The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.
| OSF SAINT ANTHONY MEDICAL CENTER | 5666 EAST STATE STREET ROCKFORD, IL 61108 | Aug. 29, 2018 |
| VIOLATION: Egress Doors | Tag No: K0222 | |
| Based upon observation and staff interview during the survey walk-thru, means of egress doors are capable of being locked to prevent egress. Failure to provide egress at all times can trap occupants during a fire condition when the building must be evacuated. Findings include: On 08/28/18 at 10:35am while in the company of the FS, it was observed that the exit doors from the Ground floor elevated exterior Terrace are equipped with locking hardware to prevent occupants from egressing from the Terrace in noncompliance with 21.2.1 and 7.2.1.5.1. |
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| VIOLATION: Illumination of Means of Egress | Tag No: K0281 | |
| Based upon observation during the survey walk-thru, illumination of means of egress lighting is not provided in accordance with Code requirements. Failure to provide lighting can compromise the safety of building occupants while exiting the building. Findings include: On 08/28/18 at 10:10am while in the company of the FS, it was observed that lighting was not provided at the exit discharge exterior stair of Stair K to comply with 21.2.8 & 7.8.1.4 because only a single lamp fixture on emergency power was provided. |
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| VIOLATION: Vertical Openings - Enclosure | Tag No: K0311 | |
| Based on observation, vertical openings between floors are not protected in accordance with Code requirements. Failure to protect vertical openings between floors can permit fire/smoke conditions to migrate to other floor levels during an emergency situation. Findings include: A. On 08/28/18 at 1:50 PM while in the company of the FM, it could not be confirmed that seven 4" conduits through the floor in the ground floor mechanical room TG 177 were sealed to prevent the passage of smoke to the floor above to comply with 18.3.1 and 8.6.3. B. On 08/28/18 at 2:00 PM while in the company of the FM, it could not be confirmed that 4" conduits through the floor in the ground floor room TG 180 were sealed to prevent the passage of smoke to the floor above to comply with 18.3.1 and 8.6.3. |
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| VIOLATION: Multiple Occupancies - Contiguous Non-Health | Tag No: K0132 | |
| Based upon staff interview and document review during the survey process, contiguous buildings not classified as Healthcare occupancy are intended to provide services simultaneously to 5 or fewer inpatients incapable of self-preservation. Failure to limit the number of inpatients permitted in an occupancy not defined as Healthcare can increase the risk to patient safety during a fire condition. Findings include: On 08/28/18 at 8:30am while in the company of the FS, FM, EHSM, VPFM, & FMGR it was noted on the available Life Safety Plans that the Cancer Care Center was indicated as a Business occupancy permitted to serve simultaneously 5 or fewer hospital inpatients incapable of self-preservation. This condition does not comply with 19.1.3.4.1. |
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| VIOLATION: Exit Signage | Tag No: K0293 | |
| Based upon observation during the survey walk-thru, exit signs are not provided to identify means of egress. Failure to identify means of egress can delay occupant movements to exit the building during a fire evacuation condition. Findings include: On 08/28/18 at 10:35am while in the company of the FS, it was observed that the elevated exterior Terrace at the Ground floor of the Cancer Center building lacked exit signage to identify the location of the two available exits from the Terrace to comply with 21.2.4.2, 21.2.10 and 7.10.1.5.1. |
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| VIOLATION: Sprinkler System - Installation | Tag No: K0351 | |
| Based upon observation during the survey walk-thru, sprinkler systems are not installed in accordance with Code requirements. Failure to install the sprinkler system in accordance with Code requirements can result in the system not performing as intended to control a fire condition. Findings include: A. On 08/28/18 at 9:55am while in the company of the FS, it was observed at Basement level Mechanical room B101CC that the escutcheon was missing at the sprinkler head to comply with NFPA 13-2010, 6.2.7 and NFPA 25-2011, 5.2.1.1.2(3). B. On 08/28/18 at 9:55am while in the company of the FS, it was observed at Basement level Storage room across the corridor from Mechanical room B101CC that the escutcheon was missing at the sprinkler head to comply with NFPA 13-2010, 6.2.7 and NFPA 25-2011, 5.2.1.1.2(3). |
