HospitalInspections.org

Based on observations and confirmed by staff, the facility failed to ensure that buildings are properly separated. Section 19.1.1.4.1 states additions shall be separated from any existing structure not conforming to the provisions within Chapter 19 by a fire barrier having not less than a 2-hour fire resistance rating and constructed of materials as required for the addition.

THE FINDINGS INCLUDE:

- During the morning & afternoon hours of November 7th & 8th, 2011 while touring the facility, it was observed that the doors separating the hospital from the adjoining office building are not properly maintained. The pair of 90-minute doors located on the 1st, 2nd and 3rd floor levels are no longer equipped with latching hardware. On each of the doors, the hardware was removed and magnetic locking devices equipped with badge swipe access were installed. However as required, these devices release during activation of the fire alarm system and the doors are no longer held in the closed position.

This was acknowledged by the Director of Engineering during the exit interview process.

Based on observations, the facility failed to ensure that all use areas are separated from corridors as required. Section 19.3.6.1, Exception #6 allows spaces other than sleeping rooms, treatment rooms and hazardous areas to be open to the corridor provided: (a) The space and corridors which the space opens onto in the same smoke compartment are protected by an electrically supervised automatic smoke detection system installed in accordance with 19.3.4, and (b) each space is protected by automatic sprinklers, and (c) The space is arranged not to obstruct access to required exits. Smoke detectors are required to be interconnected with the fire alarm system, spaced no more than 15 feet from any wall and no more than 30 feet apart.

THE FINDINGS INCLUDE:

- Observations while touring the facility on the morning of November 7, 2011 revealed that the day area is open to the corridor and that smoke detectors in two (2) corridor locations are 40 feet and 60 feet apart.
This was confirmed by the Director of Maintenance & Facilities.

Based on observations and confirmed by staff, the facility failed to ensure that doors within atriums are maintained as required. Section 8.2.5.6 states unless prohibited by Chapters 12 through 42, an atrium shall be permitted, provided that the following conditions are met:
(1) In other than existing, previously approved atria, atriums are separated from the adjacent spaces by fire barriers with not less than a 1-hour fire resistance rating with opening protectives for corridor walls.
(2) Access to exits is permitted to be within the atrium, and exit discharge in accordance with 7.7.2 is permitted to be within the atrium.
(3) The occupancy within the space meets the specifications for classification as low or ordinary hazard contents. (See 6.2.2.)
(4) The entire building is protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
(5) * For other than existing, previously approved atria, an engineering analysis is performed that demonstrates that the building is designed to keep the smoke layer interface above the highest unprotected opening to adjoining spaces, or 6 ft (1.85 m) above the highest floor level of exit access open to the atrium for a period equal to 1.5 times the calculated egress time or 20 minutes, whichever is greater.
(6) * In other than existing, previously approved atria, where an engineered smoke control system is installed to meet the requirements of 8.2.5.6(5), the system is independently activated by each of the following:
a. The required automatic sprinkler system
b. Manual controls that are readily accessible to the fire department

THE FINDINGS INCLUDE:

- During the afternoon hours of November 7, 2011 while touring the facility, it was observed that atrium doors are not maintained as required. Exception #2 to part 1 above permits atrium doors to meet the requirements of corridor doors. However, the pair of atrium doors which lead into the maturity suite are no longer equipped with any self latching hardware. The two door catches have been removed from the top jamb. The only means of keeping the doors closed are the magnetic locking devices installed on each door. However as required, these devices release during activation of the fire alarm system and the doors are no longer held in the closed position.

This was acknowledged by the Director of Engineering during the exit interview process.

Based on observations and confirmed by staff, the facility failed to ensure that smoke barrier walls are properly maintained.

THE FINDINGS INCLUDE:

- During the morning hours of November 8, 2011 while touring the facility, the following deficiencies were observed regarding smoke barrier walls:

1) The smoke barrier wall in room #364 has three (3) holes approximately 8" x 12" in size located above the ceiling tiles.

