HospitalInspections.org

.
Based on observations and interview the facility did not ensure that the Type II (222) Main Hospital Building was separated from the adjacent Type V (000) Conference Room Modular Building with at least 2-hour construction.

Findings:

On 04/26/12 at 10:32AM multiple unsealed wire penetrations were noted in the 2-hour wall separating the two (2) buildings.

Concurrent interview with the facility's Director of Engineering indicated he would inform the facility's Administrator of the issue.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.1.1.4.1, 19.1.6.2
.

.
1. Based on observations and interview the facility did not ensure that the 4-story unsprinklered Type II (222) Hospital Building was separated from the adjacent fully sprinklered Nursing Home Building.

Findings:

On 04/24/12 at 2:30PM it was noted that the corrugations in the floor and form unit in a fire wall separating the Hospital Building from the Nursing Home Building (vicinity bridge) were sealed with mineral fiber insulation only.

Concurrent interview with the facility's Director of Engineering indicated he would inform the facility's Administrator of the issue.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.1.1.4.1


2. Based on observations and interview the facility did not ensure that exposed steel structural members in the 4-story unsprinklered Type II (222) Hospital Building were protected.

Findings:

On the morning of 04/23/12 it was noted that three steel "I" beams above the suspended ceiling in the 3rd floor Detoxification Unit's multipurpose room were completely fireproofed. For example, on one beam a 3-foot section was not protected and on another beam a 6-foot section was not protected.

Concurrent interview with the facility's Director of Engineering indicated he would inform the facility's Administrator of the issue.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code:19.1.6.2
.

.Based on observations and record review, the facility did not ensure that interior finish in corridors had a flame spread rating of at least Class A or Class B.

Findings:

The facility was unable to provide documentation that the flame spread rating of the following interior finish item was at least Class A or Class B. The facility was advised at the entrance conference on 04/23/12 that such documentation would be needed, but was unable to produce the documentation by the conclusion of the survey on 04/30/12.

- Wood paneling in the corridors of the basement level of the Founder's Wing.

Concurrent interview with the facility's Director of Engineering indicated he would inform the facility's Administrator of the issue.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.3.2
.

.
Based on observations and record review, the facility did not ensure that interior finish within rooms in smoke compartments that were not provided with a complete sprinkler system, had a flame spread rating of at least Class A or Class B.

Findings:

The facility was unable to provide documentation that the flame spread rating of the following interior finish items was at least Class A or Class B. The facility was advised at the entrance conference on 04/23/12 that such documentation would be needed, but was unable to produce the documentation by the conclusion of the survey on 04/30/12.

- Wood paneling in the 1st Floor Founder's Wing Social Services Office Suite.

- Blue sound absorbent material on the walls of the 1st Floor Goldstein Auditorium.

- And wood paneling in the Basement Level Staff Dining Room.

Concurrent interview with the facility's Director of Engineering indicated he would inform the facility's Administrator of the issue.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.3.3.2
.

.
1. Based on observations and interview the facility did not ensure that corridor walls in smoke compartments not provided with a complete sprinkler system were provided with at least a ½-hour fire resistance rating.

Findings:

a) On 04/24/12 at 10:18AM, an approximately 2-inch by 6-inch hole was found in a 3rd Floor corridor wall (above the suspended ceiling) near the Day Room and electrical panel "LP 38" in the Founder's Wing.

b) On 04/24/12 at 1:30PM, several unsealed cable penetrations were noted in portions of the corridor above the suspended ceiling in the vicinity of the 2nd Floor Hyperbaric Chamber Room and the adjacent Nursing Station.

c) On the afternoon of 04/25/12, two (2) unsealed pipe penetrations were noted above the suspended ceiling in a corridor wall section in the vicinity of the 1st Floor Central Wing Medical Records Room.

d) On 04/25/12 at 9:14AM, four (4) unsealed cable penetrations were noted in portions of the corridor above the suspended ceiling in the vicinity of the 1st Floor (1 Main Wing) Ultrasound Room.

e) On 04/26/12 at 10:01AM, two (2) unsealed cable penetrations and an unsealed plumbing penetration were noted in portions of the corridor above the suspended ceiling in the vicinity of the Basement Boiler Room in the Main Wing.

Concurrent interview with the facility's Director of Engineering indicated he would inform the facility's Administrator of the issue.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.6.2.1


2. Based on observations and interview the facility did not ensure that corridor walls in smoke compartments with a complete sprinkler system formed a barrier to limit the transfer of smoke.

Findings:

On 04/25/12 at approximately 1:30PM, a 9-inch by 5-inch louvered opening was noted in the Basement Level, West Wing, former Oil Pump Room.

