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Based on an interview, the facility failed to provide a building with an acceptable construction type. This deficient practice could affect patients, staff and visitors if the building did not maintain its structural integrity for the required length of time during a fire emergency.

Findings include:

At 3:00 PM on February 24, 2015, during a telephone conference call held in Building E, first floor Conference Room E150, the Life Safety Consultant confirmed that the Building B is of Type II (000) construction. The concrete floor slabs are only 2-1/2 inches thick, which does not comply with Table 19.1.6.2.

Based on observations it was determined that the facility failed to maintain the closure of the corridor doors. This deficient practice could affect patients, staff and visitors if a fire would start in this smoke zone and would not provide a proper smoke barrier at the corridor for egress.

Findings include:

At 9:17 AM on February 25, 2015, while accompanied by the Director of Facility Operations, the surveyor observed that the dutch door serving the Lower Level Building E surgical department pharmacy does not comply with 19.3.6.3.6 because:

1. The upper leaf of the dutch door does not automatically latch into the lower leaf.
2. The meeting edges of the upper and lower leafs are not provided with an astragal, rabbet, or bevel.

Based on observations and interviews the facility failed to maintain properly rated shaft enclosures. This deficient practice could affect patients, staff and visitor if smoke and fire were allowed to expand from other areas of the facility through deficient shaft enclosures.

Findings include:

A. At 3:00 PM on February 24, 2015, during a telephone conference call held in Building E, first floor Conference Room E150, the Life Safety Consultant confirmed that the elevator shaft at the northeast end of the Building B does not carry a minimum 2 hour fire resistance rating required by 19.3.1.1 and 8.2.5.4.
B. At 3:00 PM on February 24, 2015, during a telephone conference call held in Building E, first floor Conference Room E150, the Life Safety Consultant confirmed that a series of shafts located at the northeast end of the Building B do not carry a minimum 2 hour fire resistance rating required by 19.3.1.1 and 8.2.5.4. Chute shaft enclosures identified include:

1. The shaft enclosure housing the linen chute.
2. The shaft enclosure housing the refuse chute.

C. At 1:40 PM on February 23, 2015, while accompanied by the Director of Facility Operations, the surveyor observed that the ninth floor Building B segment of the linen and refuse chutes, located within the elevator penthouse, lack shaft enclosures required by 19.3.1.1 and 8.2.5.4.
D. At 1:45 PM on February 23, 2015, while accompanied by the Director of Facility Operations, the surveyor observed that the doors to the elevators at the northeast end of the Building B could not be determined to carry a minimum 1-1/2 hour fire resistance rating, as required by 19.3.1.1, 8.2.5.4, and 8.2.3.2.3.1(1), because the fire resistance rating labels are not readable. This condition was observed on all building stories inspected.

E. At 3:00 PM on February 24, 2015, during a telephone conference call held in Building E, first floor Conference Room E150, the Life Safety Consultant confirmed that a series of ventilation shafts, which are at least 4 stories in height, lack a minimum 2 hour fire resistance rating required by NFPA 90A 1999 3-3.4.1. Ventilation shafts identified as carrying less than a 2 hour fire rating include:

1. The ventilation shaft at the southwest side of Exit Stair 3B at all levels.

2. The ventilation shaft approximately 10 feet northeast of Exit Stair 3B at all levels.
3. The center ventilation shaft.

4. A series of 15 ventilation shafts which serve the induction units installed at the exterior walls of the Building B.

Based on observations, it was determined that the facility failed to maintain proper door configurations in fire rated barriers. This deficient practice could affect patients, staff and visitors, if fire and smoke were allowed to spread beyond the location of fire origin.

Findings include:

On 2/24/2015 at 9:50 AM while accompanied by the Vice President of Facilities Management it was determined by an observation that in the Building D, lower level, emergency department contained a set of 2-hour rated double doors. When the doors were tested and closed the gap between the leading edges of the door leafs contained a ¼-inch gap. This does not comply with NFPA 101, section 8.2.3.2.3.1 and NFPA 80, section 2-3.1.7.

Based on an observation it was determined that the facility did not provided approved directional emergency illuminated exit signs readily visible from any direction of exit access where the nearest exit is not apparent. This deficient practice could affect patients, staff and visitors if improper or missing exit signs caused a delay in the evacuation of the building during an emergency.