2) The smoke barrier wall in bathroom of room #355 has an approximate 4" diameter hole above the ceiling tile.

Note: Each of these items were immediately addressed by the facility and corrected during the survey process.

This was acknowledged by the Director of Engineering during the exit interview process.

Based on observations and confirmed by staff, the facility failed to ensure smoke barrier doors are properly constructed.

THE FINDINGS INCLUDE:

- During the afternoon hours of November 7, 2011 while touring the facility, it was observed that tempered safety glass in used in smoke barrier walls. The following items were observed in the 3rd floor smoke barrier wall:

1) The set of double doors leading into the OB GYN suite has a 5" x 20" tempered glass vision panel in each of the doors.

2) The door leading into the Nutrition office is equipped with a 5" x 20" tempered glass vision panel.

3) There is a 18" x 48" tempered glass panel located in the wall to the Nutrition office.

This was acknowledged by the Director of Engineering during the exit interview process.

Based on observations and confirmed by staff, the facility failed to ensure that stairwell doors are maintained in the proper operating condition.

THE FINDINGS INCLUDE:

- During the morning & afternoon hours of November 7th & 8th, 2011 while touring the facility, the following stairwell doors were observed to be deficient in some manner:

1) The 4th floor stairwell door adjacent to the nursing station does close & latch. When the door was tested for proper operation, it hit the door frame upon closing, holding the door in the open position.

2) The communicating stairwell between the ground & basement floors is not maintained as required. The ground floor door is not equipped with a self latching device. The door located at the basement level was observed as rubbing the floor tile and sticking in the open position.

This was acknowledged by the Director of Engineering during the exit interview process.

Based on observations and confirmed by staff, the facility failed to ensure egress doors are maintained as required. Section 19.2.2.2.5 states doors located in the means of egress that are permitted to be locked under other provisions of this chapter shall have adequate provisions made for the rapid removal of occupants by means such as remote control of locks, keying of all locks to keys carried by staff at all times, or other such reliable means available to the staff at all times. Only one such locking device shall be permitted on each door.

THE FINDINGS INCLUDE:

- During the afternoon hours of November 8, 2011 while touring the facility, the rear stairwell door leading from the Maturity unit was observed as being locked. Upon closer examination of the door, the only means of unlocking the door is by activation of the fire/sprinkler alarm system. The door is not equipped with any of means of overriding the magnetic locking device. In addition, the staff behind the nursing desk was unsure of how to unlock this door as numerous switches (3) were tried until it was realized the door will not open.

This was acknowledged by the Director of Engineering during the exit interview process.

Based on observations, the facility failed to assure that corridors are at least 8 feet wide. Section 4.6.7 prohibits existing life safety features that exceed the requirements for existing buildings, to be diminished. Section 4.6.7 requiems facilities constructed with corridors up to 8 feet in width maintain the width. Section 7.1.10.1 requires every exit, exit access and exit discharge to be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. Section 7.1.10.2.1 requires that no objects be so placed so as to obstruct exits, access thereto, egress therefrom, or visibility thereof.

THE FINDINGS INCLUDE:

- Observations while touring the facility on the afternoon of November 7, 2011 revealed computers on wheels (COW) stored in the corridor plugged into a receptacle charging by room 354 and by the Maternity Unit nurses station.
This was confirmed by the Director of Maintenance & Facilities.

Based on observations, the facility failed to ensure that exit illumination is in accordance with the requirements. Section 7.8.1.2 requires a means of egress to be continuously illuminated. Switches shall only be accessible to authorized persons.

THE FINDINGS INCLUDE:

- Observations while touring the facility on the morning of November 7, 2011 revealed that continuous illumination of the fourth floor corridors is not ensured because toggle switches located on corridor walls turn off all lights in the corridors. This was confirmed by the Director of Maintenance & Facilities.

Based on record review and confirmed by staff, the facility failed to ensure that fire drills are conducted as required.

