HospitalInspections.org

Based on observation and interview it was determined the facility failed to properly maintain three vertical openings on three of nine floors in this component.

Findings include:

A. Observation on September 13, 2012, between 10:29 AM and 1:35 PM, revealed the following vertical opening deficiencies:

10:29 AM - First floor (facility basement), unprotected vertical penetration around a drain pipe in the ceiling of the tube room.

1:35 PM - Fourth floor (facility third), unprotected vertical penetration around a drain pipe in the ceiling at the nurses station above the medical gas control panel.

Exit interview with maintenance representative #1, and maintenance representative #2 on September 14, 2012, between 8:30 AM and 8:45 AM, confirmed these unprotected vertical penetrations.

B. Observation on September 14, 2012, at 7:45 AM, revealed an unprotected penetration around a water line in the Fourth floor (facility third floor) A-wing mechanical chase.

Exit interview with maintenance representative #1, and maintenance representative #2 on September 14, 2012, between 8:30 AM and 8:45 AM, confirmed the unprotected vertical penetrations.

Based on observation and interview, it was determined the facility failed to construct the smoke barrier walls to provide at least a one half hour fire resistance rating in three instances on three of nine floors in the component.

Findings include:

A. Observation of smoke barrier walls on September 13, 2012, between 10:00 AM and 1:50 PM revealed:

1. 10:00 AM - The ninth floor (facility 8th) smoke barrier wall had unsealed penetrations around copper pipes located in patient room #873.

2. 11:03 AM - The seventh (facility 6th) floor smoke barrier wall had an unsealed penetration around an electrical wire located in the auto pixis room.

3. 1:50 PM - The fourth floor (facility 3rd) smoke barrier wall had an unsealed penetration approximately 3" round located near the D-wing Dietary office.

Exit interview with maintenance representative #1, and maintenance representative #2 on September 14, 2012, between 8:30 AM and 8:45 AM, confirmed these penetrations.

Based on observation and interview it was determined the facility failed to properly maintain exit access in three locations on three of nine floors in this component.

Findings include:

A. Observation on September 13, 2012, between 11:04 AM and 1:37 PM, revealed the following exit access deficiencies:

11:04 AM - First floor (facility basement), A-wing exit stair tower had items stored on the lower landing.

11:44 AM - Second floor (facility first), exit stair tower protected passageway leading to main lobby had waste cardboard improperly stored in the passageway.

1:37 PM - Third floor (facility second), metal cart obstructing the OR back exit stair tower access door.

Exit interview with maintenance representative #1, and maintenance representative #2 on September 14, 2012, between 8:30 AM and 8:45 AM, confirmed these exit access deficiencies.

Based on observation and interview it was determined the facility failed to properly maintain one exit corridor on one of nine floors in this component.

Findings include:

A. Observation on September 13, 2012, at 9:45 AM, revealed a physical therapy step apparatus was reducing the corridor width by three feet outside the ninth floor (facility eighth) staff lounge.

Exit interview with maintenance representative #1, and maintenance representative #2 on September 14, 2012, between 8:30 AM and 8:45 AM, confirmed the step apparatus was reducing the corridor width.

Based on observation and interview it was determined the facility failed to maintain unobstructed sprinkler coverage in one instance on one of nine floors in this component.

Findings include:

A. Observation on September 13, 2012, at 11:48 AM, revealed the second floor (facility first) admissions closet had storage items placed closer that 18 inches below the sprinkler head, obstructing the flow.

Exit interview with maintenance representative #1, and maintenance representative #2 on September 14, 2012, between 8:30 AM and 8:45 AM, confirmed the sprinkler obstruction.

Based on observation and interview, it was determined the facility failed to ensure that the portable fire extinguishers are installed, inspected and maintained in two instances on two of nine floors in the component.

Findings include:

A. Observation of fire extinguishers on September 13, 2012, between 12:00 PM and 1:15 PM revealed:

1. 12:00 PM - The flush mounted fire extinguisher located adjacent to patient room #D473 on the fifth floor (facility 4th) lacked adequate signage.

2. 1:15 PM - The fire extinguisher located in the AE-6 penthouse lacked a recent monthly and annual inspection.

Exit interview with maintenance representative #1, and maintenance representative #2 on September 14, 2012, between 8:30 AM and 8:45 AM, confirmed the fire extinguisher deficiencies.

Based on observation and interview it was determined the facility failed to properly maintain one soiled linen chute on one of nine floors in this component.

Findings include:

A. Observation on September 13, 2012, at 1:40 PM, revealed the third floor (facility second) ambulatory surgery soiled linen chute access door was held open by an unauthorized stop.

Exit interview with maintenance representative #1, and maintenance representative #2 on September 14, 2012, between 8:30 AM and 8:45 AM, confirmed the soiled linen chute access door was held open by an unauthorized stop.