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| VIOLATION: Number of Exits - Patient Sleeping and Non-Sl | Tag No: K0253 | |
| Based upon observation during the survey walk-thru, two exit access paths from large rooms are not provided. Failure to provide an alternate path of exit can prevent occupants from reaching an exit or place of refuge during a fire/smoke event. Findings include: On 08/28/18 at 10:45am while in the company of the FS, it was observed at the Ground floor Material Management Storage room, indicated to be 3300 sf in size, lacks two identified means of egress from the space to comply with 19.2.5.5.2. |
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| VIOLATION: Illumination of Means of Egress | Tag No: K0281 | |
| Based on observation and staff interview, illumination of exit discharge portion of the means of egress is not provided to maintain continuous illumination. Failure to maintain illumination of the means of egress can prevent safe and unimpeded access to the public way in the event of an emergency evacuation for all building occupants. Finding includes: On 08/29/18 at 9:40am while accompanied by the FM, the exit discharge lights were found installed with a single lamp fixture. This does not comply with 39.2.7, 7.7 and 7.8.1.4. |
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| VIOLATION: Emergency Lighting | Tag No: K0291 | |
| Based on observation during the survey walk-through, Critical Care areas where anesthesia is administered is not provided with battery-powered emergency lighting as required. This deficient practice could affect patient & staff safety in the room by preventing adequate lighting to perform necessary procedures during loss of normal lighting. Findings include: On 08/28/2018 at 10:10am while accompanied by the VPFM, observation determined that the Fourth floor C-Section Room critical care area where anesthesia is administered does not contain battery-powered emergency lights to comply with NFPA 99-2012, 6.3.2.2.11.1 and NFPA 70-2011, 517-63A. |
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| VIOLATION: Vertical Openings - Enclosure | Tag No: K0311 | |
| Based on observation, exit stair between basement, first and second floors are not protected in accordance with Code requirements. Failure to protect vertical openings between floors can permit fire/smoke conditions to migrate to other floor levels during an emergency situation. Findings include: On 08/29/2018, at 9:55am while accompanied by the FM, it was observed that the exit stairs from basement to second floor was not separated between floors. Openings between floors can permit fire/smoke conditions to migrate to other floor levels during a fire/smoke emergency situation. The conditions observed do not comply with 39.2.2.3.1, 7.2.2.5.1 and 8.6. |
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| VIOLATION: Subdivision of Building Spaces - Smoke Compar | Tag No: K0371 | |
| Based on observation and document review, smoke compartments are not arranged in accordance with Code requirements. Failure to provide proper smoke compartment configurations can compromise occupant safety by not providing protected areas of refuge with required exits. Findings include: A. On 08/28/18 at 10:40am while in the company of the FS, it was observed that the smoke compartment designations on the provided Ground floor Life Safety Plan for the Cancer Center building indicated that the smoke compartment containing the new addition was not provided with access to an exit without traversing the the adjacent smoke compartment. This arrangement does not comply with 21.2.4.5 and 7.5.1.1.1. B. On 08/28/18 at 10:45am while in the company of the FS, it was observed that the smoke compartment designations on the provided Basement floor Life Safety Plan for the Cancer Center building indicated that a 4938 sf smoke compartment and a 7760 sf smoke compartment existed without a minimum 1/2-hour barrier separating the two compartments to comply with 21.3.7.5. The plan did not define a line of demarcation between the areas and graphically indicated it to be a single smoke compartment. |
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| VIOLATION: Exit Signage | Tag No: K0293 | |
| Based upon observation during the survey walk-thru, exit signs are not maintained to accurately define exit access. Failure to maintain correct exit signs can result in confusion by misleading occupants when seeking an exit from the building. Findings include: On 08/28/18 at 10:30am while in the company of the FS, it was observed that the exit sign at the north corridor on the north side of the door accessing the Lobby/waiting room was a double directional exit sign rather than a non-directional sign. The arrow to the right directed occupants to a dead end. This installation does not comply with 39.2.10 and 7.10.1.5.1. |
