HospitalInspections.org

Based on observation the facility failed to provide an adequate enclosure for a shaft.

The inspector observed, while accompanied by the Maintenance Director during the hours of the inspection from 8:30 am to 2:00 pm on 3/26/2014 that the 1st floor, west dumbwaiter door did not close and latch properly.

Based on observation the facility failed to provide an adequate exit sign.

The inspector observed, while accompanied by the Maintenance Director during the hours of the inspection from 8:30 am to 2:00 pm on 3/26/2014 that there was an exit sign that lacked illumination at BHU South Exit Corridor.

Based on observation the facility failed to provide adequate smoke barriers.

The inspector observed, while accompanied by the Maintenance Director during the hours of the inspection from 8:30 am to 2:00 pm on 3/26/2014 that there were penetrations in the smoke barriers in the following locations: 1) Basement by Maintenance office, 2) 2 hour wall by ED fire door by elevator on 1st floor, 3) 1st floor South Waiting Area, 4) 1st floor South Breezeway, 5) 2nd floor South Nurse Station, and 6) 2nd floor East Nurse Station.

Based on observation the facility failed to provide an adequate hazardous area enclosure.

The inspector observed, while accompanied by the Maintenance Director during the hours of the inspection from 8:30 am to 2:00 pm on 3/26/2014 that there was a Clean Utility at the 2nd South Wing, 2412 that did not latch properly.

Based on observation the facility failed to provide an adequate fire extinguisher.

The inspector observed, while accompanied by the Maintenance Director during the hours of the inspection from 8:30 am to 2:00 pm on 3/26/2014 that there was an out of date fire extinguisher at Old BHU Eating Unit.

Based on observation the facility failed to provide an adequate medical gas storage enclosure.

The inspector observed, while accompanied by the Maintenance Director during the hours of the inspection from 8:30 am to 2:00 pm on 3/26/2014 that there was a medical gas closet that did not have a high vent opening.

Where the total volume of medical gases connected and in storage is less than 3000 cu.ft. at STP, natural ventilation shall be permitted - NFPA 99, 2002: 5.1.3.3.1(D). Where natural ventilation is permitted, it shall consist of two louvered openings, each having a minimum free area of 72 in. sq., with one located within 1 ft. of the floor and one located within 1 ft. of the ceiling - NFPA 99, 2002: 5.1.3.3.3.1(E).

Based on observation the facility failed to provide adequate medical gas storage.

The inspector observed, while accompanied by the Maintenance Director during the hours of the inspection from 8:30 am to 2:00 pm on 3/26/2014 that there were combustible materials (leaves) inside of the bulk oxygen enclosure that must be removed.

Fuel and Water Preferred Customer Status

" Continuity of Essential Building Systems. When designated by the emergency preparedness management plan to provide continuous service in a disaster or emergency, health care facilities shall establish contingency plans for the continuity of essential building systems, as applicable: (a) Electricity, (b) Water, (c) Ventilation, (d) Fire protection systems, (e) Fuel sources, (f) Medical gas and vacuum systems (if applicable), (g) Communications systems. " - NFPA 99, 1999, 11-5.3.2

Based on observation the facility failed to provide letters from vendors for emergency fuel and water.

The inspector observed, while accompanied by the Maintenance Director during the hours of the inspection from 8:30 am to 2:00 pm on 3/26/2014 that the facility did not have letters from vendors stating that the hospital had preferred customer status for water and fuel in the event of an emergency.

Based on observation the facility failed to provide adequate generator testing.

The inspector observed, while accompanied by the Maintenance Director during the hours of the inspection from 8:30 am to 2:00 pm on 3/26/2014 that the generators were not being tested monthly with a minimum 30% load, see below.

NFPA 110, 1999, 6-4.2
Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
The date and time of day for required testing shall be decided by the owner, based on facility operations.
6-4.2.1
Equivalent loads used for testing shall be automatically replaced with the emergency loads in case of failure of the primary source.
6-4.2.2
Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.

Based on observation the facility failed to provide an adequate essential electrical system.

The inspector observed, while accompanied by the Maintenance Director during the hours of the inspection from 8:30 am to 2:00 pm on 3/26/2014 that there was the following issue: the ATS panels were not labeled in several locations according to the branch of the Essential Electrical System that they serve. This occurred in: 1) the 1952 Switchgear Room, and 2) in the 2000 building.