THE FINDINGS INCLUDE:

- During the morning hours of November 7, 2011 while performing the record review process, it was revealed that fire drills are not conducted at varied in times and quarterly on each shift as required. The fire drills for the 1st, 2nd & 3rd shifts are documented as occurring at the following times:

1st Shift (7:00 A.M.-3:00 P.M.):
7/21/11 @ 12:30 P.M.;
4/21/11 @ 9:30 A.M.;
1/27/11 2 9:28 A.M.; and
10/8/10 2 1:30 P.M..

2nd Shift (3:00PM-11:00PM):
9/28/11 @ 3:35 P.M.;
5/26/11 @ 3:14 P.M.;
3/24/11 @ 9:47 P.M.;
2/24/11 @ 3:32 P.M.; and
11/23/10 @ 3:27 P.M.

3rd Shift (11:00 P.M.-7:00 A.M.):
8/31/11 @ 5:18 A.M.; and
12/30/10 @ 5:23 A.M.

The following deficiencies were noted:

1) Three (3) out of five (5) drills conducted during the 2nd Shift were held between 3:14 P.M. & 3:35 P.M. The entire 8-hour shift period is not being utilized to conduct the drills.

2) Fire drills was not conducted for the 3rd shift during the 1st and 2nd quarters of 2011.

3) The two fire drills conducted for the 3rd shift were conducted at 5:18 A.M. and 5:23 A.M. The entire 8-hour shift period is not being utilized to conduct the drills.

These were each acknowledged by hospital staff during the exit interview process.

Based on record review and confirmed by staff interview, the facility failed to ensure that the fire alarm system is maintained and tested as required and the results of the tests on the fire alarm system are documented as required. NFPA 72, Section 7.5.2.2 requires permanent records of all inspections, testing, and maintenance of the fire alarm system be provided including detailed information as to the results. Section 7.3.2 and Table 7.3.2(20) requires off-premises transmission equipment to be tested quarterly.
Section 7.3.2 and Table 7.3.2(6) require systems with sealed batteries to have the battery charger tested annually, to conduct a 30 minute battery discharge test annually, and to conduct a load voltage test semi-annually.
Table 7.3.2(15)(c) requires suppression system(s) to be tested annually.
Table 7-3.2 (15) (a) requires duct detectors to be tested annually.
Table 7-3.2 (15) (h) requires all smoke detectors to be tested annually.
Table 7-3.2 (19) (a) & (c) requires audible devices, and visible devices to be tested annually.

THE FINDINGS INCLUDE:

- Record review of the quarterly fire alarm system inspection reports available on November 7, 8 and 9, 2001 revealed that the vendor contracted to maintain, test and inspect the fire alarm system failed to provide detailed information as to the results of the tests and inspections as required by NFPA 72.
The following are not documented on the inspection reports dated 2/03/2011 and 7/18/2010:

1) Testing of the off-premises transmission equipment semi-annually.

2) A semi-annually load test of the fire alarm system batteries.

3) An annually discharge test of the fire alarm system batteries.

4) Testing of the connection to the kitchen hood suppression system annually.

5) Testing of all duct smoke detectors annually.

6) The smoke detectors in the lobby and in central sterilization room are not tested annually as required. In the vendor report dated 2/02/2011, it stated that the vendor did not test the smoke detectors in the lobby due to the fact that the smokes detectors in the lobby actives smoke evacuation hatches and it states that hospital personal did not want to the active the smoke evacuation hatches. There were no reason given for not testing smoke detectors in central sterilization room.

7) The horn and strobes are not tested annually as required. In the vendor report dated 2/02/2011, it was stated that the hospital personal did not want the horn and strobes activated during inspection.

These were each acknowledged by hospital staff during the exit interview process.

Based on observations and confirmed by staff, the facility failed to ensure that smoke detectors are installed as required. NFPA 72 section 2-3.5.1 states smoke detectors shall not located in a direct airflow nor closer than three feet (3') from an air supply diffuser or return air opening.