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| VIOLATION: Illumination of Means of Egress | Tag No: K0281 | |
| Based on observation and staff interview, illumination of exit discharge portion of the means of egress is not provided to maintain continuous illumination. Failure to maintain illumination of the means of egress can prevent safe and unimpeded access to the public way in the event of an emergency evacuation for all building occupants. Finding includes: On 08/29/18 at 10:50am while accompanied by the FM, the exit discharge lights were found installed with a single lamp fixture. This does not comply with 39.2.7, 7.7 and 7.8.1.4. |
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| VIOLATION: Hazardous Areas - Enclosure | Tag No: K0321 | |
| Based on observation, not all enclosures for hazardous areas are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building, smoke and fire could pass from the hazardous areas to the remainder of the building in the event of a fire emergency. Findings include: On 08/29/18 at 10:45am while accompanied by the FM, observation determined that storage room 306 contains sufficient combustible material to constitute a hazardous area. The room door was observed not to be self closing to comply with 39.3.2.1 and 8.7. |
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| VIOLATION: ALCOHOL BASED HAND RUBS | Tag No: K0211 | |
| Based on observation, the means of egress from occupied spaces is not maintained in accordance with Code requirements. Failure to maintain means of egress for all spaces can result in confinement of occupants in a building during required evacuation. Findings include: A. On 08/29/18 at 9:10am while in the company of the FS, it was observed that locking devices were employed on doors which can prevent egress in noncompliance with 40.2.1.1 and 7.2.1.5.3. Locations observed: 1. A padlock was installed on the Dietary Storage room door. 2. A hasp lock was installed on both sides of the general storage room door near the stair discharge corridor at the upper level. |
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| VIOLATION: Exit Signage | Tag No: K0293 | |
| Based upon observation during the survey walk-thru, access to available exits is not readily apparent and identified by signage. Failure to identify exit access can result in occupants failing to reach available exits when required during an emergency situation. Findings include: On 08/29/18 at 9:00am while in the company of the FS, it was observed that exit signage to identify the required access to exits from the building is not provided to comply with 40.2.4.1, 40.2.10 & 7.10.2.1. Externally illuminated signs were provided only at the exterior exit doors within the Boiler room and associated mezzanine level. Visibility of these doors and signage was obstructed by equipment & piping so as not to be visible from any distance from the door. Access to a second exit was also not defined by exit signage. The at-grade exit from the west end upper level was not identified. |
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| VIOLATION: ALCOHOL BASED HAND RUBS | Tag No: K0211 | |
| Based upon observation and staff interview, egress paths are not maintained as a protected path to the public way. Failure to provide a protected path can compromise the use of the path as an exit during an emergency. Findings include: On 08/28/18 at 11:15am while in the company of the FS, it was observed that two fabric awning enclosures at the exit discharge locations from the Ground floor located at and near the exterior discharge of the exit passageway serving Stair D, were not labeled as fire/flame retardant treated to comply as non-combustible or limited combustible in accordance with 19.1.6 and 11.9.1.6. Staff indicated that documentation of compliance was not available at the time of the survey. |
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| VIOLATION: Egress Doors | Tag No: K0222 | |
| Based on observation, the means of egress doors are locked without full compliance with Code allowance provisions. Failure to install locking devices for means of egress doors in full compliance with all requirements can result in building occupants not being able to reach an area of safety or an exit from the building if there is a fire/smoke event. Findings include: A. On 08/28/2018 at 10:50am while in the company of the VPFM and the FMGR, it was observed that the delayed egress locking devices installed at the cross corridor smoke barrier doors lack the means for either manual reset to comply with 7.2.1.6.1.1 (3.d.) or access controlled egress doors to comply with 19.2.2.2.4 (3) and 7.2.1.6.2. Location observed: 1. Fourth floor South Wing pair of cross corridor doors (close to Stair B) - designated exit from the compartment. 2. Fourth floor South Wing pair of cross corridor doors north end of corridor #C4022 do not comply for manual reset. |
