HospitalInspections.org

Based on observation, it was determined that the facility failed to have smoke resistant partitions and self-closing doors in hazardous areas.

The findings include:

Observation on May 6, 2014 between 10:30 a.m. and 12:00 p.m. revealed the following hazardous areas did not have smoke resistant partitions or door closers:
1. Storage room MB5 that is within the bed storage room by the blue elevators, the wall does not extend to the ceiling.
2. Dry storage in dietary is not provided with a self-closing door.
3. Phlebotomy storage room on the ground floor north wing, the door has been removed.

These findings were verified and acknowledged by administration during the survey and exit conference on May 7, 2014.

Based on observation, it was determined that the facility failed to maintain the automatic sprinkler system and its components.

The findings include:

Observation on May 5, 2014 at 10:30 a.m. revealed sprinkler piping or hangers are being used to support non system components and sprinkler heads are not free from foreign materials in the following areas:
1. Telecom room TC1013(BW) in west basement has wires on sprinkler piping.
2. 7th floor north stairway 1 has wires on sprinkler piping.
3. 6th floor stairway 7 has wires on sprinkler piping.
4. 5th floor stairway 8 has wires on sprinkler piping.
5. NICU kitchen has an excessive build-up of lent and debris on sprinkler heads.
6. Day surgery at back nurses station has an excessive build-up of lent and debris.
7. Freezer in the kitchen has an excessive build-up of lent and debris.

These findings were verified and acknowledged by administration during the survey and exit conference on May 7, 2014.

NFPA 13 1999 Edition Standard for the Installation of Sprinkler System
6-1.1.5*
Sprinkler piping or hangers shall not be used to support non system components.

NFPA 25 1998 Edition Standard for the inspection, Testing, and Maintenance of Water-Based Fire Protection System
2-2.1.1*
Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

Based on observation, it was determined that the facility failed to have the means of egress free of all obstructions or impediments.

The findings include:

Observation on May 6, 2014 at 10:02 a.m. revealed the corridor in 5 east has wheelchairs obstructing the means of egress and the back of the x-ray corridor is obstructed by stretchers.

This finding was verified and acknowledged by maintenance and administration during the survey and exit conference on May 7, 2014.

Based on observation, it was determined that the facility failed to have soiled linen receptacles of 32 gallons exceeding a 64 square foot area from one other.

The findings include:

Observation on May 6, 2014 at 11:17 a.m. revealed soiled linen carts of 32 gallons are located side by side of one another and have exceeded the maximum 32 gallons within a 64 square foot area in the day surgery back nurses station and the emergency room fast track.

This finding was verified by maintenance and acknowledged by administration during the survey and exit conference on May 7, 2014.

Based on observation, it was determined that the facility failed to have hangers or supports for piped in medical gasses of a same or insulated material.

The findings include:

Observation above ceiling on May 6 and 7, 2014 between 8:00 a.m. and 3:00 p.m. revealed the following locations did not have hangers or supports of a copper finish or insulated between the piped in medical gasses:
1. Day surgery in front of bed 4 med gas lines are supported by a unistrut that is not insulated or copper.
2. 6th floor west in triage room 5 are supported by a unistrut that is not insulated or copper.
3. 6th floor west in triage room 4 are supported by a unistrut that is not insulated or copper.

These findings were verified and acknowledged by administration during the survey and exit conference on May 7, 2014.

NFPA 99 1999 Edition Standard for Health Care Facilities
4-3.1.2.9 Piping Installation.
(b) Piping shall be supported from the building structure in accordance with MSS Standard Practice SP-69, Piping Hangers and Supports - Selection and Application. Hangers and supports shall comply with MSS Standard Practice SP-58, Pipe Hangers and Supports - Materials, Design and Manufacture. Hangers for copper tube shall have a copper finish. In potentially damp locations, copper tube hangers or supports shall be plastic-coated or otherwise insulated from the tube.