THE FINDINGS INCLUDE:

- During the morning & afternoon hours of November 7th & 8th, 2011 while touring the facility, numerous smoke detectors were observed throughout the facility which are closer than three feet (3') from an air diffuser. These were observed in the following but not limited to locations:

1) The 4th floor corridors (2 were observed).
2) The 3rd floor corridors (2 were observed).
3) The 2nd floor corridors (2 were observed).
4) The Operating Suite (7 were observed).

This was acknowledged by the Director of Engineering during the exit interview process.

I) Based on observations, the facility failed to ensure that automatic sprinklers are installed throughout the premises. LSC Sections 8.2.5.6(4) and 9.7.1.1 requires the entire building is protected throughout by an approved, supervised automatic sprinkler system in accordance with NFPA 13.
NFPA 13, Section 5.1.1(1) requires sprinklers to be installed throughout the premises.

THE FINDINGS INCLUDE:

- Observations while touring the facility on November 7 & 8, 2011 revealed that automatic sprinkler protection is not provided in the following areas:
1. Linen closet in the pediatric suite.
2. Janitor closet in the Maternity Unit.
3. First floor electrical room by the main stair
4. First floor staff toilet room by central services
5. Electrical room off of the Medical Record office by a toilet room
6. Toilet room in the Medical Records office
7. First floor pap smear supply room.
This was confirmed by the Director of Maintenance & Facilities.



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II) Based on observations and confirmed by staff, the facility failed to ensure that non-sprinklered electrical rooms/closets are properly separated. NFPA 13 section 5.13.11 states that sprinkler protection shall be required in electrical equipment rooms. Hoods or shields installed to protect important electrical equipment from sprinkler discharge shall be noncombustible.
The exception states sprinklers shall not be required where all of the following conditions are met:
(a) The room is dedicated to electrical equipment only.
(b) Only dry-type electrical equipment is used.
(c) Equipment is installed in a 2-hour fire-rated enclosure including protection for penetrations.
(d) No combustible storage is permitted to be stored in the room.

THE FINDINGS INCLUDE:

- During the morning & afternoon hours of November 7th & 8th, 2011 while touring the facility, the following deficiencies were observed regarding sprinkler status:

1) The non-sprinklered electrical closet on the 2nd floor level is not properly separated. The closet is equipped with a non-rated door lacking a self closing device.

2) The non-sprinklered electrical closet outside of the CCU is not properly separated. The closet door is lacking a self closing device.

This was acknowledged by the Director of Engineering during the exit interview process.

Based on observations, the facility failed to ensure that sprinkler control valves are electrically supervised.

THE FINDINGS INCLUDE:

- During the morning hours of November 8, 2011 while touring the exterior of the building, it was noted that the sprinkler main Post Indicator Valve (PIV) is not electronically supervised.
Note: It was secured with a padlock.

This was acknowledged by the Director of Engineering during the exit interview process.

Based on observations and records provided, the facility failed to properly maintain the sprinkler system. NFPA #25 section 1-4.2 states the responsibility for properly maintaining a water-based fire protection system shall be that of the owner(s) of the property. By means of periodic inspections, tests, and maintenance, the equipment shall be shown to be in good operating condition, or any defects or impairments shall be revealed.
Inspection, testing, and maintenance shall be implemented in accordance with procedures meeting or exceeding those established in this document and in accordance with the manufacturer ' s instructions. These tasks shall be performed by personnel who have developed competence through training and experience.
Section 2.2.4.2 requires gauges on dry pipe sprinkler systems to be inspected weekly. to ensure that they are in good condition and that normal water supply pressure is being maintained.
Section 2-2.4.1 states that gauges on wet pipe sprinkler systems shall be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained.
Section 2.3.2 requires pressure gauges to be replaced or tested every 5 years.
NFPA 25 section 9-3.5 states the operating stems of outside screw and yoke valves shall be lubricated annually. The valve then shall be completely closed and reopened to test its operation and distribute the lubricant.
Section 9.3.4.1 requires each control valve to be operated annually through its full range and returned to its normal position.
NFPA 25 section 2-3.3 states waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly. Testing the waterflow alarms on wet pipe systems shall be accomplished by opening the inspector's test connection which simulates activation of a sprinkler head.
Section 9.3.4.3 requires valve supervisory switches to be tested at least semi-annually.
Section 9.4.1.2 states alarm valves and their associated strainers, filters, and restriction orifices shall be inspected internally every 5 years unless tests indicate a greater frequency is necessary.
Section 2.3.4 requires the freezing point of solutions in antifreeze to be tested annually by measuring the specific gravity with a hydrometer or refractometer and adjusting the solutions if necessary. Solutions shall be in accordance with Tables 2-3.4(a) and (b).
Section 9-7.1(e) states that fire department connections have identification signs.

