HospitalInspections.org

Based on observation and interview with staff, the facility failed to provide a common wall with a nonconforming building, the common wall is a fire barrier having at least a two-hour fire resistance rating constructed of materials as required for the addition . Findings include:

The Ambulance Parking Garage is not separated from the hospital and is not sprinkled. Ambulances are parked and plugged into electrical outlets, vehicles are filled with fuel and creates a hazardous area.

Based on observation and interview with staff, the facility failed to provide doors that are provided with a means suitable for keeping the door closed 19.3.6.3. Findings include:

Soiled Utility,Nutrition,Wheel Chair Storage room doors are not provided with Latching Hardware.

Based on observation and interview with staff, the facility failed to provide penetrations/ vertical openings between floors that are enclosed with construction having a fire resistance rating of at least one hour. Findings include:

The pipe sleeves under the window air conditioners (convectors) were not sealed in a manner that will provide a one hour fire separation. The foam in the sleeve shall be removed and replaced with material capable of maintaining the fire resistance of the fire barrier.

Based on observation and interview with staff, the facility failed to provide One hour fire rated construction (with ? hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protects hazardous areas. The doors are self-closing and non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door are permitted. 19.3.2.1 Findings include:

The doors to the Hospital Supply Room is not provided with controls that prevents the automatic powered assist doors to functioned during activation of all three phases of the fire alarm system.

Based on observation and interview with staff, the facility failed to provide a fire alarm system with approved components, devices or equipment that is installed according to NFPA 72, National Fire Alarm Code, as to provide effective warning of fire in any part of the building. Findings include:

The Outpatient Waiting Room is not provided with automatic smoke detection.

Based on observation and interview with staff, the facility failed to an automatic sprinkler system, it is installed in accordance with NFPA 13, the building is fully sprinkled. Findings include:

The ambulance parking area at the back of the hospital is not sprinkled.

Based on observation and interview with staff, the facility failed to provide Piped in medical gas systems that comply with NFPA 99, Chapter 4. Findings include:

The receptacles in the Bottled Oxygen Storage Room are not 5 feet above the finished floor.

Based on observation and interview with staff, the facility failed to provide Anesthetizing locations that are protected in accordance with NFPA 99, Standard for Health Care Facilities. Findings include:

Relative humidity could not be verified. The facility was not logging humidity either on daily cases or on a separate log sheet in accordance with NFPA 99 4.3.1.2.3(an) and 5.4.1.1, 19.3.2.3

Operating room suite shall be provided with a smoke evacuation system that is automatic and installed on the emergency power system. The OR Suite was not provided with this system.

Medical Gas Area Alarm was removed from the Operating Room Suite. Area Alarms are required in Critical Care Areas.

Based on observation and interview with staff, the facility failed to provide a Type I Essential Electrical System powered by a generator with a transfer switch and separate power supply. The EES is in accordance with NFPA 99, 3.4.2.2, 3.4.2.1.4. Findings include:

An Emergency Generator Enunciator Panels is not provided in the hospital. The facility shall have a main in a 24 hour manned station with an auxiliary alarm on the generator or in the Maintenance department.

Based on observation and interview with staff, the facility failed to test Generators and inspected weekly, exercised under load for 30 minutes per month in accordance with NFPA 99. 3.4.4.1. Findings include:

The generator logged run times, however, the facility failed to run under load once a month and failed to document Line Amps on the report form.
Line Amp space on the Generator Log depicted OK instead of the amp reading.

Based on observation and interview with staff, the facility failed to insure that Electrical wiring and equipment is installed in accordance with NFPA 70, National Electrical Code. 9.1.2 Findings include:

Room 131 is not provided with emergency power.

Replacement of receptacles in patient care areas have not been provided with impedance ground testing.
The facility has not done a impedance ground test of any patient care areas. The metal surface of the HVAC Equipment (diffuser) in the windows of patient rooms could be energized and should be included on the test form.

Panel schedules in electrical panels were unreadable and not marked clearly in all areas of the hospital. Maintenance staff stated that a breaker tripped and that he spent hours trying to find the breaker that controls that circut.

Line Isolation Monitors in the Operating Rooms is not a part of a Preventive Maintenance check list, no documentation available for test results.

Blood Bank was not provided with emergency power