Concurrent interview with the facility's Director of Engineering indicated he would inform the facility's Administrator of the issue.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.6.2.2
.

.
1. Based on observations and interview, the facility did not ensure that all corridor doors were provided with positive latching hardware.

Findings:

a) In many areas corridor openings were protected by a pair of doors consisting of an active leaf and inactive leaf. The inactive leafs were not provided with automatic flush bolts to ensure positive latching of the pair of doors. Examples of such pairs of doors were noted as follows:

- The 3rd Floor West Unit Day Dining Room (observed on 04/23/12 at 10:59AM).

- A Storage Room across from a 3rd Floor Day/Dining Room (observed on 04/23/12 at 11:03AM).

- A Treatment Room across from Room #361 (observed on 04/23/12 at 11:05AM).

- 3rd Floor Mechanical Room #4 (observed on 04/23/12 at 11:47AM).

- 3rd Floor EKG/EEG Room (observed on 04/23/12 at 11:53AM).

- A 3rd Floor Main Wing Lounge in the vicinity of Mechanical Room #5 (observed on 04/23/12 at 1:42PM.)

-2nd floor (Main Wing) Rooms #244 and #246 (observed on 04/24/12 at 1:54PM).

-Basement (Main Wing) Laundry Room (observed on 04/26/12 at 9:45AM).

b) On 04/25/12 at 10:00AM, it was noted that neither of the two (2) pairs of doors to the Operating Room Suite (as defined by NFPA 101-2000) were provided with compliant positive latching hardware.

c) On 04/25/12 at 11:19AM, it was noted that the 3 West Unit's Laundry Room was provided with a key operated latch in lieu of positive latching hardware.

d) On 04/25/12 at 11:50AM, it was noted that a door to a 1st Floor East Wing Storage Closet was provided with a key operated latch in lieu of positive latching hardware.

Concurrent interviews with the facility's Director of Engineering indicated he would inform the facility's Administrator of the issue.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.6.3.2


2. Based on observations and interview the facility did not ensure that doors protecting corridor door openings in smoke compartments that were not fully sprinklered were substantial doors, such as those constructed of 1¾-inch solid bonded wood core doors.

Findings:

a) On the afternoon of 04/24/12, it was noted that there was a ¼-inch gap between the meeting edges of a pair of corridor doors to the 2nd Floor Main Wing Dialysis Unit.

b) On the afternoon of 04/24/12, it was noted that there was a 10-inch crack in a wired glass vision panel in one (1) of the pair of doors to the 2nd Floor Main Wing Dialysis Unit.

c) On 04/25/12 at 11:14AM, it was noted that the corridor door to the 1st Floor Coffee Shop in the vicinity of the Hospital's Main Entrance was a plain glass door.

Concurrent interviews with the facility's Director of Engineering indicated he would inform the facility's Administrator of the issues.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.6.3
.

.
Based on observation and interview, the facility did not ensure that, in smoke compartments that were not fully sprinklered, that all vision panels in corridor walls were fixed fire window assemblies.

Findings:

a) On 4/25/12 at 11:14AM it was noted that two (2) 52-inch by 81-inch vision panels to the Coffee Shop in the vicinity of the 1st Floor Main Entrance were plain glass vision panels.

b) On 4/24/12 at 10:55AM a 14-inch by 28-inch by 14-inch sliding operable vision panel was noted in a corridor wall in the vicinity of the 2nd Floor Outpatient Clinic Area.

Concurrent interviews with the facility's Director of Engineering indicated he would inform the facility's Administrator of the issues.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.6.2.3, 19.3.6.3.8
.

.
Based on observation and interview, the facility did not ensure that all elevator shafts were enclosed with construction having at least a 1-hour fire resistance rating.

Findings:

On 4/25/12 at 1:32PM, two (2) unsealed conduit penetrations were noted in the West Wing Basement Elevator Machine Room. Concurrent interview with the facility's Director of Engineering indicated he would inform the facility's Administrator of the issue.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.1.1, 8.2.5.6
.

.
Based on observations and interview, doors to hazardous areas and smoke barriers were held open with prohibited hold-open devices.

Findings:

a) On 04/24/12 at 12:07PM, a tool cart and several cardboard boxes were stored against one (1) of the two (2) smoke barrier cross-corridor doors in the 2nd Floor of the Main Wing (2 South Unit) smoke barrier. Storage of these materials against the door would prevent it from automatically closing.

b) On 04/24/12 at 1:30PM, it was noted that both doors to the 1st Floor Founder's Wing Hyperbaric Room were held open with mechanical hold open devices. Concurrent interview with the facility's Director of Engineering indicated he would inform the facility's Administrator of the issue.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.2.2.2.6
.

