HospitalInspections.org

Based on observation and interview, the facilty failed to meet building rehabilitation requirements for one of one generator.

Findings include:

Interview on March 14, 2024, at 11:10 a.m., revealed the facility upgraded the generator control and annunciator panel in October 2023. No prior state plan approval was submitted for the upgrade, nor was an occupancy inspection granted from the Division of Life Safety. The facility is currently waiting on engineer drawings.

Interview with the facilities director on March 14, 2024 at 11:10 a.m., confirmed the unapproved upgrades.

Based on observation and interview, the facilty failed to meet building rehabilitation requirements for one of one generator.

Findings include:

Interview on March 14, 2024, at 11:10 a.m., revealed the facility upgraded the generator control and annunciator panel in October 2023. No state plan approval was submitted prior to the upgrade, nor was an occupancy inspection granted by the Division of Life Safety. The facility is currently waiting on engineer drawings for the project.

Interview with the facilities director on March 14, 2024, at 11:10 a.m., confirmed the unapproved upgrades.

Based on observation and interview, the facility failed means of egress requirements for one of over five exits.

Findings include:

Observation on March 14, 2024, at 10:11 a.m., revealed the emergency exit next to the MRI was blocked by contruction barriers.

Interview with the director of facilities on March 14, 2024, at 10:11 a.m., confirmed the emergency exit was blocked.

Based on observation and interview, the facility failed to maintain emergency lighting, affecting one of three building components.

Findings include:

Observation on March 14, 2024, at 11:41 a.m., revealed the battery back-up emergency light in the sterile processing room did not illuminate when the test button was pushed.

Interview with the maintenance technician on March 14, 2024, at 11:41 a.m., confirmed the emergency light deficiency.

Based on observation and interview, the facility failed to maintain exit signs for five of over twenty emergency exits.

Findings include:

Observation on March 14, 2024, between 10:00 a.m. and 11:10 a.m., revealed the following exit sign deficiencies:
A. (10:00 a.m.) Main floor, two doors out of three leading to enclosed courtyards failed to display "No Exit" signs;
B. (10:32 a.m.) Main floor, purchasing room B-112 discharge door failed to display an exit sign;
C. (11:07 a.m.) Main floor, conflicting directional signage was posted at rear interior entrance to the emergency room;
D. (11:10 a.m.) Main floor, exit sign was visually obscured on the exit path near the radiology entrance;
E. (11:43 a.m.) Main floor, fire doors were missing an exit sign near the house instrumentation pick-up room.

Interview with the maintenance technician on March 14, 2024, at 11:43 a.m., confirmed the exit sign deficiencies.

Based on observation and interview, the facility failed to meet alcohol-based hand rub dispenser (ABHR) requirements in one of over twenty exam rooms.

Findings include:

Observation on March 14, 2024, at 10:44 a.m., revealed the second floor suite 2300 had an ABHR mounted directly over an electrical outlet.

Interview with the director of facilities on March 14, 2024 at 10:44 a.m., confirmed the deficiency.

1. Based on document review and interview, the facility failed to meet fire alarm system testing and maintenance requirements for one of one system.

Findings include:

Document review on March 14, 2024, at 9:20 a.m., revealed the facility fire alarm system inspection, completed July 27, 2023, lacked the inspection of over 17 components, which included pull stations, smoke detectors, and duct detectors. The facility was unable to provide documentation that these components were tested within the last year.

Interview with the director of facilities on March 14, 2024, at 9:20 a.m., confirmed the deficiency existed.
2. Based on observation and interview, the facility failed to maintain fire alarm systems in one of twelve smoke compartments.

Findings include:

Observation on March 14, 2024, at 10.32 a.m., revealed the fire alarm pull station notification device was obstructed by a cart in the purchasing room located by the exit discharge door. Device obstruction could delay manual alarm system activation.

An interview with the maintenance technician on March 14, 2024, at 10.32 a.m., confirmed the fire alarm device was obstructed.

Based on observation and interview, the facility failed to maintain the sprinkler system in one of twelve smoke compartments.
Findings include:
Observation on March 14, 2024, at 11:59 a.m., revealed the first-floor kitchen storage room had a loose escutcheon plate that created an opening in the ceiling, potentially causing a delay in sprinkler activation.
Interview with the maintenance technician on March 14, 2024, at 11:59 a.m., confirmed the sprinkler escutcheon plate was not properly installed.

Based on observation and interview, the facility failed to provide portable fire extinguishers in two of over fifty rooms.

Findings include:

Observation on March 14, 2024, at 10:10 a.m. and 10:32 a.m., revealed the following discrepancies:

A. (10:10 a.m.) Main floor respiratory department had no portable fire extinguisher installed. Ref: NFPA 10 -6.2.1.2
B. (10:32 a.m.) Main floor purchasing room fire extinguisher was not readily accessible, visually obstructed by staged boxes and a cart.

Interview with the maintenance technician on March 14, 2024, at 10:10 a.m., confirmed the deficiencies.

Based on observation and interview, the facility failed to maintain smoke barrier requirements on one of one building level.

Findings include:

Observation on March 14, 2024, between 10:05 a.m., and 12:06 p.m., revealed the following deficiencies:

A. (10:05 a.m.-12:06 p.m.) Main floor smoke and fire dampers could not be identified from the underside of the ceiling tiles. Ref: NFPA 90A -6.3.1.2;
B. (10:05 a.m.-12:06 p.m.) Main floor ceiling tiles lacked maintenance, with loose, misaligned, broken, and missing tiles present, which would allow smoke passage throughout the facility.
C. (11:50 a.m.) Main floor, above the double doors near the house instrumentation pick-up room, revealed a penetration through the wall not sealed with fire caulk.

