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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. Corrected 08/09/12.
2. Corrected 08/09/12.
3. NEW ITEM 08/09/12: Pair of doors to Outpatient Surgery Suite 095.
4. NEW ITEM 08/09/12: Two pairs of doors to Emergency Department 102.
B. Corrected 08/09/12..
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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. Corrected 08/09/12.
B. NEW ITEM 08/09/12: An excisting linen chute has been removed as part of an ongoing construction project, resulting in an unprotected opening in the concrete slab between the Ground and First Floors, as prohibited by 19.3.1.1.
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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.: 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. Corrected 08/09/12.
B. Corrected 08/09/12.
C. NEW ITEM 08/09/12: The door to the Emergency Generator Room was observed to not carry a minimum 1-1/2 hour fire resistance rating required by 8.2.3.2.3.1(1), NFPA 99 1999 3-4.1.1.6(a), and NFPA 70 1999 5-2.1.
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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. Corrected 08/09/12.
C. Corrected 08/09/12.
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. Corrected 08/09/12.
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