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Based on observations during a Life Safety Code survey, it was noted that structural components of the facility were not properly protected from fire. Structural steel/steel beams located above the non-fire rated ceiling assembly were not protected to meet requirements for minimum fire rated building construction of Type II 222.

Findings include:

During tour observations of the facility from 06/20/11 to 06/24/11 between 11:00 AM to 4:00 PM, observations revealed that the I-beams and steel beams/steel web truss assemblies/steel supporting the weight of the deck above, were not completely protected with a fire resistive material. Also, some I-beams were missing the fire resistive material in parts where hanging elements/accessories were installed.

Examples of some unprotected I-beams were found in the areas of SL1 and SL2 level rooms and some in above ceiling inspections.
Some examples, including but not limited to, missing fire resistive material are the I-beams in Chiller room, Baby chiller room, and HVAC room supplying air to ORs.

Findings were verified with Staff #21
2000 NFPA 101: 19.1.6.2, 19.3.5.1, 4.6.6, 19.1.1.4.1
1999 NFPA 220: 3-1

Based on observation and interview, it was determined that the facility did not ensure that all doors opening onto and protecting the corridors from fire/smoke in the patient treatment area were kept free of impediments to ensure positive latching and quick closing doors in case of an emergency.

Findings include:

During observation tour of the facility from 06/20/11 to 06/24/11 between 10:30 AM to 4:00 PM, it was noted that in various places of the facility, the use of door stoppers/wedges was prevalent.

An example include: The gift shop where the door was propped open with a door wedge on 06/20/11 at 2:00 PM. This was brought to the notice of Staff #21.

Similarly during the tour of the 4th floor Maternity suite on 06/22/11 at 2:45 PM, it was noted that Child education room opening to the common exit corridor had a chair in front of the doorway. Such arrangement may impede the prompt closure of a door in case of fire. When brought to Staff #24's attention, he promptly removed the chair.

Furthermore, on 06/22/11 at 12:00 PM while surveying the Ultrasound room in the radiology department, it was noted that a stretcher was stored in the room in such a fashion that it will impede prompt closure of the door in case of fire. Finding was verified with Staff #24.

NFPA 101 (2000 edition) 19.2.1, 19.3.6.3, (19.3.6.3.6), 7.2.

Based on observation, the facility did not ensure that all hazardous areas are safeguarded from other spaces, by smoke/fire resisting partitions and doors which are self-closing or automatic-closing, and/or are provided with the positive latching devices to protect from fire/smoke, as detailed in 19.3.2.1.

The findings include:

During the tour of the facility from 06/20/11 to 06/24/11 between 10:30 AM to 4:00 PM, it was noted that main storage/supply rooms housing abundant combustible supplies did not latch positively. Furthermore, multiple housekeeping/janitor's closets and Soiled Utility rooms did not have a self-closing mechanism installed on the doors or did not latch positively. Some examples are, including but not limited to:
a) On 06/20/11 at 11:45 AM, it was noted that the Bio-hazard room's self-closure was not working.
b) No self-closure was installed in the Soiled Utility room and clean utility room in the Ambulatory Day Surgery unit.

Findings were verified with Staff #21, Staff #25 and other staff members of the unit present at the time of observation.

Subsection 7.2.2.4.6 (Guard Details) of NFPA 101, requires that:
(1) The height of guards required in 7.2.2.4.1 shall be measured vertically to the top of the guard from the surface adjacent thereto.
(2) Guards shall be not less than 42 in. (107 cm) high.
Exception No. 1: Existing guards within dwelling units shall be permitted to be not less than 36 in. (91 cm) high.
Exception No. 2: The requirement of 7.2.2.4.6(2) shall not apply where otherwise provided in Chapters 12 and 13.
Exception No. 3*: Existing guards on existing stairs shall be permitted to be not less than 30 in. (76 cm) high.
(3) Open guards, other than approved, existing open guards, shall have intermediate rails or an ornamental pattern such that a sphere 4 in. (10.1 cm) in diameter shall not pass through any opening up to a height of 34 in. (86 cm).
Exception No. 1: The triangular openings formed by the riser, tread, and bottom element of a guardrail at the open side of a stair shall be of such size that a sphere 6 in. (15.2 cm) in diameter shall not pass through the triangular opening.
Exception No. 2: In detention and correctional occupancies, in industrial occupancies, and in storage occupancies, the clear distance between intermediate rails, measured at right angles to the rails, shall not exceed 21 in. (53.3 cm).

