HospitalInspections.org

Based on observations and confirmed by staff, the facility failed to ensure that corridor walls are constructed as required. Section 19.3.6.2.2 states corridor walls shall form a barrier to limit the transfer of smoke. Section 19.3.6.4 states transfer grilles, regardless of whether they are protected by fusible link-operated dampers, shall not be used in these walls or doors.

THE FINDINGS INCLUDE:

- During the morning & afternoon hours of 4/25/12 while touring the facility, it was observed that corridor walls are not maintained as required. The second floor dinning room in the A-wing has an approximate 12" x 18" transfer grill in the wall.

This was acknowledged by the Director of Facilities during the building tour.

Based on observations, the facility failed to maintain corridor doors to resist the passage of smoke and failed to ensure that all corridor doors close and latch properly into their frames. The Centers for Medicare & Medicaid Services S&C-07-18 states "In a smoke compartment that is fully sprinklered, a gap between the face of a corridor door and the door stop should not exceed ?-inch".

THE FINDINGS INCLUDE:

1. Observations while touring the facility on the morning of 4/24/12 revealed that the door to patient room 507 has a 5/8" gap between the face of the door and door frame and the door to patient room 509 has a 1.5" gap between the face of the door. This was acknowledged by a maintenance staff person during the building tour. This was acknowledged by a maintenance staff person during the building tour.




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2. During the morning & afternoon hours of 4/24/12 & 4/25/12 the following items were observed regarding corridor doors:

a) The following C-Wing doors but not limited to were observed as having manually operated latching mechanisms and not equipped with self closing devices: Dayroom; Activity office; Auditorium and the A-Wing Cafeteria.

b) The food pantry door located in the C-Wing was observed as having fourteen (14) one inch holes drilled through the door for ventilation.

c) The door to room 321 B was observed as having no latching mechanism as it was removed for an unknown reason.

d) The Occupational Therapy room door is equipped with a kick stop holding the door in the open position.

e) The med room on the second floor A-wing is a dutch type door and the strip between the upper and lower leaf is loose and does not cover the gap between the two leafs.

f) The therapy #1 room and the 2A conference room on the second floor B-wing, does not have latching device, and no closer device to keep the door closed.

These were each acknowledged by the Director of Facilities during the building tour.

Based on observations, the facility failed to ensure that hazardous areas are enclosed as required. Section 8.2.3.2.1(a) requires door assemblies to be of an approved type installed in accordance with NFPA 80. Section 8.2.3.2.1(b) requires every fire door to be self-closing. NFPA 80, Section 2.1.4.1 requires self-closing doors to swing easily and freely and to be equipped with a closing device to cause the door to close and latch each time it is opened. The closing mechanism shall not have a hold-open feature. Section 2.4.1.2 requires a closing device to be installed on every fire door. Section 2.4.1.3 requires all components of closing devices used shall be attached securely to doors and frames by steel screws or through-bolts. Section 2.4.1.4 requires all closing mechanisms to be adjusted to overcome the resistance of the latch mechanism so that positive latching is achieved on each door operation. Section 2.4.4.3 requires all single doors and active leaves of pairs of doors to be provided with an active latch bolt that cannot be held in a retracted position. Section 2.4.4.5 requires that where a pair of doors are needed for the movement of equipment and where the inactive leaf of the pair of doors is not required for exit purposes, labeled, top and bottom, self-latching or automatic flush bolts, or labeled two-point latches to be used.

THE FINDINGS INCLUDE:

1. Observations while touring the facility on the morning of 4/24/12 revealed the storage room door by room 525 is not equipped with a latch.
2. Observations while touring the facility on the afternoon of 4/24/12 revealed that corridor doors to rooms D12, D26, D27, G14 and G15 in the basement have holes drilled in them.
3. Observations while touring the facility on the afternoon of 4/24/12 revealed trash stored in the corridor outside of the central supply room in the basement.
These were acknowledged by a maintenance staff person during the building tour.



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4. During the morning & afternoon hours of 4/24/12 & 4/25/12 the following items were observed regarding hazardous areas:

a) The self closing device on the medical records room door is currently disconnected. As a result, the door will no longer self close & latch as required.

b) The door to storage room D-12 is not equipped with a self closing device. In addition the latching system is manually operated utilizing a dead bolt style latch.

c) The door to storage room D-25 is not equipped with a self closing device.

d) The following rooms in the basement do not have latching devices or self closing devices
i) Plumbing Room
ii) Steamfitters Room
iii) Electrical Room
iv) Carpentry Room

e) Basement housekeeping room is not self closing, the self closer device has been disconnected.

f) The basement central supply door does not have a self closing device.

g) The basement bulk sterilizing room does not self latch.

