HospitalInspections.org

Based on observations made during the survey of the facility (Guest Hospital) between the hours of 1:00 pm and 5:30 pm, while accompanied by the CEO, Safety Officer, Chief Nursing Officer, Director of Quality/Infection Control, Structures Mgr. (FM), Construction Mgr. (FM), and Mechanical Mgr. (FM) it was observed that the required 2 hour fire-rated separation construction was not in compliance with the requirements for rated construction between the Guest Hospital (Hospital being surveyed) - Floor Level 7, and the Host Hospital - Floor Levels 1 thru 8. The following deficiencies were identified:
1. LEVEL 7 - ELECTRICAL RM. 7932 (GUEST HOSPITAL) was not separated with 2 hour construction from the HOST HOSPITAL on floors above and below LEVEL 7. Room 7932 was open to the full height vertical shaft which began in the HOST HOSPITAL on Level 1 and was continuous for every floor up thru Level 8, including the (GUEST HOSPITAL) LEVEL 7. The floor plan foot print of the shaft opening into this GUEST HOSPITAL room is approximately 3 ft. x 15 ft. The vertical shaft appears to be similar in size on all other levels of the building (HOST HOSPITAL). This is a non-compliant Life Safety issue which appears to stem from the original design/construction of this building.
2. LEVEL 7 - Near the ENTRY TO PARKER WING location there was an electrical conduit running parallel with the top of the 2 hour fire-rated separation wall. The conduit was positioned such that it conflicted with where fire-rated sealant is required to seal continuously along the top of the wall. Relocate conduit and provide the required fire-rated sealant continuously along the top of wall.
3. LEVEL 7 - In the EMPLOYEE ACCESS CORRIDOR it was observed that the STENCILING on 2 hour fire-rated wall was missing, and there are red arrows stenciled in place which did not appear to mean anything. These arrows should be painted over.

Based on observations made during the survey of the facility between the hours of 1:00 pm and 5:30 pm, while accompanied by the CEO, Safety Officer, Chief Nursing Officer, Director of Quality/Infection Control, Structures Mgr. (FM), Construction Mgr. (FM), and Mechanical Mgr. (FM) it was observed that the facility failed to maintain the required fire/smoke rating for a portion of the SMOKE BARRIER WALL at PATIENT BED ROOM 7917. There were multiple unsealed penetrations located in this wall. Additionally, at this location the SMOKE BARRIER WALL was not fire-stopped continuously along the top where the wall meets the structural deck above. In some locations the STENCILING on the wall was missing. Locations identified with similar failures such as these (including 7917) are as follows:
A. PATIENT BED ROOM 7917.
B. Above CROSS-CORRIDOR DOORS.
C. ASSISTED BATHING (possibly a wall in front of a rated wall).
D. NURSE STATION (bottom of 4 ft. wide concrete beam at plenum).
E. CENTRAL SET OF CROSS-CORRIDOR DOORS (gypsum broken out).
F. MEN ' S STAFF DRESSING ROOM (cut out gypsum board)

Based on observations made during the survey of the facility between the hours of 1:00 pm and 5:30 pm, while accompanied by the CEO, Safety Officer, Chief Nursing Officer, Director of Quality/Infection Control, Structures Mgr. (FM), Construction Mgr. (FM), and Mechanical Mgr. (FM) it was observed that the facility failed to provide a log indicating consistent, systematic compliance with requirement for quarterly fire drills on each shift. While it was documented that the facility had accomplished many fire drills for the past few years, the documentation was incomplete lacking names &/or signatures of the staff participants.

Based on observations made during the survey of the facility between the hours of 1:00 pm and 5:30 pm, while accompanied by the CEO, Safety Officer, Chief Nursing Officer, Director of Quality/Infection Control, Structures Mgr. (FM), Construction Mgr. (FM), and Mechanical Mgr. (FM) it was observed that the facility failed to provide a log indicating compliance with requirement for monthly testing by staff of the fire alarm system and its automatic signal response.

Based on observations made during the survey of the facility between the hours of 1:00 pm and 5:30 pm, while accompanied by the CEO, Safety Officer, Chief Nursing Officer, Director of Quality/Infection Control, Structures Mgr. (FM), Construction Mgr. (FM), and Mechanical Mgr. (FM) it was observed that the facility failed to provide a log indicating compliance with the requirement for annual inspection / testing of the fire sprinkler system.

For complex and intricate systems - like the WATER-BASED FIRE PROTECTION SYSTEMS (which includes wet & dry fire sprinkler systems) - it is not enough to simply say the annual inspection / testing were done. Records kept by the facility should include documentation upon request which demonstrate that the intracacies of inspecting, testing, and maintaining of a complex system are indeed being watched and looked after on a consistent and systematic basis.

Re: NFPA 25, 1998: TABLE 2-1
" SUMMARY OF SPRINKLER SYSTEM INSPECTION, TESTING, AND MAINTENANCE "

Re: NFPA 1, 1997: "FIRE PREVENTION CODE"
7-5 INSPECTION, TESTING, AND MAINTENANCE

7-5.2 "A sprinkler system installed in accordance with this Code shall be inspected, tested, and maintained in accordance with NFPA 25, STANDARD FOR THE INSPECTION, TESTING, AND MAINTENANCE OF WATER-BASED FIRE PROTECTION SYSTEMS."

7-5.4 "Annually, prior to the onset of freezing weather, buildings with wet pipe systems shall be inspected to verify that windows, skylights, door, ventilators, other openings and closures, blind space, unused attics, stair towers, roof houses, and low spaces under buildings do not expose water-filled sprinkler piping to freezing and that adequate heat (minimum 40 degrees is available. (25:2-2.5)

Based on observations made during the survey of the facility between the hours of 1:00 pm and 5:30 pm, while accompanied by the CEO, Safety Officer, Chief Nursing Officer, Director of Quality/Infection Control, Structures Mgr. (FM), Construction Mgr. (FM), and Mechanical Mgr. (FM) it was observed that while it appears the facility had accomplished some of the requirements, the facility failed to provide logs indicating consistent, systematic compliance on the following issues and items:

PLEASE NOTE: Both comments 1 and 2 below for this Survey are the same comments that were also made in the prior inspection done on 07/26/2012. It appears that no " Logs " were sufficiently put in place for the Plan of Correction response.

1. Electrical equipment inspections - Biomedical.
Critical Areas: Semi-annually.
General Areas: Annually
2. Electrical power and distribution and grounding systems - Effectiveness.
Critical Areas: Semi-annually.
General Areas: Annually