THE FINDINGS INCLUDE:

- During the days of November 7, 8 and 9, 2001 while reviewing hospital sprinkler records and touring the hospital, the following items were observed regarding sprinkler systems:

1) The hospital has a dry type sprinkler system for the front lobby. After reviewing records and examining the valves, it was observed that weekly sprinkler pressure readings are not documented.

2) The hospital has one wet type sprinkler system. After reviewing records and examining the valves it was observed that monthly pressure readings are not documented.

3) There was no documentation to show that the sprinkler pressure gages throughout the hospital have been tested or replaced in the last 5 years.

4) There was no documentation to show that the OS&Y valves have been lubricated in the last year.

5) There was no documentation to show that any sprinkler control valves throughout the hospital have been operated though their full range and returned to their normal position in the last year.

6) The hospital documentation on the sprinkler system show that the sprinkler alarm was tested by flowing water from the inspectors test valve on October 11, 2011 and April 13, 2011. The requirement calls for the test to be conducted quarterly. The records show that the test was conducted semi annually.

7) The dry sprinkler system for the front lobby has a low pressure alarm. There was no documentation to show that the low pressure alarm was tested quarterly as required.

8) There was no documentation to show that the main sprinkler alarm valve has been internally inspected in the last 5 years.

9) There was no documentation to show that the anti-freeze loop for the loading dock has been tested for proper freeze point of the solution in the last year.

10) The hospital has three fire department connection located on the outside of the building. Only one of the three fire department connections has a sign showing the location of the fire department connection. The fire department connection at the west stairwell exit and at the kitchen exit do not have signs to show location of the fire department connections.

These were each acknowledged by hospital staff during the exit interview process.

Based on observations and record review, the facility failed to ensure that HVAC systems are installed in accordance with NFPA 90A.
Section 4.4.2 requires:
Smoke detectors listed for use in air distribution systems shall be located as follows:
(1) Downstream of the air filters and ahead of any branch connections in air supply systems having a capacity greater than 2000 ft3/min
(2) At each story prior to the connection to a common return and prior to any recirculation or fresh air inlet connection in air return systems having a capacity greater than 15,000 ft3/min and serving more than one story
Exception No. 1: Return system smoke detectors shall not be required where the entire space served by the air distribution system is protected by a system of area smoke detectors.
Exception No. 2: Fan units whose sole function is to remove air from the inside of the building to the outside of the building.
Section 4.4.4.2 states: "In addition to the requirements of 4.4.3, where an approved fire alarm system is installed in a building, the smoke detectors required by the provisions of Section 4.4 shall be connected to the fire alarm system in accordance with the requirements of NFPA 72, National Fire Alarm Code. Smoke detectors used solely for closing dampers or for heating, ventilating, and air-conditioning system shutdown shall not be required to activate the building evacuation alarm."
Section 3.9.5.3 states:
"Connections between fire alarm systems and the HVAC system for the purpose of monitoring and control shall operate and be monitored in accordance with applicable NFPA standards. Smoke detectors mounted in the air ducts of HVAC systems shall initiate either an alarm signal at the protected premises or a supervisory signal at a constantly attended location or supervising station."