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| VIOLATION: Doors with Self-Closing Devices | Tag No: K0223 | |
| Based upon observation during the survey walk-thru, doors required to be self-closing and/or positive latching are not installed in accordance with Code requirements. Failure to properly install doors can compromise the openings designed to resist the passage of fire/smoke during a fire/smoke emergency. Findings include: A. On 08/28/18 while in the company of the FS, power operated corridor doors are not provided with smoke detection to comply with 7.2.1.9.2(4). Locations observed: 1. At 9:20am at the Basement level Environmental Storage room B001. 2. At 10:55am at the Ground floor Materials Management corridor doors. 3. At 11:30am at the Ground floor Clean & Soiled linen storage rooms near the south wing elevators. |
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| VIOLATION: Exit Signage | Tag No: K0293 | |
| Based on observation, directional exit signs are not provided to define access to at least two means of egress from a floor level to comply with Code requirements. Failure to define exits can prevent occupants from reaching an alternate exit when the primary exit access is compromised during an emergency event. Findings include: On 08/28/18 at 1:30pm, while in the company of the FM, the directional exit sign from the south elevator lobby to the adjoining suite pair of doors in the existing building directs to the wall with an arrow, not in accordance with 19.2.10.1 and 7.10. The identified exiting of a corridor into a suite does not comply with 7.5.1.2. The Elevator Lobby/Corridor area was not identified as a suite on the Life Safety Plans provided for review. |
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| VIOLATION: Number of Exits - Corridors | Tag No: K0252 | |
| Based upon observation during the survey walk-thru, two exit access paths from corridors are not provided. Failure to provide an alternate path of exit can prevent occupants from reaching an exit or place of refuge during a fire/smoke event. Findings include: On 08/28/18 at 10:15am while in the company of the FS, it was observed, at the Ground floor corridor serving the MRI suite, that only one path of egress was identified to the stair in noncompliance with 19.2.5.4 & 7.5.1.1. The corridor leading to the Cancer Center is greater than 30' in length and not marked as an exit because the doors are locked from the hospital side after hours. These doors are not provided with signage to indicate it is not an available path after hours. The doors to the corridor leading north are also not otherwise identified as the required 2nd available path of egress. |
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| VIOLATION: Dead-End Corridors and Common Path of Travel | Tag No: K0251 | |
| Based on observation during the survey walk through, dead end corridor lengths exist which exceed what is permitted. This deficient practice could require a person to traverse a longer route to reach an exit and may compromise the prompt care and movement of patients, visitors and staff during a fire/smoke emergency. Findings include: On 08/28/2018 at 3:10pm while accompanied by the VPFM , the designated means of egress from the Fourth floor, South Wing, corridor #C4032, Patient room #'s 488, 487, 489, 490, 491, 492 near the C-Section area (indicated as a suite on the Life Safety drawings) to the nearest exit is in a length greater than allowed by 19.2.5.2. |
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| VIOLATION: Exit Signage | Tag No: K0293 | |
| Based on observation, exit signs are not provided to define access to at least two means of egress from a floor level to comply with Code requirements. Failure to define exits can prevent occupants from reaching an alternate exit when the primary exit access is compromised during an emergency event. Findings include: On 08/28/18 while in the company of the FM, the following areas were observed missing directional exit signs to comply with 19.2.10.1 and 7.10. A. Main Building - Second Floor. 1. At 10:55am, east portion of the Tower elevator lobby on second floor, to direct occupants to the available second exit on main building second floor. Between Corridors C-2123 and C-2129 and at cross corridor C-2129. 19.2.10.1 and 7.10 B. Main Building - First Floor. 1. At 1:30pm, North and South of Exit corridor C-1025. 2. At 1:45pm, Exit corridor C - 1086 in Interventional Neurology at door by room 1218 and 1219. 3. At 1:55pm, At the corner by room 1252 and 1243. 4. At 2:15pm, At the intersection of exit corridor C-1065 and 1059. 5. At 2:25pm, South and West of exit corridor C-1018. 6. At 2:30pm, At door by waiting 1044. 7. At 2:40pm, At intersection of Corridor C-1106 and at smoke door. C. Main Building - Ground Floor. 1. At 1:35pm while in the company of the FS, the exit signage provided in the corridor east of the Ground floor Dining room was not fully visible at all locations within the corridor to comply with 7.10.1.8 due to ceiling mounted obstructions. |
