HospitalInspections.org

Based on observations and confirmed by staff, the facility failed to ensure corridor walls are constructed as required. Exception #6 to 19.3.6.1 states spaces other than patient sleeping rooms, treatment rooms, and hazardous areas shall be permitted to be open to the corridor and unlimited in area, provided that the following criteria are met:
(a) The space and the corridors onto which it opens, where located in the same smoke compartment, are protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4.
(b) Each space is protected by automatic sprinklers, or the furnishings and furniture, in combination with all other combustibles within the area, are of such minimum quantity and arrangement that a fully developed fire is unlikely to occur.
(c) The space does not obstruct access to required exits.

THE FINDINGS INCLUDE:

- During the afternoon hours of May 11, 2011 it was observed that the Radiology reception office is open to the corridor. There is an approximate 4' x 4' gliding window installed in the corridor wall and the office area is not equipped with a smoke detector.

This was acknowledged by the Director of Maintenance during the building tour.

Based on observations and confirmed by staff, the facility failed to ensure that corridor doors are maintained as required.

THE FINDINGS INCLUDE:

- During the morning and afternoon hours of May 10 & 11, 2011, the following items were noted regarding corridor door issues:

1) The double doors leading into the Osgood Lounge have a 1/2" gap between the door leaves when they are in the closed position.

2) The double doors leading into the Bradford Lounge have a 3/8" gap between the door leaves when they are in the closed position.

3) The linen room on the East wing is equipped with double doors. The secondary door is not equipped with any type of latching device to secure the door to the door frame. As a result, when the primary door is latched into the secondary door, the doors do not have positive latching as required as the doors can still be pulled open without turning the handle.

4) The linen room on the West wing is equipped with double doors. The secondary door is not equipped with any type of latching device to secure the door to the door frame. As a result, when the primary door is latched into the secondary door, the doors do not have positive latching as required as the doors can still be pulled open without turning the handle.

These were each acknowledged by the Director of Maintenance during the building tour.

Based on observations and confirmed by staff, the facility failed to ensure that stairwells/shafts are constructed as required. Section 19.3.1.1 requires any vertical opening to be enclosed or protected in accordance with 8.2.5. Section 8.2.5.2 states openings through floors, such as stairways, hoistways for elevators, dumbwaiters, and inclined and vertical conveyors; shaftways used for light, ventilation, or building services; or expansion joints and seismic joints used to allow structural movements shall be enclosed with fire barrier walls. Such enclosures shall be continuous from floor to floor or floor to roof. Openings shall be protected as appropriate for the fire resistance rating of the barrier. Where enclosure is provided , the construction shall not have less than a 1-hour fire resistance.

THE FINDINGS INCLUDE:

- During the morning hours of May 10, 2011 while touring the facility, it was observed that the 2nd level atrium doors (2-total) have a 20-minute label. In addition to viewing the actual door labels, the original building prints were reviewed and it was confirmed that the doors were specified to be 1-hour rated.

This was acknowledged by the Director of Maintenance during the building tour.

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 and afternoon hours of May 10 & 11, 2011, the following items were noted regarding smoke barrier wall deficiencies:

1) The building was designed using chapter 12 "New Construction" of the 1985 Life Safety Code which required smoke barrier walls to be provided on each floor level with occupant loads greater than 50 people. After reviewing the building floor plans provided by the hospital, it was confirmed that the occupant load of the 1st floor level is 477 people. It was also confirmed after reviewing the floor plans that the 1st floor level was designed to have a smoke barrier wall dividing the floor into two equal compartments of approximately 21,900 square feet each. During the building tour, it was observed that the wall was not constructed as specified on the floor plans. The specified smoke barrier wall was observed as having the following items noted as being deficient:
a) There is an approximate 13' x 4' plain glass window installed in the wall at the out-patient reception area. In addition, approximately 8' of the window glass has been removed and is open to the atrium area.
Note: The building plans originally called for an automatic roll down shutter door to be installed over the opening space. This specified door was never installed during construction.
b) There is an approximate 3' x 5' newly installed sliding plain glass window in the wall at the pediatric office.
Note: This opening is not on the original building plans.
c) The door leading into the gift shop is equipped with 15 plain glass light panels.
Note: The building plans originally called for a 1-hour rated door in this location.
d) There is an approximate 3' x 3' plain glass vision panel in the gift shop wall.