Findings include:

At 10:02 AM on February 25, 2015, while accompanied by the Quality Safety and Compliance Coordinator in the lower level surgery area of Building E, the surveyor observed that the north passage by OR3 within the surgical suite is not provided with an exit sign as required by 19.2.10.1.

Based on observations of hazardous areas and interviews, the facility failed to provide properly operating latching and self-closing door hardware that provides separation between hazardous areas and exit access corridors. This deficient practice could affect patients, staff and visitors if a fire could spread without proper fire separation.

Findings include:

On 2/23/2015 at 2:40 PM while accompanied by the Vice President of Facilities Management an observation determined that in Building C, 6th floor, Storage Room C612 contained a large amount of storage and combustibles and the door was not self closing and does not comply with NFPA 101, section 19.3.2.1.

Based on observations and interviews, the facility failed to provide exit stairways enclosed with construction having the proper fire resistance rating and provide a continuous path of escape from exit discharge to public access way. This deficient practice could affect patients, staff and visitors if fire and smoke were to enter the exit enclosure and encumber evacuation of the facility during a fire emergency.

Findings include:

At 3:00 PM on February 24, 2015, during a telephone conference call held in Building E, first floor Conference Room E150, the Life Safety Consultant confirmed that a series of exit stair enclosures within the Building B do not carry a minimum 2 hour fire resistance rating required by 19.3.1.1 and 8.2.5.4. This determination was confirmed by the Director of Facility Operations at that time. Building B exit stair enclosures at which this condition was indicated include:
1. Exit Stair 2B at all levels.
2. Exit Stair 3B at all levels.

Based on observations, it was determined that the facility failed to maintain handrails. This deficient practice could affect patients, staff and visitors required to utilize the exit components by preventing those occupants from safely reaching the public way from an exit from the building.

Findings include:

On 2/23/2015 while accompanied by the Vice President of Facilities Management it was determined by an observation that the following stair location did not comply with the proper handrail spacing. Existing exit stair handrail spacing was determined to be +/- 11-inches, this does not comply with NFPA 101, section 7.2.2.4.6 (3).

1. 2:12 PM, Stair 1D contained handrails spacing that would allow a 4-inch sphere to pass through. This deficiency was observed at all floor levels.

Based on observations and interviews the facility failed to provide proper exit door hardware. This deficient practice could affect patients, staff and visitors if door hardware prevented timely exiting from a compartment of fire origin.

Findings include:

A. At 9:10 AM on February 25, 2015, while accompanied by the Director of Facility Operations, the surveyor observed the following conditions at the Lower Level Building E entry to the post anesthesia care unit:
1. The door from the PACU corridor to the elevator lobby, which is provided with an exit sign above it on the southeast side, was observed to be equipped with a magnetic lock which prevents egress toward the northwest as prohibited by 19.2.2.2.4.
2. The corridor from a pair of doors from the G Corridor was observed to constitute a dead corridor of excessive length, as measured to a door at the southeast end of the elevator lobby, as prohibited by 19.2.5.10, because the door to the G Corridor is also equipped with a magnetic locking device.



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B. At 9:33 AM on February 25, 2015, while accompanied by the Quality Safety and Compliance Coordinator in the lower level surgery area of Building E, the surveyor observed that the cross corridor doors that provide exit access from the surgical suite are provided with magnetic locks. Staff interview confirmed that these doors are locked after hours and that a card is required to open the doors, which does not comply with 19.2.2.2.4.

Based on observations during the survey walk through the facility failed to maintain a properly functioning fire alarm system the installation did not meet all of the code requirements. This could affect patients, staff and visitor if the fire alarm system does not operate properly during a fire emergency.

Findings include:

A. While accompanied by the Director of Facility Operations, the surveyor observed rooms, housing fire alarm system Notification Appliance Circuit (NAC) Panels, which lack smoke detectors required by NFPA 72 1999 1-5.6. Locations observed include (All E Building)
1. 8:31 AM February 24, 2015, Electrical Closet E400.

2. 9:05 AM February 24, 2015, Electrical Closet E300.

3. 10:36 AM February 25, 2015, Electrical Closet E278.





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B. On 2/24/2015 at 2:30 PM while accompanied by the Engineering Operations Supervisor - Electricians, the surveyor observed that the NAC panel in Closet E278 was located in an unmanned room and was not equipped with a smoke detector as required by NFPA-72, Section 1-5.6.

Based on observations, the facility failed to provide a complete sprinkler system in all building compartments. This deficient practice could affect patients, staff and visitors, if sprinkler heads were not present in all areas of a building during a fire emergency.