These were each acknowledged by the Director of Facilities during the building tour.

Based on observations and confirmed by staff, the facility failed to ensure that stairwells are maintained as required:

THE FINDINGS INCLUDE:

- During the morning & afternoon hours of 4/24/12 & 4/25/12 the following items were observed regarding stairwell enclosures:

1) The C-Wing 2nd floor stairwell door does not latch when in the closed position.

2) The B-Wing basement stairwell door leading into a storage room is not equipped with a self closing device.

3) The A-Wing stair door leading into the Respiratory Therapy room is non-rated. Upon closer inspection, it was observed that this door in question was replaced with a non-rated wood door as all of the other stairwell doors were B-labeled steel doors.

These were each acknowledged by the Director of Facilities during the building tour.

Based on observations, the facility failed to ensure that doors in the path of egress are in accordance with Chapter 7. Section 7.2.1.5.1 states 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.
Section 7.1.10.1 states 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.
Section 7.2.1.5.4 states that a latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. and not more than 48 in. above the finished floor. Doors shall be operable with not more than one releasing operation.

THE FINDINGS INCLUDE:

1. Observations while touring the facility on the morning of 4/24/12 revealed the fifth floor soiled and clean utility room doors are equipped with two (2) latches, passage sets and dead bolt latches.
This was acknowledged by a maintenance staff person during the building tour.



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2. During the morning & afternoon hours of 4/24/12 & 4/25/12 the following items were observed regarding exit egress routes:

a) The following locations but not limited to were observed as having hasps & padlocks on the corridor side of the doors: 3rd floor woman's room; basement level housekeeping storage room and storage room D27.

b) The C-Wing stairwell at the discharge level was observed as having leaves, dirt and various items located in the route of passage.

c) The Utility room doors on the 3rd floor level were observed as having two latching mechanism installed on each door.

These were each acknowledged by the Director of Facilities during the building tour.

Based on observations and confirmed by staff, the facility failed to ensure that egress lighting is properly provided. Section 7.8.1.2 requires all illumination in the means of egress be continuous during the time that the conditions of occupancy require that the means of egress be available for use.

THE FINDINGS INCLUDE:

- During the afternoon hours of 4/24/12 while touring the 3rd floor level, it was observed that light switches are mounted in the main corridor accessible to staff, patients and visitors. When the switches were tested for operation, the entire corridor was put into complete darkness.

This was acknowledged by the Director of Facilities during the building tour.

Based on observations, the facility failed to ensure that the building is protected throughout by automatic sprinklers in accordance with NFPA 13. LSC, Section 19.3.5.1 states where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7. This facility is required to be fully sprinklered to meet the numerous exceptions which are utilized by installation of the automatic sprinkler system.
NFPA 13, Section 5.13.3.1 states sprinklers shall be installed beneath all stairways of combustible construction. Section 5.13.3.2 states in noncombustible stair shafts with noncombustible stairs, sprinklers shall be installed at the top of the shaft and under the first landing above the bottom of the shaft.
Section 5.6.4.1.1 states under unobstructed construction, the distance between the sprinkler deflector and the ceiling shall be a minimum of 1 in. and a maximum of 12 in.
Section 5.13.11 states: "Sprinkler protection shall be required in electrical equipment rooms. Hoods or shields installed to protect important electrical equipment from sprinkler discharge shall be noncombustible. Exception: Sprinklers shall not be required where all of the following conditions are met:
(a) The room is dedicated to electrical equipment only.
(b) Only dry-type electrical equipment is used.
(c) Equipment is installed in a 2-hour fire-rated enclosure including protection for penetrations.
(d) No combustible storage is permitted to be stored in the room."
NFPA 101, Section 8.2.3.2.3.1 requires openings in 2-hour rated fire barriers to be protected by doors having at least a 1.5-hour fire protection rating.
NFPA 80, Section 8.2.3.2.1(b) requires every fire door to be self-closing.

THE FINDINGS INCLUDE:

1. Observations while touring the facility on the mornings & afternoons on 4/24/12 & 4/25/12 revealed that doors to the following non-sprinklered rooms are not 1.5-hour fire rated:
a) Electrical room by room #517
b) Electrical communication room on the fifth floor
c) Electrical room on the second floor (formally dumbwaiter)
d) Electrical room by room #220
e) Electrical room on the second floor A wing corridor
These were acknowledged by a maintenance staff person during the building tour.