2) The 2nd level smoke barrier wall outside of the Rehabilitation office is not sealed where it meets the decking above. The 1-1/2" metal fluting is open and not filled with any smoking sealing material. In addition, an approximate 6" x 6" hole was noted in the wall at this location.

These were each acknowledged by the Director of Maintenance during the building tour.

Based on observations and confirmed by staff, the facility failed to ensure that hazardous areas are separated as required.

THE FINDINGS INCLUDE:

- During the morning and afternoon hours of May 10 & 11, 2011, the following items were noted regarding hazardous area deficiencies:

1) The 15' x 18' storage room located across from the maintenance shop is lacking a self closing device on the door.

2) The latching mechanism to the corridor loading dock door is non-functional. The latching assembly currently has a broken spring and the throw-latch remains in the retracted position. As a result, the door can not latch as required.

3) The linen chute discharge room is non-sprinklered. The door to the room was observed as not being latched when checked for proper operation. Upon closer observation, it was noted that the striker plate on the door jamb is covered over with tape preventing the door from latching.

These were each acknowledged by the Director of Maintenance during the building tour.

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

THE FINDINGS INCLUDE:

- During the morning hours of May 10, 2011 while conducting the record review process, the following deficiencies were noted regarding fire drills:

The reviewed drills dates & times are as follows:

1st Shift (7:00AM-3:00PM): The fire drills were satisfactory.

2nd Shift (3:00PM-11:00PM): March 2, 2011 @ 4:12PM; October 12, 2010 @ 10:30PM; May 24, 2010 @ 3:30PM and February 25, 2010 @ 4:00PM.

3rd Shift (11:00PM-7:00AM): March 18, 2011 @ 6:30AM; November 3,. 2010 @ 4:55AM; June 22, 2010 @ 12:30AM and January 21, 2010 @ 6:15AM.

1) After reviewing all of the fire drills provided, it was noted that the facility failed to conduct a 2nd shift fire drill during the 3rd quarter (July, August & September) of 2010. A period of nearly four and one half months passed between required fire drills.

2) After reviewing all of the fire drills provided, it was noted that the facility failed to conduct a 3rd shift fire drill during the 3rd quarter (July, August & September) of 2010. A period of nearly four and one half months passed between required fire drills.

3) Three of four drills conducted during the 2nd shift were held between 3:30PM and 4:12PM. The entire 8-hour shift period is not utilized to conduct fire drills.

4) The drills conducted during the 3rd shift on March 18, 2011 @ 6:30AM and January 21, 2010 @ 6:15AM were conducted as silent drills not using the fire alarm system as required.

These were acknowledged by the Director of Maintenance and Administrator during the exit interview process.

Based on record review and confirmed by staff, the facility failed to test and maintain records of the tests for the back-up batteries to the fire alarm system. LSC Section 4.6.12.1 requires that whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction. NFPA #72, Section 7.3.2 and Table 7.3.2 require systems with sealed batteries to have the battery charger tested annually, replace the battery every 4 years, to conduct a 30 minute battery discharge test annually, and to conduct a load voltage test semi-annually.

THE FINDINGS INCLUDE:

- During the morning hours of May 10, 2011 while conducting the record review process, it was observed that the fire alarm system is not maintained as required. After reviewing the inspection/test forms dated February 11, 2011; October 1, 2010; July 11, 2010; June 22, 2010; and March 3, 2010, it was noted that the fire alarm batteries have not been subjected to any type of testing. There are no line items on the inspection forms indicating that the semi-annual load voltage testing and annual discharge testing is being performed.

This was acknowledged by the Director of Maintenance during the record review process.