Based on observation, it was determined that the facility failed to have smoke resistant partitions and self-closing doors in hazardous areas.

The findings include:

Observation on May 6, 2014 between 10:30 a.m. and 12:00 p.m. revealed the following hazardous areas did not have smoke resistant partitions or door closers:
1. Storage room MB5 that is within the bed storage room by the blue elevators, the wall does not extend to the ceiling.
2. Dry storage in dietary is not provided with a self-closing door.
3. Phlebotomy storage room on the ground floor north wing, the door has been removed.

These findings were verified and acknowledged by administration during the survey and exit conference on May 7, 2014.

Based on observation, it was determined that the facility failed to maintain the automatic sprinkler system and its components.

The findings include:

Observation on May 5, 2014 at 10:30 a.m. revealed sprinkler piping or hangers are being used to support non system components and sprinkler heads are not free from foreign materials in the following areas:
1. Telecom room TC1013(BW) in west basement has wires on sprinkler piping.
2. 7th floor north stairway 1 has wires on sprinkler piping.
3. 6th floor stairway 7 has wires on sprinkler piping.
4. 5th floor stairway 8 has wires on sprinkler piping.
5. NICU kitchen has an excessive build-up of lent and debris on sprinkler heads.
6. Day surgery at back nurses station has an excessive build-up of lent and debris.
7. Freezer in the kitchen has an excessive build-up of lent and debris.

These findings were verified and acknowledged by administration during the survey and exit conference on May 7, 2014.

NFPA 13 1999 Edition Standard for the Installation of Sprinkler System
6-1.1.5*
Sprinkler piping or hangers shall not be used to support non system components.

NFPA 25 1998 Edition Standard for the inspection, Testing, and Maintenance of Water-Based Fire Protection System
2-2.1.1*
Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

Based on observation, it was determined that the facility failed to have the means of egress free of all obstructions or impediments.

The findings include:

Observation on May 6, 2014 at 10:02 a.m. revealed the corridor in 5 east has wheelchairs obstructing the means of egress and the back of the x-ray corridor is obstructed by stretchers.

This finding was verified and acknowledged by maintenance and administration during the survey and exit conference on May 7, 2014.

Based on observation, it was determined that the facility failed to have soiled linen receptacles of 32 gallons exceeding a 64 square foot area from one other.

The findings include:

Observation on May 6, 2014 at 11:17 a.m. revealed soiled linen carts of 32 gallons are located side by side of one another and have exceeded the maximum 32 gallons within a 64 square foot area in the day surgery back nurses station and the emergency room fast track.

This finding was verified by maintenance and acknowledged by administration during the survey and exit conference on May 7, 2014.

Based on observation, it was determined that the facility failed to have hangers or supports for piped in medical gasses of a same or insulated material.

The findings include:

Observation above ceiling on May 6 and 7, 2014 between 8:00 a.m. and 3:00 p.m. revealed the following locations did not have hangers or supports of a copper finish or insulated between the piped in medical gasses:
1. Day surgery in front of bed 4 med gas lines are supported by a unistrut that is not insulated or copper.
2. 6th floor west in triage room 5 are supported by a unistrut that is not insulated or copper.
3. 6th floor west in triage room 4 are supported by a unistrut that is not insulated or copper.

These findings were verified and acknowledged by administration during the survey and exit conference on May 7, 2014.

NFPA 99 1999 Edition Standard for Health Care Facilities
4-3.1.2.9 Piping Installation.
(b) Piping shall be supported from the building structure in accordance with MSS Standard Practice SP-69, Piping Hangers and Supports - Selection and Application. Hangers and supports shall comply with MSS Standard Practice SP-58, Pipe Hangers and Supports - Materials, Design and Manufacture. Hangers for copper tube shall have a copper finish. In potentially damp locations, copper tube hangers or supports shall be plastic-coated or otherwise insulated from the tube.