.
Based on observations and interviews smoke barrier walls were not constructed to provide at least a ½-hour fire resistance rating.

Findings:

a) On the afternoon of 04/23/12, a partially sealed 4-inch pipe penetration and an unsealed wire penetration were noted above the cross-corridor doors (i.e., smoke wall Q) in the 3 Main-3 Central smoke barrier.

b) On 04/23/12 at 11:30AM a ¼-inch gap was noted between the sheet rock partition and a protected steel beam in a portion of the 3 Main-3 Central smoke barrier wall. In addition, two (2) 4-inch by 2-inch holes were noted on one (1) face of the sheet rock that was part of the smoke barrier wall.

c) On 04/24/12 at 10:32AM, an unsealed plumbing penetration and a partially sealed cable penetration were found in a 3rd Floor smoke barrier wall (above the cross-corridor doors between the Founder's Wing and the East Wing). In addition, a duct penetration in the above-mentioned smoke barrier wall that contained a motorized fire/smoke damper was found to have been improperly sealed with intumescent firestopping materials. Intumescing firestopping materials expand when exposed to heat and would impinge on the duct, possibly crushing the duct, and could prevent the fire/smoke damper from operating properly.

d) On 04/24/12 at 2:00PM two (2) unsealed duct penetrations were noted above the cross-corridor doors in a smoke barrier in the vicinity of Room #250.

e) On 04/24/12 at 2:28PM, it was noted that the corrugations in the floor and form unit in a smoke barrier on the 2 West Wing (above cross-corridor smoke doors "I") were sealed with mineral fiber insulation only. In addition, a duct penetration in the above-mentioned smoke barrier wall that contained a motorized fire/smoke damper was found to have been improperly sealed with intumescent firestopping materials. Intumescing firestopping materials expand when exposed to heat and would impinge on the duct, possibly crushing the duct, and could prevent the fire/smoke damper from operating properly.

f) On 04/25/12 at 8:55AM, three (3) unsealed cable penetrations and one (1) unsealed plumbing penetration were noted in a 1st Floor (West Wing) smoke barrier wall in the Emergency Department.

Concurrent interviews with the facility's Director of Engineering indicated he would inform the facility's Administrator of the issues.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.7.3
.

.
1. Based on observations and staff interview during the recertification survey, the facility did not ensure that all hazardous areas that lack complete automatic sprinkler protection were separated from other spaces by at least 1-hour fire resistance rated construction and self-closing doors.

Findings:

a) On 04/24/12 at 1:50PM, an unsealed cable penetration and an approximately ½-inch wide by 6-inch long hole was noted in one (1) side of a 1-hour fire resistance rated construction separation barrier between the 2nd Floor Main Wing Chronic Dialysis Unit and the 2 South Medical/Surgical Unit that is currently being renovated. In addition, it was noted that exiting from the Dialysis Unit was improperly directed through the area (e.g., the 2 South Medical/Surgical Unit) that is under renovation.

b) On 04/24/12 at 2:40PM, it was noted that there was no 1-hour fire resistance rated fire barrier wall to separate the 2 South Medical/Surgical Unit that is currently being renovated from the adjacent occupied space (e.g., the 2 South On-Call Room).

c) On 04/25/2012 at 10:42 AM, it was noted that the door to 1st floor Main Wing Storage Room #3 (vicinity Smoke Door E) was not provided with a self closing device.

d) On 04/25/12 at 11:20AM, it was noted that a 8-foot high by 7-foot wide combustible (wood particle board) partition was improperly used to separate areas on the 1st Floor that are currently under construction from occupied areas. A minimum of a 1-hour fire resistance rated fire barrier is required.

Concurrent interviews with the facility's Director of Engineering indicated he would inform the facility's Administrator of the issues.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.2.1, 19.7.9


2. Based on observations and staff interview during the recertification survey, the facility did not ensure that all hazardous areas that have complete automatic sprinkler protection were provided with self-closing doors.

Findings:

On 04/26/12 at 9:21AM, it was noted that the door to a basement Founder's Wing Medical Records Storage Room was not provided with a self closing device. In addition, this door was a sliding door that would not meet all of the requirements for corridor doors found in NFPA 101-2000: 19.3.6.3 (e.g., no positive latching device, not 1¾ -in. thick, solid-bonded core wood or of construction that resists fire for not less than twenty (20) minutes and shall be constructed to resist the passage of smoke).

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.2.1, 19.3.6.3
.

.
Based on observations and interview the facility did not endure that the 3 Main Laboratory was separated from the adjacent corridor with at least 1-hour fire resistance rating.