Findings include:

A. At 9:30 AM on February 25, 2015, while accompanied by the Director of Facility Operations, the surveyor observed that portions of the acoustic ceiling assembly in Lower Level Building G, Telephone Room G003, are missing or have been removed, which compromises sprinkler coverage in the room by allowing heat to rise past sprinkler heads in a manner which does not comply with NFPA 13 1999 5-6.4.1.1.




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B. At 9:30 AM on February 24, 2015, while accompanied by the Quality Safety and Compliance Coordinator, on G Building fifth floor, the surveyor observed that the linen closet near Room G567 is not provided with a sprinkler head as required by 19.3.5.1.

Based on observations and interviews it was determined that the facility failed to properly manage and maintain the existing Air-conditioning and Ventilating Systems. This deficient practice could affect patients, staff and visitors if smoke and fire were to pass from chases that were not proper enclosed.

Findings include:

At 10:00 AM on February 24, 2015, while accompanied by the Director of Facility Operations, the surveyor observed the following conditions at a Second Floor Building E ventilation shaft adjacent to Electrical Room E222A:

1. The door to the ventilation shaft did not close to latch upon release as required by 8.2.3.2.3.1(1).
2. The frame for the door, which was observed to be wider than the shaft wall assembly in which it was installed, was not installed in accordance with a UL Design for compliance with 8.2.3.2.3.1(1) because the exposed portions of the door frame jamb have been laminated with drywall.

Based on observations it was determined that the facility did not maintain the medical gas systems. This deficient practice could affect patients, staff and visitors if a delay in staff response during an emergency with the medical gas system occured.

Findings include:

A. On 2/24/15 at 9:00 a.m., while in the company of the Engineering Operations Supervisor - HVAC & Plumbing that the facility failed to provide separation of the controlling medical gas zone valves from the patient outlets/inlets they serve on the 6th floor in the CCU. (NFPA 99, 1999, 4-3.1.2.3)

B. The surveyor finds by direct observation 2/24/15 at 9:30 a.m., while in the company of the Engineering Operations Supervisor - HVAC & Plumbing that the facility failed to provide separation of the controlling medical gas zone valves from the patient outlets/inlets they serve on the 4th floor in the dialysis unit. (NFPA 99, 1999, 4-3.1.2.3)


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Based on observations and staff interviews during the survey walk-through, February 23-26, 2015, and based on document review, and staff interview, the surveyors find the facility is not in compliance with the life safety code and other code requirements that are documented under the K-tags of this survey.

Findings include:

Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

Based on observations made during the survey walk through while accompanied by the Supervisor of Electrical and Mechanical Systems, the surveyor found that the emergency electrical installation did not meet all of the requirements of NFPA-70. This could affect all occupants of the building if the emergency power system does not operate properly upon the loss of normal power.

Findings include:

On 2/23/2015 at 2:20 PM the surveyor learned through staff interview with the Engineering Operations Supervisor - Electricians, that most of the emergency electrical system in Building G is mixed life safety, critical and equipment which does not meet the requirements of NFPA-70, Sections 517-30 through 157-34.

Some examples:

Life safety panel EM2A serves hall receptacles and nurse call which is not allowed by NFPA-70, Section 517-32. This situation was observed in several life safety panels in Building G.

Based on observations, it was determined that the facility failed to maintain proper electrical distribution requirements. This could affect any occupant of the facility if proper safety precautions are not met when electrical systems are installed.

Findings include:

A. At 1:00 PM on February 23, 2015, while accompanied by the Engineering Operations Supervisor - Electricians it was determined by an observation that the elevator cab lights in elevators G1, G2 and G3 were not fed from the life safety branch of emergency power in accordance with NFPA-70, Section 517-32.



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B. At 9:04 AM on February 24, 2015, while accompanied by the Quality Safety and Compliance Coordinator, on Building G sixth floor in the corridor near Door G619, the surveyor observed that data cabling is supported by the suspended ceiling system and not independently as required by NFPA 70 1999 800-6.

C. At 10:11 AM on February 24, 2015, while accompanied by the Quality Safety and Compliance Coordinator, on Building G fourth floor, the surveyor observed that patient rooms located on the 10 Wing are not provided with critical power receptacles as required by NFPA 99 1999 3-3.2.1.2(a)1 and NFPA 70 1999 517-18.