HospitalInspections.org

Based on observation and staff interview, the facility failed to ensure all smoke barriers were maintained as a continuous membrane in 2 of 11 smoke compartments. The findings were:
Observation on 7/20/10 between 9 AM and 3 PM revealed a one square foot of ceiling tile was missing in the linen sorting room in the basement and a one square foot ceiling tile was ajar in the third floor stairwell. The plant operations manager verified these findings at the time of the observations.

Based on observation and staff interview, the facility failed to ensure all corridor doors were resistant to the passage of smoke in 2 of 11 smoke compartments. The findings were:

Observation on 7/20/10 at 11:30 AM and again at 2:48 PM revealed neither the corridor door to resident room #W15 on the third floor nor the "storage" room door on the first floor in the outpatient clinic closed completely in their respective frames unless force in excess of 5 foot pounds of pressure was applied. Interview with the facility plant operations manager at the time of the observations confirmed the doors did not seat in their frames and needed adjusting.

Based on observation and staff interview the facility failed to ensure 1 of 11 smoke barrier walls was smoke resistant. The findings were:

Observation on 7/20/10 at 3:18 PM revealed the smoke barrier wall over the door to the "Lions Den" had one unsealed penetration with several cables running through it. The gap was approximately 1/2 inch wide. Interview with the plant operations manager at the time of the observation revealed the smoke barrier wall above the ceiling tile had not been sealed after computer cables were recently installed.

Based on observation and staff interview, the facility failed to ensure all hazardous areas were separated from patient use areas in 5 of 14 smoke compartments. The findings were:

Observation on 7/20/10 between 9 AM and 3 PM revealed the following concerns:
a. The surgical locker room doors and the door to the autoclave soiled room in the surgical suite had self closure devices (SCD) attached. However, none of the three doors latched in their frames with three separate attempts.
b. An electrical cord prevented the door to the surgical soiled utility room from being closed. The door did have a SCD attached. The electrical cord was attached to a battery pack for "Stryker" hoods. The hoods and batteries were sitting in a basket in the corridor. But the electrical cord from the battery pack was plugged into an electrical outlet in the soiled utility room, which prevented the door from being closed.
c. The storerooms on the third floor had seven hangers on the door, which prevented complete door closure. The door had a functional SCD attached to it.
d. The door to the pharmacy "chem pack" room on the first floor had an SCD attached to it, but the door did not latch into its frame with three separate attempts.
e. The environmental services door in the basement did not have an SCD attached to the door. Cleaning chemicals and supplies were stored in the environmental services room. The plant operations manager stated, at the time of the observation, the environmental services door should have an SCD and also confirmed the doors that had SCD's did not latch in their frames.

Based on observation and staff interview the facility failed to maintain the installed fire alarm system in accordance with the provisions of NFPA 72. The findings were:

Observation on 7/20/10 at 9:48 AM revealed neither the medical records storage room, nor the electrical room near the paper shredder room in the basement had notification devices (strobe, horn, etc.) in the rooms. The plant operations manager confirmed the above observations.

Based on observation and staff interview the facility failed to ensure all sprinkler heads in 5 of 11 smoke compartments were installed as required. Escutcheons were noted to be missing for eight heads. The findings were:

Observation on 7/20/10 between 9 AM and 2:30 PM revealed the eight sprinkler head escutcheons were missing in the following locations:
a. The maintenance laundry cleaning room behind the dryers.
b. The hallway outside the "Lions Den" computer room in the basement.
c. The janitor's closet in the emergency room on the first floor.
d. The fluoroscopy room on the first floor.
e. The surgical storage area at the end of the hall in the basement.
f. The clean utility room #365 on the third floor.
g. The women's restroom on the third floor.
The facility plant operations manager confirmed the above observations.

Based on observation, review of facility records and staff interview, the facility failed to ensure the fire suppression (sprinkler) system was properly maintained. The findings were:

Observation on 7/20/10 at 9:48 AM revealed a gap greater than one half inch existed between the sprinkler head escutcheons and the ceiling in the outpatient clinic restroom on the first floor and in the hallway outside exam room #7. In addition, review of the facility's preventive maintenance records on revealed the static and residual water pressures were not recorded for the main drain tests during two of the previous four quarters. Interview with the plant operations manager at the time of the observations confirmed the escutcheons needed to be adjusted, and the water pressures were not recorded.

Based on observation and staff interview the facility failed to maintain access to all portable fire extinguishers in 1 of 11 smoke compartments. The findings were:

Observation on 7/20/10 at 10:48 AM revealed the wall-mounted, portable fire extinguisher (ABC type) located in the hallway outside the "Lions Den" computer training room was obstructed by a chair. Interview with the plant operations manager at the time confirmed access to the fire extinguisher was blocked by the chair.

Based on observation and staff interview the facility failed to ensure the electrical system was maintained as required in 2 of 11 smoke compartments. The findings were:

Observation on 7/20/10 between 9:30 AM and 3:20 PM revealed surge protectors were plugged into other surge protectors in the following five locations:
a. The materials management store room.
b. The material manager's office.
c. The preventive manager's office d. The massage therapist's office
e. The nursing administration receptionist office.
Interview with the plant operations manager at the time of the observations confirmed surge proctectors were plugged into other surge protectors in these locations.