Findings:

On 04/24/12 at 9:10AM, a 14-inch by 9-inch hole was observed in a corridor wall above the suspended ceiling near a lab entrance door. Health care laboratories shall be separated from surrounding areas by at least 1-hour fire resistive construction.

Concurrent interview with the facility's Director of Engineering indicated he would inform the facility's Administrator of the issue.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.2.2, NFPA 99-1999 Standard for Health Care Facilities: 10.3.1
.

.
1. Based on observations and interview, the facility did not ensure that all exit stairwells were enclosed with at least 1-hour construction:

Findings:

a) On 04/23/12 at 11:41AM, it was noted that the corrugations in the floor and form unit in Stairwell #9 (3rd Floor) were sealed with mineral fiber insulation.

b) On 04/26/12 at 9:32AM, an unsealed plumbing penetration was found in an enclosure wall of Exit Stair #4 (Basement Level).

Concurrent interviews with the facility's Director of Engineering indicated he would inform the facility's Administrator of these issues.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.1.1


2. Based on observations and interview, the facility did not ensure that openings into stairwells enclosures were limited to those necessary for access to the enclosure from normally occupied spaces and corridors and for egress from the enclosure.

Findings:

a) On 04/25/12 at 11:35AM, it was noted that two (2) metal hatches (30-inch by 30-inch) and (28-inch by 28-inch) opened into exit Stairwell #4. Concurrent interview with the facility's Director of Engineering indicated that the hatches served not normally occupied crawl spaces and that he would inform the facility's Administrator of the findings.

b) On 04/25/12 at 11:59AM, it was noted that the door to a Mechanical Equipment Room opened into exit Stairwell #2. As per concurrent interview with the facility's Director of Engineering, he would inform the facility's Administrator of the finding.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 7.1.3.2.1
.

.
1. Based on observations and interview, two (2) room travel distance within the 1st Floor Operating Suite was in excess of fifty (50) feet.

Findings:

On 04/25/12 at 10:00AM, it was noted that travel distance from the interior of the Operating Room Clean Work Room and both sets of exit access doors from the Operating Room Suite to the respective corridors was approximately sixty-seven (67) feet and approximately eighty-four (84) feet.

Suites of rooms are permitted to have two (2) intervening rooms where the travel distance within the suite to the exit access door does not exceed fifty (50) feet.

Concurrent interview with the facility's Director of Engineering indicated he would inform the facility's Administrator of the issue.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.2.5.8


2. Based on observations and interview the facility did not ensure that all exit access was not through a hazardous area as defined by NFPA 101-2000: 19.3.2.

Findings:

On 04/24/12 at 1:45PM, it was noted that the second means of egress from the 2 Main Wing Dialysis Unit was through the 2 Main Wing (2 South) renovation area. Concurrent interview with the facility's Director of Engineering indicated he would inform the facility's Administrator of the issue.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.2.5.5
.

.
Based on observations and interview, the paths of travel between the termination of the hospital's exits and their associated public ways (i.e., exit discharges) were not provided with adequate illumination under all circumstances.

Findings:

- On 04/25/12 at 1:09PM, it was noted that lighting for the exit discharge for the North East exit from the Goldstein Auditorium was provided by a single, one (1) bulb lighting fixture.

Interview with the facility's Director of Engineering indicated he would inform the facility's Administrator of the issue.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 18.2.8, 7.8
.

.
Based on observations, the paths of travel between the termination of the Hospital's exits and their associated public ways (i.e., exit discharges) were not provided with adequate emergency illumination.

Findings:

-On 04/25/12 at 1:00PM it was noted that the exit discharge for exit Stair #9 was not provided with emergency lighting.

-On the afternoon of 04/15/12, it was noted that exit discharge lighting for Stair #4 consisted of High Intensity Discharge lighting. Due to their extensive re-striking periods the sole use of HID fixtures is prohibited

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code:18.2.5.1, NFPA 70-1999 National Electrical Code: Article 700
.

.
1. Based on observations and interview, electrical fixtures in oxygen and oxidizing gas (i.e., nitrous oxide) storage locations were not mounted at least 60-inches above the finished floor.

Findings:

On the afternoon of 04/25/12 it was noted that switches in both the West Wing Basement Level Nitrous Oxide/Oxygen Storage Rooms were mounted 50-inches above the finished floor.

Concurrent interview with the facility's Director of Engineering indicated he would inform the facility's Administrator of the issue.

42 CFR 482.41(b), NFPA 99-1999: 4-3.1.1.2


2. Based on observations and interview rooms used for the storage of oxygen and other oxidizing gasses (i.e., nitrous oxide) were not provided with dedicated mechanical ventilation.