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| VIOLATION: Vertical Openings - Enclosure | Tag No: K0311 | |
| Based on observation during the survey walk through, the facility failed to maintain compartment separations between floors/areas. This deficient practice could affect patients, staff and visitors to safely reach an exit on a floor level during a fire event on a separate level. Findings include: On 08/29/2018 at 10:50am while in the company of the FMGR and the VPFM, it was observed that a multi-story shaft that is open to the ceiling cavity of the Second floor. The shaft is not enclosed in fire rated construction to comply with 19.3.1.1, and NFPA 90A. Location observed: 2nd floor Surgery Waiting area #2071 - toward center of waiting area - west of Men's Toilet # 200E. |
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| VIOLATION: Hazardous Areas - Enclosure | Tag No: K0321 | |
| Based on observation, hazardous areas are not protected in accordance with Code requirements. Failure to provide protection of areas with a higher degree of hazard than normal to the remaining occupancy can compromise the safety of all occupants during a fire/smoke event originating within the hazardous area. Findings include: A. On 08/28/18 at 3:00pm while in the company of the FS, it was observed that the Ground floor Foundation Conference room Storage room door was not positive latching in accordance with the labeling requirements to comply with 19.3.2.1, 8.7.1.3 & NFPA 80-2010, 6.1.4. The inactive leaf was equipped with manual flush bolts which were not engaged to provide latching for both doors of the pair. The inactive leaf also lacked a closer and coordinator to provide a point of latching for the active door which was equipped with a closer. B. On 08/28/2018, at 9:45am while in the company of the VPFM, the fourth floor East Wing, which is not occupied, contains a Janitors closet with a rubbish chute. The room is considered a hazardous area. The corridor door to the Janitor's closet does not comply with 19.3.2.1.2 and 19.3.2.1.3 due to the following: 1. Door does not self close. 2. Door does not latch. C. On 08/29/2018 at 9:01am while in the company of the VPFM, doors to hazardous areas were observed which do not comply with 19.3.2.1 and 8.4 for separation requirements. Location observed: Room # PH103 (IT equipment) in the north elevator penthouse. |
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| VIOLATION: Fire Alarm - Control Functions | Tag No: K0344 | |
| Based upon observation during the survey walk-thru, fire alarm systems are not installed in accordance with Code requirements. Failure to install the fire alarm system in accordance with Code requirements can result in disruption of the system to not function as required. Findings include: On 08/28/18 at 9:25am while in the company of the FS, it was observed, at the Basement level Equipment room adjacent the PBX room, that the fire alarm circuit #17 in panel "EM-UPS-A" was not provided with a mechanical lock-on device to comply with NFPA 72-2010, 10.5.5.3. |
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| VIOLATION: Sprinkler System - Installation | Tag No: K0351 | |
| Based upon observation during the survey walk-thru, sprinkler systems are not installed in accordance with Code requirements. Failure to install the sprinkler system in accordance with Code requirements can result in the system not performing as intended to control a fire condition. Findings include: A. On 08/28/18 at 9:30am while in the company of the FS, it was observed at the Equipment room adjacent the PBX room that sprinkler coverage provided on one side of the room could not reach the entire room due to the sprinklers provided being obstructed by cables, ducts & equipment in noncompliance with NFPA 13-2010, 8.6.5.1.1. B. On 08/28/18 at 2:35pm while in the company of the FS, it was observed that the Ground floor old analog phone system closet in the corridor serving the SPD near the communicating Stair G that no ceiling existed to contain the room relative to sprinkler activation to comply with NFPA 13-2010, 