Based on observation and staff interview, the facility failed to ensure alcohol based hand rub (ABHR) dispensers were not installed over ignition sources in 2 of 11smoke compartments. The findings were:

Observation on 7/20/10 at 11:18 AM and at 1:11 PM revealed one ABHR dispenser was attached to the wall directly over a light switch in the nursery on the first floor and one ABHR dispenser was attached to the wall over an electrical outlet in the outpatinet clinic exam room also on the first floor. Interview with the plant operations manager at the time of the observations confirmed the dispensers were located over possible ignition sources.

Based on observation and staff interview, the facility failed to ensure all smoke barriers were maintained as a continuous membrane in 2 of 11 smoke compartments. The findings were:
Observation on 7/20/10 between 9 AM and 3 PM revealed a one square foot of ceiling tile was missing in the linen sorting room in the basement and a one square foot ceiling tile was ajar in the third floor stairwell. The plant operations manager verified these findings at the time of the observations.

Based on observation and staff interview, the facility failed to ensure all corridor doors were resistant to the passage of smoke in 2 of 11 smoke compartments. The findings were:

Observation on 7/20/10 at 11:30 AM and again at 2:48 PM revealed neither the corridor door to resident room #W15 on the third floor nor the "storage" room door on the first floor in the outpatient clinic closed completely in their respective frames unless force in excess of 5 foot pounds of pressure was applied. Interview with the facility plant operations manager at the time of the observations confirmed the doors did not seat in their frames and needed adjusting.

Based on observation and staff interview the facility failed to ensure 1 of 11 smoke barrier walls was smoke resistant. The findings were:

Observation on 7/20/10 at 3:18 PM revealed the smoke barrier wall over the door to the "Lions Den" had one unsealed penetration with several cables running through it. The gap was approximately 1/2 inch wide. Interview with the plant operations manager at the time of the observation revealed the smoke barrier wall above the ceiling tile had not been sealed after computer cables were recently installed.

Based on observation and staff interview, the facility failed to ensure all hazardous areas were separated from patient use areas in 5 of 14 smoke compartments. The findings were:

Observation on 7/20/10 between 9 AM and 3 PM revealed the following concerns:
a. The surgical locker room doors and the door to the autoclave soiled room in the surgical suite had self closure devices (SCD) attached. However, none of the three doors latched in their frames with three separate attempts.
b. An electrical cord prevented the door to the surgical soiled utility room from being closed. The door did have a SCD attached. The electrical cord was attached to a battery pack for "Stryker" hoods. The hoods and batteries were sitting in a basket in the corridor. But the electrical cord from the battery pack was plugged into an electrical outlet in the soiled utility room, which prevented the door from being closed.
c. The storerooms on the third floor had seven hangers on the door, which prevented complete door closure. The door had a functional SCD attached to it.
d. The door to the pharmacy "chem pack" room on the first floor had an SCD attached to it, but the door did not latch into its frame with three separate attempts.
e. The environmental services door in the basement did not have an SCD attached to the door. Cleaning chemicals and supplies were stored in the environmental services room. The plant operations manager stated, at the time of the observation, the environmental services door should have an SCD and also confirmed the doors that had SCD's did not latch in their frames.

Based on observation and staff interview the facility failed to maintain the installed fire alarm system in accordance with the provisions of NFPA 72. The findings were:

Observation on 7/20/10 at 9:48 AM revealed neither the medical records storage room, nor the electrical room near the paper shredder room in the basement had notification devices (strobe, horn, etc.) in the rooms. The plant operations manager confirmed the above observations.

Based on observation and staff interview the facility failed to ensure all sprinkler heads in 5 of 11 smoke compartments were installed as required. Escutcheons were noted to be missing for eight heads. The findings were:

Observation on 7/20/10 between 9 AM and 2:30 PM revealed the eight sprinkler head escutcheons were missing in the following locations:
a. The maintenance laundry cleaning room behind the dryers.
b. The hallway outside the "Lions Den" computer room in the basement.
c. The janitor's closet in the emergency room on the first floor.
d. The fluoroscopy room on the first floor.
e. The surgical storage area at the end of the hall in the basement.
f. The clean utility room #365 on the third floor.
g. The women's restroom on the third floor.
The facility plant operations manager confirmed the above observations.

Based on observation, review of facility records and staff interview, the facility failed to ensure the fire suppression (sprinkler) system was properly maintained. The findings were:

Observation on 7/20/10 at 9:48 AM revealed a gap greater than one half inch existed between the sprinkler head escutcheons and the ceiling in the outpatient clinic restroom on the first floor and in the hallway outside exam room #7. In addition, review of the facility's preventive maintenance records on revealed the static and residual water pressures were not recorded for the main drain tests during two of the previous four quarters. Interview with the plant operations manager at the time of the observations confirmed the escutcheons needed to be adjusted, and the water pressures were not recorded.

Based on observation and staff interview the facility failed to maintain access to all portable fire extinguishers in 1 of 11 smoke compartments. The findings were:

Observation on 7/20/10 at 10:48 AM revealed the wall-mounted, portable fire extinguisher (ABC type) located in the hallway outside the "Lions Den" computer training room was obstructed by a chair. Interview with the plant operations manager at the time confirmed access to the fire extinguisher was blocked by the chair.

Based on observation and staff interview the facility failed to ensure the electrical system was maintained as required in 2 of 11 smoke compartments. The findings were:

Observation on 7/20/10 between 9:30 AM and 3:20 PM revealed surge protectors were plugged into other surge protectors in the following five locations:
a. The materials management store room.
b. The material manager's office.
c. The preventive manager's office d. The massage therapist's office
e. The nursing administration receptionist office.
Interview with the plant operations manager at the time of the observations confirmed surge proctectors were plugged into other surge protectors in these locations.