Findings:

On the afternoon of 04/25/12, it was noted that both the West Wing Basement Level Nitrous Oxide/Oxygen Storage Rooms shared an exhaust ventilation duct with an adjacent Elevator Machine Room.

Concurrent interview with the facility's Director of Engineering indicated he would inform the facility's Administrator of the issue.

42 CFR 482.41(b), NFPA 99-1999: 4-3.1.1.2
.

.
1. Based on observations, the facility did not ensure that required separation distances between bulk oxygen systems and parked vehicles were maintained in accordance with NFPA 50 - Bulk Oxygen Systems.

Findings:

a) On 04/25/12 at 7:45AM two (2) vans were noted parked less than ten (10) feet from the Bulk Oxygen System on the North side of the Hospital Building. One (1) van was 67-inches from the systems exposed piping and the other van was parked 6-feet from the enclosure. Interview with the facility's Director of Engineering indicated he would inform the facility's Administrator of the issue.

b) On 04/26/12 at 7:46AM, a red SUV was noted parked less than ten (10) feet from the Bulk Oxygen system. The SUV was parked 75-inches from the Bulk Oxygen System.

42 CFR 482.41(b), NFPA 99-1999, NFPA 50


2. Based on observations, record reviews, and staff interviews, the facility did not ensure that medical air systems were required with required monitoring systems and alarms.

Findings:

a) On 04/26/12 at 8:59AM, review of the master medical gas system alarm panel located in the Communication's Room in the Founder's Wing Basement revealed that this alarm panel was not provided with required alarm signals for high carbon monoxide and high dew point.

b) On 04/26/12 at 11:15AM, the medical air system compressor located in the 4th Floor Mechanical Room of the West Wing was found to lack required dew point and carbon monoxide monitoring systems and local alarms. As per concurrent interview with the Director of Engineering, the facility has a plan to install the required monitoring and alarms on the medical air system.

c) On 04/26/12 at 1:33PM, review of the facility's 04/16/11 annual medical gas system testing records revealed that dew points at medical air outlets throughout the facility were above maximum 39°F allowed by NFPA 99. For example, the dew points of the medical air outlets in Emergency Room Bed #1 was 45*F, Operating Room #1 was 45*F, Operating Room #4 was 45*F, Recovery Room Bed #1 was 45*F, Respiratory Therapy Room #2 was 45*F, and Intensive Care Unit Bed #3 was 45*F.

42 CFR 482.41(b), NFPA 99-1999 Standard for Health Care Facilities: 4-3.1.1.9 (e), 4-3.1.1.9 (i) (3), 4-3.1.2.2
.

.
1. Based on observations and record (i.e., panelboard schedule) reviews and interview the hospital building was not provided with a Type 1 Essential Electrical System installed in accordance with NFPA 99.

The findings include, but are not limited to, the following:

a) 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. For example:

- Emergency electrical panelboard EC-3-1, located on the 3 West Wing served both Equipment System loads (e.g., fan coil units) and Emergency System loads (e.g., exit access lighting in corridors).

- Emergency electrical panelboard ELP-3 (vicinity Mechanical Room #5, 3rd Floor Main Wing) served both Equipment System Loads (e.g., circuit #25 - receptacle for cook/chill unit) and Emergency System loads (e.g., emergency lighting in North rooms).

- Emergency panel EA3 (vicinity Electrical Closet near 3 Main Elevator) served both Equipment System loads (e.g., 2nd Floor air conditioning unit) and an Emergency System load (e.g., fire alarm panel).

- Emergency electrical panelboard EC-1-1-R (vicinity 1 West Wing Electric Room) served both Equipment System loads (e.g. Fan Coil Unit #4) and an Emergency System load (e.g., outlets in Trauma Room).

b) 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. For example:

- Emergency electrical panelboard EC-3-1, located on the 3 West Wing served both Emergency System - Life Safety Branch loads (e.g., exit access lighting in corridors) and an Emergency System - Critical Branch load (e.g., nurse call system).

- Emergency electrical panelboard ELS-2-1 , located on the 2 West Wing served both Emergency System - Life Safety Branch loads (e.g., exit stair lighting) and Emergency System - Critical Branch loads (e.g., nurse call system, an ICU outlet).

- Emergency electrical panelboard #7EM (vicinity West Wing Electrical Closet near Room #256) served both Emergency System - Life Safety Branch loads (e.g., North exit and corridor lighting and an Emergency System - Critical Branch load (i.e., a receptacle in Room #244).

c) Emergency System wiring was not separated from the normal building wiring.

- Emergency electric panel EA3 (vicinity electrical closet near 3 Main Wing Elevator) shared a common wiring trough with a normal electrical panel (i.e., panel A3).

