through 35.
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Tag No.: K0147
Based on random observation during the survey walk-through not all portions of the building systems are installed in accordance with NFPA 70 (1999). Improper grounding could create ashock hazard for all occupants of the building.
Findings include:
A.Staff was not able to locate were the med gas piping was bonded as required by NFPA-70, Section 250.104(c).
B. Not all receptacles served by the emergency power system were marked with a distinctive color as required by NFPA-70, Section 517-33(c).
C. All components of the emergency power system, including panelboards, were not permanently marked as components of the emergency power system as required by NFPA-70, Section 700-9(a).
26665
Based on random observation during the survey walk-through, not all portions of the facility's electrical installation are in accordance with NFPA 70 1999.
Findings include:
D. During the lower level walk-through on the afternoon of November 7, 2011the electrical room across from the engineering office was observed with maintenance carts and other storage in front of the electrical panels and not in accordance with 110-26 (a) for proper working clearances of 36".
The blockage could cause injury due to a delay in disconnecting the electrical service.
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