Based on observation, it was determined that the facility did not comply with the above code requirements in that the facility's staircase landings (which have open sides and are more than 30 inches above the floor below) are not provided with guards which have intermediate rails or an ornamental pattern such that a sphere 4 inches (10.1cm) in diameter cannot pass through any openings. This was noted on the Med/Surg floor's staircase at 2 Broadway.

Findings include:

On 06/24/11 at 2:45PM, it was observed that the guardrails at the landings of staircase in the Med Surg floor of 2 Broadway, are provided with the horizontal guard rails, approximately 6-8 inches apart from each other and the landings. This is in excess of the maximum 4 inches permitted by the code. There are no intermediate rails or other ornamental pattern for safety installed in accordance with NFPA 101, 7.2.2.4.6.

Findings were verified with Staff #21.

Sub-Section 7.1.10.1 requires that:
Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency, and,
Sub-Section 18.2.3.3 requires that
Aisles, corridors and ramps required for exit access in a hospital shall not be less than 8 ft in clear and unobstructed width.

Based on observations and staff interviews, the facility did not ensure that the exit passageways of the Emergency Department are maintained free of obstruction or impediments for full and instant use, in the case of fire or other emergency.

The findings include:

On 06/21/11 at 11:15AM, it was observed that two stretchers/beds were parked in one Exit passageway of the Emergency Department and another stretcher was parked in another exit passageway of the Emergency Department. As per staff present in the unit, these stretchers/beds are permanently placed in these passage ways and the beds are identified/labelled as Hallway beds #1, 2 and 3.

Such arrangement compromises the full instant use of the means of egress to the Exit. Findings were verified with Staff #21 at the time of observation.

Based on document review and staff interview, it was determined that the facility did not ensure that the fire drills were conducted under varying conditions and that planning/evaluation of fire drills were done as per NFPA 101.

Findings include:

1. During fire drill record review on 06/24/11 at 11:30 AM, it was noted that the fire drill report of the facility is in the form of a checklist which is incomplete and highlights only a few points of the drill on which the 'observer' of the drill checks off "yes" or "no". Although the facility's fire drill records included staff sign-in sheets and brief comments, the facility failed to report/document a detailed critique in the records regarding staff's fire drill response and knowledge of evacuation procedure, to ensure staff is fully aware of fire drill/evacuation protocols .

2.a. Review of fire drill records indicated that although the hospital's fire drills include transmission of a fire alarm signal, the hospital failed to conduct fire drills which include simulation of various types of emergency fire conditions to ensure that each staff has a full and clear understanding of facility's fire safety plan and how to execute it successfully under the varying conditions.

2.b. Hospital fire drills also did not include utilization of different components of the fire alarm system, such as smoke detectors, sprinkler system, and others, to help ensure that staff are aware of the different bell/chime counts they elicit during drills, and that Staff can determine if the fire alarm system is in optimal working order.

Findings were confirmed with Staff #21 and Staff #26..

Based on observations, it was determined that the facility did not ensure that all sprinklers are maintained free of any foreign material or paints as per NFPA 25 and NFPA 13, Standard for the Inspection, Testing and Maintenance of Water Based Fire and Protection System.

The findings include:

During observation tour of the facility from 06/20/11 to 06/24/11 between 10:45 AM to 4:00 PM, it was observed that the sprinkler heads in various locations were covered with thick dust/dirt/lint.

Examples, including but not limited to, are:
i. Three out of five heads in the Central Sterile Processing room were dirty.
ii. Many sprinkler heads in the area of the Billing/Registration Department were dirty.
iii. Sprinkler heads by the entrance of the Neuro Med/Surg were noted dirty and dusty.

Findings were verified by Staff #21 and Staff #24.

Based on observation, it was determined that the facility failed to ensure that all its portable fire extinguishers are installed such that the top of the fire extinguisher is not more than 5 feet (60 inches) above the floor (see reference NFPA 10, 1-6.10).

