HospitalInspections.org

Based on observation the facility failed to provide adequate smoke barriers.

The inspector observed, while accompanied by the Plant Manager and the Administrator during the hours of the inspection from 9:00 am to 3:00 pm on 1/8/2014 that there were penetrations in the smoke barriers at the following locations: 1) above door 3G, 2) above the mechanical room doors on the 2nd floor, and 3) above door 1D.

Based on observation the facility failed to provide adequate hazardous area separation.

The inspector observed, while accompanied by the Plant Manager and the Administrator during the hours of the inspection from 9:00 am to 3:00 pm on 1/8/2014 that there were the following issues.

First, the following areas did not have closers on the doors: 1) Biohazard on the 3rd floor, 2 doors, 2) Sterile Storage on the 1st floor O.R. area, and 3) kitchen storage.

Second, the latch did not work or the closer requires adjustment at the following locations: 1) 3rd floor soiled linen, 2 doors, 2) 3rd floor clean linen, 3) 3rd floor supply room, 4) 2nd soiled linen also on 3rd floor, 2 doors, 5) 2nd floor soiled utility, 2 doors, and 6) soiled linen at the laundry area.

Based on observation the facility failed to provide adequate illumination at required exit doors on the 1st floor.

The inspector observed, while accompanied by the Plant Manager and the Administrator during the hours of the inspection from 9:00 am to 3:00 pm on 1/8/2014 that there were exits on the first floor that did not have two sources of illumination connected to the Life Safety Branch.

Based on observation the facility failed to provide adequate fire drills.

The inspector observed, while accompanied by the Plant Manager and the Administrator during the hours of the inspection from 9:00 am to 3:00 pm on 1/8/2014 that there was a missing fire drill for December of 2013.

Based on observation the facility failed to provide adequate cross referencing of the FACP to the Panel and breaker supplying power.

The inspector observed, while accompanied by the Plant Manager and the Administrator during the hours of the inspection from 9:00 am to 3:00 pm on 1/8/2014 that the FACP and the panel supplying power to it were not cross referenced.

" A dedicated electrical circuit to the life safety branch of the EES shall be provided. The circuit shall be identified with a red marking and identified as "FIRE ALARM CIRCUIT CONTROL". - NFPA 72, 1999: 1-5.2.5.2. " The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit. " - NFPA 72, 1999: 1-5.2.5.2.

Based on observation the facility failed to provide adequate clearance between the sprinkler heads and storage below.

The inspector observed, while accompanied by the Plant Manager and the Administrator during the hours of the inspection from 9:00 am to 3:00 pm on 1/8/2014 that there was storage of items that obstruct sprinkler patterns in the following locations: 1) 3rd floor respiratory storage, 2) CNO storage closet, and 3) 1st floor medical records. All items must be lower than 18 inches below the sprinkler output.

Based on observation the facility failed to provide adequate curtains.

The inspector observed, while accompanied by the Plant Manager and the Administrator during the hours of the inspection from 9:00 am to 3:00 pm on 1/8/2014 that there was the following issue. The Radiology Tech Sleep Room and curtains that did not meet NFPA 701.

Based on observation the facility failed to provide an adequate bulk oxygen enclosure.

The inspector observed, while accompanied by the Plant Manager and the Administrator during the hours of the inspection from 9:00 am to 3:00 pm on 1/8/2014 that there were the following issues. They were: 1) there were combustibles located near the bulk oxygen tank, and 2) it was not clear that parking is not allowing within 10 feet of the bulk oxygen enclosure.

Also, there were locations were the medical gas piping was in contact with steel unistrut supports. These were seen at: 1) above door 3, and 2) above the mechanical room doors on the 2nd floor.

" The minimum distance from any bulk oxygen system to any public sidewalk or parked vehicle shall be 10 ft. " - NFPA 50, 2001, 2.2.12.

" Connections of surface-mounted medical gas rail systems to piping systems of dissimilar metals shall require plating of the connecting components to prevent interaction between dissimilar metals. " - NFPA 99, 1999, 4-3.1.2.5(f).

Electrical Room used for Storage

" Clear Spaces. Working space required by this section shall not be used for storage. When normally enclosed live parts are exposed for inspection or servicing, the working space, if in a passageway or general open space, shall be suitably guarded. " - NFPA 70, 2002, 110.26(B)

" Dedicated Equipment Space: All switchboards, panelboards, distribution boards, and motor control centers shall be located in dedicated spaces and protected from damage. " - NFPA 70, 2002, 110.26(F)

Based on observation the facility failed to provide adequate electrical rooms free from storage.

The inspector observed, while accompanied by the Plant Manager and the Administrator during the hours of the inspection from 9:00 am to 3:00 pm on 1/8/2014 that there were the following issues. There were electrical rooms being used for storage in the following locations: 1) the main electrical room on the first floor, and 2) an electrical room on the 2nd floor.


Generator Space Use for Storage

The room or space in which the EPS equipment is located shall not be used for storage purposes. - NFPA 110, 2002: 7.11.1.

Based on observation the facility failed to provide an adequate generator space.

The inspector observed, while accompanied by the Plant Manager and the Administrator during the hours of the inspection from 9:00 am to 3:00 pm on 1/8/2014 that there were the following issues. They were: 1) the space the generator was located in had a kitchen grease container adjacent to the generator, and 2) there was a tree that was making contact with the generator and must be trimmed back.


Fuel and Water Preferred Customer Status

" Continuity of Essential Building Systems. When designated by the emergency preparedness management plan to provide continuous service in a disaster or emergency, health care facilities shall establish contingency plans for the continuity of essential building systems, as applicable: (a) Electricity, (b) Water, (c) Ventilation, (d) Fire protection systems, (e) Fuel sources, (f) Medical gas and vacuum systems (if applicable), (g) Communications systems. " - NFPA 99, 1999, 11-5.3.2

Based on observation the facility failed to provide letters from vendors for emergency fuel.

The inspector observed, while accompanied by the Plant Manager and the Administrator during the hours of the inspection from 9:00 am to 3:00 pm on 1/8/2014 that there was not a letter for fuel.

Based on observation the facility failed to provide covers on all electrical j-boxes.

The inspector observed, while accompanied by the Plant Manager and the Administrator during the hours of the inspection from 9:00 am to 3:00 pm on 1/8/2014 that a j-box was observed without a cover on the 2nd floor outside the mechanical room doors.