- Emergency electric panel 7EM (vicinity West Wing Electrical Closet near Room #256) shared a common wiring trough with a normal electrical panel (i.e., 6A).

Concurrent interviews with the facility's Director of Engineering indicated he would inform the facility's Administrator of the issues with the Essential Electrical System.

42 CFR 482.41(b), NFPA 99-1999Standard for Health Care Facilities: CH3, NFPA 70


2. Based on observations and interview, the facility did not ensure that every corridor provided exit access to not less than two (2) approved exits without passing through other than corridors or lobbies.

Findings:

On 04/25/12 at 8:41AM it was noted that access to an exit from the 1 West Wing elevator area was through the Emergency Department Suite.

Concurrent interview with the facility's Director of Engineering indicated he would inform the facility's Administrator of the issue.

42 CFR 482.41(b), NFPA101-2000 Life Safety Code: 19.2.5.9


3. Based on observations and staff interview, the facility did not ensure that compressed medical gas cylinders were appropriately stored to protect cylinders from accidental damage or dislocation.

Findings:

On 04/26/12 at 10:20AM, an "E" cylinder stored on the floor in a oxygen cylinder storage closet located next to the Anesthesia Work Room in the 1 Main Operating Room Suite was found to not be stored in an approved cylinder stand, cylinder storage rack, or securely fastened to the wall by a chain or similar restraining device. Concurrent interview with the facility's Director of Engineering indicated he would inform the facility's Administrator of the issue.

42 CFR 482.41(b), NFPA 99-1999 Standard for Health Care Facilities: 4-3.1.1.2 (a) (3)


4. Based on observations, record review, and staff interview, the facility did not ensure that where extinguishment or control of fire is effectively accomplished by a type of automatic extinguishing system other than an automatic sprinkler system, such as Halon 1301, that such systems shall be installed, inspected, and maintained in accordance with appropriate NFPA standards.

Findings:

a) On 04/25/12 at 9:05AM, the CAT Scan Room was found to be protected by a Halon system and the adjacent CAT Scan Control Room is protected by automatic sprinklers. The door between these rooms was improperly provided with a mechanical hold-open device. In order to prevent loss of agent through openings to adjacent hazards or work areas, openings, such as this door, shall be permanently sealed or equipped with automatic closures. As per concurrent interview with the facility's Director of Engineering, he would inform the facility's Administrator of the issue.

b) On 04/26/12 at 1:40PM, review of the most recent (e.g., 01/27/12), inspection, testing, and maintenance report for the vendor responsible for inspecting, maintaining, and testing the Halon extinguishing system revealed that the vendor failed to identify on his report what, if any, inspection, maintenance, or testing work he performed during the 01/27/12 visit. As per concurrent interview with the facility's Director of Engineering, he would inform the facility's Administrator of the issue.

42 CFR 482.41(b), NFPA101-2000 Life Safety Code: 9.7.3, NFPA 12A, Standard on Halon 1301 Fire Extinguishing Systems: 3-3.1.2, 4-1.1


5. Based on observations and interview, the facility did not ensure that all sleeping rooms (i.e., Lodging and Rooming House occupancies) that would require a smoke detector were provided with one.

Findings:

a) On 04/24/12 at 11:51AM, the On-Call Physician Sleeping Room (Room 232) located on 2nd Floor North Unit of the Main Wing was found to lack a required smoke detector in the room.

b) On 04/24/12 at 2:32PM, the On-Call Physician Sleeping Room located on 2nd Floor of the West Wing (near the Intensive Care Unit) was found to lack a required smoke detector in the room.

c) On 04/24/12 at 2:40PM, the On-Call Physician Sleeping Room located on 2nd Floor South Unit of the Main Wing was found to lack a required smoke detector in the room.

Concurrent interview with the facility's Director of Engineering indicated he would inform the facility's Administrator of the issue.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.1.2, 6.1.4, 26.3.3.5


6. Based on observations and interviews, the facility did not ensure that exiting from all assembly use areas was in compliance with all of the requirements found in NFPA 101.

Findings:

On 04/26/12 at 10:12AM, the Staff Dining Room in the basement of the Main Wing was found to have seating for ninety (90). A minimum of two (2) exits or exit access doors are required and shall be placed at a distance from one another not less than one-half (½) the length of the maximum overall diagonal dimension of the building or area to be served, measured in a straight line between the nearest edge of the exit doors or exit access doors. Both of the exit access doors were located next to each other rather than remotely from each other. In addition, one (1) of these two (2) doors did not open in the direction of egress travel and the other door has a key-operated lock on the non-egress side of the door that cannot be disengaged from the egress side. As per concurrent interview with the facility's Director of Engineering, he would inform the facility's Administrator of the issue.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.1.2, 13.2.1, 7.2.1.4.2, 7.2.1.5.1, 7.5.1.4


7. Based on observations and interviews, the facility did not ensure that prohibited locking devices were installed on doors. Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.