Based on observations and confirmed by staff, the facility failed to ensure that sprinkler heads are properly positioned and unobstructed. NFPA 13 section 5-6.5.1.1 sprinklers shall be located so as to minimize obstructions to discharge as defined in 5-6.5.2 and 5-6.5.3, or additional sprinklers shall be provided to ensure adequate coverage of the hazard.
NFPA 101 section 19.1.6.2 requires buildings 2-stories in height to be of at least Type I (443), Type I (332) or Type II (222). If the building is fully sprinklered it may be of Type II (111), Type II (000), Type III (211), Type IV (2HH) or Type V (111) construction.
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 and afternoon hours of May 10 & 11, 2011, the following items were noted regarding the sprinkler system:

1) Both garages (ambulance & receiving) each have two over-head style garage doors. When the doors are in the up position, the sprinkler heads are obstructed and no longer provide protection to the garage areas below. There is a total of four sprinkler heads which are obstructed by the doors.

2) The building is classified as a Type II (000) construction type, requiring full sprinkler coverage throughout the facility. No sprinkler heads were observed in the following locations:
a) The men's locker room is lacking protection as a newly installed petition obstructs the only head present.
b) The house-keeping closet across from the laundry room has no sprinkler protection.

3) The main transfer switch room which is non-sprinklered is not separated by 2-hour rated construction. There are numerous penetrations through the wall above the ceiling tiles which are not sealed with fire stopping.

These were each acknowledged by the Director of Maintenance during the building tour.

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.
NFPA 101 section 4.6.12.1 requires any device, equipment, system, condition, arrangement, level of protection or any other feature required for compliance with the provision of this code to be continuously maintained in accordance with applicable NFPA requirements. "Central Sprinkler Corporation" has numerous sprinkler heads manufactured from the mid 1970's through 2001 which have been determined to be defective and must be replaced.
NFPA 25 section 2.4.1.4 requires a stock of at least 6 spare of sprinklers, including at least two of each type and temperature rating installed in the system be stored in a cabinet on the premises for replacement purposes. Section 2.4.1.5 requires sprinkler systems with 300 to 1000 sprinkler heads to have no fewer than twelve (12) spare sprinkler heads. Section 2.4.1.6 requires a special sprinkler wrench, appropriate for each type of head to be stored in a cabinet on the premises.
NFPA 13 section 5-6.3.4 states the minimum spacing distance between sprinklers for standard pendent and upright spray sprinklers shall be not less than 6 ft (1.8 m) on center.

THE FINDINGS INCLUDE:

- During the morning and afternoon hours of May 10 & 11, 2011, the following items were noted regarding the automatic sprinkler system:

1) All of the resident rooms located on the 2nd floor level which have built-in wardrobe closets are equipped with recalled sprinkler heads. The closets have 1997 type GB "Central Sprinkler" side wall sprinkler heads which were deemed as defective and must be replaced. It was also observed that the front vestibule area has this same type of sprinkler heads installed. Approximately 70 heads of this type were observed during survey. In addition, there were some random recessed sprinkler heads noted in the service areas which were observed as being 1997 type GB "Central Sprinkler" heads which were also deemed defective and must be replaced.
Note: Most of these sprinkler heads were showing signs of corrosion as a result of the o-rings leaking.

2) The spare sprinkler box does not contain any spare recessed sprinkler heads.

3) Resident room #223 has two sprinkler heads which are 5' apart in spacing. The room had a closet removed and the sprinkler head was left in place for an unknown reason.

These were each acknowledged by the Director of Maintenance during the building tour.

Based on observations and confirmed by staff, the facility failed to ensure that linen chutes are constructed and maintained as required. NFPA 82 section 3-2.3 states vertical waste or linen chutes in all stories above the storage or compacting room shall be enclosed within a continuous enclosure constructed of noncombustible materials and extending from the ceiling of the storage or compacting room to or through the roof so as to retain the integrity of the fire separation. The walls of the enclosure, or the walls of the masonry chute, shall have a fire resistance rating of not less than 1 hour if the building is less than 4 stories in height and not less than 2 hours if the building is 4 or more stories in height.
Section 3-2.2.4 states a waste or linen chute shall extend (full size) at least 3 ft (0.92 m) above the roof of the building. The chute shall be open to the atmosphere with the opening being the same cross-sectional area as the chute.
Section 3-2.6.2 states automatic sprinklers shall be installed in chute terminal rooms.

THE FINDINGS INCLUDE:

- Observations while touring the facility on the afternoon of May 11, 2011 revealed the following regarding the linen chute and chute discharge room:

1) The linen chute is not enclosed within a 1-hour rated shaft on either of the two floors.