THE FINDINGS INCLUDE:

- Observations while touring the facility on the November 7 and 8, 2011 revealed that the five (5) HVAC systems in the basement mechanical room are not equipped with smoke detectors in air supply systems.
This was confirmed by the Director of Maintenance & Facilities.

Based on record review, observations and confirmed by staff interview, the facility failed to inspect the kitchen range automatic extinguishing system as required. NFPA 17A, Section 5.2.1 requires inspections to be conducted on a monthly basis in accordance with the manufacturer's listed installation and maintenance manual or the owner's manual. As a minimum, this "quick check" or inspection shall include verification of the following:
(a) The extinguishing system is in its proper location.
(b) The manual actuators are unobstructed.
(c) The tamper indicators and seals are intact.
(d) The maintenance tag or certificate is in place.
(e) No obvious physical damage or condition exists that might prevent operation.
(f) The pressure gauge(s), if provided, is in operable range.
(g) The nozzle blowoff caps are intact and undamaged.
(h) The hood, duct, and protected cooking appliances have not been replaced, modified, or relocated.
Section 5.2.4 requires at that least monthly, the date the inspection is performed and the initials of the person performing the inspection to be recorded. The records shall be retained until the next semiannual maintenance.
NFPA 96 Section 8.3.1 states hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Table 8.3.1. The system is required to be inspected/cleaned semi-annually per table 8.3.1.
Section 8.3.1.1 states that upon inspection, if found to be contaminated with deposits from grease-laden vapors, the entire exhaust system shall be cleaned by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Section 8.3.
Section 8.3.1.2 states when a vent cleaning service is used, a certificate showing date of inspection or cleaning shall be maintained on the premises. After cleaning is completed, the vent cleaning contractor shall place or display within the kitchen area a label indicating the date cleaned and the name of the servicing company. It shall also indicate areas not cleaned.

THE FINDINGS INCLUDE:

1) Observations while touring the facility on the morning of November 8, 2011 revealed the kitchen range automatic extinguishing system is not inspected monthly. A review of the back of the semi-annual inspection tag dated September 20, 2011 used to document monthly inspections reveled the absence of monthly documentation. Interview with the hospital engineering staff revealed that the system it serviced semiannually by a contractor but no one in the facility inspects the system monthly.

2) During the morning hours of November 7, 2011 while performing the record review process, it was observed that the kitchen range hood/venting system is not inspected/cleaned semi-annually. The last dated inspection/cleaning of the exhaust hood was conducted on 8/26/2010. A period of 1-year 2 months passed between inspections.

Based on observations, the facility failed to ensure that portable electric heaters are prohibited from the building.

THE FINDINGS INCLUDE:

- Observations while touring the facility at 11:45 a.m. on November 7, 2011 revealed a portable electric heater in the Medical Director's Office on the fourth floor. This was confirmed by the Director of Maintenance & Facilities.

Based on observations and confirmed by staff, the facility failed to ensure that mobile paper recycle containers and trash containers are stored in properly enclosed rated rooms.

THE FINDINGS INCLUDE:

- During the morning & afternoon hours of November 8, 2011 while touring the facility, the following items were observed regarding storage of combustibles:

1) Two recycle barrels were observed as being stored in the corridor adjacent to the Hospitalist RN office.

2) Two trash containers were observed as being stored in the corridor outside of the Cesarian Section room.

This was acknowledged by the Director of Engineering during the exit interview process.

Based on observations and confirmed by staff, the facility failed to ensure that suites containing sleeping rooms do not exceed size limitations. Section 19.2.5.6 states suites of sleeping rooms shall not exceed 5000 ft2 (460 m2).

THE FINDINGS INCLUDE:

- During the afternoon hours of November 8, 2011 while touring the facility, it was observed that the Critical Care Unit suite (CCU) is 8,379 square feet in size. This is also noted on the facility floor plans provided by engineering staff.

This was acknowledged by the Director of Engineering during the exit interview process.