Interview with the maintenance supervisor on February 29, 2024, at 10:52 a.m., confirmed the smoke barrier deficiency.

Based on observation and interview, the facility failed to maintain soiled linen/trash quantities in one of more than ten soiled linen/trash rooms.

Findings include:

Observation on March 14, 2024, at 11:01 a.m., revealed soiled linen/trash on the floor, creating a fire hazard.

Interview with the maintenance technician on March 14, 2024, at 12:02 p.m., confirmed the deficiency.

Based on document review and interview, the facility failed to meet gas and vacuum piped system requirements for one of one system.

Findings include:

Document review on March 14, 2024, between 9:50 a.m. and 10:01 a.m., revealed the following system deficiencies on the March 9, 2023, inspection report, lacked corrective documentation:

A. (9:50 a.m.) Outdoor bulk pad lacked a demand pressure switch;
B. (9:51 a.m.) Outdoor bulk pad emergency 02 connection was not present;
C. (9:51 a.m.) Outdoor bulk pad main line gauge was not present;
D. (9:52 a.m.) Mechanical room carbon monoxide monitor was not accurate;
E. (9:53 a.m.) Mechanical room had no main line vacuum switch or gauge present;
F. (9:54 a.m.) Mechanical room source valve was not tagged and discharge piping was not labeled;
G. (9:56 a.m.) Mechanical room exhaust was not turn down screened or protected;
H. (9:56 a.m.) Manifold room pigtails were out of date;
I. (9:56 a.m.) Manifold room manifold was obsolete;
J. (9:56 a.m.) Manifold location was non-compliant;
K. (9:57 a.m.) Manifold room had no demand check on the pressure switch;
L (10:01 a.m.) Floor 1C nurse station panel model was not compliant and needed replaced.

Interview with the facilities director on March 14, 2024 at 10:01 a.m., confirmed the deficiencies and could not provide corrective documentation at the time of the survey.

Based on document review and interview, the facility failed to meet gas and vacuum-piped system requirements for one of one system.

Findings include:

Document review on March 14, 2024, between 9:50 a.m. and 10:01 a.m., revealed the following system deficiencies, documented on the March 9, 2023 inspection report, lacked corrective documentation:

A. (9:50 a.m.) Outdoor bulk pad lacked a demand pressure switch;
B. (9:51 a.m.) Outdoor bulk pad emergency 02 connection was not present;
C. (9:51 a.m.) Outdoor bulk pad main line gaug wase not present;
D. (9:52 a.m.) Mechanical room carbon monoxide monitor was not accurate;
E. (9:53 a.m.) Mechanical room had no main line vacuum switch or gauge present;
F. (9:54 a.m.) Mechanical room source valve was not tagged and discharge piping was not labeled;
G. (9:56 a.m.) Mechanical room exhaust was not turn down screened or protected;
H. (9:56 a.m.) Manifold room pigtails were out of date;
I. (9:56 a.m.) Manifold room manifold was obsolete;
J. (9:56 a.m.) Manifold location was non-compliant;
K. (9:57 a.m.) Manifold room had no demand check on pressure switch;
L (10:01 a.m.) Floor 1C nurse station panel model was not compliant and needed replaced.

Interview with the facilities director on March 14, 2024, at 10:01 a.m., confirmed the deficiencies did not have corrective documentation at the time of the survey.

Based on observation and interview, the facility failed to maintain electrical systems for one of over five electrical rooms.
Findings include:
Observation on March 14, 2024, at 11:01 a.m., revealed the emergency room storage had boxes in front of the electrical panels, preventing access.

Interview with the maintenance technician on March 14, 2024, at 11:10 a.m., confirmed the items were blocking the electrical panels at the time of the survey.

Based on observation and interview, the facility failed to meet electrical receptacle requirements for one of one facility.

Findings include:

Observation on March 14, 2024, at 12:30 p.m., revealed the exam and break rooms throughout the medical suites lacked receptacles with ground fault circuit interrupter (GFCI) protection within six feet of water sources.

Interview with the director of facilities on March 14, 2024, at 12:30 p.m., confirmed the facility had several outlets not protected by GFCIs.

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

Findings include:

Observation on March 14, 2024, between 10:27 a.m. and 12:05 a.m., revealed the facility failed to ensure ground fault circuit interrupter (GFCI) protection within six feet of sinks and water sources in the following locations:

A. (10:27 a.m.) Main floor kitchen, women's restroom;
B. (10:37 a.m.) Main floor operating room, break room;
C. (10:48 a.m.) Main floor histology room, workstation strip multi outlets;
D. (10:53 a.m.) Main floor laboratory, workstation strip outlets;
E. (10:58 a.m.) Main floor laboratory, cleaning sink;
F. (11:13 a.m.) Main floor x-ray room 3;
G. (11:15 a.m.) Main floor x-ray room 1;
H (11:20 a.m.) Main floor SPU, nurses station;
I. (11:24 a.m.) Main floor SPU, recovery room, bed 11;
J. (11:26 a.m.) Main floor sterile utility, hopper room;
K. (11:29 a.m.) Main floor emergency room, men's locker room;
L. (11:58 a.m.) Main floor emergency room, soiled laundry room;
M. (12:00 p.m.) Main floor soiled utility room, across from room C-122;
N (12:05 p.m.) Main floor ICU department, nourishment room, ice machine.

Interview with the maintenance technician on March 14, 2024, at 12:05 p.m., confirmed the electrical deficiencies.