2) The linen chute terminates in the 2nd floor chute room approximately 4' from the floor deck. The chute is vented from this location with a 8" duct which extends up through the roof.

3) The linen chute discharge room is not equipped with automatic sprinklers. It was stated by staff that the room is not sprinklered due to the fact that an electrical transformer is located within the same room. The dry type transformer is rated at 112.5 kVA and is located 6' above the floor height. This meets the requirements of NFPA 70, article 450-21 for mounting locations of transformers. However, the exception for non-sprinklered electrical rooms can not be utilized as linen chute discharge rooms are required to be sprinklered per NFPA 82 section 3-2.6.2.

These were each acknowledged by the Director of Maintenance during the building tour.

Based on observations and confirmed by staff, the facility failed to ensure that suites of rooms meet the required size limitations. Section 19.2.5.7 requires suites of rooms, other than patient sleeping rooms, to not exceed 10,000 square feet in size.

THE FINDINGS INCLUDE:

- Observations while touring the facility on the afternoon of May 11, 2011 revealed the 1st floor outpatient Rehabilitation Suite is over sized. Upon closer review, it was observed that the door between the PT Gym and the Recreational Therapy Room has been removed. As a result of the door being removed, the suite size is increased to approximately 14,000 (140' X 100') total square feet. It was confirmed by staff that the door was in fact recently removed.

This was acknowledged by the Director of Maintenance during the building tour.

Based on observations and confirmed by staff, the facility failed to ensure that liquid oxygen is properly stored/transfilled in accordance with NFPA 99. Sections 8.3.1.11.2(f) and 4.3.1.1.2(a)11d require ordinary electrical wall fixtures in storage locations to be installed in fixed locations not less than 5 ft above the floor to avoid physical damage.

THE FINDINGS INCLUDE:

- Observations while touring the facility on the afternoon of May 11, 2011 revealed the following regarding the storage/transfilling of liquid oxygen:

1. The oxygen storage room where liquid oxygen is transfilled from one container to another has vinyl flooring.
2. A sign is not posted when liquid oxygen is being transferred from one container to another.
sign.
3) The electrical switch is positioned at 48" from the floor level. The electrical outlet is positioned at 18" from the floor level.
4) The storage room is currently full of combustible materials such as cardboard boxes.

These were each acknowledged by the Director of Maintenance during the building tour.

Based on record review and confirmed by staff, the facility failed to ensure that the generator is run monthly under a load condition for the required 30-minutes. NFPA 110 section 6-4.1 states level 1 and level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly. NFPA 99 3-4.4.1.1 states generator sets shall be tested twelve (12) times a year with testing intervals not less than 20 days or exceeding 40 days.
NFPA 110 section 6-4.2 states generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
The date and time of day for required testing shall be decided by the owner, based on facility operations.
Section 6-4.2.2 states diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.
Section 6-4.3 states load tests of generator sets shall include complete cold starts.

THE FINDINGS INCLUDE:

- During the morning hours of May 10, 2011 while performing the record review process, it was noted that the generator is not maintained as required. The generator log book has no documented monthly load amperage readings for the month of May 2010 through January 2011. Although the monthly forms were partially completed, amperage readings were not documented to substantiate that the generator was in fact operating under a load condition. It was further stated that there was a change in maintenance personnel during December of 2010.

This was acknowledged by the Director of Maintenance and Administrator during the exit interview process.

Based on observations and confirmed by staff, the facility failed to ensure that extension cords are used in accordance with NFPA 70. Article 305-3 permits temporary wiring to be used during periods of construction, remodeling, maintenance, and repair of buildings, during emergencies, and for a period not to exceed 90 days. Article 400-8 prohibits flexible cords from being use as a substitute for the fixed wiring of a structure. LSC 19.5.1

THE FINDINGS INCLUDE:

- Observations while touring the facility on the afternoon of May 11, 2011 revealed that two (2) extensions cords were found in the dialysis treatment room. Although the cords were not being actively used, they were as observed as being plugged in to an electrical outlet awaiting use. It was stated by a staff member that the cords are provided for electric beds when the patients are wheeled in for treatment.

This was acknowledged by the Director of Maintenance during the building tour.