Findings include:

During survey of the facility from 06/20/11 to 06/24/11 between 10:30 AM to 4:00 PM, it was noted that the fire extinguisher at various places were installed on the wall with its topmost portion higher than the required 5 ft. (60 inches) above the floor.

Examples, including but not limited to, are:
i. Fire extinguisher in break room #33.
ii. Fire extinguisher in the Ambulatory Day Surgery, near the Endoscopy Room #2.
iii. Fire Extinguisher by the 3rd floor Med/Surg (Broadway) unit's nursing station.

Findings were verified with Staff #21 and Staff #24 at the time of observation.

Based on observation and staff interview, it was determined that the facility failed to ensure that the artificial decorative plants displayed in the facility are not constructed of combustible material, unless otherwise rendered flame retardant.

The findings include:

On 06/22/11 at 2:45 PM during the tour of the Maternity Suite, it was observed that the facility had provided decorative artificial plants in Whirlpool room and some other rooms. An interview with Staff #24 at that time revealed that he could not confirm the non-combustible nature or the flame-retardant properties of these artificial trees. He stated that he did not think that those plants were rendered flame retardant by any chemical treatment.

Based on observation, the facility did not ensure that all soiled linen collection receptacles with capabilities greater than 32 gallons are located in a room protected as a hazardous area when not attended. The carts used to store and transport soiled linens were noted stored in the corridor of the basement Morgue near elevators.

Findings include:

On 06/20/11 at 1:00 PM, at least four large soiled linen containers greater than 32 gallons were noted stored unattended in the basement alcove/corridor in proximity of the Morgue. These four receptacles were noted to be still parked there on 06/22/11 at 12:00 PM when the surveyor went to survey the Morgue.

Findings on 06/20/11 were verified with Staff #21 who acknowledged that these should not be stored in such a manner.

Based on record review and staff interview, it was determined that the facility did not ensure that the piped in medical gas system's discrepancies were corrected in a timely manner and as per NFPA 99.

Findings include:

On 06/24/11 at 12:30 PM during the review of the medical gas report of the facility from 'Granger Medical Inc' dated March 2011, it was noted that the report indicated many repair deficiencies, leaks, flow failure and master alarm connection deficiencies. No follow up report was provided indicating if these deficiencies were corrected. Furthermore, there were rooms in Maternity Suite that did not get their outlets checked and were marked in the room as 'Could not get in this room". Staff #25 could not provide a response whether these rooms were checked on a later date or were completely overlooked.

Findings were confirmed with Staff #21.

A. Based on staff interview it was determined that the facility did not ensure all electrical receptacles were tested as per NFPA 99.
Findings include:
On 06/23/11 at 2:45 PM, Staff # 24 was asked to provide documentation for electrical receptacle testing in patient care, critical care and wet locations. Staff #25 could not provide any documentation as he was unaware of the requirement.
NOTE:As per NFPA 99 (1999) 3-3.4.2.3 Maintenance and Testing of Electrical system Testing Interval for Receptacles in Patient Care Areas. (1) Testing shall be performed after initial installation, replacement, or servicing of the device.
Facility needs to provide information for the servicing of the electrical receptacles as per NFPA 99 to ensure that all receptacles are operational with no electrical leakage or any other problem. The codes of NFPA 99 1999 3-3.3.3 and 3-3.3.3.2 identify the most pertinent tests required to be verified. However, facility needs to ensure full compliance with NFPA 99 Chapter 3 and NFPA 70.

B. Section 8-3.1.11.2 of NFPA 99 states:
Storage for nonflammable gases less than 3000 ft. 3 (85 m3).
(a) Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry.
(b) Oxidizing gases, such as oxygen and nitrous oxide, shall not be stored with any flammable gas, liquid, or vapor.
(c) Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by either:
1. A minimum distance of 20 ft. (6.1 m), or
2. A minimum distance of 5 ft. (1.5 m) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, or
3. An enclosed cabinet of noncombustible construction having a minimum fire protection rating of one-half hour for cylinder storage. An approved flammable liquid storage cabinet shall be permitted to be used for cylinder storage.
(d) Liquefied gas container storage shall comply with 4-3.1.1.2(b)4.
(e) Cylinder and container storage locations shall meet 4-3.1.1.2(a)11e with respect to temperature limitations.
(f) Electrical fixtures in storage locations shall meet 4-3.1.1.2(a)11d.
(g) Cylinder protection from mechanical shock shall meet 4-3.5.2.1(b)13.
(h) Cylinder or container restraint shall meet 4-3.5.2.1(b)27.
(i) Smoking, open flames, electric heating elements, and other sources of ignition shall be prohibited within storage locations and within 20 ft. (6.1 m) of outside storage locations.
(j) Cylinder valve protection caps shall meet 4-3.5.2.1(b)14.

