HospitalInspections.org

Based on review, the facility fire stopping of penetrations does not comply with requirements.

Observations during inspection walk thru on 07.08.2014 at 15:25 hours found in admin stairway several conduits penetrating stairway were not being fire stopped around.

Observations during inspection walk thru on 07.08.2014 at 14:25 hours found one green wire at stairway were not sealed on the corridor side outside of medical records at the corridor.

Between 13:30 hours and 15:30 hours on 7.9.2014, observations were made that the stairway walls located in stairway within patient area do not extend to the underside of the roof deck, and the required one hour rating of the ceiling could not be verified.

Based on review, the facility fire rating does not comply with requirements.

Observations during inspection walk thru on 07.09.2014 at 11:18 hours found rating along Operating Room (OR) #2 stops at corridor between OR #2 and OR #4 and not as indicated on the plan.

Based on review, the facility maintenance of smoke barriers does not comply with requirements.

Observations during inspection walk thru on 07.08.2014 at 14:29 hours found three insulated pipes were not sealed in the wall penetration above the ceiling at stairway corridor between mechanical room #2 on corridor side.

Observations during inspection walk thru on 07.08.2014 at 14:37 hours found openings between seven bar joists on the men's locker room side, and three above the men's locker room sink and toilet at mechanical room #2 were not sealed.

Observations during inspection walk thru on 07.08.2014 at 14:46 hours found metal flexible conduit and duct were not sealed above the old sink and toilet room in quality office at mechanical room #2.

Observations during inspection walk thru on 07.08.2014 at 14:54 hours found two - 1 1/4 inch metal conduits were not sealed above ceiling in the laundry at mechanical room #2.

Observations during inspection walk thru on 07.08.2014 at 15:01 hours found four - one inch metal conduits in smoke partition above ceiling in dryer laundry were not sealed.

Observations during inspection walk thru on 07.08.2014 at 15:11 hours found one single blue wire, two blue and one red wire, one blue and one yellow wire, and 14 blue wires in smoke partition above double corridor doors to ER were not sealed on both sides of wall. Top of smoke partition non existent.

Observations during inspection walk thru on 07.08.2014 at 15:21 hours found mechanical room #2 above Hankison compressed air dryer 3/4 inch conduit were not sealed under insulated pipe in upper corner.

Observations during inspection walk thru on 07.08.2014 at 15:26 hours found two bundles of insulated pipe penetrations above ceiling in therapy above long file cabinet and also in corner above bookcase were not sealed.

Observations during inspection walk thru on 07.08.2014 at 15:51 hours found above double corridor doors at conference room 1 of 3 metal conduits at top, one black wire at conduit, one gray and five white wires, and four blue wires were not sealed.

Observations during inspection walk thru on 07.09.2014 at 10:32 hours found 3/4 inch conduit containing three red wires were not sealed above double corridor doors right side toward physical therapy.

Observations during inspection walk thru on 07.09.2014 at 10:34 hours found three conduits above left side corridor double doors toward physical therapy were not sealed.

Observations during inspection walk thru on 07.09.2014 at 10:39 hours found three black insulated pipes and a conduit through the floor in mechanical room #4 were not sealed.

Observations during inspection walk thru on 07.09.2014 at 10:54 hours found one - 3/4 inch conduit were not sealed at the wall between pharmacy and pharmacy office and one - 1 inch conduit with one green insulated ground wire above pharmacy (folic acid 1 mg) bin were not sealed.

Observations during inspection walk thru on 07.09.2014 at 10:59 hours found one - 3/4 inch conduit end, two copper pipes, one conduit and end of green wire and one conduit with one green wire were not sealed along wall of pharmacy office.

Between 13:30 and 15:30 hours on 7.9.2014 observations were made that the smoke barriers between smoke compartments four and five as indicated on the building construction plans did not extend to the underside of the roof deck.

Based on review, the facility smoke doors does not comply with requirements.

Observations during inspection walk thru on 07.08.2014 at 14:10 hours found left leaf of L3 - L4 smoke door not closing in to frame when viewed from L4 side.

Based on review, the facility fire door drop testing does not comply with requirements.