Findings:

a) On 04/26/12 at 9:03AM, a key-operated padlock device was installed on the non-egress side of a door to the "TV-R" Storage Room in the basement Founder's Wing.

b) On 04/26/12 at 9:21AM, a key-operated padlock device was installed on the non-egress side of a door to the Medical Records Storage Room in the basement Founder's Wing.

Concurrent interviews with the facility's Director of Engineering indicated he would inform the facility's Administrator of these issues.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.2.2, 7.2.1.5.1


8. The following deficiencies apply to the free standing, single story outpatient building located to the South of the Main Hospital Building. The building housed three (3) outpatient clinics and was classified as an Existing Business Occupancy (i.e., NFPA101-2000: Chapter 39).

The clinics were identified as follows:

- Outpatient Behavioral Health (Counseling Center)

- Alcohol and Addiction Services (FACTS)

- Methadone Maintenance Treatment (MMT)

a) Based on observation and interview all outside exit stairs were not provided with required handrails.

Findings:

On 04/26/12 at 9:34AM it was noted that an outside stair (i.e., South stair) that served the Outpatient Behavioral Health Clinic was not provided with any handrails. Concurrent interview with the facility's Assistant Director of Engineering indicated he would inform the facility's Administrator of the issue.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 7.2.2.4.2

b) Based on observations all handrails serving outside exit stairs were not maintained in good repair. Specific reference is made to a West exit stair that served the Alcohol and Addiction Services Clinic (i.e., FACTS).

Findings:

On 04/26/12 at 9:06AM it was noted that one (1) of the two (2) wood handrails that served a West exit outside stair had separated from the body of the wooden stair.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 7.2.2.4.2

c) Based on observations, the paths of travel between the termination of the clinics, exits and their associated public ways (i.e., exit discharges) were not provided with adequate illumination.

Findings:

- On the morning of 04/26/12, it was noted that exit discharge lighting for the Alcohol and Addiction Service's Main Entrance consisted of a single light fixture in the vicinity of the Main Entrance/Exit Door. The entire path of travel to the public way was not provided with illumination.

- No exit discharge lighting was provided for a West exit discharge from the Clinic Building.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 7.8.1

d) Based on observations and interview the facility did not ensure that exit access doors were operable with one releasing device. Reference is made to doors provided with prohibited 2-step releasing devices.

Findings:

- On the morning of 04/26/12, it was noted that an exit door in the vicinity of a FACTS Clinic's Social Worker's Office was provided with both conventional latching hardware and an additional sliding bolt latch.

- On the morning of 04/26/12, it was noted that the door to the Clinic Building's boiler was provided with both a convention knob operated latch and an additional sliding bolt latch.

- On the morning of 04/26/12 it was noted that an exit access door between the FACTS Clinic and the adjacent MMT Clinic was provided with both a conventional knob operated latch and an additional sliding bolt latch.

Concurrent interview with the facility's Assistant Director of Engineering indicated he would inform the facility's Administrator of the issue.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 7.2.1.5.4
.

.
1. Based on observations and staff interviews, the facility did not ensure that the electrical wiring was installed in a neat and workman like manner or maintained in good repair.

Findings:

a) On 04/23/12 at 10:50AM, an unprotected opening (e.g., a missing spacer bar) was found in electrical panel "PP-EQPH" in the 4th Floor West Wing Mechanical Room.

b) On 04/24/12 at 10:28AM, an electrical junction box located above the suspended ceiling in a 3rd Floor office (e.g., the Rehabilitation Unit Office that is across from the Nurses' Station) was found to lack a cover plate on one side. Unused openings in boxes, raceways, auxiliary gutters, cabinets, equipment cases, or housings shall be effectively closed to afford protection substantially equivalent to the wall of the equipment.

c) On 04/24/12 at 11:12AM, an electrical junction box located above the suspended ceiling in a 2nd Floor corridor (near Room #4 and the Wound Care Office in the Founder's Wing) was found to lack a cover plate on one side. Unused openings in boxes, raceways, auxiliary gutters, cabinets, equipment cases, or housings shall be effectively closed to afford protection substantially equivalent to the wall of the equipment.

d) On 04/26/12 at 9:30AM, an electrical junction box that was attached to the ceiling in the "Disaster Cabinet Room" in the Founder's Wing basement was found to lack a cover plate on one side. Unused openings in boxes, raceways, auxiliary gutters, cabinets, equipment cases, or housings shall be effectively closed to afford protection substantially equivalent to the wall of the equipment. As per concurrent interviews with the facility's Director of Engineering, he would inform the facility's Administrator of these issues.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: Article 110-12


2. Based on observations and staff interviews, the facility did not ensure that temporary wiring was removed immediately upon completion of construction or purpose for which the wiring was installed.