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2. During the morning & afternoon hours of 4/24/12 & 4/25/12 the following items were observed regarding the installation of the sprinkler system:

a) The stairwell by the Auditorium located in the C-Wing is not protected by the sprinkler system at the top level.

b) The ambulance vestibule is not protected by the sprinkler system.

c) The basement main electrical room is not sprinklered. The doors to the rooms are not fire rated and the double doors do not have self closeing devices.

These were each acknowledged by the Director of Facilities during the building tour.

Based on observations, and facility's records review, the facility failed to maintain and inspect the sprinkler system in accordance with NFPA 13 and NFPA 25.
NFPA 13, Sections 4.7.7 requires a listed pressure to be installed immediately below the control valve of each system.
NFPA 25, Section 2.2.4.1 requires gauges on wet pipe sprinkler systems to be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained. Section 2.2.4.2 requires gauges on dry pipe sprinkler systems to be inspected weekly to ensure that normal air and water pressures are being maintained.

THE FINDINGS INCLUDE:

1) Observations made while touring the facility on the morning and afternoon of 4/24/12 revealed that a pressure gauge is not installed where the municipal water supply pressure can accurately be monitored. Pressure gauges are installed immediately below the control valves of each (wet & dry) system, however they are installed on the supply side of the back-flow preventer. Back-flow preventers allow water to pass through them in one direction locking the water pressure on the system (house) side of the device. This prevents the water pressure on the system side from going down when the pressure on the supply side goes down, such as during peak use periods during the day. A pressure gauge must be installed on the supply side of the back-flow preventers.

2) Observation made on the morning of 4/24/12 while reviewing hospital records found the hospital does not inspect the wet pipe sprinkler gauges monthly as required.

These were each acknowledged by the Director of Facilities during the building tour.

Based on record review and confirmed by staff, the facility failed to assure compliance with NFPA 90A.
Section 3.3.4.1 requires the enclosure of vertical shafts to have a minimum fire rating of 2 hours where such air ducts are located in a building four stories or more in height. Section 3.3.4.4 requires fire dampers to be installed at each direct or ducted opening into or out of enclosures required by 3.3.4.1. Section 3.3.1.1 requires approved fire dampers to be provided where air ducts penetrate or terminate at openings in walls or partitions required to have a fire resistance rating of 2 hours or more.
Section 2.3.4.1 requires a service opening to be provided in air ducts adjacent to each fire damper, smoke damper, and smoke detector. The opening shall be large enough to permit maintenance and resetting of the device.
Section 2.3.4.2 requires service openings to be identified with letters having a minimum height of 1/2 in. to indicate the location of the fire protection device(s) within.

THE FINDINGS INCLUDE:

- Observations while touring the facility on the morning and afternoon of 4/24/12 revealed two (2) vertical shafts at the ends of "A" & "B" wings. During an interview with the Director of Facilities he said he did not know if fire dampers are provided in the ducts penetrating the shafts. There appear to be service openings on the outside of the building but the Director of Facilities said he did not a safe way to access them on the day of survey.

Based on observations, the facility failed to ensure that portable electric heaters are prohibited from the building.

THE FINDINGS INCLUDE:

1. Observations while touring the facility on 4/24/12 at 11:10 a.m. revealed a portable electric heater in the fifth floor Case Managers' office.
2. Observations while touring the facility on 4/24/12 at 11:40 a.m. revealed an oil filled type portable electric heater in use in room #527.
This was acknowledged by a maintenance staff person during the building tour.

Based on observations and confirmed by staff, the facility failed to ensure that linen chutes are properly maintained. NFPA 82 (Standards for waste & linen handling systems) states that all chute loading doors into a waste chute shall be provided with a self-closing, positive latching frame and gasketed fire door assembly approved for Class B openings and having a fire resistance rating of not less than 1 hour. The door frame shall be fastened into the chute and the shaft wall. The design and installation shall be such that no part of the frame or door projects into the chute.

THE FINDINGS INCLUDE:

- During the morning & afternoon hours of 4/24/12 & 4/25/12 the following items were observed regarding the linen & trash chutes:

1) The 2nd floor linen chute door located in the C-Wing was found in the open position during the facility tour. In addition, the door latch was also observed as being broken and the door is missing the self closing device. The door currently is equipped with a hasp & padlock for closure purposes, but it was not in use when observed.
Note: The 2nd floor unit is currently vacant and the chute is not being used.

2) The B-Wing linen chute discharge door is currently equipped with two manually operated slide bolts for a latching mechanism.

3) The B-Wing trash chute discharge door currently has a loose latching mechanism and must be latched manually.

4) The A-Wing linen chute discharge door is currently equipped with two manually operated slide bolts for a latching mechanism.