8.6.4. The room appeared to be open to the above ceiling space of the corridor. C. On 08/28/18 at 2:50pm while in the company of the FS, it was observed at the Ground floor Mechanical room housing AHU-34 that sprinkler protection under ducts wider than 4'-0" was not provided at all such locations to comply with NFPA 13-2010, 8.5.5.3.1. Based on observation during the survey walk through the facility failed to install all required components of the wet pipe fire suppression system. Failure to install and maintain these systems could result in malfunction and delayed response. This deficient practice could affect patients, staff and visitors during a fire event. Findings include: D. On 08/29/2018 at 11:10am while in the company of the VPFM, it was observed that exit Stair E (which serves 5 levels) is not sprinkler protected to comply with NFPA 13-2010, 8.11.5.1 and 8.15.3.2.2 at the top of the stair section from the Ground floor (at the First floor landing). |
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| VIOLATION: Sprinkler System - Maintenance and Testing | Tag No: K0353 | |
| Based upon observation during the survey walk-thru, the fire pump & equipment is not separated from other use areas to provide a reasonable degree of protection for the system. Failure to separate fire pump equipment to provide protection from other uses can jeopardize the function of the fire pump to provide required fire protection service. Findings include: On 08/28/18 at 1:45pm while in the company of the FS, it was observed that the fire pump & equipment was not separated by minimum 1-hour construction from the remainder of the Mechanical equipment room to comply with NFPA 20-2010, 4.12.1.1.2. |
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| VIOLATION: Corridor - Doors | Tag No: K0363 | |
| Based upon observation during the survey walk-thru, corridor doors are not positive latching. Failure to provide positive latching corridor doors can compromise the effectiveness of the door to remain closed to prevent the passage of smoke from one side of the corridor wall to the other. Findings include: On 8/28/18 at 1:30pm while in the company of the FS, it was observed that the Ground floor Tray Return corridor pair of doors were equipped with a manual flush bolt on the inactive leaf which must be engaged to provide latching for active leaf to comply with 19.3.6.3.5. Closing and latching the door takes multiple operations rather than one motion for each door leaf. |
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| VIOLATION: Corridor - Openings | Tag No: K0364 | |
| Based upon observation during the survey walk-thru, corridor walls are not resistant to the passage of smoke. Failure to provide corridors protected from smoke can prevent use of the corridor as a required means of egress during a smoke/fire condition. Findings include: A. On 08/28/18 at 9:20am while in the company of the FS, it was observed at the Basement level Environmental Storage room that a transfer grille from the room to above the ceiling of the corridor was provided with a fire damper only. The fire damper does not provide protection from the transfer of smoke to the corridor side of the wall. This condition does not comply with 19.3.6.4.1. B. On 08/28/18 at 10:55am while in the company of the FS, it was observed at the Ground floor Materials Management north corridor door that a transfer grille was installed from the room to above the ceiling of the corridor and provided with a fire damper only. The fire damper does not provide protection from the transfer of smoke to the corridor side of the wall. This condition does not comply with 19.3.6.4.1. |
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| VIOLATION: HVAC | Tag No: K0521 | |
| Based on an observation, it was determined that the facility failed to properly manage and maintain the existing Air-conditioning and Ventilating Systems. This deficient practice could affect patients, staff and visitors if components of the system build up with dust in quantities deemed hazardous which may contribute to the systems failure to limit the spread of fire/smoke during a fire event. Findings include: A. On 08/29/2018 at 10:50am while in the company of the FMGR and the VPFM, a duct penetrated the bottom of a 2-hour rated shaft enclosure. The installation does not comply with 8.3.5.7, 9.2.1, NFPA 90A-2012, 5.4.4 and 5.4.7.1 due to the following: 1. The ductwork penetrates through the bottom of a vertical shaft and does not appear to be installed in accordance with the condition of it's listing. Location observed: 2nd floor Surgery Waiting area #2071 - toward center of waiting area - west of Men's Toilet # 200E B. On 08/28/2018 at 2:25pm while accompanied by the VPFM, it was observed that supply outlets serving patient care areas do not comply with NFPA 90A-2012, 4.3.7.1 and ASHRAE Standard 170, 2008 7.2 due to the following: 1. Dust and lint build up on a ceiling air outlet in patient rooms #8,#9 third floor ICU suite . 