Based on observation and interview it was determined the facility failed to properly maintain five medical gas storage areas on three of nine floors in this component.

Findings include:

A. Observation on September 13, 2012, between 10:59 AM and 1:28 PM, revealed the following medical gas storage deficiencies:

10:59 AM - First floor (facility basement), loading dock area, 20 E-sized oxygen cylinders stored in racks, area not properly configured as a medical gas cylinder storage area due to close proximity to combustibles and electrical outlet installed less than five feet from the floor.

11:22 AM - First floor (facility basement), H-tank room, used to store over 3,000 cubic feet of oxygen, was not properly configured as a medical gas cylinder storage area due to lack of 72 square inches of ventilation.

1:12 PM - Third floor (facility second), ICU alcove, contained 2 unsecured E-sized oxygen cylinders.

1:27 PM - Fourth floor (facility third), respiratory care equipment room, contained 3 unsecured E-sized oxygen cylinders.

1:28 PM - Third floor (facility second), PACU nurses station, contained 2 unsecured E-sized oxygen cylinders.

Exit interview with maintenance representative #1, and maintenance representative #2 on September 14, 2012, between 8:30 AM and 8:45 AM, confirmed the medical gas cylinder storage deficiencies.

Based on observation and interview it was determined the facility failed to properly label piped in medical gas components in one location, on one of nine floors in the component.

Findings include:

Observation of piped in medical gas components on September 13, 2012, at 11:02 AM revealed the lines were not labeled above the suspended ceiling, located on the ninth floor (facility 8th) of patient room #873.

Exit interview with maintenance representative #1, and maintenance representative #2 on September 14, 2012, between 8:30 AM and 8:45 AM confirmed the lines were not labeled.

Based on observation and interview it was determined the facility failed to provide electrical wiring and equipment in two instances on one of nine floors in the component.

Findings include:

A. Observation of electrical wiring and equipment on September 13, 2012, between 1:25 PM and 2:08 PM revealed:

1. 1:25 PM - An unauthorized extension cord was being used to supply power to a surge protector which had a microwave and toaster oven plugged in, located on the fourth floor (facility 3rd floor) Respiratory Care break-room.

2. 2:08 PM - The fourth floor (facility 3rd floor) Peds Nurses Lounge had a microwave, toaster, and toaster oven plugged into a surge suppressor power strip.

Exit interview with maintenance representative #1, and maintenance representative #2 on September 14, 2012, between 8:30 AM and 8:45 AM, confirmed the electrical deficiencies.

Based on observation and interview it was determined the facility failed to properly maintain three vertical openings on three of nine floors in this component.

Findings include:

A. Observation on September 13, 2012, between 10:29 AM and 1:35 PM, revealed the following vertical opening deficiencies:

10:29 AM - First floor (facility basement), unprotected vertical penetration around a drain pipe in the ceiling of the tube room.

1:35 PM - Fourth floor (facility third), unprotected vertical penetration around a drain pipe in the ceiling at the nurses station above the medical gas control panel.

Exit interview with maintenance representative #1, and maintenance representative #2 on September 14, 2012, between 8:30 AM and 8:45 AM, confirmed these unprotected vertical penetrations.

B. Observation on September 14, 2012, at 7:45 AM, revealed an unprotected penetration around a water line in the Fourth floor (facility third floor) A-wing mechanical chase.

Exit interview with maintenance representative #1, and maintenance representative #2 on September 14, 2012, between 8:30 AM and 8:45 AM, confirmed the unprotected vertical penetrations.

Based on observation and interview, it was determined the facility failed to construct the smoke barrier walls to provide at least a one half hour fire resistance rating in three instances on three of nine floors in the component.

Findings include:

A. Observation of smoke barrier walls on September 13, 2012, between 10:00 AM and 1:50 PM revealed:

1. 10:00 AM - The ninth floor (facility 8th) smoke barrier wall had unsealed penetrations around copper pipes located in patient room #873.

2. 11:03 AM - The seventh (facility 6th) floor smoke barrier wall had an unsealed penetration around an electrical wire located in the auto pixis room.

3. 1:50 PM - The fourth floor (facility 3rd) smoke barrier wall had an unsealed penetration approximately 3" round located near the D-wing Dietary office.

Exit interview with maintenance representative #1, and maintenance representative #2 on September 14, 2012, between 8:30 AM and 8:45 AM, confirmed these penetrations.

Based on observation and interview it was determined the facility failed to properly maintain exit access in three locations on three of nine floors in this component.

Findings include:

A. Observation on September 13, 2012, between 11:04 AM and 1:37 PM, revealed the following exit access deficiencies:

11:04 AM - First floor (facility basement), A-wing exit stair tower had items stored on the lower landing.

11:44 AM - Second floor (facility first), exit stair tower protected passageway leading to main lobby had waste cardboard improperly stored in the passageway.

1:37 PM - Third floor (facility second), metal cart obstructing the OR back exit stair tower access door.