Findings:

On 04/23/12 at 11:30AM, temporary wiring and lighting fixtures were found above a suspended ceiling in the 3rd Floor corridor (near the West Wing elevators). As per concurrent interview with the facility's Director of Engineering, he would inform the facility's Administrator of the issue.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: 305-3


3. Based on observations and interview, the facility did not ensure that all manufacturers' instructions for electrically powered biomedical equipment and electrical equipment are followed as per the requirements of NFPA 70, National Electrical Code.

The findings include, but are not limited to, the following examples:

a) On 04/23/12 at 11:05AM, a Ground Fault Circuit Interrupter (GFCI) duplex receptacle in a 3rd Floor West Wing Psychiatric Unit treatment area toilet room was found to be labeled by the manufacturer "TEST MONTHLY". As per record reviews for GFCI receptacle testing and interview with the facility's Assistant Director of Engineering on 04/26/12 at 2:10PM, the facility currently only tests GFCI receptacles in the 2nd Floor Chronic Dialysis Unit.

b) On 04/26/12 at 8:55AM, an the cord set from an Accu-Check "Inform System" glucose monitor that was labeled "CAUTION-GROUNDING RELIABILITY CAN ONLY BE ACHIEVED WHEN THIS EQUIPMENT IS CONNECTED TO A RECEPTACLE MARKED 'HOSPITAL GRADE'" was improperly connected to a non-Hospital Grade portable power tap/surge protector in the Outpatient Primary Care Unit's Pediatric Clean Utility Room in the basement of the East Wing. As per concurrent interview with the facility's Director of Engineering, he would inform the facility's Administrator of the issue.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: 110-3 (b)


4. Based on observations and staff interviews, the facility did not ensure that flexible cords and cables are not used as a substitute for the fixed wiring of a structure.

Findings:

a) On 04/24/12 at 9:02AM, an electrical extension cord was found to be improperly used to connect the cord set of a "biohazard" refrigerator in the 3rd Floor Main Wing Laboratory Area to an electrical receptacle. As per concurrent interview with the facility's Director of Engineering, he would inform the facility's Administrator of the issue.

b) On 04/26/12 at 9:33AM, an electrical extension cord was found to be improperly used connect the cord set of a portable fan in a Medical Records Storage Room in the Founder's Wing basement.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: 110-3, 400-8


5. Based on observations and staff interviews, the facility did not ensure that listed Tamper Resistant electrical receptacles were provided in all designated pediatric use areas.

Findings:

On 04/26/12 at 8:50AM, a duplex electrical receptacle in the Outpatient Primary Care Unit's Pediatric Waiting Area in the basement of the East Wing was found to not be a listed Tamper Resistant electrical receptacle. As per concurrent interview with the facility's Director of Engineering, he would inform the facility's Administrator of the issue.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: 517-18 (c)
.

.
Based on observations and staff interviews, the facility did not ensure that existing elevators in the building having a travel distance of 25-feet or more above or below the level that best serves the needs of emergency personnel for fire fighting or rescue purposes shall conform to the Fire Fighters' Service Requirements of ASME/ANSI A17.3, Safety Code for Existing Elevators and Escalators.

Findings:

On 04/27/12 at 8:59AM, interview with the facility's Director of Engineering revealed that the passenger elevators in the Founder's Wing and Central Wing lacked Phase I emergency call operation so that they can recall to a designated floor in the event of a fire and Phase II Firefighters' emergency in-car operation controls for use by firefighters in the event of an emergency. He also said that the passenger elevators in the West and Main Wings were provided with the ability to be manually recalled to the designated floor in the event of a fire rather than having an automatic recall feature using their Phase II controls. According to the facility's Director of Engineering, the facility has a plan to upgrade all of their passenger elevators so that they all will have code compliant Phase I and Phase II controls.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.5.3, 9.4.3.2
.

.
Based on observations and interview, the facility did not ensure that Alcohol Based Hand Rub (ABHR) dispensers were not placed in carpeted areas in buildings that were not fully sprinklered.

Findings:

On 04/25/12 at 11:41AM an ABHR dispenser was noted mounted on the wall in the 1st floor medical library. The library was carpeted but neither the wing that housed the library (nor the library) was provided with a complete sprinkler system.

Concurrent interview with the facility's Director of Engineering indicated he would inform the facility's Administrator of the issue.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 8.4.3