Based on observation, it was determined that the facility did not ensure that oxygen cylinders on patient floors were stored as per the requirement mentioned above in NFPA 99.

Findings include:

a. During the tour of the Respiratory Therapy Department on 06/22/11 at 4:00PM, it was noted that fourteen E class oxygen cylinders (12 on a rack and 2 on vent machines) were stored inside a sprinklered clean utility room. The clean utility room was not secured for unauthorized entry (as per 8-3.1.11.2.a).

b. The above-referenced clean utility room had an abundant supply of combustible materials such as boxes, alcohol-based hand sanitizers, plastic wraps/supplies and other materials. The oxygen tanks were kept on racks which were not placed in a manner to ensure at least 5 feet distance away from the combustibles.

c. As per the S&C letter issued by Center for Medicaid & Medicare Services dated 01/12/2007, no more than twelve E sized Cylinders can be stored in an enclosure per smoke compartment. It was noted that, there were two more oxygen cylinders on the Respiratory Vent than allowed twelve E cylinders stored in the same space making a total of fourteen.

Findings were verified with Staff #24 at the time of observation.

Based on document review and staff interview, it was determined that the facility performs general anesthesia and has two emergency generators installed in the facility 200kVA and 408 kVA which are not wired as a Type I EES (essential electrical system). NFPA 99 3-4.

Findings include:

In an interview with Staff #21 on 06/20/11 at 11:15 AM, staff #21 suggested that the wiring configuration in the facility for the Type I EES (200K and 408 K) may not be compliant with 1999 NFPA 99 3-4.2.2.1. The specific issue involved was the separation of the generator branches into a life safety, critical, and equipment system for the facility. Discussion with Staff #25 revealed that the branches of the generators are divided only in a few newly renovated parts of the hospital, but the hospital as a whole does not have the generator branching off in three branches. The facility operates a ventilator dependent unit, and as such, requires a Type I EES.

Document review of the panel and switches also revealed that the wiring for items required to be served by the Equipment System was not independent from wiring for items required to be served by the Emergency System, and the wiring for items required to be served by the Emergency System - Life Safety Branch was not independent from wiring for items required to be served by the Emergency System - Critical Branch.

1999 NFPA 99 3-4.2.1.4, 3-4.2.2, NFPA 70: Article 517 and Article 700.

Based on observation, the hospital failed to ensure that electrical wiring is utilized in accordance with the National Electrical Code NFPA 70

The finding is:

During a tour of the Main Chemistry Laboratory on 06/22/11 at 3:45 PM, it was noted that 4-5 permanent equipment/appliances were all plugged into one receptacle through the use of a multi-plug adaptor. It could not be verified by the staff present if the extension cord was Hospital grade. Finding was verified with Staff #25.

NOTE: Extension cords shall not be used as a substitute for permanent wiring and shall not be used for fixed or stationary appliances. Extension cords shall be plugged directly into an approved receptacle, power tap, or multi-plug adapter and shall, except for approved multi-plug extension cords, serve only one portable appliance.


NFPA 70 400-8, 210-20(b) (1) & (2) / 210-23

Based on staff interview, it was determined that all the elevator banks in the facility are not equipped with fire fighter recall.

Findings include:

On 06/20/11 at 12:00 PM, Staff #21 stated that all the elevators in the facility at this time are not equipped with fire fighter recall. He stated that the issue was identified during a State pre-opening survey and the facility has a plan to resolve the issue by 10/2011. However, due to financial constraints. at this time the work has not begun to equip the elevators with fire fighter recall.