2. Dust and lint build up on two ceiling mounted sprinkler heads in patient rooms #8,#9 third floor ICU suite. 3. Dust and lint build up on two locations of the ceiling mounted trapeze in patient rooms #8,#9 third floor ICU suite 4. Dust and lint build up on ceiling mounted recessed metal rails in the Cardiac Lab #2 second floor Cath Lab suite 5. Dust and lint build up on ceiling air outlet(eggcrate style) in corridor #C2039 in the second floor Cath Lab suite. C. On 08/28/2018 at 3:15pm while accompanied by the VPFM, it was observed that air handling unit #30 (serves ICU) does not comply with NFPA 90A-2012, 4.3.7.1 and ASHRAE Standard 170, 2008 due to the following: 1. The facility failed to provide a means to monitor the condition of the filter assembly for pressure drop and bypass. The condition of the downstream access door for the unit was gaining supply air from the mechanical room. This is bypassing filter installations and does not comply with ASHRAE 6.2. |
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| VIOLATION: Elevators | Tag No: K0531 | |
| Based on observation during the survey walk through, the facility failed to correctly install components for the elevator firefighter service and recall systems. Failure to install and maintain these systems could result in malfunction and lack of response to the recall function. This deficient practice could affect patients, staff and visitors during a fire event. Findings include: A. On 08/28/2018 at 9:05am, while in the company of the VPFM , it was that observed the Elevator machine room lacks a compliant means to automatically disconnect the main power supply to elevators prior to the application of water due to activation of the fire sprinkler system. (A17.1, 102.2.c.3). 1. The elevator machine room for elevators #1, 2, 3 and 4 heat detectors are not installed within 2 feet of the sprinkler head for elevator shutdown. This does not comply with 19.5.3 ANSI/ASME A17.1, Section 102.2(c)(3), NFPA-72, 2010, Section 21.4.2. Based on observation during the survey walk through, the facility failed to correctly separate components for the elevator systems. Failure to separate areas dedicated to the functioning of the elevators during emergency use could result in a malfunction which can lead to a delayed use by the fire department. This deficient practice could affect patients, staff and visitors during a fire event. Findings include: B. On 08/28/2018 at 9:10am while accompanied by the VPFM, it was observed there is a room dedicated to IT equipment which has a separate use from the elevator machine room. The Life Safety floor plans indicate that this room is not separated from the elevator machine room by fire rated construction to comply with ANSI/ASME A17.3 Section 2.2.1 and 2.2.5. |
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| VIOLATION: Electrical Systems - Essential Electric Syste | Tag No: K0915 | |
| Based upon observation during the survey walk-thru, the Essential Electrical System (EES) is not arranged as a Type 1 system. Failure to provide a Type 1 EES can result in failure of the system to provide required electrical power upon loss of normal utility electrical service. Findings include: A. On 08/28/18 at 9:15am while in the company of the FS, it was observed at panel "EM BE2" that both Life Safety branch loads and Critical branch loads were served from the same panel. The FS indicated that the original building emergency electrical system is not separated into Life Safety branch, Critical branch & Equipment branch to comply with NFPA 99-2012, 6.3.2.2.10.1 as a Type 1 EES. B. On 08/28/18 at 1:22pm while in the company of the VPFM, it was observed panels that contain both Life Safety branch, Critical branch and Equipment branch loads. Location observed: Third floor Office #334, EM panel E32A and E32. During on site discussion facility staff indicated that the original building's emergency electrical system is not separated into Life Safety branch, Critical branch & Equipment branch. This condition does not comply with NFPA 99-2012, 6.3.2.2.10.1 as a Type 1 EES. |
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| VIOLATION: Rubbish Chutes, Incinerators, and Laundry Chu | Tag No: K0541 | |
