HospitalInspections.org

Based on observation and interview, the facility failed to maintain two-hour fire barriers with a non-conforming building on one of two building levels located immediately next to a non-conforming health care occupancy.

Findings include:

Observation on August 14, 2017, at 1:30 PM, revealed the first floor stair tower door to the Medical Arts Building lacked positive latching.

Interview with the Certified General Maintenance II, on August 14, 2017, at 1:30 PM, confirmed the above fire barrier door with a non-conforming building lacked positive latching.

Based on observation and interview it was determined that the facility failed to maintain the building construction type on one of six levels.

Findings include:

1. Observation on August 15, 2017, between 8:35 AM and 8:45 AM, revealed the following:
A. (8:35 AM) Basement biomed store room, had an unsealed penetration in the fire rated monolithic ceiling assembly;
B. (8:45) AM) Basement main store room, had missing spray on fire proofing on the structural beam to the left inside of the main entrance doors.

Interview with the Certified General Maintenance II, on August 15, 2017, at 8:45 AM, confirmed the structural beam was missing a section of spray on fire proofing.

Based on observation and interview it was determined that the facility failed to maintain fire barriers on one of six levels.

Findings include:

Observation on August 15, 2017, at 8:30 AM, revealed the Basement Firewall at Fire door GFD#26, had unsealed penetrations through the rated wall, above the door, around an electrical junction box, and two insulated pipes.

Interview with the Certified General Maintenance II on August 15, 2017, at 8:30 AM, confirmed the unsealed penetrations existed.

Based on observation and interview, the facility failed to maintain horizontal exits at six of six building levels.

Findings include:

1. Observation on August 14, 2017, between 10:45 AM and 2:25 PM, revealed the following horizontal exit fire barriers were deficient:
A. (10:45 AM) Third floor fire doors, 3FD#7, lacked positive latching with the coordinator;
B. (10:46 AM) Third floor fire barrier wall, above 3FD#7 doors, had multiple unsealed penetrations (data cables);
C. (12:55 PM) First floor fire barrier wall, above 1FD#7 doors, had multiple unsealed penetrations (data cables);
D. (1:42 PM) Ground floor, the fire rated door frame by Nuclear Medicine, lacked a fire rated label;
E. (2:17 PM) First floor, fire rated cross corridor doors by the Information desk, lacked a fire rated label;
F. (2:25 PM) First floor, stairwell #1, 1-FD#20, fire rated door latching hardware, lacked evidence hardware was fire rated.

Interview with the Certified General Maintenance II, on August 14, 2017, at 2:25 PM, confirmed the above horizontal exit fire barriers did not meet regulations.

2. Observation on August 14, 2017, between 10:07 AM and 1:20 PM, revealed the following horizontal exit fire barriers were deficient:
A. (10:07 AM) Fourth floor, old ICU Fire Door 4FD#2, frame lacked a fire rated label;
B. (12:40 PM) Second floor, fire door frame by room # 201, fire rated label was not legible;
C. 1972 North Wing, the following fire barrier doors lacked positive latching hardware:
1. (12:55 PM) 1st floor;
2. (2:20 PM) 2nd floor;
3. (2:25 PM) 3rd floor.
D. (1:05 PM) Ground floor, ER stairwell #4. fire rated door frame lacked label;
E. (1:20 PM) Ground floor, Fast Trac stairwell #5, fire rated door frame label was painted and not legible;

Interview with Maintenance Tech I on August 14, 2017 at 1:20 PM confirmed the deficiencies listed above existed.

3. Observation on August 15, 2017, at 8:55 AM, revealed the Basement fire doors, B-FD#8 by the MIS Director office, had the following deficiencies:
A. Frame lacked a fire rated label;
B. Left door leaf, the fire rated label was not legible.

Interview with the Certified General Maintenance II, on August 15, 2017, at 8:55 AM, confirmed the above horizontal exit fire barrier did not meet regulations.

Based on document review and interview, the facility failed to maintain emergency lighting requirements in all areas with installed battery-pack emergency lighting.