During record review on 07.08.2010 at 10:32 hours found documentation for last annual fire door drop testing dated 9.7.2010 for Pharmacy dispensing window. NFPA 80.

Based on review, the facility penetrations of smoke compartments does not comply with requirements.

Observations during inspection walk thru on 07.09.2014 at 10:26 hours found penetrations in supply room, two sprinkler pipes between sprinklers three and four and one - 1/2 inch conduit above the sprinkler pipe and one - 3/4 inch conduit beside 2nd sprinkler pipe near the Carrier hanging heater.

Observations during inspection walk thru on 07.08.2014 at 14:01 hours found two blue wires, one tan wire penetrating wall above ceiling at elevator between supply room and maintenance room were not sealed.

Observations during inspection walk thru on 07.08.2014 at 14:05 hours found insulated pipe, 1/2 inch conduit and missing sheetrock above ceiling and above each small refrigerator in maintenance room were not sealed.

Observations during inspection walk thru on 07.08.2014 at 14:09 hours found 3/4 inch conduit end not filled in corner above the ceiling above electrical panel in maintenance room.

Based on review, the facility corridor egress does not comply with requirements.

Observations during inspection walk thru on 07.08.2014 at 13:20 hours found in medical records corridor boxes and two carts obstructing egress corridor.

Observations during inspection walk thru on 07.08.2014 at 14:09 hours found in corridor between ER and surgical suite has x-ray equipment and roller carts obstructing egress corridor.

Observations during inspection walk thru on 07.08.2014 at 14:14 hours found in surgical suite main corridor has tots, bed, privacy dividers, used linen cart, used linen barrel, roller shelving, roller carts, and frame boxes obstructing egress corridor.

Observations during inspection walk thru on 07.08.2014 at 14:54 hours found hasp latch and pad lock improperly installed to patient room door leading to area changed from patient room to office space in room 123 A/B. Per maintenance director facility has plans after renovations to convert space back to a patient room.

Based on review, the facility fire drill records does not comply with requirements.

During record review on 07.08.2014 at 10:28 hours found per documentation one shifts fire drill missed for the first quarter of 2014.

Based on review, the facility central fire alarm system maintenance and testing does not comply with requirements.

Findings Include:

During record review on 07.08.2014 at 10:04 hours found smoke detector counts for number of devices attached to central fire alarm panel conflicted with the number of devices identified on maintenance and testing reports from years past.

Observations during inspection walk thru on 07.08.2014 at 13:10 hours found several smoke detectors pulling out of ceiling in the maintenance corridor.

Observations during inspection walk thru on 07.08.2014 thru 07.09.2014 found all pull stations located in basement and first floor levels were mounted too high off the floor.

Observations and maintenance director interview during inspections on 07.08.2014 thru 07.09.2014 found not all door closure devices on smoke compartment fire doors in corridors that are connected to central fire alarm panel were not operational and undetermined if parts are still available to repair devices.

Observation and record review on 07.09.2014 from 13:00 thru 15:00 hours documentation and field findings did not reflect testing of delayed egress and access controlled door operation with loss of power, fire alarm, and sprinkler activation.

Based on review, the facility sprinkler system maintenance and testing does not comply with requirements.

During record review on 07.08.2014 at 10:20 hours found no documentation of current back flow preventer annual pressure testing at time of inspection. Maintenance director advised back flow preventer is leaking and have bids out to get rebuild performed.

During record review on 07.08.2014 at 10:40 hours found over the last six quarterly sprinkler testing was not performed quarterly as required. Too much time between inspection dates on at least two quarterly inspections.

Observations during inspection walk thru on 07.08.2014 at 11:48 hours found dirty sprinkler head in ER waiting room.

Observations during inspection walk thru on 07.08.2014 at 13:41 hours there were ceiling tiles missing in maintenance shop which could affect proper sprinkler head operations.

Observations during inspection walk thru on 07.08.2014 at 13:45 hours found sprinkler head too close to wall partition in basement x-ray room.

Observations during inspection walk thru on 07.08.2014 at 13:55 hours there were ceiling tiles missing in old data processing room which could affect proper sprinkler head operations.

