HospitalInspections.org

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Based on observation, the facility failed to maintain the means of egress per the requirements of:

2012 NFPA 101, 21.2.1, and 7.2.1.9.1.3

This deficiency affects 1 set of powered egress doors.

Findings include:

During a tour of the facility, the surveyor observed the power-assisted manually operated powered egress cross-corridor doors between the Endoscopy Area and the Boiler Room Corridor did not have a sign on the egress side that read:
"IN EMERGENCY, PUSH TO OPEN".

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to maintain a horizontal fire barrier exit per the requirements of:

2012 NFPA 101, 19.2.2.5, 7.2.4.3.1, and 8.3.5.1

This deficiency affects one horizontal fire barrier exit.

Findings include:

During a tour of the facility, the surveyor observed penetrations of multiple conduits and cables in the horizontal fire barrier exit, above the ceiling, over the fire barrier cross corridor doors (between the Ultra-sound Waiting area and Room 100) sealed with an unapproved expanding foam sealant.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to store Alcohol-Based Hand-Rub (ABHR) solution per the requirements of:

2012 NFPA 101, 19.3.2.6 (7)

This deficiency affects 1 of 8 smoke compartments.

Findings include:

During a tour of the facility, the surveyor observed 6.9 gallons of ABHR solution stored in the Basement Purchasing and Receiving Room (one smoke compartment) and did not meet the requirements of NFPA 30 (Flammable and Combustible Liquids Code).

A member of maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to post a list of sprinklers installed in the property at the sprinkler cabinet per the requirements of:

2012 NFPA 101, 19.3.5.1, 9.7.1.1, and 9.7.7
2010 NFPA 13, 6.2.9.7, and 6.2.9.7.1

This deficiency affects the complete sprinkler system.

Findings include:

During a tour of the facility, the surveyor observed the facility failed to post a list of sprinklers installed in the property at the sprinkler cabinet. The list shall include the following:

(1) Sprinkler identification number; or the manufacturer, model, orifice, deflector type, thermal sensitivity, and pressure rating
(2) General description
(3) Quantity of each type to be contained in the cabinet
(4) Issue or revision date of the list

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to post a list of sprinklers installed in the property at the sprinkler cabinet per the requirements of:

2012 NFPA 101, 4.6.1.2, 4.6.12.3, 4.6.12.4, 4.6.12.5, 9.7.1.1, and 9.7.7
2010 NFPA 13, 6.2.9.7, and 6.2.9.7.1

This deficiency affects the complete sprinkler system.

Findings include:

During a tour of the facility, the surveyor observed the facility failed to post a list of sprinklers installed in the property at the sprinkler cabinet. The list shall include the following:

(1) Sprinkler identification number; or the manufacturer, model, orifice, deflector type, thermal sensitivity, and pressure rating
(2) General description
(3) Quantity of each type to be contained in the cabinet
(4) Issue or revision date of the list

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation and document review, the facility failed to maintain the automatic sprinkler per the requirements of:

2012 NFPA 101, 4.6.1.2, 4.6.12.3, 4.6.12.4, 4.6.12.5, and 9.7.5
2011 NFPA 25, 13.7.1 (5), 5.3.1.2, and 5.3.1.3

This deficiency affects the complete sprinkler system.

Findings include:

During a tour of the facility, the surveyor observed the Fire Department Connection (FDC) did not have an FDC identification sign in place.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation and review of documentation, the facility failed to maintain the automatic sprinklers per the requirements of:

2012 NFPA 101, 19.3.5.1, and 9.7.5
2011 NFPA 25, 5.3.1.1.1.6, and 5.2.1.1.2(5)

This deficiency affects the complete sprinkler system.

Findings include:

During a tour of the facility, the surveyor observed the following:

1. The facility failed to provide documentation that the (11) dry sprinklers installed in 2014, located in the walk-in cooler and freezer, Front Entrance Vestibule, the Loading Dock, and at the Outside Medical Gas Storage Areas had been replaced or a representative sample tested within 10 years of installation

2. A sprinkler located in the 2nd Floor DRG Room was loaded (had excessive dust insulating the bulb of the sprinkler), this may delay the activation of the sprinkler

3. A representative sample of 4 sprinklers from the first floor where tested. One sprinkler failed to meet the test requirements. The facility must test another sprinkler from the Lobby or replace all the sprinklers within the area represented by the failed sample sprinkler.

A member of the maintenance staff and the administrator were present when this deficiency was identified.

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Based on observation, the facility failed to maintain the oxygen cylinders in the Respiratory Storage Room per the requirements of:

2012 NFPA 99, 11.6.2.3 (11), 11.3.2.3, 11.3.4.1, and 11.3.4.2

This deficiency affects 1 of 8 smoke compartments.

Findings include:

During a tour of the facility, the surveyor observed the following in the Respiratory Storage Room:

1. Eight 24 cu. ft. oxygen cylinders:
a. Laying in carts on their sides, unsecured
b. Located within 3' of combustibles (wooden shelving, cardboard boxes, etc.)

2. There was not a precautionary sign displayed on the door of the room that included the following: "Caution: Oxidizing Gas(es) Stored Within No Smoking"

A member of the maintenance staff was present when this deficiency was identified.