Exit interview with maintenance representative #1, and maintenance representative #2 on September 14, 2012, between 8:30 AM and 8:45 AM, confirmed these exit access deficiencies.

Based on observation and interview it was determined the facility failed to properly maintain one exit corridor on one of nine floors in this component.

Findings include:

A. Observation on September 13, 2012, at 9:45 AM, revealed a physical therapy step apparatus was reducing the corridor width by three feet outside the ninth floor (facility eighth) staff lounge.

Exit interview with maintenance representative #1, and maintenance representative #2 on September 14, 2012, between 8:30 AM and 8:45 AM, confirmed the step apparatus was reducing the corridor width.

Based on observation and interview it was determined the facility failed to maintain unobstructed sprinkler coverage in one instance on one of nine floors in this component.

Findings include:

A. Observation on September 13, 2012, at 11:48 AM, revealed the second floor (facility first) admissions closet had storage items placed closer that 18 inches below the sprinkler head, obstructing the flow.

Exit interview with maintenance representative #1, and maintenance representative #2 on September 14, 2012, between 8:30 AM and 8:45 AM, confirmed the sprinkler obstruction.

Based on observation and interview, it was determined the facility failed to ensure that the portable fire extinguishers are installed, inspected and maintained in two instances on two of nine floors in the component.

Findings include:

A. Observation of fire extinguishers on September 13, 2012, between 12:00 PM and 1:15 PM revealed:

1. 12:00 PM - The flush mounted fire extinguisher located adjacent to patient room #D473 on the fifth floor (facility 4th) lacked adequate signage.

2. 1:15 PM - The fire extinguisher located in the AE-6 penthouse lacked a recent monthly and annual inspection.

Exit interview with maintenance representative #1, and maintenance representative #2 on September 14, 2012, between 8:30 AM and 8:45 AM, confirmed the fire extinguisher deficiencies.

Based on observation and interview it was determined the facility failed to properly maintain one soiled linen chute on one of nine floors in this component.

Findings include:

A. Observation on September 13, 2012, at 1:40 PM, revealed the third floor (facility second) ambulatory surgery soiled linen chute access door was held open by an unauthorized stop.

Exit interview with maintenance representative #1, and maintenance representative #2 on September 14, 2012, between 8:30 AM and 8:45 AM, confirmed the soiled linen chute access door was held open by an unauthorized stop.

Based on observation and interview it was determined the facility failed to properly maintain five medical gas storage areas on three of nine floors in this component.

Findings include:

A. Observation on September 13, 2012, between 10:59 AM and 1:28 PM, revealed the following medical gas storage deficiencies:

10:59 AM - First floor (facility basement), loading dock area, 20 E-sized oxygen cylinders stored in racks, area not properly configured as a medical gas cylinder storage area due to close proximity to combustibles and electrical outlet installed less than five feet from the floor.

11:22 AM - First floor (facility basement), H-tank room, used to store over 3,000 cubic feet of oxygen, was not properly configured as a medical gas cylinder storage area due to lack of 72 square inches of ventilation.

1:12 PM - Third floor (facility second), ICU alcove, contained 2 unsecured E-sized oxygen cylinders.

1:27 PM - Fourth floor (facility third), respiratory care equipment room, contained 3 unsecured E-sized oxygen cylinders.

1:28 PM - Third floor (facility second), PACU nurses station, contained 2 unsecured E-sized oxygen cylinders.

Exit interview with maintenance representative #1, and maintenance representative #2 on September 14, 2012, between 8:30 AM and 8:45 AM, confirmed the medical gas cylinder storage deficiencies.

Based on observation and interview it was determined the facility failed to properly label piped in medical gas components in one location, on one of nine floors in the component.

Findings include:

Observation of piped in medical gas components on September 13, 2012, at 11:02 AM revealed the lines were not labeled above the suspended ceiling, located on the ninth floor (facility 8th) of patient room #873.

Exit interview with maintenance representative #1, and maintenance representative #2 on September 14, 2012, between 8:30 AM and 8:45 AM confirmed the lines were not labeled.

Based on observation and interview it was determined the facility failed to provide electrical wiring and equipment in two instances on one of nine floors in the component.

Findings include:

A. Observation of electrical wiring and equipment on September 13, 2012, between 1:25 PM and 2:08 PM revealed:

1. 1:25 PM - An unauthorized extension cord was being used to supply power to a surge protector which had a microwave and toaster oven plugged in, located on the fourth floor (facility 3rd floor) Respiratory Care break-room.

2. 2:08 PM - The fourth floor (facility 3rd floor) Peds Nurses Lounge had a microwave, toaster, and toaster oven plugged into a surge suppressor power strip.

Exit interview with maintenance representative #1, and maintenance representative #2 on September 14, 2012, between 8:30 AM and 8:45 AM, confirmed the electrical deficiencies.