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Based on observation and interview with staff, the facility failed to provide corridors separated by use areas by walls with at least one-half hour fire resistance rating. Findings:

1) Section 19.3.6.2.1, Exception No. 1 reads "in smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.2, a corridor shall be permitted to be separated from all other areas by non-fire-rated partitions and shall be permitted to terminate at the ceiling where the ceiling is constructed to limit the transfer of smoke." The suspended acoustical ceiling was found to have damaged tiles at various locations in the facility, thus rendering it unable to limit the transfer of smoke at those locations.

2) At the north end of the East Med Surg Wing, an alcove area approx. 5' deep x 8' wide is open to the corridor, is used to store clean linens (clean linen room) and is separated from the corridor only by a cubicle curtain. Refer to 19.3.6.1. It must have a partition constructed to limit the transfer of smoke and latching hardware on the door per 18.3.6.3.

3) In the corridor between Radiology and Dining, an alcove area approx. 4' deep x 30' wide is open to the corridor, is used to store medical records and is not separated from this corridor. Refer to 19.3.6.1. It must have a partition constructed to limit the transfer of smoke and latching hardware on the door per 18.3.6.3.2.

4) At the east end of the East Med Surg Wing, next to Room 305, a room storing respiratory equipment has a cased opening instead of a door. This room must be separated from the corridor. Refer to 19.3.6.1. A door with latching hardware is required per 18.3.6.3.2.

Based on observation and interview with staff, the facility failed to provide smoke compartment that do not exceed 22,500 square feet. Findings:

1) The West Smoke Compartment, including the Business Office, Conference Rooms, Outpatient Holding, Emergency Department, Radiology, and Dietary exceeds the maximum 22,500 square feet as required by Section 19.3.7.1. Confirmation of a smoke barrier, dividing these areas into smoke compartments less than 22,500 square feet could not be determined.

Based on observation and interview with staff, the facility failed to provide smoke barriers constructed to provide at least a one half hour fire resistance rating. Findings:

1) Open penetrations were found in the smoke compartment wall (smoke barrier), including around wiring, conduit, and piping passing through the wall.

2) Above Door 9-38, an approx. 16" x 16" void exists in the smoke barrier.

3) Above Door 5-3, one concrete masonry unit (concrete block) is missing in the smoke barrier.

Based on observation and interview with staff, the facility failed to verify that staff is familiar with procedures and is aware that drills are part of established routine. Findings:

1) Participation of individual staff members in fire drills is not documented in the quarterly fire drill reports.

Based on observation and interview with staff, the facility failed to provide HVAC complying with 19.5.2.1 and 9.2. Findings:

1) The exhaust fan in the Soiled Linen Room adjacent to ICU does not work.

2) The Patient Room toilet rooms do not have exhaust out of the room. No exhaust grille or fan was found.

Based on observation and interview with staff, the facility failed to provide anesthetizing locations protected in accordance with NFPA 99. Findings:


1) There is no written policy for procedures taken in the operating rooms when the when humidity is outside of the required levels. Refer to 5-4.1.1.

2) The Operating Rooms do not have "smoke evacuation" within the HVAC system. Supply and exhaust systems shall be arranged to automatically vent smoke and products of combustion. Ventilating systems for anesthetizing locations shall be provided that automatically prevent recirculation of smoke originating within the surgical suite, and prevent the circulation of smoke entering the system intake. Refer to 5-4.1.2 and 5-4.1.3.

Based on observation and interview with staff, the facility failed to provide a Type 1 Essential Electrical System in accordance with NFPA 99. Findings:

1) A remote annunciator, storage battery powered, shall be provided to operate outside of the generating area in a location readily observed by operating personnel at a regular work station. The facility does not have a remote annunciator. Refer to 3-4.1.1.15.

Based on observation and interview with staff, the facility failed to provide procedures for laboratory emergencies. Findings:

1) Lab personnel could not locate the Emergency Procedures Manual for the Lab.

Based on observation and interview with staff, the facility failed to provide a Type 1 EES Essential Electrical System in accordance with NFPA 99 - 1999 Edition. Findings:

1) The facility failed to provide a Type 1 EES comprised of two separate systems; the Emergency System and the Equipment System. The Emergency System shall be divided into two Life Safety Branch and the Critical Branch, and shall supply power to those items and areas identified in 3-4.2.2.2 (b) and (c). The Equipment Branch shall supply power as identified in 3-4.2.2.3.

2) Each branch of the emergency system and each equipment system shall have one or more transfer switches. Only one transfer switch was found for each of the generators (Onan and Caterpillar).

Based on observation and interview with staff, the facility failed to provide electrical wiring and equipment in accordance with NFPA 70 and NFPA 99. Findings:

1) Open junction boxes were found in various locations above the ceiling in the facility.

2) The Line Isolation Monitors for the two operating rooms are not in service, and the staff could not confirm that the Operating Room receptacles are protected by ground-fault circuit interrupter devices. NFPA 99, 3-3.2.1.2 (f) Wet Locations: "Wet location patient care areas (ORs) shall be provided with special protection against electric shock. This special protection shall be provided by a power distribution system that inherently limits the possible ground-fault current due to a first fault to a low value, without interrupting the power supply; or by a power distribution system in which the power supply is interrupted if the ground-fault current does, in fact, exceed a value of 6 mA."