Findings include:

Document review on August 14, 2017, at 9:30 AM, revealed the facility lacked documentation that the battery-pack emergency lighting was tested annually for 1-1/2 hours (drain test).

Interview with the Engineering and Security Manager, on August 14, 2017, at 9:30 AM, confirmed the above emergency lighting documentation was not available at the time of the survey.

Based on observation and interview, the facility failed to maintain vertical openings at two of over ten vertical openings.

Findings include:

1. Observation on August 14, 2017, at 10:35 AM, revealed the third floor, O. R. stair tower door hardware, 3FD#20, had an attached label of "panic hardware", instead of the required "fire exit hardware".

Interview with the Certified General Maintenance II, on August 14, 2017, at 10:35 AM, confirmed the above stair tower door hardware did not have a "fire exit hardware" label.

2. Observation on August 14, 2017 at 9:55 AM revealed the fourth floor, old doctor dictation room, had an unsealed penetration around mechanical pipes, through the fire rated shaft wall above the lay-in ceiling.

Interview with the Maintenance Tech I, on August 14, 2017, at 9:55 AM, confirmed the unsealed penetration in the fire rated shaft existed.

Based on observation and interview, the facility failed to maintain hazardous areas on two of six building levels.

Findings include:

1. Observation on August 14, 2017, between 10:36 AM and 1:15 PM, revealed the following corridor doors were deficient in maintaining hazardous area requirements:
A. (10:36 AM) Third floor, Recovery soiled utility room, 3FD#10, lacked positive latching with the self-closure;
B. (1:00 PM) First floor, file room doors, 1FD#9 and 1FD#10, lacked labels to indicate a fire rating on the door frames (non-sprinklered area);
C. (1:15 PM) First floor, Health Information Management Dictation file storage room door, 1FD#11, lacked a label to indicate a fire rating on the door frame (non-sprinklered area).

Interview with the Certified General Maintenance II, on August 14, 2017, at 1:15 PM, confirmed the above locations did not meet hazardous area requirements.

Based on observation and interview it was determined that the facility failed to maintain and inspect the automatic sprinkler system on one of six levels.

Findings include:

Observation on August 14, 2017, at 11:05 AM, revealed the Second floor East, Bright Horizons unit, had two different types of sprinkler heads in the main corridor compartment.

Interview with the Maintenance Tech I on August 14, 2017 at 11:05 AM confirmed the sprinkler heads in the compartment were different types.

Based on observation and interview, the facility failed to maintain corridor doors at three of over 100 corridor door locations.

Findings include:

1. Observation on August 14, 2017, between 10:30 AM and 11:45 AM, revealed the following corridor doors were deficient in resisting the passage of smoke:
A. (10:30 AM) Third floor, O. R. Women's Locker room door (elevator area), lacked positive latching with the self-closure;
B. (11:30 AM) First floor, room 100, door lacked a door knob;
C. (11:45 AM) First floor, room 121, lacked a corridor door.

Interview with the Certified General Maintenance II, on August 14, 2017, at 11:45 AM, confirmed the above locations would not resist the passage of smoke.

Based on observation and interview it was determined that the facility failed to maintain and inspect the electrical system on one of six levels.

Findings include:

1. Observation on August 14, 2017, between 11:25 AM and 11:28 AM, revealed the following locations had water filled hydrocollators that were not plugged into ground fault interrupter electrical outlets.
A. (11:25 AM) Second floor, physical therapy room;
B. (11:28 AM) Second floor, occupational therapy, second room.

Interview with Maintenance Tech I on August 14, 2017, at 11:28 AM, confirmed the hydrocollators were not plugged into ground fault interrupter electrical outlets.

Based on observation and interview, the facility failed to maintain electrical equipment on one of six building levels.

Findings include:

Observation on August 14, 2017, at 10:38 AM, revealed the third floor, Recovery area, had a refrigerator plugged into a surge protector.

Interview with the Certified General Maintenance II, on August 14, 2017, at 10:38 AM, confirmed the above refrigerator was not plugged directly into an electrical outlet.