| Based on observation, soiled linen, trash chutes and collection rooms are not protected. Trash chute collection rooms are used for purposes not related to the trash chute functions and chutes form unprotected openings between floors. Failure to protect these areas during a fire/smoke event, permits fire/smoke to migrate from one room or area to other floor levels rather than being contained. Findings include: A. On 08/29/18 at 9:10 AM while accompanied by the FM, it was observed that neither the soiled linen/trash chute access doors or the corridor doors across from Nurses Station 142 on first floor were rated to comply with 19.5.4.1, 8.3.3. and 8.3.4. B. On 8/28/18 at 2:25pm while in the company of the FS, it was observed that the Trash Chute Collection room (located near the mechanical room containing the fire pump) did not have a corridor door which would close to a latched condition to comply with 19.5.4.4 and the door labeling in accordance with NFPA 80. C. On 08/28/18 at 11:00am while in the company of the FS, it was observed that emergency electrical panel "140 EM-GE3" was located within the Trash Chute Collection room in noncompliance with 19.5.4.4. The Trash Chute Collection room has a higher potential for a fire condition which could compromise a portion of the emergency power system. D. On 08/28/2018, at 9:55am while in the company of the VPFM, it was observed that the Fourth floor East Wing rubbish chute door does not close to a latched position to comply with 19.5.4.1 for minimum 1-hour enclosure/separation of the chute. Janitor closets with a rubbish chute and Soiled Utility rooms with a linen chute. Both areas are considered hazardous. These rooms do not comply with 19.5.4.1, 8.3.3.and 8.3.4. |
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| VIOLATION: Electrical Systems - Other | Tag No: K0911 | |
| Based upon direct observation during the survey walk-thru, electrical systems are not maintained in conformance with Code requirements. Failure to maintain the electrical system can lead to confusion when selected components require shut-down for maintenance and power circuits cannot be accurately identified. Findings include: A. On 08/28/2018 at 10:15am while in the company of the FMGR and the VPFM, it was observed in the elevator machine room for elevators #1, 2, 3 and 4 contained the elevator car light switches. However, the installations do not comply with the NEC-NFPA 70-2011, 620.22 (A) and 620.51(D) due to the following: 1. The disconnects were not labeled per the elevator served. 2. The disconnects did not indicate which branch they are served by on the emergency electrical system. B. On 08/29/2018 at 11:44 am while accompanied by the VPFM and the EHSM, in the Mechanical room #015, D Wing, during staff interview and observation of the grounding/bonding for med gas, building steel, and water piping, a disconnected metal cable at one end of the installation was observed. Staff were not able to confirm compliance with NFPA 99-2012, 5.1 and NFPA 70-2011, 517 for a completely bonded system for healthcare. C. On 08/29/2018 at 11:10 am while accompanied by the VPFM in the Med Gas Manifold room adjacent to the loading dock, staff interview and observation of the condition for complete bonding of the med gas system, it was determined that it does not comply with NFPA 99-2012, 5.1 and NFPA 70-2011, 517. It was observed that only one of two manifolds contained bonding. |
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| VIOLATION: Electrical Systems - Receptacles | Tag No: K0912 | |
| Based on observation during the survey walk-through, not all electrical receptacles are installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the rooms because electrical equipment required for their care may fail to operate under emergency conditions if the electrical receptacles are not properly installed and maintained. Findings include: On 08/28/2018 at 11:15am while accompanied by the VPFM, it was determined that critical care patient beds lack electrical receptacles served by normal power as required by NFPA 70-2011, 517-19(A). Location observed: Fourth floor C-Section procedure room. |
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| VIOLATION: Electrical Systems - Wet Procedure Locations | Tag No: K0913 | |
| Based upon observation during the survey walk-thru, ground fault circuit interruption (GFCI) is not provided in accordance with Code requirements. Failure to provide GFCI protection can result in electrical shock hazards to occupants. Findings include: A. On 08/28/18 while in the company of the FS, it was observed that receptacles within 6'-0" of sink fixtures were not provided with GFCI protection to comply with NFPA 70-2011, 210.8(B)(6). Locations observed: 1. At 1:55pm at the Ground floor Morgue. 2. At 3:15pm at the Lab typical casework sinks. GFCI breakers were not otherwise observed at the electrical panel serving the Lab receptacles. |
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