Observations during above ceiling inspection on 07.09.2014 at 10:30 hours found sprinkler head incorrectly mounted above drop ceiling grid track above fire doors as you enter into the cafeteria corridor.

Observations during inspection walk thru on 07.08.2014 at 15:30 hours found sprinkler head missing trim ring in Lab corridor.

Based on review, the facility portable fire extinguishers does not comply with requirements.

Observations during inspection walk thru on 07.08.2014 at 11:35 hours found in laundry room a portable fire extinguisher was mounted too high off floor.

Observations during inspection walk thru on 07.09.2014 at 14:15 hours found in corridor at entrance door to the cafeteria corridor a portable fire extinguisher was mounted too high off floor.

Based on review, the facility compressed gas cylinders tip over or fall protection does not comply with requirements.

Observations during inspection walk thru on 07.08.2014 at 10:50 hours found compressed gas cylinder not being secured to prevent tip over and provide fall protection in maintenance shop - mechanical room. NFPA 99

Observations during inspection walk thru on 07.08.2014 at 11:48 pm found compressed gas cylinder not being secured to prevent tip over and provide fall protection in central supply decon area. NFPA 99

Based on review, the facility smoke compartment rated walls do not comply with requirements and what is shown of the Life Safety Code Plans..

During plan review and field evaluation on 07.08.2014 thru 07.09.2014 found building prints for proposed first floor Life Safety Plans do not match what was seen in the field for locations of smoke compartments. Multiple rated walls shown on plans do not conform to conditions seen in the field.

Based on review, the facility generator maintenance and testing does not comply with requirements.

During record review on 07.08.2014 at 10:42 hours found the following conditions:

Cummins Generator:
- No documentation on hand at time of inspection of weekly preventative maintenance and monthly maintenance with 30 minute load transferring as required per NFPA 110.
- No proper documentation on hand at time of inspection of annual maintenance, servicing, and testing per NFPA 110.
- No documentation on hand at time of inspection of required load bank testing per NFPA 110.

New Generator:
- No documentation on hand at time of inspection of any maintenance, testing, or service being provided since finished installation documentation dated 5.29.2014. No documentation of acceptance testing on hand for new installation.

Based on review, the facility electrical maintenance does not comply with requirements.

Observations during inspection walk thru on 07.08.2014 at 10:39 hours found pull box not covered above Furnas disconnect #2 in mechanical room #4.

Observations during inspection walk thru on 07.08.2014 at 11:08 hours found in maintenance shop - mechanical room panel H - the spare breakers are not labeled and no clearance from combustibles in front of panels. Panel 11x has no label for any of the breakers and no clearance from combustibles in front of panels. Temporary electric service panel has knockouts missing exposing electric service.

Observations during inspection walk thru on 07.08.2014 at 13:34 hours found exposed 110 volt wiring under outside canopy above ER entrance door.

Observations during inspection walk thru on 07.09.2014 at 14:30 hours found two junction boxes one on each side of fire doors missing covers above ceiling near room M109.

Observations during inspection walk thru on 07.08.2014 at 13:55 hours found open junction box above ceiling of old data processing room.

Observations during inspection walk thru on 07.08.2014 at 14:02 hours found two daisy chained power strips and cords taped to floor of medical records room.

Observations during inspection walk thru on 07.08.2014 at 14:37 hours found open electrical box above first filter door in the mechanical room.

Observations during inspection walk thru on 07.08.2014 at 15:04 hours found in first floor electrical closet flexible cable going to construction trailer being improperly run thru knock out in electrical panel.

Observations during inspection walk thru on 07:09.2014 at 14:50 hours found wiring to flourescent light fixtures not to code in quality office.

Observations during inspection walk thru on 07.09.2014 at 15:33 hours found junction box missing cover above ceiling in small storage room across from receiving, purchasing stores.

Observations during inspection walk thru on 07.09.2014 at 15:42 hours found openings in two junction boxes above ceiling in physical therapy room above desk and one above ceiling at track lighting junction box.

Observations during inspection walk thru on 07.09.2014 at 10:39 hours found electrical wiring to the removed well pump from Furnas #2 is not connected in mechanical #4.