5) The fourth floor B-Wing linen chute and trash chute doors are missing. In its place was a piece of 5/8 inch of gypsum wall board that has a fire rating of one hour. The chute is six stories in height required to be enclosed with construction having a fire rating of two hours or approved fire door.

These were each acknowledged by the Director of Facilities during the building tour.

Based on observations and record review and confirmed by staff interview, the facility failed to ensure that that oxygen is stored in accordance with NFPA 99. Sections 12.3.8 and 8.3.1.11.1 require storage for nonflammable gases to comply with 4.3.1.1.2 and 4.3.5.2.2.
Section 4.3.1.1.2 (a)2 requires enclosures to be constructed of an assembly of building materials with a fire-resistive rating of at least 1 hour. Such enclosures shall serve no other purpose.
Section 4.3.1.1.2 (a)3 requires provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.
Section 4.3.1.1.2 (a)4 requires electric wall fixtures, switches, and receptacles to be installed in fixed locations not less than 5 ft. above the floor as a precaution against their physical damage.
Section 4.3.1.1.2 (a)5 requires storage locations for oxygen and nitrous oxide to be kept free of flammable materials.
Section 4.3.1.1.2 (a)7 prohibits combustible materials, such as paper, cardboard, plastics, and fabrics, from being stored or kept near cylinders containing oxygen.
Section 4.3.1.1.2 (a)11d requires ordinary electrical wall fixtures in storage rooms to be installed in fixed locations not less than 5 ft above the floor to avoid physical damage.
Sections 8.3.1.1.2(d) and 4.3.1.1.2 (b) requires locations storing liquefied gas containers to be vented to the outside by a dedicated mechanical ventilation system or by natural venting. If natural venting is used, the vent opening or openings shall be a minimum of 72 in.2 in total free area.

THE FINDINGS INCLUDE:

- Observations while touring the facility on the morning and afternoon of 4/24/12 revealed the following:
1. Five (5) portable liquid oxygen containers stored in the clean utility room by room 517. The room is enclosed with unrated construction, contains combustibles and has ordinary electrical wall fixtures (light switches and receptacles) located less than 5 feet above the floor.
2. Thirty-eight (38) "H" and "E" cylinders of oxygen standing upright unsecured in the basement oxygen storage room.
3. An "E" cylinder of oxygen standing upright unsecured in the first floor rehabilitation department.
This was acknowledged by a maintenance staff person during the building tour.

Based on observations and confirmed by staff, the facility failed to ensure that liquid oxygen is properly stored/transfilled in accordance with NFPA 99.

THE FINDINGS INCLUDE:

- Observations while touring the facility on the afternoon of 4/24/12 revealed the following regarding the storage/transfill of liquid oxygen:

1. The 3rd floor oxygen transfilling room is not labeled with any signage.

2. A liquid oxygen canister was observed as being stored in the Rehabilitation storage room. It was later stated by respiratory staff that the canister was stored there in order to transfill portable containers for patients utilizing the rehabilitation department. The room is not constructed to store or transfill liquid oxygen.

These were each acknowledged by the Director of Facilities during the building tour.

Based on observations, the facility failed to ensure that utilities comply with the provisions of Section 9.1. Section 9.1.2 requires electrical wiring and equipment to be installed in accordance with NFPA 70.
NFPA 70, Article 305-3 permits temporary wiring to be used during periods of construction, remodeling, maintenance, and repair of buildings, during emergencies, and for a period not to exceed 90 days. Article 400-8 prohibits flexible cords from being use as a substitute for the fixed wiring of a structure. Article 400-8 prohibits flexible cords from being used for:
1. A substitute for the fixed wiring of a structure,
2. Where run through holes in walls, structural ceilings suspended ceilings, dropped ceilings, or floors,
3. Where run through doorways, windows, or similar openings
4. Where attached to building surfaces,
5. Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors, and
6. Where installed in raceways, except as otherwise permitted in this Code. LSC 19.5.1

THE FINDINGS INCLUDE:

- Observations while touring the staff education department on the fourth floor on the morning of 4/24/12, revealed two (2) power cords running through a doorway and an extension cord plugged into a strip outlet supplying power to a coffee pot. This was acknowledged by a maintenance staff person during the building tour.

Based on observations, the facility failed to properly install alcohol based hand rub (ABHR) dispensers.

THE FINDINGS INCLUDE:

- Observations while touring the facility on the morning of 4/24/12, revealed an alcohol based hand sanitizing dispenser mounted above a receptacle by room #513.
This was acknowledged by a maintenance staff person during the building tour.